1Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA. 2Department of Radiology, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA. 3Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children's Hospital, Hershey, PA.
Crit Care Med. 2015 May;43(5):937-46. doi: 10.1097/CCM.0000000000000867.
Although all definitions of acute respiratory distress syndrome use some measure of hypoxemia, neither the Berlin definition nor recently proposed pediatric-specific definitions proposed by the Pediatric Acute Lung Injury Consensus Conference utilizing oxygenation index specify which PaO2/FIO2 or oxygenation index best categorizes lung injury. We aimed to identify variables associated with mortality and ventilator-free days at 28 days in a large cohort of children with acute respiratory distress syndrome.
Prospective, observational, single-center study.
Tertiary care, university-affiliated PICU.
Two-hundred eighty-three invasively ventilated children with the Berlin-defined acute respiratory distress syndrome.
None.
Between July 1, 2011, and June 30, 2014, 283 children had acute respiratory distress syndrome with 37 deaths (13%) at the Children's Hospital of Philadelphia. Neither initial PaO2/FO2 nor oxygenation index at time of meeting acute respiratory distress syndrome criteria discriminated mortality. However, 24 hours after, both PaO2/FIO2 and oxygenation index discriminated mortality (area under receiver operating characteristic curve, 0.68 [0.59-0.77] and 0.66 [0.57-0.75]; p < 0.001). PaO2/FIO2 at 24 hours categorized severity of lung injury, with increasing mortality rates of 5% (PaO2/FIO2, > 300), 8% (PaO2/FIO2, 201-300), 18% (PaO2/FIO2, 101-200), and 37% (PaO2/FIO2, ≤ 100) across worsening Berlin categories. This trend with 24-hour PaO2/FIO2 was seen for ventilator-free days (22, 19, 14, and 0 ventilator-free days across worsening Berlin categories; p < 0.001) and duration of ventilation in survivors (6, 9, 13, and 24 d across categories; p < 0.001). Similar results were obtained with 24-hour oxygenation index.
PaO2/FIO2 and oxygenation index 24 hours after meeting acute respiratory distress syndrome criteria accurately stratified outcomes in children. Initial values were not helpful for prognostication. Definitions of acute respiratory distress syndrome may benefit from addressing timing of oxygenation metrics to stratify disease severity.
虽然急性呼吸窘迫综合征的所有定义都使用了某种程度的低氧血症，但柏林定义或最近由儿科急性肺损伤共识会议提出的特定于儿科的定义都没有指定最佳分类肺损伤的 PaO2/FIO2 或氧合指数。我们旨在确定与大量患有急性呼吸窘迫综合征的儿童的死亡率和 28 天无呼吸机天数相关的变量。
前瞻性、观察性、单中心研究。
三级保健、大学附属儿科重症监护病房。
283 名接受柏林定义的急性呼吸窘迫综合征有创通气的儿童。
无。
2011 年 7 月 1 日至 2014 年 6 月 30 日，费城儿童医院的 283 名儿童患有急性呼吸窘迫综合征，其中 37 人死亡（13%）。在符合急性呼吸窘迫综合征标准时，初始 PaO2/FO2 和氧合指数均不能区分死亡率。然而，24 小时后，PaO2/FIO2 和氧合指数都能区分死亡率（接受者操作特征曲线下面积，0.68 [0.59-0.77] 和 0.66 [0.57-0.75]；p<0.001）。24 小时后 PaO2/FIO2 可分类肺损伤严重程度，随着柏林分类严重程度的增加，死亡率分别为 5%（PaO2/FIO2>300）、8%（PaO2/FIO2201-300）、18%（PaO2/FIO2101-200）和 37%（PaO2/FIO2≤100）。这种趋势在 24 小时 PaO2/FIO2 中也可见，在逐渐恶化的柏林分类中，无呼吸机天数分别为 22、19、14 和 0 天（p<0.001），幸存者通气时间分别为 6、9、13 和 24 天（p<0.001）。24 小时氧合指数也得到了类似的结果。
急性呼吸窘迫综合征发生后 24 小时的 PaO2/FIO2 和氧合指数准确地对儿童的结局进行了分层。初始值对预后没有帮助。急性呼吸窘迫综合征的定义可能受益于解决氧合指标的时间，以分层疾病严重程度。
