Progress in Acute Respiratory Distress Syndrome in Pediatrics

PowerPoint PresentationChildren’s Intensive Care Unit
KK Women’s and Children's Hospital,Singapore
1
2
Organizer of WFPICCS 2018 Video at the end of my presentation
Overview
• Current Epidemiology
4
Ashbaugh et al. Lancet 1967 Ware and Matthay. N Engl J Med 2004
Pediatric ARDS
• Lack of pediatric specific data
5
Cheifetz. Respir Care 2016
• Pediatric Acute Lung Injury
Khemani et al. Ped Crit Care Med 2015
Age Exclude patients with perinatal related lung disease
Timing Within 7 days of known clinical insult
Origin of Edema Respiratory failure not fully explained by cardiac failure or fluid
overload
Chest Imaging Chest imaging findings of new infiltrates consistent with acute
pulmonary parenchymal disease
Full face-mask bi-level
Special Populations
Cyanotic Heart Disease Standard criteria above for age, timing, origin of edema
and chest imaging with an acute deterioration in
oxygenation not explained by underlying cardiac disease.
Chronic Lung Disease Standard criteria above for age, timing and origin of
edema with chest imaging consistent with new infiltrate
and acute deterioration in oxygenation from baseline
which meet oxygenation criteria above.
Left Ventricular
Standard criteria for age, timing and origin of edema with
chest imaging changes consistent with new infiltrate and
acute deterioration in oxygenation which meet criteria
above not explained by left ventricular dysfunction.
Khemani et al. Ped Crit Care Med 2015
How would I change my practice?
• Move away from adult-based definitions o AECC definition
o No more “acute lung injury”
o Berlin definition
• Increased recognition of mild PARDS
9
Overview
• Current Epidemiology
Tale of Two Systematic Reviews Schouten et al.
• Aims: – Estimate population
• Excluded studies with < 10 patients
Wong et al.
• Medline, Embase and Web of Science
• 1960 – August 2015
12
Schouten et al. Crit Care Med 2016
Wong et al. Journal of Intensive Care 2017
Pediatric ARDS
• Population-based incidence: 3.5 per 100,000 person years (95% CI: 2.2 – 5.7)
• PICU-based incidence: 2.3% (95% CI: 1.9 – 2.9%)
13
14
• Significant higher mortality in studies performed in Asia
• No change in mortality over time in Asia
Study design did not influence reported mortality rates
Schouten et al. Crit Care Med 2016
• Overall mortality: 24%
(95% CI: 19 – 31)
• A later year of study was associated with survival [OR for mortality: 0.94; 95%: 0.94 – 0.95]
15
Observational studies
• No difference in mortality reported in observational studies and RCTs
Overview
• Current Epidemiology
• Pressing need for pediatric critical care medicine collaboration in Asia
• Predominantly single center studies
18
19
• Included only patients on
(n=135) P value
Age, years 1.0 (0.3,4.3) 1.0 (0.3, 4.1) 2.3 (0.7, 5.5) 0.008
Gender, male 52 (58.4) 77 (51.7) 67 (49.6) 0.419
Weight, kg 8.4 (4.7, 14) 7.8 (5, 15) 11 (7, 20) 0.001
PIM 2 score 6.9 (2.8, 13.7) 7.4 (3.5, 18.3) 9.8 (4.4, 30) 0.038
