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Description : Check out this medical titled "Defining Pediatric ARDS- Past and Future” by Robinder G. Khemani MD, MsCI.

This medical is about Pediatric ARDS (Acute Respiratory Distress Syndrome), a severe form of lung injury that affects children. ARDS can occur as a result of a wide range of illnesses or injuries that cause damage to the lungs, including pneumonia, sepsis, trauma, and inhalation injuries.

The diagnostic criteria for pediatric ARDS include the presence of respiratory failure, decreased oxygen levels in the blood, and evidence of bilateral lung infiltrates on imaging studies such as chest X-ray or CT scan.

Treatment of pediatric ARDS involves supportive care, including mechanical ventilation and supplemental oxygen. In some cases, children may require extracorporeal membrane oxygenation (ECMO), a form of life support that takes over the work of the lungs and heart.

Prevention of pediatric ARDS involves early recognition and treatment of the underlying causes, as well as measures to prevent infections and injuries that can lead to lung damage. Prognosis for pediatric ARDS depends on the severity of the underlying illness or injury, as well as the childs overall health and response to treatment.

Tags : Pediatric ARDS, Pediatric Acute Respiratory Distress Syndrome, lung injury, Neonatal-Perinatal Medicine, Neonatal-Perinatal Medicine

Published on : Jun 01, 2023 | Views : 1501 | Downloads : 0

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Slide 1-

Defining Pediatric ARDS- Past and Future Robinder G. Khemani MD, MsCI Associate Professor of Clinical Pediatrics University of Southern California Keck School of Medicine Attending Physician, Critical Care Medicine Children’s Hospital Los Angeles
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Sources of Financial Support
Slide 3-

