Noninvasive Respiratory Support in Pediatric ARDS

Noninvasive respiratory support (NRS) is frequently trialed in pediatric ARDS despite limited evidence supporting its efficacy. We aim to describe patient, disease, and NRS characteristics associated with NRS failure in ARDS and investigate outcomes associated with early versus delayed intubation.

This is a retrospective cohort study. Patients meeting pediatric ARDS criteria (2023 PALICC-2 definition) initially supported by NRS were included. Eligible patients were divided into 2 groups: NRS success (NRS use without subsequent endotracheal intubation) versus NRS failure (NRS use with subsequent endotracheal intubation). Subject characteristics, disease severity, and NRS usage patterns were evaluated. NRS failure rate, PICU and hospital stay, and mortality are reported. The NRS failure group was further stratified by early (≤8 h) versus late (>8 h) intubation. Chi squared, Fisher exact, and Wilcoxon rank sum tests were performed as appropriate.

123 subjects were included (79 NRS success and 44 NRS failure). The initial median $S_{{\mathrm{pO}}_2}$/$F_{{\mathrm{IO}}_2}$ ratio for the entire cohort was 160 (mild/moderate ARDS). Initial $S_{{\mathrm{pO}}_2}$/$F_{{\mathrm{IO}}_2}$ ratios did not differ between the groups (P = .12). Subjects in the NRS failure group were more likely to have genetic comorbidities (P = .009), higher PRISM III scores (P < .001), and ARDS etiologies of sepsis and aspiration. The NRS failure rate was 35.8%, and mortality was low at 4.9%. PICU (P < .001) and hospital (P < .001) stay were significantly longer in the failure group. Within the failure group, the median time to intubation was 8 h. Subjects intubated before 8 h had fewer ventilator days (P = .052) and significantly shorter PICU (P = .03) and hospital (P = .033) stay compared with subjects intubated after 8 h.

NRS failure was associated with longer PICU and hospital stay. Early intubation in the failure group was associated with decreased PICU and hospital stay.