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Defining Pediatric ARDS- Past and Future

Robinder G. Khemani MD, MsCI Associate Professor of Clinical Pediatrics University of Southern California Keck School of Medicine Attending Physician, Critical Care Medicine Children’s Hospital Los Angeles. Defining Pediatric ARDS- Past and Future. Sources of Financial Support. Disclosures.

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Defining Pediatric ARDS- Past and Future

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  1. Robinder G. Khemani MD, MsCI Associate Professor of Clinical Pediatrics University of Southern California Keck School of Medicine Attending Physician, Critical Care Medicine Children’s Hospital Los Angeles Defining Pediatric ARDS- Past and Future

  2. Sources of Financial Support

  3. Disclosures • Paid Consultant/Advisor • OrangeMed (Nihon Kohden) • Hamilton Medical

  4. Pediatric ARDS Definitions • Chapter 1: Historical ARDS definitions • Chapter 2: The Pediatric Acute Lung Injury Consensus Conference (PALICC) • Chapter 3: The Pediatric ARDS Incidence and Epidemiology (PARDIE) study • Chapter 4: Future directions

  5. Chapter 1 Historical Definitions of Acute Respiratory Distress Syndrome (ARDS)

  6. ARDSyndrome Clinical syndrome characterized by diffuse inflammation in the lung Results in significant hypoxemia from endothelial injury to the pulmonary vasculature and alveolar epithelial injury No definitive diagnostic test (i.e. biomarker) which is present in all cases (even histopathology inconsistent) Ware NEJM 2000

  7. Hallmark Symptoms of Pathophysiology –Pediatrics and Adults • Hypoxemia (Shunt) • Poor Respiratory System Compliance • Decreased End Expiratory Lung Volumes (FRC) • Diffuse Process • Endothelial Injury • Edema • Increased alveolar dead space

  8. ARDS Historical Definitions • First description Ashbaugh -1967 • 12 patients • acute respiratory distress • cyanosis refractory to oxygen • decreased respiratory system compliance • diffuse pulmonary infiltrates • Initially Adult Respiratory Distress Syndrome • Changed to Acute Respiratory Distress Syndrome, to account for the fact that children have it too

  9. Murray Lung Injury Score -1988 First attempt at consensus definition for ARDS Patho physiologic Concept Diffuse vs. Lobar Degree of Hypoxemia Lower EELV (FRC) Poor Compliance Murray 1988

  10. PEDIATRIC LUNG INJURY SCOREModified from: Murray et al. Am Rev Respir Dis 1988; 138:720-723Hammer, Numa & Newth. Pediatr Pulmonol 1997; 23:1176-183

  11. American European Consensus Conference (AECC) 1994

  12. AECC Limitations Phua: CCM 2008; Wheeler: NEJM; 2006; Villar: AJRCCM 2007;Meade: AJRCCM 2000;Rubenfeld Chest 1999; Komadina: Chest 1991;

  13. Berlin Draft Definition - 2012 eSUPPLEMENT 1) Include radiographs of consensus interpretations for qualifying opacities vs not vs equivocal 2) Include case vignettes on how to assess “not fully explained by cardiac failure of fluid overload”

  14. Severe 14% Mild 22% Moderate 64% Mortality 45% Evaluation of Severe Ancillary variables identify a smaller group of patients with similar mortality 45% Mortality Severe 28% Mild 22% Moderate 50% Final ARDS PaO2/FiO2 < 100 mmHg PEEP > 5 cm H2O Bilateral opacities on CXR Draft ARDS PaO2/FiO2 < 100 mmHg PEEP > 10 cm H2O 3 or 4 quadrant opacities on CXR Crs < 40 ml/cm H2O or VeCorr > 10 L/min

  15. Final Berlin Definition of ARDS Limited Validation in Children

  16. Chapter 2 The Pediatric Acute Lung Injury Consensus Conference

  17. 2015

  18. Pediatric versus Adult ARDS Rubenfeld GD et al. N Engl J Med 2005. Pediatric Adult 12.8/100,000 < 15 years Age- and Risk-Specific Incidence of and Age-Specific Mortality from Acute Lung Injury. Zimmerman J et al. Pediatrics 2009.

