Duane Wong

Third QPEM Conference 11-13th of January 2019

Pediatric Acute Respiratory Distress Syndrome: Recent Evidence

I do not have any relevant financial relationship with commercial interest to disclose.

DISCLOSURE

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Learning Objectives

Describe the Background to PARDS – PALICC and PARDIE

Review PALICC

Review PARDIE – First Prospective Study using PALICC

BackgroundARDS was first defined in 1967 by Ashbaugh et al.• In 1994 American-European Consensus Conference proposed “ARDS” as a clinical entity with acute onset

of hypoxemia in adults• The Berlin definition in 2012 became the new reference, but did not account for pediatric differences

Pediatric Acute Lung Injury Consensus Conference (PALICC):• Retrospective study over 3 years (2012-2014)• Panel consisted of 27 experts from 8 different countries• 151 recommendations

• 132 STRONG recommendations• 19 WEAK recommendations

Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology (PARDIE):• Prospective, cross-sectional, observational study• 145 PICU’s, across 27 countries• May 2016 - June 2017 (published October 2018)• Collected data over 10 study weeks

The Pediatric Acute Lung Injury Consensus Conference (PALICC) has provided the critical care community with the first focused definition for Pediatric Acute Respiratory Distress Syndrome (PARDS).

R.G. Khemani, L.S. Smith, J.J. Zimmerman, S. Erickson, for the Pediatric Acute Lung Injury Consensus Conference Group. Pediatric acute respiratory distress syndrome: definition, incidence, and epidemiology. Proceedings from the pediatric acute lung injury consensus conference, 16 (2015), pp. S23-S40

Pediatric Acute Lung Injury Consensus Conference (PALICC)

PALICC

Adult (Berlin) definition vs. PALICC:

Both abandon (alike BERLIN) the “ALI” category.

• Includes patients receiving NIV• Focuses attention on early intervention

• Includes patients with CLD, CHD• Includes patients with unilateral infiltrates on radiographic exam • Utilizes OI (OSI) rather than P/F ratio

PALICC

“In comparison to Berlin definition, the PALICC criteria identified more number of patients with ARDS. Proportion with severe ARDS and complications was greater in the “Berlin with or without PALICC” group as compared to the “PALICC only” group. There were no differences in clinical outcomes between the groups”

Gupta et al., (April 2018). Comparison of Prevalence and Outcomes of Pediatric Acute Respiratory Distress Syndrome Using Pediatric Acute Lung Injury Consensus Conference Criteria and Berlin Definition. Fronti. Pediatr. 6:93. doi: 10.9989/fped.2018.00093

Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology (PARDIE): An International, Observational Study

PARDIE aimed to validate the incidence and outcomes of children who meet the

PALICC definition of PARDS• Prospective, cross-sectional, observational study, 145 PICUs from 27 countries were

recruited, and over a continuous 5 day period across 10 weeks all patients were screened for enrolment

• Inclusion: Patients who had a new diagnosis of PARDS that met PALICC criteria, during the study week

• Exclusion: Meeting PARDS criteria more than 24h before screening for, cyanotic heart disease,

active perinatal lung disease, and preparation or recovery from a cardiac intervention

PARDIE

• Using the Berlin definition 32% would have qualified• 17% mortality using the PALICC recommendations vs.

27% mortality using the Berlin criteria

Outcomes

PICU mortality was the primary outcomeSecondary outcomes included:

• 90 day mortality• Timing of PARDS diagnosis• Length of non-invasive and invasive ventilation• Ventilator free days (over a 28 day period, if survive to PICU discharge (death

prior to discharge = 0))• Cause of death

Outcomes

Mild group had higher mortality than moderate (suggests that we wait to intervene)

Suggests that there is not a great difference with regards mild and moderate PARDS ventilation days

PARDIE

PARDIE

Summary:

• PARDS occurs in approximately 6% of all admissions into PICU’s internationally• Patients associated with severe hypoxemia have high mortality rates (~30%) • 40% more patients diagnosed early (compared to Berlin) and identified the disease 8

hours sooner, within the first 3 days• By far, the most qualifying diseases are pneumonia-type pathologies and sepsis• 3 major differences between Berlin and PALICC:

1. Use of pulse oximetry, when invasive blood gas measurements are not available2. Single sided radiographic criteria3. The use of OI (OsI) instead of P/F ratios for patient on invasive mechanical

ventilation• Diagnosis of ARDS does not have a gold standard – this could mean that there is an

over-diagnosis based on the PALICC consensus• PALICC definition can be used as a good framework for PARDS• More pediatric research still needed