Pediatric ARDS Identification, Stratification With PALICC Definition
The severity of PARDS 6 hours after initial diagnosis via the PALICC definition did a better job of discriminating pediatric ICU mortality than severity at diagnosis.
Using the Pediatric Acute Lung Injury Consensus Conference (PALICC) definition of pediatric acute respiratory distress syndrome (PARDS) identifies more patients with PARDS than the Berlin definition, which was designed for adults, and improves mortality risk stratification, according to a study published in the Lancet Respiratory Medicine.
Researchers in this international, cross-sectional, prospective, observational study sought to evaluate the PALICC definition for PARDS by determining the incidence and outcomes of pediatric patients meeting this definition compared with those meeting the Berlin definition. Patients were screened for enrollment at 145 pediatric intensive care units in 27 countries between May 9, 2016 and June 16, 2017. Exclusion criteria included cyanotic heart disease, preparation for or recovery from a cardiac intervention, and active perinatal lung disease. Pediatric ICU mortality was the primary outcome, and secondary outcomes included duration of invasive and noninvasive ventilation, ventilator-free days, 90-day mortality, and cause of death.
Of the 744 patients diagnosed with PARDS during the study, 708 (95%) had complete data for analysis. Only 230 of the 708 patients met the Berlin criteria for PARDS. Overall mortality rate in the 708 patients was 17% (n=121; 95% CI, 14%-20%), with a 27% mortality rate in the 230 patients who met the Berlin criteria (n=61; 95% CI, 21%-33%).
In the 3 days after the initial diagnosis of PARDS, an additional 26% (n=183) of patients met the Berlin criteria with 21% mortality (n=38; 95% CI, 16%-27%). The severity of PARDS 6 hours after initial diagnosis via the PALICC definition (area under the curve [AUC], 0.69; 95% CI, 0.62-0.76) did a better job of discriminating pediatric ICU mortality than severity at diagnosis (AUC, 0.64; 95% CI, 0.58-0.71), and outperformed the Berlin definition severity groups at 6 hours (AUC, 0.64; 95% CI, 0.58-0.70; P=.01).
Mortality rates were 10% to 15% in patients with mild to moderate PARDS who received noninvasive ventilation and 33% in patients with severe PARDS (95% CI, 26%-41%; P <.0001). Half of the 160 noninvasively ventilated patients were later intubated, with a mortality rate of 25% (95% CI, 16%-36%).
Study investigators concluded, “The PALICC definition for PARDS can be applied internationally, identifies substantially more patients than the Berlin definition, and appears to adequately stratify mortality and duration of ventilation among patients with PARDS when applied 6 h[ours] after diagnosis.”
Khemani RG, Smith L, Lopez-Fernandez YM, et al; on behalf of the Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology (PARDIE) Investigators and the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network. Paediatric acute respiratory distress syndrome incidence and epidemiology (PARDIE): an international, observational study [published online October 22, 2018]. Lancet. doi:10.1016/S2213-2600(18)30344-8