  19. Pediatric Specific Definition • Build off Berlin Definition- is Berlin alone Adequate? • Pediatric Considerations • Timing (similar to adults?) • Age? • Co-existence with Cardiac Disease (similar to adults?) • What are best respiratory criteria for risk stratification/disease severity • How do we handle patients on non-invasive ventilation and/or those without arterial lines • How important/reliable are Radiographic Criteria for Definition of ARDS • Defining it in patients with cardiac or pulmonary co-morbidites

  20. PALICC p ARDS Definition OI = oxygenation index = (FiO2* mean airway pressure*100)/ PaO2 OSI = oxygen saturation index = (FiO2* mean airway pressure*100) /SpO2 PALICC PCCM 2015

  21. Pediatric Specific Definition • Build off Berlin Definition- is Berlin alone Adequate? • Pediatric Considerations • Timing (similar to adults?) • Age? • Co-existence with Cardiac Disease (similar to adults?) • What are best respiratory criteria for risk stratification/disease severity • How do we handle patients on non-invasive ventilation and/or those without arterial lines • How important/reliable are Radiographic Criteria for Definition of ARDS • Defining it in patients with cardiac or pulmonary co-morbidites

  22. Measures of Oxygenation in the Definition 1.5.1 Oxygenation Index [OI=(FiO2* mean airway pressure*100)/ PaO2], in preference to PaO2/FiO2 (PF) ratio, should be the primary metric of lung disease severity to define P-ARDS for all patients treated with invasive mechanical ventilation. Strong agreement 1.5.2 PaO2/FiO2 (PF) ratio should be used to diagnose ARDS for patients receiving non‐invasive full face mask ventilation (CPAP or BiPAP) with a minimum CPAP of 5 cm H2O. Strong agreement PALICC PCCM 2015

  23. Reasons for OI versus PF • Lower and more variable ventilator management and in particular PEEP use in Pediatrics compared to Adults • Need to control for ventilator support • More Frequent use of HFOV PALICC PCCM 2015

  24. OI versus PF ratio PEEP 14 cmH20 PaO2 = 120, FiO2=0.5, MAP = 19 PF Ratio 240 OI = 8 PEEP 5 cmH20 PaO2 = 60, FiO2=0.6, MAP = 8 PF Ratio 100 OI =8

  25. PEEP levels in Pediatric ARDS • * > 50% of patients with PEEP ≤5 cmH20 • > 50% of adults in ARDSNet studies on PEEP ≥10cmH20 at study inclusion (Britos CCM)

  26. Variable PEEP use in Pediatrics Newth CPPCRN 2014 Khemani ICM 2011 Because PEEP management is not protocolized in children, it may confound ascertainment of disease severity (alters PF ratio) and ability to examine other treatment effects (Tidal Volume etc.) Santichi PALIVE 2011

  27. Which OI cut points to use? Look to the Data (CHLA) PALICC PCCM 2015

  28. Validation Datasets PALICC PCCM 2015

  29. Pediatric Specific Definition • Build off Berlin Definition- is Berlin alone Adequate? • Pediatric Considerations • Timing (similar to adults?) • Age? • Co-existence with Cardiac Disease (similar to adults?) • What are best respiratory criteria for risk stratification/disease severity • How do we handle patients on non-invasive ventilation and/or those without arterial lines • How important/reliable are Radiographic Criteria for Definition of ARDS • Defining it in patients with cardiac or pulmonary co-morbidites

  30. Pulse Oximetry versus PaO2 1.6.1 Oxygen Saturation Index [OSI =(FiO2* mean airway pressure*100)/SpO2]should be used when an OI is not available for stratification of risk for patients receiving invasive mechanical ventilation. Strong agreement 1.6.2 SF(SpO2/FiO2)ratio can be used when PF ratio is not available to diagnose P-ARDS in patients receiving non‐invasive full face mask ventilation (CPAP or BiPAP) with a minimum CPAP of 5 cm H2O. Strong agreement

  31. Characterizing oxygenation using pulse oximetry 1.8.1 To apply SpO2 criteria to diagnose P-ARDS, oxygen therapy should be titrated to achieve an SpO2 between 88- 97%. Strong agreement PALICC PCCM 2015

  32. Khemani CCM 2012

  33. Parvathaneni PCCM 2016

  34. Requiring PF ratio selects for patients with hypoxemia and cardiovascular dysfunction Not using pulse oximetry criteria underestimates the prevalence of ARDS and over-estimates mortality, by selecting for a more ill patient population

  35. Pediatric Specific Definition • Build off Berlin Definition- is Berlin alone Adequate? • Pediatric Considerations • Timing (similar to adults?) • Age? • Co-existence with Cardiac Disease (similar to adults?) • What are best respiratory criteria for risk stratification/disease severity • How do we handle patients on non-invasive ventilation and/or those without arterial lines • How important/reliable are Radiographic Criteria for Definition of ARDS • Defining it in patients with cardiac or pulmonary co-morbidites

  36. Radiographic Findings 1.4.1 Chest imaging findings of new infiltrate(s) consistent with acute pulmonary parenchymal disease are necessary to diagnose P-ARDS. Strong agreement PALICC PCCM 2015

