Clinical application of the Pediatric Acute Lung Injury Consensus Conference definition of acute respiratory distress syndrome

Byuh Ree Kim; Soo Yeon Kim; In Suk Sol; Yoon Hee Kim; Kyung Won Kim; Myung Hyun Sohn; Kyu-Earn Kim

doi:10.4168/aard.2019.7.1.44

Journal List > Allergy Asthma Respir Dis > v.7(1) > 1125518

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Kim, Kim, Sol, Kim, Kim, Sohn, and Kim: Clinical application of the Pediatric Acute Lung Injury Consensus Conference definition of acute respiratory distress syndrome

Original Article

Allergy Asthma Respir Dis 2019;7(1):44-50.

Published online: 12 January 2019

DOI: https://doi.org/10.4168/aard.2019.7.1.44

Clinical application of the Pediatric Acute Lung Injury Consensus Conference definition of acute respiratory distress syndrome

Byuh Ree Kim¹, Soo Yeon Kim¹, In Suk Sol¹, Yoon Hee Kim¹, Kyung Won Kim¹, Myung Hyun Sohn¹, Kyu-Earn Kim²

^¹Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul Korea

^²Sowha Children's Hospital, Seoul Korea

Correspondence to: Soo Yeon Kim https://orcid.org/0000-0003-4965-6193 Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: +82-2-2228-2050, Fax: +82-2-393-9118, E-mail: sophi1@yuhs.ac

• This work was supported by Institute for Information & communications Technology Promotion (IITP) grant funded by the Korea government (MSIT) (No. 2017–0–00599, Development of Big Data Analytics Platform for Military Health Information).

Received 28 August 2018 Revised 18 October 2018 Accepted 18 October 2018

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

Despite improved quality of intensive care, acute respiratory distress syndrome (ARDS) significantly contributes to mortality in critically ill children. As pre-existing definitions of ARDS were adult-oriented standards, the Pediatric Acute Lung Injury Consensus Conference (PALICC) group released a new definition of pediatric ARDS. In this study, we aimed to assess the performance of PALICC definition for ARDS risk stratification.

Methods

Total 332 patients who admitted to the intensive care unit at Severance Hospital from January 2009 to December 2016 and diagnosed as having ARDS by either the PALICC definition or the Berlin definition were retrospectively analyzed. Patient characteristics and mortality rates were compared between the individual severity groups according to both definitions.

Results

The overall mortality rate was 36.1%. The mortality rate increased across the severity classes according to both definitions (26% in mild, 37% in moderate and 68% in severe by the PALICC definition [P<0.001]; 20% in mild, 32% in moderate and 64% in severe by the Berlin definition [P<0.001]). The mortality risk increased only for severe ARDS in both definitions (hazard ratio [95% confidence interval]: 2.279 [1.414–3.672], P =0.001 by the PALICC definition; 2.674 [1.518–4.712], P =0.001 by the Berlin definition). There was no significant difference in mortality discrimination between the 2 definitions (difference in integrated area under the curve: 0.017 [−0.018 to 0.049]).

Conclusion

The PALICC definition demonstrated similar discrimination power on PARDS’ severity and mortality as the Berlin definition.

Keywords: Pediatric acute respiratory distress syndrome, Pediatric Acute Lung Injury Consensus Conference, Berlin definition, Mortality

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Supplementary Fig. 1.

Distribution of patients according to Pediatric Acute Lung Injury Consensus Conference (PALICC) and Berlin definition. PARDS, pediatric acute respiratory distress syndrome.

Fig. 2.

Kaplan-Meier survival curves for mortality according to Pediatric Acute Lung Injury Consensus Conference (PALICC) (A) and Berlin definition severity group (B). (A) Black line represents mild acute respiratory distress syndrome (ARDS), gray line represents moderate ARDS, and light gray line represents severe ARDS. (B) Black, gray, and light gray lines represent mild, moderate, and severe ARDS, respectively.

Fig. 3.

Predictive accuracy for mortality: integrated area under the curve (iAUC) by follow-up time. Solid and dotted lines represent the Pediatric Acute Lung Injury Consensus Conference (PALICC) and Berlin definition respectively.

Table 1.

