The Clinical Characteristics of ARDS in Children With Hematological Neoplasms

Comparing the clinical characteristics and risk factors of prognosis in pediatric ARDS with and without malignancies: a retrospective cohort study

BACKGROUND

The number of malignancy patients with respiratory failure is rising in pediatric intensive care units (PICU). Our study aims to compare the clinical characteristics and prognostic risk factors of acute respiratory distress syndrome (ARDS) with or without malignancies.

METHODS

This retrospective study reviewed medical records of 188 ARDS patients admitted to the PICU between January 2018 and December 2022, including 60 with malignancies and 128 without. Clinical data were collected within 48 h post-ARDS diagnosis. Multivariate logistic regression analysis and receiver operating characteristic curve (ROC) analysis were used to investigate the risk factors for PICU mortality in the malignancy and non-malignancy groups.

RESULTS

Compared with pediatric patients without malignancy, the ARDS patients with malignancy presented higher mortality (55.0% vs. 31.3%, P = 0.002), a higher incidence of community-acquired fungal infection (36.1% vs. 6.3%, P < 0.001) and multidrug resistance (MDR) bacteria (65.4% vs. 30.5%, P = 0.003). There were substantial differences in levels of lactate [1.5 (0.8-3.7) vs. 1.0 (0.7-2.0) mmol/L, P = 0.008], C-reactive protein (CRP) [150.0 (83.0-168.0) vs. 31.0 (10.0-108.0) mg/L, P = 0.02], procalcitonin (PCT) [10.4 (2.0-27.5) vs. 1.2 (0.3-6.2) mg/L, P < 0.001], counts of platelet [17.0 (8.0-73.0) vs. 232.0 (152.0-330.0) × 109/µL, P < 0.001], the distribution of CD8 + T [36.9 (26.0-53.6) vs. 21.9 (17.3-29.1) %, P < 0.001], CD19 + T cells [9.9 (0.9-30.2) vs. 33.6 (22-46.6) %, P < 0.001], and higher peak vasoactive-inotropic score (VIS) in ARDS with malignancy [73.0 (20-208) vs. 15.0 (5.0-82.0), P < 0.01]. In multivariable analysis, only VIS independently predicted mortality in ARDS patients with malignancy (OR, 1.011; 95% confidence interval [CI]: 1.003-1.018; P = 0.005). Neither pSOFA scores (OR, 1.249, 95% CI: 0.958-1.628, P = 0.101) nor lactate levels (OR, 1.192, 95% CI: 0.928-1.531, P = 0.170) showed significant associations.

CONCLUSION

ARDS patients with malignancies exhibited poorer outcomes. VIS is only an independent predictor of mortality in pediatric ARDS patients with malignancies.

Pathobiology, Severity, and Risk Stratification of Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

OBJECTIVES

To review the literature for studies published in children on the pathobiology, severity, and risk stratification of pediatric acute respiratory distress syndrome (PARDS) with the intent of guiding current medical practice and identifying important areas for future research related to severity and risk stratification.

DATA SOURCES

Electronic searches of PubMed and Embase were conducted from 2013 to March 2022 by using a combination of medical subject heading terms and text words to capture the pathobiology, severity, and comorbidities of PARDS.

STUDY SELECTION

We included studies of critically ill patients with PARDS that related to the severity and risk stratification of PARDS using characteristics other than the oxygenation defect. Studies using animal models, adult only, and studies with 10 or fewer children were excluded from our review.

DATA EXTRACTION

Title/abstract review, full-text review, and data extraction using a standardized data collection form.

DATA SYNTHESIS

The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize relevant evidence and develop recommendations for clinical practice. There were 192 studies identified for full-text extraction to address the relevant Patient/Intervention/Comparator/Outcome questions. One clinical recommendation was generated related to the use of dead space fraction for risk stratification. In addition, six research statements were generated about the impact of age on acute respiratory distress syndrome pathobiology and outcomes, addressing PARDS heterogeneity using biomarkers to identify subphenotypes and endotypes, and use of standardized ventilator, physiologic, and nonpulmonary organ failure measurements for future research.

