Characteristics and prognostic factors of previously healthy children who required respiratory support in a pediatric intensive care unit

Minyoung Jung¹; Minji Kim; Ok Jeong Lee; Ah Young Choi; Taewoong Hwang; Joongbum Cho

doi:10.4168/aard.2018.6.2.103

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Jung¹, Kim, Lee, Choi, Hwang, and Cho: Characteristics and prognostic factors of previously healthy children who required respiratory support in a pediatric intensive care unit

Original Article

Allergy Asthma Respir Dis 2018;6(2):103-109.

Published online: 5 March 2018

DOI: https://doi.org/10.4168/aard.2018.6.2.103

Characteristics and prognostic factors of previously healthy children who required respiratory support in a pediatric intensive care unit

Minyoung Jung¹, Minji Kim², Ok Jeong Lee³, Ah Young Choi⁴, Taewoong Hwang⁴, Joongbum Cho⁴

¹Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

²Department of Pediatrics, Hallym University Dongtan Sacred Heart Hospital, Hallym University School of Medicine, Hwaseong, Korea

³Department of Pediatrics, Myongji Hospital, Seonam University College of Medicine, Goyang, Korea

⁴Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Correspondence to: Joongbum Cho https://orcid.org/0000-0001-5931-7553 Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea Tel: +82-2-3410-6399, Fax: +82-2-2148-7088, E-mail: joongbum.cho@gmail.com

Received 3 July 201718 August 2017 Accepted 23 August 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

Comorbidities have been considered a mortality risk factor in pediatric critical care patients. We studied the characteristics and prognostic factors of children without comorbidities who were admitted to the intensive care unit (ICU) due to respiratory failure.

Methods

We reviewed the medical charts of patients (<18 years) admitted to the ICU for respiratory support in a single tertiary center between January 2006 and December 2016. Patients with comorbidities and perioperative statuses were excluded.

Results

Of the 4,712 ICU patients, 73 (1.5%) were included in this study. The median age was 31 months (8–57) and 51 (69.9%) were boys. Twenty-nine patients (39.7%) presented with pneumonia, 14 (19.2%) with acute respiratory distress syndrome (ARDS), and 11 (15.1%) with obstructive airway disease. The median duration of ICU hospitalization was 5 days (2–14.5), and 45 of the 73 patients (61.6%) needed mechanical ventilation. Mortality was 13.7% (10/73). None of the patients with pneumonia or obstructive airway disease died. The most frequent cause of death was ARDS (5 of 10, 50%). In adjusted analysis, the extent of extrapulmonary organ dysfunction was significantly associated with mortality (odds ratio, 2.89; 95% confidence interval, 1.17–7.11; P=0.023).

Conclusion

The mortality rate of previously healthy pediatric patients needing respiratory support in the ICU should not be negligi-ble. Multiple organ dysfunctions might be a significant risk factor for mortality in such patients.

Keywords: Child, Respiratory insufficiency, Comorbidity, Critical care, Mortality

REFERENCES

1. Carville KS, Lehmann D, Hall G, Moore H, Richmond P, de Klerk N, et al. Infection is the major component of the disease burden in aboriginal and non-aboriginal Australian children: a population-based study. Pediatr Infect Dis J. 2007; 26:210–6.

2. Crow SS, Undavalli C, Warner DO, Katusic SK, Kandel P, Murphy SL, et al. Epidemiology of pediatric critical illness in a population-based birth cohort in Olmsted County, MN. Pediatr Crit Care Med. 2017; 18:e137–45.

3. Namachivayam P, Shann F, Shekerdemian L, Taylor A, van Sloten I, Del-zoppo C, et al. Three decades of pediatric intensive care: who was admitted, what happened in intensive care, and what happened afterward. Pediatr Crit Care Med. 2010; 11:549–55.

4. Erickson S, Schibler A, Numa A, Nuthall G, Yung M, Pascoe E, et al. Acute lung injury in pediatric intensive care in Australia and New Zea-land: a prospective, multicenter, observational study. Pediatr Crit Care Med. 2007; 8:317–23.

5. Randolph AG, Meert KL, O'Neil ME, Hanson JH, Luckett PM, Arnold JH, et al. The feasibility of conducting clinical trials in infants and children with acute respiratory failure. Am J Respir Crit Care Med. 2003; 167:1334–40.

6. Barreira ER, Munoz GO, Cavalheiro PO, Suzuki AS, Degaspare NV, Shieh HH, et al. Epidemiology and outcomes of acute respiratory distress syndrome in children according to the Berlin definition: a multicenter prospective study. Crit Care Med. 2015; 43:947–53.