Disclosures Paid Consultant/Advisor OrangeMed (Nihon Kohden) Hamilton Medical
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Pediatric ARDS Definitions Chapter 1: Historical ARDS definitions Chapter 2: The Pediatric Acute Lung Injury Consensus Conference (PALICC) Chapter 3: The Pediatric ARDS Incidence and Epidemiology (PARDIE) study Chapter 4: Future directions
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Chapter 1 Historical Definitions of Acute Respiratory Distress Syndrome (ARDS)
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Clinical syndrome characterized by diffuse inflammation in the lung Results in significant hypoxemia from endothelial injury to the pulmonary vasculature and alveolar epithelial injury No definitive diagnostic test (i.e. biomarker) which is present in all cases (even histopathology inconsistent) ARD Syndrome Ware NEJM 2000
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Hallmark Symptoms of Pathophysiology –Pediatrics and Adults Hypoxemia (Shunt) Poor Respiratory System Compliance Decreased End Expiratory Lung Volumes (FRC) Diffuse Process Endothelial Injury Edema Increased alveolar dead space
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ARDS Historical Definitions First description Ashbaugh -1967 12 patients acute respiratory distress cyanosis refractory to oxygen decreased respiratory system compliance diffuse pulmonary infiltrates Initially Adult Respiratory Distress Syndrome Changed to Acute Respiratory Distress Syndrome, to account for the fact that children have it too
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Murray Lung Injury Score -1988 First attempt at consensus definition for ARDS Murray 1988 Diffuse vs. Lobar Patho physiologic Concept Degree of Hypoxemia Lower EELV (FRC) Poor Compliance
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PEDIATRIC LUNG INJURY SCOREModified from: Murray et al. Am Rev Respir Dis 1988; 138:720-723Hammer, Numa & Newth. Pediatr Pulmonol 1997; 23:1176-183
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American European Consensus Conference (AECC) 1994
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Phua: CCM 2008; Wheeler: NEJM; 2006; Villar: AJRCCM 2007;Meade: AJRCCM 2000; Rubenfeld Chest 1999; Komadina: Chest 1991; AECC Limitations
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Berlin Draft Definition - 2012 eSUPPLEMENT 1) Include radiographs of consensus interpretations for qualifying opacities vs not vs equivocal 2) Include case vignettes on how to assess “not fully explained by cardiac failure of fluid overload”
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Evaluation of Severe Ancillary variables identify a smaller group of patients with similar mortality Draft ARDS PaO2/FiO2 < 100 mmHg PEEP > 10 cm H2O 3 or 4 quadrant opacities on CXR Crs < 40 ml/cm H2O or VeCorr > 10 L/min Final ARDS PaO2/FiO2 < 100 mmHg PEEP > 5 cm H2O Bilateral opacities on CXR 45% Mortality Moderate 64% Mild 22% Severe 14% Mild 22% Moderate 50% Severe 28% Mortality 45%
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Final Berlin Definition of ARDS Limited Validation in Children
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Chapter 2 The Pediatric Acute Lung Injury Consensus Conference
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2015
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Rubenfeld GD et al. N Engl J Med 2005. Age- and Risk-Specific Incidence of and Age-Specific Mortality from Acute Lung Injury. Zimmerman J et al. Pediatrics 2009. < 15 years 12.8/100,000 Pediatric versus Adult ARDS Adult Pediatric
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Pediatric Specific Definition Build off Berlin Definition- is Berlin alone Adequate? Pediatric Considerations Timing (similar to adults?) Age? Co-existence with Cardiac Disease (similar to adults?) What are best respiratory criteria for risk stratification/disease severity How do we handle patients on non-invasive ventilation and/or those without arterial lines How important/reliable are Radiographic Criteria for Definition of ARDS Defining it in patients with cardiac or pulmonary co-morbidites
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PALICC p ARDS Definition OI = oxygenation index = (FiO2* mean airway pressure*100)/ PaO2 OSI = oxygen saturation index = (FiO2* mean airway pressure*100) /SpO2 PALICC PCCM 2015
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Pediatric Specific Definition Build off Berlin Definition- is Berlin alone Adequate? Pediatric Considerations Timing (similar to adults?) Age? Co-existence with Cardiac Disease (similar to adults?) What are best respiratory criteria for risk stratification/disease severity How do we handle patients on non-invasive ventilation and/or those without arterial lines How important/reliable are Radiographic Criteria for Definition of ARDS Defining it in patients with cardiac or pulmonary co-morbidites
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Measures of Oxygenation in the Definition 1.5.1 Oxygenation Index [OI=(FiO2* mean airway pressure*100)/ PaO2], in preference to PaO2/FiO2 (PF) ratio, should be the primary metric of lung disease severity to define P-ARDS for all patients treated with invasive mechanical ventilation. Strong agreement 1.5.2 PaO2/FiO2 (PF) ratio should be used to diagnose ARDS for patients receiving non‐invasive full face mask ventilation (CPAP or BiPAP) with a minimum CPAP of 5 cm H2O. Strong agreement PALICC PCCM 2015
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Reasons for OI versus PF Lower and more variable ventilator management and in particular PEEP use in Pediatrics compared to Adults Need to control for ventilator support More Frequent use of HFOV PALICC PCCM 2015
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PEEP 5 cmH20 PaO2 = 60, FiO2=0.6, MAP = 8 PF Ratio 100 OI =8 PEEP 14 cmH20 PaO2 = 120, FiO2=0.5, MAP = 19 PF Ratio 240 OI = 8 OI versus PF ratio
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PEEP levels in Pediatric ARDS * > 50% of patients with PEEP ≤5 cmH20 > 50% of adults in ARDSNet studies on PEEP ≥10cmH20 at study inclusion (Britos CCM)
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Variable PEEP use in Pediatrics Santichi PALIVE 2011 Khemani ICM 2011 Because PEEP management is not protocolized in children, it may confound ascertainment of disease severity (alters PF ratio) and ability to examine other treatment effects (Tidal Volume etc.) Newth CPPCRN 2014
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Which OI cut points to use? Look to the Data (CHLA) PALICC PCCM 2015
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Validation Datasets PALICC PCCM 2015
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Pediatric Specific Definition Build off Berlin Definition- is Berlin alone Adequate? Pediatric Considerations Timing (similar to adults?) Age? Co-existence with Cardiac Disease (similar to adults?) What are best respiratory criteria for risk stratification/disease severity How do we handle patients on non-invasive ventilation and/or those without arterial lines How important/reliable are Radiographic Criteria for Definition of ARDS Defining it in patients with cardiac or pulmonary co-morbidites
Slide 30-