CONCLUSIONS

Based on an extensive literature review, we propose clinical management and research recommendations related to characterization and risk stratification of PARDS severity.

2021 Year in Review: Pediatric Mechanical Ventilation

Mechanical ventilation is commonly used in the pediatric intensive care unit. This paper reviews studies of pediatric mechanical ventilation published in 2021. Topics include physiology, ventilator modes, alarms, disease states, airway suctioning, ventilator liberation, prolonged ventilation, and others.

Risk factors for air leakage during invasive mechanical ventilation in pediatric intensive care units

Purpose

This study aimed to investigate air leakage during invasive mechanical ventilation (IMV) in a pediatric intensive care unit (PICU) and explore potential risk factors.

Methods

We conducted a retrospective cohort study of children who underwent IMV in a single-center PICU in a tertiary referral hospital. Air leakage risk factors and factors associated with an improved outcome were assessed.

Results

A total of 548 children who underwent IMV were enrolled in this study. Air leakage occurred in 7.5% (41/548) of the cases in the PICU. Air leakage increased the duration of IMV and hospitalization time. Multivariate logistic regression analysis showed a higher risk of air leakage during IMV for PICU patients with acute respiratory dyspnea syndrome (ARDS) (OR = 4.38), a higher pediatric critical illness score (PCIS) (OR = 1.08), or a higher peak inspiratory pressure (PIP) (OR = 1.08), whereas the risk was lower for patients with central respiratory failure (OR = 0.14). The logistic model had excellent predictive power for air leakage, with an area under the curve of 0.883 and tenfold cross-validation. Patients aged between 1 and 6 years who were diagnosed with measles or pneumonia and had a low positive end-expiratory pressure (PEEP) or high PaO2/FiO2 ratio were associated with improved outcomes. Patients diagnosed with central respiratory failure or congenital heart diseases were associated with less desirable outcomes.

Conclusions

Patients with ARDS, a higher PCIS at admission or a higher PIP were at higher risk of air leakage.

The Association Between Oxygenation Status at 24 h After Diagnosis of Pulmonary Acute Respiratory Distress Syndrome and the 30-Day Mortality among Pediatric Oncological Patients

BACKGROUND

Pediatric oncology patients with acute respiratory distress syndrome (ARDS) secondary to pneumonia are at high risk of mortality. Our aim was to describe the epidemiology of ARDS in this clinical population and to identify the association between the oxygenation status at 24 h after diagnosis and the 30-day mortality rates, stratified by the severity of ARDS.

METHODS

This was a retrospective cohort study of 82 pediatric oncology patients, with a median age of 4 years, admitted to our pediatric intensive care unit with a diagnosis of ARDS between 2013 and 2021. Demographic and clinical factors were compared between the survivor (n = 52) and non-survivor (n = 30) groups. Univariate and multivariate Cox proportional hazards regression models were used to determine the association between the oxygenation status at 24 h after diagnosis and the 30-day mortality rates.

RESULTS

The mean airway pressure at ARDS diagnosis, PaO₂/FiO₂ (P/F) ratio, oxygenation index (OI) value, peak inspiratory pressure, and lactate level at 24 h after ARDS diagnosis, as well as complications (i.e., septicemia and more than two extrapulmonary organ failures) and adjunctive continuous renal replacement therapy, were significant mortality risk factors. After adjusting for other covariates, the oxygenation status P/F ratio (Hazard ratio [HR] = 0.98, 95% confidence interval [CI] = 0.96-1.00, P = 0.043) and OI value (HR = 1.12, 95% CI = 1.02-1.23, P = 0.016) at 24 h remained independent mortality risk factors. According to the Kaplan-Meier survival curve, a low P/F ratio (≤ 150) and high OI (>10) were associated with a higher risk of 30-day mortality (50.9 and 52.9%, respectively; both P < 0.05).

CONCLUSION

The P/F ratio and OI value measured at 24 h after ARDS diagnosis can provide a better stratification of patients according to ARDS disease severity to predict the 30-day mortality risk.