  37. Radiographic Findings • Eliminated requirement for bilateral infiltrates • 1. Poor Inter-observer reliability, unclear if can be improved with common training • 2.Poor Sensitivity of CXR to detect disease, CXR lags behind hypoxemia, poor correlation with CT • 3. Pathophysiology may be present with radiographic unilateral disease (inability to detect inflammation in other lung) • 4. Unclear if Bilateral Infiltrates adds anything prognostically over hypoxemia PALICC PCCM 2015

  38. Bilateral Infiltrates and hypoxemia • Two adult studies demonstrating no prognostic relevance when controlling for hypoxemia, one showing important (Luhr 1999,2000, Roupie 1999) • Two pediatric studies in China showing prognostic importance, but not adequately controlling for hypoxemia (ALI v ARDS) ( Hu 2010, Zhu 2012) • Secondary Analysis of Published data (CHLA cohort, ICM 2009) PALICC 2015

  39. Chapter 3 The Pediatric ARDS Incidence and Epidemiology Study (PARDIE)

  40. PARDIE The Pediatric Acute Respiratory Distress syndrome Incidence and Epidemiology study PARDIE is an international initiative to better understand the implications of the new Pediatric Acute Lung Injury Consensus Conference (PALICC) definition of Pediatric ARDS Executive committee: Philippe Jouvet, Robinder Khemani, Christopher Newth, Lincoln Smith, Neal Thomas, Doug Willson On Behalf of the PARDIE Investigators Pediatric ARDS Incidence and Epidemiology (PARDIE) http://pardie.palisi.org/

  41. PARDIE study funding • CHLA, RSR, St Justine • PARDIE Data entry Website/Database, Admin Support • SC CTSI • To support secondary analysis (statistical support) and data management

  42. PARDIE Study as a test • International cross sectional (incidence) design to test several aspects of the new definition • Designed as a Main study (V.0) plus ancillaries • 5 continuous days of screening and patient enrollment (M-F), performed 10 times in a year (50 total study days) • Only new cases of ARDS diagnosed within previous 24 hours included • Data collection largely in first 3 days of ARDS diagnosis • Follow clinical outcomes such as mortality and length of ventilation for included patients.

  43. PARDIE V.0 questions • 1. To determine the number and frequency of new cases of PARDS amongst non-cardiac PICU patients, and their respective outcomes, including ICU and hospital mortality and VFDs • 2. To evaluate how the PALICC recommended mild, moderate, and severe classification of PARDS performs in discriminating ICU and hospital mortality • 3. To determine the relevance of the timing of hypoxemia metrics (OI, OSI, PF, SF) within the first three days of ARDS onset affects the discrimination ability of ICU and hospital mortality

  44. What will happen to PARDS Epidemiology? • SpO2 criteria • Simplified CXR • CHD and CLD pts • Co-existence with cardiac disease • Explicit criteria for NIV Parvatheneni PCCM 2017

  45. PARDIE V.0 questions • 1. To determine the number and frequency of new cases of PARDS amongst non-cardiac PICU patients, and their respective outcomes, including ICU and hospital mortality and VFDs • 2. To evaluate how the PALICC recommended mild, moderate, and severe classification of PARDS performs in discriminating ICU and hospital mortality • 3. To determine the relevance of the timing of hypoxemia metrics (OI, OSI, PF, SF) within the first three days of ARDS onset affects the discrimination ability of ICU and hospital mortality

  46. Are the OI/OSI cut points correct? Combination of studies, several years old No use of Pulse oximetry Criteria Is this representative of current practice and outcomes?

  47. PARDIE V.0 questions • 1. To determine the number and frequency of new cases of PARDS amongst non-cardiac PICU patients, and their respective outcomes, including ICU and hospital mortality and VFDs • 2. To evaluate how the PALICC recommended mild, moderate, and severe classification of PARDS performs in discriminating ICU and hospital mortality • 3. To determine the relevance of the timing of hypoxemia metrics (OI, OSI, PF, SF) within the first three days of ARDS onset affects the discrimination ability of ICU and hospital mortality

  48. Initial versus a Delayed Value? OI/OSI Only OI Yehya, PCCM 2015 Parvatheneni, PCCM 2017

  49. Perhaps 12 hours post PARDS captures risk well?

  50. Main Study (V.0) plus ancillaries • V.0 – PARDIE • V.1 – Risk factors for Mortality in PARDS • V.2 – Monitoring/Ventilator Management in PARDS • V.3 – Chest Imaging • V.4 – At Risk for ARDS • Cardiac PARDIE • 97 is the new 100

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