Pulse Oximetry versus PaO2 1.6.1 Oxygen Saturation Index [OSI =(FiO2* mean airway pressure*100)/SpO2]should be used when an OI is not available for stratification of risk for patients receiving invasive mechanical ventilation. Strong agreement 1.6.2 SF (SpO2/FiO2)ratio can be used when PF ratio is not available to diagnose P-ARDS in patients receiving non‐invasive full face mask ventilation (CPAP or BiPAP) with a minimum CPAP of 5 cm H2O. Strong agreement
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Characterizing oxygenation using pulse oximetry 1.8.1 To apply SpO2 criteria to diagnose P-ARDS, oxygen therapy should be titrated to achieve an SpO2 between 88- 97%. Strong agreement PALICC PCCM 2015
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Khemani CCM 2012
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Parvathaneni PCCM 2016
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Requiring PF ratio selects for patients with hypoxemia and cardiovascular dysfunction Not using pulse oximetry criteria underestimates the prevalence of ARDS and over-estimates mortality, by selecting for a more ill patient population
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Pediatric Specific Definition Build off Berlin Definition- is Berlin alone Adequate? Pediatric Considerations Timing (similar to adults?) Age? Co-existence with Cardiac Disease (similar to adults?) What are best respiratory criteria for risk stratification/disease severity How do we handle patients on non-invasive ventilation and/or those without arterial lines How important/reliable are Radiographic Criteria for Definition of ARDS Defining it in patients with cardiac or pulmonary co-morbidites
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Radiographic Findings 1.4.1 Chest imaging findings of new infiltrate(s) consistent with acute pulmonary parenchymal disease are necessary to diagnose P-ARDS. Strong agreement PALICC PCCM 2015
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Radiographic Findings Eliminated requirement for bilateral infiltrates 1. Poor Inter-observer reliability, unclear if can be improved with common training 2.Poor Sensitivity of CXR to detect disease, CXR lags behind hypoxemia, poor correlation with CT 3. Pathophysiology may be present with radiographic unilateral disease (inability to detect inflammation in other lung) 4. Unclear if Bilateral Infiltrates adds anything prognostically over hypoxemia PALICC PCCM 2015
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Bilateral Infiltrates and hypoxemia Two adult studies demonstrating no prognostic relevance when controlling for hypoxemia, one showing important (Luhr 1999,2000, Roupie 1999) Two pediatric studies in China showing prognostic importance, but not adequately controlling for hypoxemia (ALI v ARDS) ( Hu 2010, Zhu 2012) Secondary Analysis of Published data (CHLA cohort, ICM 2009) PALICC 2015
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Chapter 3 The Pediatric ARDS Incidence and Epidemiology Study (PARDIE)
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Pediatric ARDS Incidence and Epidemiology (PARDIE) Executive committee: Philippe Jouvet, Robinder Khemani, Christopher Newth, Lincoln Smith, Neal Thomas, Doug Willson On Behalf of the PARDIE Investigators PARDIE The Pediatric Acute Respiratory Distress syndrome Incidence and Epidemiology study PARDIE is an international initiative to better understand the implications of the new Pediatric Acute Lung Injury Consensus Conference (PALICC) definition of Pediatric ARDS http://pardie.palisi.org/
Slide 41-

PARDIE study funding CHLA, RSR, St Justine PARDIE Data entry Website/Database, Admin Support SC CTSI To support secondary analysis (statistical support) and data management
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PARDIE Study as a test International cross sectional (incidence) design to test several aspects of the new definition Designed as a Main study (V.0) plus ancillaries 5 continuous days of screening and patient enrollment (M-F), performed 10 times in a year (50 total study days) Only new cases of ARDS diagnosed within previous 24 hours included Data collection largely in first 3 days of ARDS diagnosis Follow clinical outcomes such as mortality and length of ventilation for included patients.
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PARDIE V.0 questions 1. To determine the number and frequency of new cases of PARDS amongst non-cardiac PICU patients, and their respective outcomes, including ICU and hospital mortality and VFDs 2. To evaluate how the PALICC recommended mild, moderate, and severe classification of PARDS performs in discriminating ICU and hospital mortality 3. To determine the relevance of the timing of hypoxemia metrics (OI, OSI, PF, SF) within the first three days of ARDS onset affects the discrimination ability of ICU and hospital mortality
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What will happen to PARDS Epidemiology? SpO2 criteria Simplified CXR CHD and CLD pts Co-existence with cardiac disease Explicit criteria for NIV Parvatheneni PCCM 2017
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PARDIE V.0 questions 1. To determine the number and frequency of new cases of PARDS amongst non-cardiac PICU patients, and their respective outcomes, including ICU and hospital mortality and VFDs 2. To evaluate how the PALICC recommended mild, moderate, and severe classification of PARDS performs in discriminating ICU and hospital mortality 3. To determine the relevance of the timing of hypoxemia metrics (OI, OSI, PF, SF) within the first three days of ARDS onset affects the discrimination ability of ICU and hospital mortality
Slide 46-

Combination of studies, several years old No use of Pulse oximetry Criteria Is this representative of current practice and outcomes? Are the OI/OSI cut points correct?
Slide 47-

PARDIE V.0 questions 1. To determine the number and frequency of new cases of PARDS amongst non-cardiac PICU patients, and their respective outcomes, including ICU and hospital mortality and VFDs 2. To evaluate how the PALICC recommended mild, moderate, and severe classification of PARDS performs in discriminating ICU and hospital mortality 3. To determine the relevance of the timing of hypoxemia metrics (OI, OSI, PF, SF) within the first three days of ARDS onset affects the discrimination ability of ICU and hospital mortality
Slide 48-

