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Pediatric acute respiratory distress syndrome(PARDS)is a pulmonary inflammation syndrome caused by a variety of proinflammatory factors induced by many causes, which is mainly characterized by noncardiogenic pulmonary edema.The main pathophysiological feature is the destruction of the integrity of the alveolar capillary membrane, and the loss of the alveolar epithelial-endothelial barrier function.In the PARDS′s clinical practice, the mainstay of the treatment is supportive.Although there is still no clear definition and general consensus or guidelines, appropriate liquid therapy is an important part of non-ventilatory treatment measures.Proper fluid management strategy is helpful to improve pulmonary edema, maintain normal circulatory perfusion, prevent functional failure of important organs and improve the prognosis of patients.According to volume status, implementing the goal-oriented and phased differentiated fluid management strategy is significant for the therapy of PARDS patients.However, the effects of fluid strategy management according to PARDS phenotypes remain to be evaluated.
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Resumen Introducción: Existen pocos reportes de síndrome de dificultad respiratoria aguda (SDRA) con COVID-19 en pacientes pediátricos. El objetivo de este estudio fue describir las características de los pacientes pediátricos críticamente enfermos con COVID-19, la frecuencia del SDRA, la mecánica ventilatoria y los resultados de la posición prona. Métodos: Se llevó a cabo un estudio retrospectivo y observacional de los pacientes ingresados del 1 de abril al 30 de septiembre de 2020. Resultados: Ingresaron 34 pacientes a la unidad de terapia intensiva pediátrica (UTIP) con prueba positiva para SARS-CoV-2. De ellos, 13 presentaron SDRA, 11 requirieron ventilación mecánica invasiva y siete fueron pronados como estrategia de oxigenación. Todos los pacientes clasificados como SDRA graves fueron pronados. La obesidad fue la comorbilidad más importante. Las complicaciones asociadas con SDRA fueron el síndrome inflamatorio multisistémico (p < 0.05) y la lesión renal aguda (p < 0.05). La procalcitonina fue mayor en los pacientes con SDRA, al igual que los días de estancia en la UTIP (p < 0.05). El éxito de la maniobra de pronación se alcanzó 8 horas después.Los resultados observados fueron los siguientes relación presión arterial de oxígeno/fracción inspirada de oxígeno 128 vs. 204, índice de oxigenación 8.9 vs. 5.9, distensibilidad pulmonar estática 0.54 vs. 0.70 ml/cmH2O/kg, y presión meseta 24 vs. 19 cmH2O (p < 0.05). El uso de narcóticos fue mayor en el grupo de SDRA más pronación que en los no pronados (124 vs. 27 h; p < 0.01). La mortalidad asociada con SARS-CoV-2 fue del 5.8%. Conclusiones: El SDRA se presentó en el 38.2% de los niños admitidos a UTIP, y con mayor frecuencia en los pacientes con obesidad. La maniobra de pronación aplicada en los casos severos, mejoró la oxigenación de la mécanica pulmonar. Ninguno de los pacientes falleció por SDRA.
Abstract Background: There are only a few reports of acute respiratory distress syndrome (ARDS) in patients with SARS-CoV-2 in pediatrics. This study aimed to describe the characteristics of critically ill pediatric patients with COVID-19, the frequency of ARDS, ventilatory mechanics and results of prone position. Methods: We conducted a retrospective, observational study of patients admitted to the pediatric intensive care unit (PICU) between April 1 to September 30, 2020. Results: Thirty-four patients were admitted to pediatric intensive care unit, 31.7% were SARS-CoV-2 positive. 13 presented ARDS, 11 required invasive mechanical ventilation, and seven were pronated as an oxygenation strategy. All patients classified as severe ARDS were pronated. Obesity was the most important comorbidity. The complications associated with ARDS were multisystemic inflammatory syndrome (8 vs. 4; p < 0.05) and acute kidney injury (8 vs. 3; p < 0.05). Procalcitonin was higher in patients with ARDS, as were the days of stay in PICU (p < 0.05). The success of the pronation maneuver was achieved 8 hours later , with the following results: arterial oxygen partial pressure to fractional inspired oxygen ratio 128 vs. 204, oxygenation index 8.9 vs. 5.9, static lung compliance 0.54 vs. 0.70 ml/cmH2O/kg, plateau pressure 24 vs. 19 cmH2O (p < 0.05). The use of narcotics was higher in the group with ARDS plus pronation 124 vs. 27 hours in the non-pronated (p < 0.01). Mortality associated with SARS-CoV-2 was 5.8%. Conclusions: ARDS was presented in 38.2% of the children admitted to PICU and was more frequent in obese patients. Pronation, performed in severe cases, improved oxygenation and lung mechanics indexes. No patient died of ARDS.