Demographics of patients with pediatric acute respiratory distress syndrome

Variable	PALICC definition (n=283)	Berlin definition (n=323)
Age (yr)	3.7 (1.3–10.5)	3.6 (1.0–10.0)
Male sex	168 (59.4)	188 (58.2)
PRISM III	9.0 (5.0–15.0)	8.0 (4.0–14.0)
PIM 3	7.7 (4.7–27.1)	7.4 (4.4–24.7)
Comorbidities at ICU admission
Respiratory	89 (31.4)	112 (34.7)
Neurologic	68 (24.0)	79 (24.5)
Hemato-oncologic	71 (25.1)	71 (22.0)
ARDS etiology
Infectious pneumonia	177 (62.5)	206 (63.8)
Aspiration pneumonia	31 (11.0)	38 (11.8)
Sepsis	61 (21.6)	63 (19.5)
Outcomes
Mortality	112 (39.6)	119 (36.8)
In survivors
ICU length of stay (day)	11.0 (7.0–21.0)	10.5 (6.0–20.0)
Ventilator care duration (day)	9.0 (6.0–18.0)	9.0 (6.0–17.0)

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

PALICC, Pediatric Acute Lung Injury Consensus Conference; PRISM III, pediatric risk of mortality III; PIM 3, pediatric index of mortality 3; ICU, intensive care unit; ARDS, acute respiratory distress syndrome.

Table 2.

Clinical characteristics and physiologic variables of patients across severity categories using the PALICC definition and the Berlin definition

Variable	PALICC definition (n=283)			Berlin definition (n=323)
Variable	Mild (n=119)	Moderate (n=96)	Severe (n=68)	Mild (n=85)	Moderate (n=158)	Severe (n=80)
Age (yr)	3.3 (1.1–10.6)	3.7 (1.0–9.0)	4.5 (1.8–12.0)	2.2 (0.8–7.2)	3.6 (1.0–10.4)	4.3 (1.7–10.9)
Male sex	72 (60.5)	60 (62.5)	36 (52.9)	48 (56.5)	98 (62)	42 (52.5)
PRISM III	7.5 (4.0–12.0)	8.0 (4.3–14.0)	13.5 (9.0–19.0)^†,‡	7.0 (3.0–13.0)	7.0 (3.0–12.5)	12.0 (7.2–28.0)^†,‡
PIM 3	5.5 (4.1–17.9)	7.4 (4.7–21.8)	24.5 (8.6–41.0)^†,‡	5.2 (3.1–11.3)	6.4 (4.2–18.7)	24.5 (7.9–41.0)^†,‡
GCS	9 (6–11)	9 (6–13.8)	7 (4–11)	9 (7–11.5)	9 (6–12)	7.5 (3.3–11)
Primary outcomes
Mortality (%)	31 (26.1)	35 (36.5)	46 (67.6)^†,‡	17 (20)	51 (32.3)	51 (63.8)^†,‡
Secondary outcomes
ICU care days	11.0 (7.0–21.0)	10.0 (6.0–19.5)	15.0 (6.5–25.3)	9.0 (5.3–21.3)	11.0 (6.0–16.0)	19.0 (7.0–30.5)
Ventilator days	9.0 (6.0–16.0)	8.0 (5.5–17.0)	15.5 (7.8–28.0)	8.0 (5.0–16.5)	9.0 (6.0–15.0)	17.0 (6.5–28.5)*

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

*Mild ARDS vs. sever ARDS, P<0.05.

^† Mild ARDS vs. severe ARDS, P<0.01.

^‡ Moderate ARDS vs. severe ARDS, P<0.01.

Table 3.

Multivariate analysis using Cox model for mortality

Definition	Hazard ratio	95% CI	P-value
PALICC definition
Mild ARDS (reference)
Moderate ARDS	1.425	0.867–2.342	0.162
Severe ARDS	1.702	1.055–2.744	0.029
Berlin definition
Mild ARDS (reference)
Moderate ARDS	1.104	0.633–1.925	0.728
Severe ARDS	1.773	1.010–3.114	0.046

Age, sex, pediatric risk of mortality III, comorbidity adjusted.

PALICC, Pediatric Acute Lung Injury Consensus Conference; CI, confidence interval;

ARDS, acute respiratory distress syndrome.

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