Comparison of Prognostic Factors Between Direct and Indirect Pediatric ARDS

Abstract

BACKGROUND: Pediatric ARDS is a heterogeneous disease entity with high morbidity and mortality. In this study, we categorized pediatric ARDS by direct and indirect initial triggering events and identified characteristics of survivors and nonsurvivors in these 2 subtypes. METHODS: This was a single-center, retrospective, observational study that included critically ill subjects with pediatric ARDS (age 1 month to 18 y) who had undergone mechanical ventilation support and had been admitted to our 14-bed, multidisciplinary, tertiary pediatric medical ICU between January 2010 and March 2019. RESULTS: A total of 162 subjects with pediatric ARDS were included. The direct ARDS subtype accounted for 128 cases, and 34 cases were classified as indirect ARDS. The most common initiating events were pneumonia and sepsis for direct and indirect ARDS, respectively. Subjects with indirect ARDS had higher serum lactate levels, greater Pediatric Risk of Mortality III (PRISM III) and Pediatric Sequential Organ Failure Assessment (pSOFA) scores than those with direct ARDS (P < .05). Nonsurvivors with the direct subtype had worse mechanical ventilation-related parameters, including F IO 2 , PEEP, P aw , peak inspiratory pressure, oxygenation index, and P aO 2 /F IO 2 ratio than survivors with the direct subtype. The likelihood of mortality rose with the severity of ARDS in association with the direct subtype but not with the indirect subtypes. Among children with indirect ARDS, lactate levels and pSOFA scores were significantly higher among nonsurvivors than survivors. CONCLUSIONS: Direct and indirect pediatric ARDS had distinct clinical characteristics, especially in terms of prognostic factors. Variables related to mechanical ventilation were significantly associated with mortality among subjects with direct pediatric ARDS, but not among subjects with indirect pediatric ARDS. Thus, this study provides evidence of the potential benefit of categorizing patients with pediatric ARDS by subtype for evaluating prognostic factors and developing adjusted management strategies to improve clinical outcomes.

Sepsis-related pediatric acute respiratory distress syndrome

“…Our prospective study reported the overall incidence of PARDS accounted for 10.7% of the screened population. The incidence of sepsis-related PARDS was 19.7%, which was comparable to other studies that reported rates ranging from 8.2% to 22%, [ 5 19 20 ]and PICU mortality rate was 30.7% (8/26) which was higher than a recent retrospective study that revealed the PICU mortality rate of sepsis-related PARDS was 24.6%. [ 21 ]A single-center retrospective study involving 203 sepsis-related PARDS from 828 sepsis patients showed that ARDS severity, PRISM III, and the number of organ dysfunction were associated with increased 90-day mortality in sepsis-related PARDS.…”

“…A recent study found the worse ventilator parameter, and oxygen index, including PF ratio, was associated with higher mortality in the direct risk factor group, while lactate and pSOFA scores were associated with higher mortality in the indirect risk factor group. [ 19 ]…”