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High frequency oscillatory ventilation(HFOV) in the treatment of acute respiratory distress syndrome(ARDS), there are significant differences in clinical research status and evidence level among different participants.HFOV for adult ARDS: current clinical evidence suggests that HFOV is not recommended for routine mechanical ventilation in adults with ARDS.HFOV for pediatric ARDS: there is no sufficient evidence to show that HFOV is superior to conventional mechanical ventilation.Nor does it prove that HFOV is harmful.The current recommendation is: HFOV could be considered as an alternative ventilatory mode in patients with moderate-to-severe pediatric ARDS, whom with conventional mechanical ventilation plateau airway pressures exceed 28 cmH 2O(1 cmH 2O=0.098 kPa) in the absence of clinical evidence of reduced chest wall compliance.HFOV for neonatal ARDS: the existing research evidence shows that HFOV can moderately reduce the incidence of chronic lung disease in the premature infants with neonatal ARDS.It has certain advantages in improving oxygenation and alleviating ventilator induced lung injury in acute phase.It also has certain advantages for improving pulmonary function and neurodevelopmental in the long term.
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Pneumonia is the most common cause of pediatric acute respiratory distress syndrome.Pneumonia combined with pediatric acute respiratory distress syndrome due to different pathogens has certain characteristics, and clinicians should pay attention to individualized anti-infective, anti-inflammatory and respiratory support therapy in the diagnosis and treatment.
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Prone position ventilation(PPV) is an effective treatment for moderate to severe pediatric acute respiratory distress syndrome(PARDS) and should be used in the early stage. PPV can improve oxygenation and reduce mortality.However, at present, the rate of application of PPV in moderate to severe PARDS is still low, which may be related to the insufficient understanding of its therapeutic effect and the lack of trained and skilled staff.Prone operation requires the coordinated efforts of doctors and nurses.Three to five medical personnel are required to participate in this routine operation, and the endotracheal tube and various invasive tubes must be carefully fixed.The safety of children during the prone operation should be guaranteed, and the extubation, migration or kinking of invasive pipelines must be avoided.Children receiving extracorporeal membrane oxygenation can be ventilated in prone position, but additional operators are required during prone operation.Medical staff should receive training related to the prone operation, master the contraindications of PPV, and avoid related complications.After the outbreak of COVID-19, the application of PPV has gradually increased.The key research progress of PPV in acute respiratory distress syndrome mostly comes from the adult field.More clinical studies should be carried out on the use of PPV in pediatrics in the future, so as to better treat PARDS.
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BACKGROUND@#Severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) is a novel pathogen that has rapidly caused a devastating pandemic of Coronavirus disease 2019 (COVID-19). The real time reverse transcriptase polymerase chain reaction cycle threshold values are inversely related to viral load and believed to have a role in terms of mortality and severity of the disease however, there is limited data in children. @*OBJECTIVES@#This study aims to determine the RT-PCR cycle threshold level in relation to mortality and pediatric acute respiratory distress syndrome (pARDS) among COVID-19 patients admitted at Philippine Children’s Medical Center.@*METHODS@#A cross sectional study was done on patients with RT-PCR confirmed covid-19 admitted at Philippine Children’s Medical Center from September 2020 to June 2021.@*RESULTS@#50 nasopharyngeal swab specimens from children admitted for COVID-19 were analyzed. 12 (24%) had acute respiratory distress syndrome. Among the 12 children who had pARDS, six (50%) expired; in those without pARDS, two (5.26%) expired. There was no difference in cycle threshold values between patients who died and who survived, as well as those with or without pARDS. @*CONCLUSIONS AND RECOMMENDATIONS@#We have no evidence to demonstrate a difference in Ct values alone between children who died or survived, or those who developed pARDS or those who did not. RT-PCR cycle threshold alone cannot predict mortality and development of pARDS, it can only indicate the presence of infection but not its severity. Cycle threshold and its significance may further be explored with a bigger population size in children in future studies.
