Subtypes of pediatric acute respiratory distress syndrome have different predictors of mortality

• Published in: Intensive care medicine Vol. 44; no. 8; pp. 1230 - 1239
• Main Authors: Yehya, Nadir, Keim, Garrett, Thomas, Neal J.
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01.08.2018; Springer; Springer Nature B.V
• Subjects: Analysis; Anesthesiology; Berlin; Blood Gas Analysis; Child; Children; Critical Care Medicine; Development and progression; Emergency Medicine; Etiology; Germany; Heterogeneity; Humans; Illnesses; Intensive; Intensive care; Lung; Medicine; Medicine & Public Health; Mortality; Original; Oxygenation; Pain Medicine; Patient outcomes; Pediatrics; Pennsylvania; Pneumology/Respiratory System; Prospective Studies; Regression analysis; Respiratory distress syndrome; Respiratory Insufficiency - complications; Respiratory Insufficiency - diagnosis; Respiratory Insufficiency - mortality; Respiratory therapy; United Kingdom; United States; Berlin; United Kingdom; United States; Germany; Pennsylvania; Infectious ARDS; Children; Direct ARDS; PARDS; ARDS
• ISSN: 0342-4642; 1432-1238; 1432-1238
• DOI: 10.1007/s00134-018-5286-6

Purpose Acute respiratory distress syndrome (ARDS) is heterogeneous in etiology, which may affect outcomes. Stratification into biologically-defined subtypes may reduce heterogeneity. However, it is unknown whether pediatric ARDS has clinically relevant subtypes. We aimed to determine whether clinical characteristics and predictors of mortality differed between direct and indirect ARDS, and separately between infectious and non-infectious ARDS. Methods This was a single center, prospective cohort study of 544 children with ARDS (Berlin) between July 2011 and June 2017, stratified into direct versus indirect ARDS, and separately into infectious versus non-infectious ARDS. Multiple logistic regression was used to test for predictors of mortality in the entire cohort, and separately within subtypes. Effect modification by subtype was assessed using interaction tests. Results Direct ARDS had lower severity of illness ( p  < 0.001) but worse oxygenation ( p  < 0.001), relative to indirect. Predictors of mortality were similar for direct and indirect ARDS. When comparing infectious and non-infectious ARDS, infectious ARDS had lower severity of illness ( p  < 0.001), worse oxygenation ( p  = 0.014), and lower mortality ( p  = 0.013). In multivariable analysis, immunocompromised status demonstrated effect modification between infectious and non-infectious ARDS ( p  = 0.005 for interaction), with no association with mortality in non-infectious ARDS. Conclusions In children, direct and indirect ARDS have distinct clinical characteristics, but similar outcomes and similar predictors of mortality. In contrast, infectious and non-infectious ARDS demonstrate heterogeneity of clinical characteristics, mortality, and predictors of mortality, with traditional predictors of ARDS mortality only applicable to infectious ARDS.