7. Edwards JD, Houtrow AJ, Vasilevskis EE, Rehm RS, Markovitz BP, Graham RJ, et al. Chronic conditions among children admitted to U.S. pediatric intensive care units: their prevalence and impact on risk for mortality and prolonged length of stay. Crit Care Med. 2012; 40:2196–203.

8. Spaeder MC, Custer JW, Bembea MM, Aganga DO, Song X, Scafidi S. A multicenter outcomes analysis of children with severe viral respiratory infection due to human metapneumovirus. Pediatr Crit Care Med. 2013; 14:268–72.

9. Randolph AG, Reder L, Englund JA. Risk of bacterial infection in previously healthy respiratory syncytial virus-infected young children admitted to the intensive care unit. Pediatr Infect Dis J. 2004; 23:990–4.

10. Wong KK, Jain S, Blanton L, Dhara R, Brammer L, Fry AM, et al. Influ-enza-associated pediatric deaths in the United States, 2004-2012. Pediatrics. 2013; 132:796–804.

11. Byington CL, Wilkes J, Korgenski K, Sheng X. Respiratory syncytial virus-associated mortality in hospitalized infants and young children. Pediatrics. 2015; 135:e24–31.

12. Nizam M, Norzila MZ. Stress among parents with acutely ill children. Med J Malaysia. 2001; 56:428–34.

13. Bartel DA, Engler AJ, Natale JE, Misra V, Lewin AB, Joseph JG. Working with families of suddenly and critically ill children: physician experiences. Arch Pediatr Adolesc Med. 2000; 154:1127–33.

14. Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, et al. The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med. 1994; 149(3 Pt 1):818–24.

15. Goldstein B, Giroir B, Randolph A. International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005; 6:2–8.

16. Lee OJ, Jung M, Kim M, Yang HK, Cho J. Validation of the Pediatric Index of Mortality 3 in a single pediatric intensive care unit in Korea. J Korean Med Sci. 2017; 32:365–70.

17. Hwang HS, Lee NY, Han SB, Kwak GY, Lee SY, Chung SY, et al. Performance effectiveness of pediatric index of mortality 2 (PIM2) and pediatricrisk of mortality III (PRISM III) in pediatric patients with intensive care in single institution: Retrospective study. Korean J Pediatr. 2008; 51:1158–64.

18. Panico FF, Troster EJ, Oliveira CS, Faria A, Lucena M, João PR, et al. Risk Factors for Mortality and Outcomes in Pediatric Acute Lung Injury/Acute Respiratory Distress Syndrome. Pediatr Crit Care Med. 2015; 16:e194–200.

19. Weiss SL, Asaro LA, Flori HR, Allen GL, Wypij D, Curley MA, et al. Multiple organ dysfunction in children mechanically ventilated for acute respiratory failure. Pediatr Crit Care Med. 2017; 18:319–29.

20. Flori HR, Glidden DV, Rutherford GW, Matthay MA. Pediatric acute lung injury: prospective evaluation of risk factors associated with mortality. Am J Respir Crit Care Med. 2005; 171:995–1001.

21. Kang SS, Pae RM, Lee EK, Bang KW, Kim HS, Chun YH, et al. Outcome of acute respiratory distress syndrome in children: a single center study. Allergy Asthma Respir Dis. 2014; 2:266–71.

22. Pediatric Acute Lung Injury Consensus Conference Group. Pediatric acute respiratory distress syndrome: consensus recommendations from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med. 2015; 16:428–39.

23. Ware LB, Matthay MA. The acute respiratory distress syndrome. N Engl J Med. 2000; 342:1334–49.

24. ARDS Definition Task Force. Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, et al. Acute respiratory distress syndrome: the Berlin definition. JAMA. 2012; 307:2526–33.

25. Kim SY, Kim YH, Sol IS, Kim MJ, Yoon SH, Kim KW, et al. Application of the Berlin definition in children with acute respiratory distress syndrome. Allergy Asthma Respir Dis. 2016; 4:257–63.

26. Ko JM, Ha EJ, Lee EH, Lee SY, Kim HB, Hong SJ, et al. Clinical outcome and prognostic factors of acute respiratory distress syndrome in children. Korean J Pediatr. 2005; 48:599–605.

27. Khemani RG, Thomas NJ, Venkatachalam V, Scimeme JP, Berutti T, Schneider JB, et al. Comparison of SpO2 to PaO2 based markers of lung disease severity for children with acute lung injury. Crit Care Med. 2012; 40:1309–16.