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Objective: To investigate the application and safety of mobile extracorporeal membrane oxygenation (ECMO) in inter-hospital transport of pediatric patients with acute respiratory distress syndrome (pARDS). Methods: Data were retrospectively collected of children with pARDS transported by mobile ECMO from Jan. 1, 2019 to Nov. 25, 2019. All children suffered from severe ARDS, and the curative effect in their local hospital was not good, the disease was still progressing after traditional conservative treatments such as mechanical ventilation (MV), small tidal volume protective ventilation, prone position ventilation, and fluid restriction, and the severity of the disease reached the applicable ECMO indications. The age, sex, clinical manifestations, ECMO transfer time, ECMO transfer distance, ECMO duration, MV duration, length of hospital stay, prognosis and complications were collected and analyzed. Results: Seven pediatric patients were included in present study including 6 males and 1 female, aged (43.3±42.9) months, body weight (18.4±17.7) kg, ECMO travel distance (9.4±8.9) km, and ECMO travel time (5.7±17.2) min. After arriving in the Guangdong Provincial People's Hospital, 6 pediatric patients (4 were cured and 2 died) were discharged and 1 pediatric patient was still being treated. The MV duration was (17±11) d, ECMO duration was (307.4±233.6) h, and the length of hospital stay was (23±15) d. Of the 7 pediatric patients, 4 were caused by adenovirus infection, and the other 3 cases were infected by unclear pathogenic bacteria. The cause for death was severe sepsis shock combined with severe heart dysfunction and severe pulmonary hemorrhage. Conclusions: With a skilled ECMO teams, mobile ECMO may provide a safe and effective inter-hospital transport of pARDS patients. Mobile ECMO provides a good way to treat children patients with respiratory critical condition.
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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.
Asunto(s)
Niño , Humanos , Lesión Pulmonar Aguda , Berlin , Consenso , Cuidados Críticos , Enfermedad Crítica , Discriminación en Psicología , Unidades de Cuidados Intensivos , Mortalidad , Síndrome de Dificultad Respiratoria , Estudios RetrospectivosRESUMEN
Pediatric acute respiratory distress syndrome (PARDS) is the most leading cause of death in Pediatric Intensive Care Unit.PARDS can be classified as mild, moderate, and severe according to the oxygenation index.In recent years, because of the application of lung protection ventilation strategy, the outcome of PARDS has been greatly improved, but the mortality of severe PARDS still remains high.Therefore, it is of great clinical significance to understand the definition, diagnosis, and the application of lung protective ventilation strategy and the application of extracorporeal membrane oxygenation in severe PARDS.
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Objective To summarize the clinical course of acute interstitial pneumonitis (AIP) associated pediatric acute respiratory distress syndrome (PARDS) in 8 recipients after liver transplantation,and further discuss the potential risk factors and therapeutic highlights.Methods A total of 476 pediatric patients received liver transplantation in Tianjin First Center Hospital from January 2012 to September 2016.Among them,8 cases of AIP associated PARDS in ICU were recruited in this study.Medical data including clinical presentation,ICU management and outcomes were analyzed retrospectively.Results The onset time-window of AIP associated PARDS was (2.67 ± 0.77) months after liver transplantation,and the time interval between initial symptom and ICU administration was (6.75 ± 5.82) days.Five cases had the history of acute rejection therapy,and 5 cases had CMV and/or EBV viremia history.All 8 cases received mechanical ventilation,2 cases given nasal non-invasive ventilation and the rest 6 cases given invasive ventilation,3 of which were switched to high frequency oscillatory ventilation (HFOV) combined with inhaled nitric oxide.At the stage of hypoxic climax,the fraction of inspired oxygen (FiO2) was up-regulated to 1.0 to maintain the oxygenation index (OI) of (25.24 ± 5.94).Temporary replacement of immunosuppressants with intravenous glucocorticoids was implemented in all 8 cases without acute rejection episode.Of 8 cases,2 cases died from PARDS,1 case died from portal thrombosis associated hepatic failure,and the rest 5 cases survived.Conclusion AIP associated PARDS is a critical complication with high mortality in pediatric patients after liver transplantation.Excessively strong immunosuppression therapy at early post-transplant stage shows a risk factor for AIP.Lung protective ventilation strategy and HFOV are recommended to reduce ventilator induced lung injury in pediatric patients.Temporary intravenous glucocorticoids may reduce acute inflammatory reaction in PARDS patients without increasing the risk of acute rejection.