Yehya, PCCM 2015 Initial versus a Delayed Value? Parvatheneni, PCCM 2017 Only OI OI/OSI
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Perhaps 12 hours post PARDS captures risk well?
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Main Study (V.0) plus ancillaries V.0 – PARDIE V.1 – Risk factors for Mortality in PARDS V.2 – Monitoring/Ventilator Management in PARDS V.3 – Chest Imaging V.4 – At Risk for ARDS Cardiac PARDIE 97 is the new 100
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Study Weeks May 9-13, 2016 (103 sites) July 11-15, 2016 (131 sites) September 12-16, 2016 (141 sites) November 14-18, 2016 (165 sites) January 9-13, 2017 (166 sites) February 13-17,2017 (129 sites) March 20-24, 2017 (128 sites) April 17-21, 2017 (129 sites) May 15-19, 2017 (128 sites) June 12-16, 2017 (131 sites)
Slide 52-

PARDIE THE PEDIATRIC ACUTE RESPIRATORY DISTRESS SYNDROME INCIDENCE AND EPIDEMIOLOGY STUDY 45 38 50 3 9
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Lancet Respiratory Medicine 145 International Sites 289 Investigators 27 Countries PARDIE, Lancet Respiratory Medicine
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Lancet Respiratory Medicine 2018 PALICC PARDS Incidence and outcomes PALICC vs. Berlin comparisons Pulse Oximetry Bilateral Infiltrates PF vs OI Hypoxemia severity, timing with mortality NIV PARDS descriptive analysis Multivariable model for mortality with focus on PARDS definition
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PARDS Incidence 145 PICUs 23,315 patients admitted 12,270 were on study defined mechanical ventilation 744 new cases of PARDS 3.1% amongst ICU patients 6.1% amongst those on MV PARDIE, Lancet Respiratory Medicine
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PARDS Incidence PARDIE, Lancet Respiratory Medicine
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PARDIE, Lancet Respiratory Medicine
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PARDIE, Lancet Respiratory Medicine
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Outcome by Initial PARDS Severity- Invasive MV only * indicates different than mild PARDS in multiple comparisons # indicates different than moderate PARDS in multiple comparisons. PARDIE, Lancet Respiratory Medicine
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Initial PARDS, OI >15 risk increase PARDIE, Lancet Respiratory Medicine
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PARDIE, Lancet Respiratory Medicine
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ppt slide no 62 content not found
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NIV PARDS – Initial Severity ½ of all NIV PARDS patients are intubated, 87% within 48 Hours of PARDS NIV PARDS patients who are intubated have mortality between moderate and severe PARDIE, Lancet Respiratory Medicine
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PARDIE, Lancet Respiratory Medicine
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Bilateral infiltrates Site PI: Bilateral infiltrates 74% of children at PARDS diagnosis 87% within 3 days of PARDS diagnosis 759 chest x-rays evaluated by both a pediatric intensivist and a radiologist (v.3) poor agreement regarding bilateral infiltrates (kappa= 0.34). PARDIE, Lancet Respiratory Medicine
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Multivariable Model for Mortality * Bilateral infiltrates not significant p>0.2 PARDIE, Lancet Respiratory Medicine
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Take home from PARDIE PARDS affects 3% of PICU patients Mortality > 30% for severe hypoxemia PALICC identified 40% more children as having ARDS compared to Berlin (with arterial PF ratio), and diagnoses ARDS a median of 12-30 hours sooner. PALICC based OI/OSI severity groups appear to stratify mortality better than PF/SF groups PARDS severity 6 hours after PARDS diagnosis may be good marker for risk PALICC groups are calibrated for VFD and length of MV in survivors. Many factors outside of PARDS severity associated with mortality PARDIE, Lancet Respiratory Medicine
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Lung Protective Ventilation targets
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Achieving Lung Protective Ventilation is challenging N = 600 PARDS Patients, 100 International ICUs, q 6 hr. settings Lancet Respiratory Medicine 2018
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Ancillary Studies V.1. Risk factors for mortality and practice patterns for ancillary therapies V.2 Ventilator management and monitoring practices and relationship with outcome V.3 Chest imaging and inter-observer variability, relationship with outcome, automated methodologies V.4. At risk for PARDS group and outcomes, prediction of PARDS progression, feasibility of PARDS prevention studies 97 is the new 100- QI paper describing methodology for decreasing FiO2
Slide 71-

Public Use Dataset Public Use dataset: An anonymous version of the PARDIE dataset will be made publicly available approximately five (5) years after publication of the Main PARDIE Paper, with the relevant case report forms to facilitate data analysis.
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Chapter 4 What is next?
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High level of evidence lacking in nearly all PARDS recommendations
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PALICC Summary Recommendations
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Since 2015, 109 “PARDS” Publications
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Ongoing studies in PARDS 16 current clinical trials in pediatric ARDS on clinicaltrials.gov Variety of multi-center clinical trials in planning stages through international organizations Secondary analysis of large datasets of PARDS cohorts
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Have we generated enough new evidence?