A Simple and Robust Bedside Model for Mortality Risk in Pediatric Patients With Acute Respiratory Distress Syndrome*

Abstract

Objective Despite declining mortality, ARDS is still involved in up to one third of pediatric intensive care deaths. The recently convened Pediatric Acute Lung Injury Consensus Conference has outlined research priorities for the field, which include the need for accurate bedside risk-stratification of patients. We aimed to develop a simple yet robust model of mortality risk among pediatric patients with ARDS to facilitate the targeted application of high-risk investigational therapies and stratification for enrollment in clinical trials. Design Prospective, multi-center cohort. Setting Five academic pediatric intensive care units. Patients 308 children ages >1 month and ≤ 18 years, admitted to the intensive care unit, with bilateral infiltrates on chest x-ray and P/F ratio <300 in the clinical absence of left atrial hypertension. Interventions None. Measurements and Main Results Twenty clinical variables were recorded in the following 6 categories: demographics, medical history, oxygenation, ventilation, radiographic imaging, and multi-organ dysfunction. Data were measured 0–24 and 48–72 hours after ARDS onset (Day 1 and Day 3) and examined for associations with hospital mortality. Among 308 enrolled patients, mortality was 17%. Children with a history of cancer and/or hematopoietic stem cell transplant (HSCT) had higher mortality (47% vs. 11%, p<0.001). Oxygenation index (OI), the P/F ratio, extrapulmonary organ dysfunction, PRISM-3, and positive cumulative fluid balance were each associated with mortality. Using two statistical approaches, we found that a parsimonious model of mortality risk using only OI and cancer/HSCT history performed as well as other more complex models that required additional variables. Conclusions In the pediatric intensive care unit, OI and cancer/HSCT history can be used on ARDS Day 1 or Day 3 to predict hospital mortality without the need for more complex models. These findings may simplify risk assessment for clinical trials, counseling families, and high-risk interventions such as extracorporeal life support.

Subtypes of pediatric acute respiratory distress syndrome have different predictors of mortality

“…This is the first study to suggest that non-infectious pediatric ARDS has different outcome predictors. Previous cohorts have suggested immunocompromised status as a predictor of mortality [8, 23]. Given that the most common etiologies in those cohorts, as in ours, was pneumonia and non-pulmonary sepsis, it is possible that over-representation of infectious ARDS, and particularly pneumonia, made apparent an association of immunocompromised status and mortality for the entire cohort.…”

Incorporating Inflammation into Mortality Risk in Pediatric Acute Respiratory Distress Syndrome

“…We also tested for relationships with a history of hematopoietic cellular transplantation (HCT), which we have previously shown to significantly impact pediatric ARDS outcomes and plasma biomarkers (26–28). …”

Early Plasma Matrix Metalloproteinase Profiles. A Novel Pathway in Pediatric Acute Respiratory Distress Syndrome

“…In children, the acute respiratory distress syndrome (ARDS) is defined by clinical oxygenation impairment and radiographic evidence of new-onset noncardiogenic pulmonary edema (1). This disease is mediated by systemic inflammation, pulmonary endothelial and epithelial injury, and abnormal coagulation and fibrinolysis, resulting in 15-20% mortality and significant morbidity among survivors (2)(3)(4)(5). As such, identification of novel biochemical pathways related to disease onset and severity is of paramount interest to clinicians and researchers.…”