Specific Viral Etiologies Are Associated With Outcomes in Pediatric Acute Respiratory Distress Syndrome*

Abstract

Objectives: Infectious pneumonia is the most common cause of acute respiratory distress syndrome, with viruses frequently implicated as causative. However, the significance of viruses in pediatric acute respiratory distress syndrome is unknown. We aimed to characterize the epidemiology of viral pneumonia in pediatric acute respiratory distress syndrome and compare characteristics and outcomes between pneumonia subjects with and without viruses. Secondarily, we examined the association between specific viruses and outcomes. Design: We performed a secondary analysis of a prospectively enrolled pediatric acute respiratory distress syndrome cohort. Subjects with pneumonia acute respiratory distress syndrome underwent testing of respiratory secretions for viruses and culture for bacteria and fungi and were stratified according to presence or absence of a virus. Setting: Tertiary care children’s hospital. Patients: Children with acute respiratory distress syndrome. Interventions: None. Measurements and Main Results: Of 544 children with acute respiratory distress syndrome, 282 (52%) had pneumonia as their inciting etiology, of whom 212 were virus-positive. In 141 of 282 (50%) pneumonia acute respiratory distress syndrome cases, a virus was the sole pathogen identified. Virus-positive pneumonia had fewer organ failures but worse oxygenation, relative to virus-negative pneumonia, with no differences in antibiotic use, ventilator duration, or mortality. Subjects with respiratory syncytial virus-associated acute respiratory distress syndrome had lower mortality (0%), and subjects with influenza-associated acute respiratory distress syndrome had shorter ventilator duration, relative to other viral acute respiratory distress syndrome. Nonadeno herpesviruses, tested for exclusively in immunocompromised subjects, had greater than 80% mortality. Conclusions: Pneumonia was the most common cause of pediatric acute respiratory distress syndrome, and viruses were commonly isolated as the sole pathogen. Respiratory syncytial virus and influenza were associated with better outcomes relative to other viral etiologies. Viral pneumonias in immunocompromised subjects, particularly nonadeno herpesviruses, drove the mortality rate for pneumonia acute respiratory distress syndrome. Specific viral etiologies are associated with differential outcomes in pediatric acute respiratory distress syndrome and should be accounted for in future studies.

Acute viral bronchiolitis as a cause of pediatric acute respiratory distress syndrome

“…Acute viral bronchiolitis and viral pneumonia are overlapping, and it is often difficult to differentiate between them, particularly in children under 2 years of age. Viruses were the identified pathogen in 92% of our patients, compared to 70% in a similar study reported by Roberts et al [ 5 ].…”

“…Furthermore, infections account for more than half of the cases of PARDS, particularly lower respiratory tract infections such as pneumonia and bronchiolitis, with viruses frequently implicated [ 3 ]. However, the importance of viral infections as a cause of PARDS in infants has not previously been described [ 5 , 6 ].…”

“…RSV and rhinovirus are the most common respiratory pathogens in children under the age of 1 year and account for many admissions to pediatric intensive care units (PICUs) [ 9 ]. Despite this, few studies have investigated the frequency of viral-induced PARDS in infants and its impact on prognosis [ 4 , 5 , 10 , 11 ].…”

Cytokine Panels and Pediatric Acute Respiratory Distress Syndrome: A Translational Investigation*

“…Respiratory infections leading to bronchiolitis or viral/bacterial pneumonia are the most common cause of admission to the PICU ( 1 ). Although some viruses, such as influenza A, are associated with worse outcomes, pediatric acute respiratory distress syndrome (PARDS) develops in patients from even mild viruses such as respiratory syncytial virus (RSV) ( 2 , 3 ). New respiratory viruses, such as severe acute respiratory syndrome coronavirus 2, are especially challenging as they may not be detected on first-pass testing.…”

“…However, clinical measurement of BAL biomarkers has not become standard practice, possibly due to the heterogeneity of disease and host factors in adult ARDS. In contrast, PARDS may represent a more homogenous condition, as it is usually triggered by viral respiratory infections ( 2 ).…”