Predicting Mortality in Children With Pediatric Acute Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study

Abstract

Objectives: Pediatric acute respiratory distress syndrome is heterogeneous, with a paucity of risk stratification tools to assist with trial design. We aimed to develop and validate mortality prediction models for patients with pediatric acute respiratory distress syndrome. Design: Leveraging additional data collection from a preplanned ancillary study (Version 1) of the multinational Pediatric Acute Respiratory Distress syndrome Incidence and Epidemiology study, we identified predictors of mortality. Separate models were built for the entire Version 1 cohort, for the cohort excluding neurologic deaths, for intubated subjects, and for intubated subjects excluding neurologic deaths. Models were externally validated in a cohort of intubated pediatric acute respiratory distress syndrome patients from the Children’s Hospital of Philadelphia. Setting: The derivation cohort represented 100 centers worldwide; the validation cohort was from Children’s Hospital of Philadelphia. Patients: There were 624 and 640 subjects in the derivation and validation cohorts, respectively. Interventions: None. Measurements and Main Results: The model for the full cohort included immunocompromised status, Pediatric Logistic Organ Dysfunction 2 score, day 0 vasopressor-inotrope score and fluid balance, and Pao 2/Fio 2 6 hours after pediatric acute respiratory distress syndrome onset. This model had good discrimination (area under the receiver operating characteristic curve 0.82), calibration, and internal validation. Models excluding neurologic deaths, for intubated subjects, and for intubated subjects excluding neurologic deaths also demonstrated good discrimination (all area under the receiver operating characteristic curve ≥ 0.84) and calibration. In the validation cohort, models for intubated pediatric acute respiratory distress syndrome (including and excluding neurologic deaths) had excellent discrimination (both area under the receiver operating characteristic curve ≥ 0.85), but poor calibration. After revision, the model for all intubated subjects remained miscalibrated, whereas the model excluding neurologic deaths showed perfect calibration. Mortality models also stratified ventilator-free days at 28 days in both derivation and validation cohorts. Conclusions: We describe predictive models for mortality in pediatric acute respiratory distress syndrome using readily available variables from day 0 of pediatric acute respiratory distress syndrome which outperform severity of illness scores and which demonstrate utility for composite outcomes such as ventilator-free days. Models can assist with risk stratification for clinical trials.

Phenotypes and personalized medicine in the acute respiratory distress syndrome

“…Pediatric critical care clinicians have long recognized the inadequacies of adult based operational definitions for ARDS when applied to children [ 59 , 60 ]. First, pediatric risk factors, etiologies, pathophysiology, and outcomes differ [ 61 , 62 ]. Second, PaO 2 is measured less often, making the calculation of PaO 2 /FiO 2 more challenging, since invasive arterial sampling is used more sparingly in children.…”

Performance of acute respiratory distress syndrome definitions in a high acuity paediatric intensive care unit

“…Alternatively, mortality may not be the right endpoint in PARDS since many patients die with and not from ARDS [ 21 ]. In fact, neurologic aetiologies of death in children with PARDS are common, confounding true mortality rates [ 22 ]. Overall mortality in our study was low, like other high-income countries but lower than low-income countries, and increased with increasing severity [ 23 , 24 ].…”

Prognostic relevance and inter-observer reliability of chest-imaging in pediatric ARDS: a pediatric acute respiratory distress incidence and epidemiology (PARDIE) study

“…Finally, there are many variables which will confound the relationship between bilateral infiltrates and mortality. We only evaluated oxygenation impairment in this manuscript but have previously shown that radiographic criteria do not retain an independent relationship with mortality after controlling for other factors such as immune-suppressed status and ARDS trigger [13,30].…”