28. Lobete C, Medina A, Rey C, Mayordomo-Colunga J, Concha A, Menén-dez S. Correlation of oxygen saturation as measured by pulse oximetry/fraction of inspired oxygen ratio with Pao2/fraction of inspired oxygen ratio in a heterogeneous sample of critically ill children. J Crit Care. 2013; 28:538.e1–7.

29. Rice TW, Wheeler AP, Bernard GR, Hayden DL, Schoenfeld DA, Ware LB, et al. Comparison of the SpO2/FIO2 ratio and the PaO2/FIO2 ratio in patients with acute lung injury or ARDS. Chest. 2007; 132:410–7.

30. Ghuman AK, Newth CJ, Khemani RG. The association between the end tidal alveolar dead space fraction and mortality in pediatric acute hypoxemic respiratory failure. Pediatr Crit Care Med. 2012; 13:11–5.

31. DeBruin W, Notterman DA, Magid M, Godwin T, Johnston S. Acute hypoxemic respiratory failure in infants and children: clinical and pathologic characteristics. Crit Care Med. 1992; 20:1223–34.

32. Nichols DG, Walker LK, Wingard JR, Bender KS, Bezman M, Zahurak ML, et al. Predictors of acute respiratory failure after bone marrow transplantation in children. Crit Care Med. 1994; 22:1485–91.

33. Zimmerman JJ, Akhtar SR, Caldwell E, Rubenfeld GD. Incidence and outcomes of pediatric acute lung injury. Pediatrics. 2009; 124:87–95.

34. Petrucci N, De Feo C. Lung protective ventilation strategy for the acute respiratory distress syndrome. Cochrane Database Syst Rev. 2013; (2):CD003844.

35. Amato MB, Meade MO, Slutsky AS, Brochard L, Costa EL, Schoenfeld DA, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015; 372:747–55.

36. Kim KW, Ahn K, Yang HJ, Lee S, Park JD, Kim WK, et al. Humidifier disinfectant-associated children's interstitial lung disease. Am J Respir Crit Care Med. 2014; 189:48–56.

Table 1.

Clinical characteristics of admitted pediatric patients who required re spiratory support in the intensive care unit (n=73)

Variable	Value
Demographics
Age (mo)	31 (8–57)
Male sex	51 (69.9)
Body weight
<3rd percentile	65 (89.0)
3rd–95th percentile	6 (8.2)
>95th percentile	1 (1.4)
Transfer from other hospitals	34 (46.6)
Clinical characteristics
Causes of respiratory support
ARDS	14 (19.2)
Pneumonia	29 (39.7)
Airway obstructive disease	11 (15.1)
Sepsis	10 (13.7)
Neurologic disorder	9 (12.3)
Identified pathogens	56 (76.7)
Extrapulmonary organ dysfunction	28 (38.4)
PICU LOS (day)	5 (2.0–14.5)
Hospital LOS (day)	11 (7.0–28.5)
Death	10 (13.7)
Interventions
Invasive MV	45 (61.6)
HFOV	11 (24.4)
ECMO	8 (17.8)
Noninvasive	28 (38.4)
Nasal cannula	21 (71.4)
Mask with reservoir	4 (14.8)
CPAP	2 (7.1)
HFNC	1 (3.5)
Respiratory parameters
Respiratory rate at admission	40 (32–48)
Worst SpO2/FiO2 within 24 hr	240 (121–384)
Worst SpO₂/FiO₂ during hospitalization	230 (108–367)
Highest PaCO2 during hospitalization	52 (41–68)
PaO₂/FiO₂ ratio∗	77 (53–143)

Values are presented as median (interquartile range) or number (%).

ARDS, acute respiratory distress syndrome; PICU, pediatric intensive care unit; LOS length of stay; MV, mechanical ventilation; HFOV, high frequency oscillation ventila tion; ECMO, extracorporeal membrane oxygenation; CPAP, continuous positive air way pressure; HFNC, high flow nasal cannula; SpO2, saturation by pulse oxymeter FiO₂, fraction of inspired oxygen; PaCO₂, partial arterial pressure of carbon dioxide PaO₂, partial arterial pressure of oxygen.

^∗ Values are calculated in the patients with acute respiratory distress syndrome.

Table 2.