PELOD score 3 (1, 12) 3 (1, 12) 11 (2, 16) 0.048
Presence of co-morbidities 36 (40.4) 77 (51.7) 84 (62.2) 0.006
Risk factors for PARDS:
Near drowning 5 (3.5) 6 (4.0) 3 (2.2) 0.414
Others 4 (4.5) 17 (11.4) 14 (10.4) 0.185
OI 5.9 (4.9, 6.7) 11.3 (9.8, 13.6) 25.2 (18.5, 33.2) < 0.001
OSI 5.52 (4.5, 7.2) 9 (7.0, 11.2) 17.1 (14.1, 22.2) < 0.001
PICU mortality: 113/373 (30.3%)
100-day mortality: 126/314 (39.7%)
100-day mortality based on
21
Severity Categories Unadjusted Hazard Ratio P value Adjusted Hazard Ratio P value
Mild Reference Reference
Moderate 2.69 (1.39 – 5.19) <0.01 2.64 (1.35 – 5.14) <0.01
Severe 4.15 (2.17 – 7.93) < 0.01 4.10 (2.02 – 8.32) <0.01
Using COX Proportional hazard regression model Adjusted for site, presence of co-morbidities and Pediatric Index of Mortality 2 score
Outcomes of Extrapulmonary PARDS
Sepsis (non-pulmonary)
Aspiration Trauma
Total number of PARDS patients fulfilling PALICC
criteria=427
Not PARDS after data
PARDS=373
factor=315
Pnuemonia + sepsis Pneumonia + transfusion
Characteristics PARDSp (n=272) PARDSExp (n=43) P value
Age 1.1 (0.4, 3.6) 2.6 (0.5, 6.6) 0.0272
Gender 146 (53.7) 24 (55.8) 0.7938
Weight 8.4 (5.4, 15.0) 13.3 (6.5, 20.0) 0.0371
Co-morbidities 134 (49.3) 26 (60.5) 0.1722
Bacteremia 23 (8.5) 23 (53.5) < 0.001
PIM 2 score 6.6 (2.9, 14.1) 19.3 (6.6, 43.0) < 0.0001
PELOD score 10 (1, 12) 12 (3, 22) 0.0001
PF Ratio 126.7 (86.7, 180.0) 103.8 (65.6, 180.9) 0.0792
OI 11.3 (7.2, 17.7) 15.1 (8.6, 25.1) 0.1012
Multiorgan
dysfunction
Cardiovascular 54 (19.9) 26 (60.5) < 0.0001
Neurologic 21 (07.7) 3 (07.0) 0.8643
Hematologic 38 (14.0) 26 (60.5) < 0.0001
Renal 34 (12.5) 15 (34.9) 0.0002
Hepatic 35 (12.9) 19 (44.2) < 0.0001
Etiologies
Pneumonia 250 (92) Non-pulmonary sepsis 35 (81)
Aspiration 8 (3) Trauma 4 (9)
Drowning/near drowning 14 (5) Transfusion 0 (0)
Others 4 (9)
PICU Mortality 66 (24.3) 20 (46.5) 0.002
100-day mortality 72 (32.6) 22 (53.7) 0.01
Ventilator free days 19.0 (0.5, 24.0) 2.0 (0.0, 18.0) 0.001
Ventilator Duration 8.0 (4.0, 15.0) 10.0 (4.0, 17.0) 0.295
PICU Duration 11.0 (6.0, 19.0) 12.0 (6 to 29) 0.318
PICU free days 16 (1 to 22) 10 (0 to 21) 0.069
Outcomes
26
Covariates
Unadjusted HR (95%CI) P value Adjusted HR (95%CI) P value
PIM 2 score 1.017 (1.01 - 1.024) < 0.001 1.025 (1.016 - 1.033) < 0.001
Comorbidities 1.757 (1.154 - 2.677) 0.009 2.566 (1.593 - 4.135) < 0.001
Multiorgan Dysfunction 3.278 (2.17 - 4.953) < 0.001 3.327 (1.967 - 5.628) < 0.001
PARDSExp
(Ref: PARDSp) 1.742 (1.081 - 2.809) 0.023 1.689 (0.971 - 2.935) 0.063
PARDS Severity
(Ref: Mild)
Cox Regression
• Current Epidemiology
• Increasing studies in PARDS over the next 5 – 10 years
• PALICC consensus statements’ publication is a major step in pediatric critical care
• Future studies should consider the needs and gaps highlighted by this document
• Long term follow-up of survivors of PARDS
• Multi-center studies across the globe to compare and contrast current practices
Concluding Remarks
feasible
overcome
equally important