Comparison between survivors and nonsurvivors in intensive care unit

Variable	Survivors (n=63)	Nonsurvivors (n=10)	P-value
Clinical characteristics
Age (mo)	17 (4–66)	37 (29–43)	0.304
Male sex	48 (76.2)	3 (30.0)	0.007
Transfer from other hospitals	27 (42.9)	7 (70.0)	0.172
Cause of respiratory support			0.003
ARDS	9 (14.3)	5 (50.0)
Pneumonia	29 (46.0)	0 (0)
Airway obstructive disease	11 (17.5)	0 (0)
Sepsis	8 (12.7)	2 (20.0)
Neurologic disorder	6 (9.5)	3 (30.0)
Proven bacterial infection	12 (19.0)	1 (10.0)	0.679
Proven viral infection	45 (71.4)	5 (50.0)	0.270
ICU hospitalization	5 (2–9)	25 (8.3–52.3)	0.001
Probability of death (%)∗	1.4 (0.3–5)	10.9 (2–41.6)	0.010
Number of extrapulmonary organ dysfunction	0 (0–1)	2.5 (1–4.3)	<0.001
Interventions
Mechanical ventilation	35 (55.6)	10 (100)	0.011
HFOV	6 (9.5)	5 (50.0)	0.003
NO	7 (11.3)	6 (60.0)	0.002
Neuromuscular blocker	52 (82.5)	4 (40.0)	0.008
Vasoactive agent	12 (19.4)	9 (90.0)	<0.001
ECMO	5 (7.9)	3 (30.0)	0.073
Respiratory parameters
Worst SpO2/FiO2 within 24 hr	244 (132–387)	139 (83–294)	0.170
Worst SpO₂/FiO₂ during hospitalization	244 (120–376)	121 (69–230)	0.045
PEEP^‡	6 (5–9)	6 (5–9)	0.860
Above PEEP^†,‡	10 (0–19)	21.5 (17.3–26.5)	0.007
Duration of mechanical ventilation^†	6 (3.8–14.0)	25 (8.3–51.3)	0.003

Values are presented as median (interquartile range) or number (%).

ARDS, acute respiratory distress syndrome; ICU, intensive care unit; HFOV, high frequency oscillation ventilation; NO, nitric oxide; ECMO, extracorporeal membrane oxygenation; SpO₂, saturation by pulse oximeter; FiO₂, faction of oxygen; PEEP, positive end expiratory pressure.

^∗ Values are calculated by the Pediatric Index of Mortality (PIM) 3 score.

^† Values are calculated in the mechanically ventilated patients.

^‡ Values are calculated in the mechanically ven (PIP) and PEEP in the pressure control mode.

Table 3.

Risk factors associated with mortality in previous healthy children who admitted to pediatric intensive care unit

Variable	OR (95% CI)	P-value
Male sex	0.09 (0.07–1.05)	0.055
ARDS	2.34 (0.57–96.76)	0.654
Sepsis	0.20 (0.004–10.67)	0.426
Neurologic disorder	4.65 (0.05–403.10)	0.499
No. of extrapulmonary organ dysfunction	2.89 (1.17–7.11)	0.023
Worst SpO₂/FiO₂ ratio during hospitalization	0.99 (0.98–1.02)	0.794
Above PEEP∗	1.14 (0.93–1.40)	0.200

OR, odds ratio; CI, confidence interval; ARDS, acute respiratory distress syndrome; SpO2, saturation by pulse oxymeter; FiO2, fraction of inspired oxygen; PEEP, positive end expiratory pressure.

^∗ Difference between peak inspiratory pressure (PIP) and PEEP in the pressure control mode.

Table 4.

Clinical characteristics of nonsurvivors

Subjec	ctAge (yr)	Sex	Diagnosis	Pathogen	PRD (%)	ICU duration (day)	Number of extrapulmonary organ failure	Worst SpO₂/FiO₂ during hospitalization	Highest above PEEP during hospitalization	Other treatments
1	3	F	ARDS	Unknown	2.29	73	2	176	20
2	2	M	ARDS	RSV	8.87	32	3	79	21	Veno-venous ECMO
3	4	M	Encephalitis	HSV, mycoplasma	1.03	29	3	223	26
4	0	F	ARDS	Unknown	12.83	44	1	38	29
5	4	F	Septic shock	Enterovirus	20.54	2	1	84	28
6	0	F	Encephalitis	Unknown	0.46	8	1	457	12
7	0	F	ARDS	Unknown	7.69	19	1	81	19	Veno-venous ECMO
8	1	F	Septic shock	HSV	36.65	9	5	7	22
9	10	M	ARDS	Unknown	5.54	99	4	158	12	Veno-venous ECMO, Lung transplantation
10	2	F	Reye syndrome	Influneza B	56.39	5	5	253	22

PRD, probability of death calculated by Pediatric Index of Mortality 3 score; ICU, intensive care unit; SpO₂, saturation by pulse oxymeter; FiO₂, fraction of oxygen; PEEP, positive end expiratory pressure; ARDS, acute respiratory distress syndrome; RSV; respiratory syncytial virus; ECMO, extracorporeal membrane oxygenation; HSV, herpes simplex virus.

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