ACUTE RESPIRATORY DISTRESS SYNDROME IN CHILDREN IN SRINAGARIND HOSPITAL:

A 5 YEAR RETROSPECTIVE STUDY

Amnuayporn Apiraksakorn1, MD Jamaree Teeratakulpisarn1, MD

Jiraporn Srinakarin2, MD

Department of Pediatrics1 and Radiology2,Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand

Acute Respiratory Distress Syndrome (ARDS)

A severe form of acute respiratory failure associated with a high mortality rate in

children

Pathophysiology of ARDSProtein rich edema fluid

Diagnostic criteria The 1994 American European Concensus

Conference (AECC) criteria1. Acute onset

2. PaO2/FiO2 ratio < 200

3. Bilateral, infiltrates on chest radiograph

4. Pulmonary-artery wedge pressure ≤ 18 mmHg or absent of clinical evidence of left atrial hypertension

The AECC on ARDS. Am J Respir Crit Care Med 1994; 149: 818-24.

Literature review

Erickson S et al. Acute lung injury in pediatric intensive care in Australia and New Zealand.Pediatr Crit Care Med 2007; 8: 317-23.

Descriptions Goh et al. (1998)

Costil et al. (1995)

Dahlem et al. (2003)

Flori et al. (2005)

ANZICS PSG (2007)

Incidence (% admissions)

4.2 % 2 % 4 % NA 2.2 %

Etiology Sepsis 43%Pneumonia 33%

Pneumonia 65%Sepsis 16%

Sepsis 34%RSV 16%

Pneumonia 35%Aspiration 15%Sepsis 13%

Bacterial LRTI 27%Viral LRTI 27%Sepsis 19%

Mortality 62 % 60 % 31 % 29 % 39 %

Objectives

• incidence• predisposing factors• mechanical ventilatory settings• outcomes• complications• mortality

To assess

MethodsRetrospective descriptive study Approved by The Khon Kaen University

Ethics Committee For Human ResearchAll charts of ARDS admitted to Pediatric

Intensive Care Unit (PICU), Srinagarind Hospital, Thailand, from 2004 to 2008 were reviewed

Inclusion criteria1. All pediatric patients age 1 month to

16 years admitted to PICU in Srinagarind Hospital during 1 January 2004 to 31 December 2008

2. Diagnosed with ARDS according to AECC criteria (reviewed CXR by radiologist)

Exclusion criteria1. cyanotic congenital heart

diseases2. chronic hypoxemic lung

diseases3. unavailable or incomplete

medical records

ResultsJ80: ARDS

34 cases

Unavailablemedical record 1 case

No CXR 1 case

Not admitted in PICU 2 cases

No bilateral infiltrates on CXR 7 cases

Total ARDS 23 cases

ARDS in PICU

0

1

2

3

4

5

6

2004 2005 2006 2007 2008

Alive

Dead

0

1

2

3

4

5

6

2004 2005 2006 2007 2008

Alive

Dead

cases

Year

Results23 cases met AECC criteria for ARDS

Male : female = 1 : 1.6

average age 7.4 years (0.9 - 15.8 years)

The incidence 2.2% of PICU admissions

The incidence 0.2% of all hospitalized children

The major predisposing factors: pneumonia, sepsis

Most cases (22/23) on PCV, one case on HFOV,

maximum settings: PIP 24 - 50 cmH2O, PEEP 6 - 14 cmH2O, FiO2 0.8 - 1.0The mortality rate: 82.6% 8.0% PICU mortality 7.1% all hospitalized

pediatric mortalityCauses of death: sepsis (52%)

severe pneumonia(42%)

Underlying diseases in ARDS

Underlying diseases N (%)Hemato-oncologic diseases 7 (30.4%)

Neuromuscular diseases 5 (21.7%)

Systemic lupus erythematosus 3 (13.0%)

End stage renal diseases 2 (8.7%)

Immunodeficiency 2 (8.7%)

Obstructive sleep apnea 1 (4.3%)

None 3 (13.0%)

Maximum ventilatory settings of non-survived patients

NoAge (yr) Sex

Predisposing factors

Duration(days) FiO2

PEEP(cmH2O)

PIP(cmH2O)

cause ofdeath

1 7.8 M Pneumonia 16 0.8 10 50 Pneumonia2 3.2 M Pneumonia 3 1 12 34 Pneumonia3 2.7 F Pneumonia 13 1 12 47 PCP4 13.1 M Sepsis 1 1 8 32 Sepsis5 5.8 F Sepsis 29 1 14 47 Sepsis6 12.5 M Pneumonia 14 1 5 40 Pneumonia 7 3 F Sepsis 2 0.95 10 24 Sepsis8 10.1 F Sepsis 1 1 6 28 Sepsis9 1.9 M Sepsis 12 0.8 12 34 Sepsis

10 3.4 F Pneumonia 8 1 12 32 Pneumonia

No Age (yr)

Sex Predisposingfactors

Duration(days)

FiO2 PEEP(cmH2O)

PIP(cmH2O)

cause ofdeath

11 13 F Sepsis 5 0.85 10 28 Sepsis

12 9.8 F Pneumonia 32 1 14 36 Pneumonia

13 0.9 M Pneumonia 3 1 9 36 Sepsis

14 6.8 F Pneumonia 4 1 10 24 Sepsis

15 1.5 M Sepsis 2 1 10 32 Sepsis

16 2.1 F Aspiration 18 0.6 MAP25 dP 60 Pneumonia

17 8.5 F Pneumonia 25 1 8 32 Staph IE

18 12.8 F Sepsis 3 1 10 24 Sepsis

19 15.8 F Pneumonia 11 1 12 35 Pneumonia

Non-survived patients(cont.)

Survived patients

No Age (yr)

Sex Predisposingfactors

Duration(days)

FiO2 PEEP(cmH2O)

PIP(cmH2O)

1 9.8 M Pneumonia 5 1 10 28

2 2.1 F Aspiration 38 1 9 44

3 15 F Pneumonia 4 1 10 26

4 9 F Aspiration 22 1 8 36

Complications in ARDSComplications NAir leak 7Organ failure NHypotension 6Acute renal failure 4DIC 4Seizure 3Hepatitis 1

Factors associated with mortality in ARDS

Total organ failure 4 Survived Patients (%)

19 Non-survived patients (%)

None 4 (100%) 2 (10.5%)

1 organ failure 0 11 (58.0%)

2 organ failure 0 4 (21.0%)≥ 3 organ failure (Multi-organ failure) 0 2 (10.5%)

ARDS PICU Total admission

Number (cases) 23 1,050 13,333

Deaths (cases) 19 235 267

Mean LOS (days) 23 NA 8.1

Median LOS (days) 18 NA NA

Mean cost (Bahts) 96,374 NA 23,981

Median cost (Bahts) 77,400 NA NA

ARDS: Prolonged hospital stay was 2.8 folds of average LOS

High hospital cost was 4 folds of average hospital cost

DiscussionThis study Thailand1,2 Erickson et al3

Incidence 2.2% 3.3 - 3.6% 2.2 - 4.2%

Predisposing factors

Pneumonia 52%Sepsis 35%

Submersion 26.7%Sepsis 13.3%

Pneumonia 33 - 65%Sepsis 13 - 43%

Air leak 30% 23.3 - 37.5% 8 - 42%

Mortality rate 82.6% 75 - 83% 29 - 62%

1T. Prasanphanich et al. ARDS in children at Prapokklao Hospital. J Prapokklao Hosp Clin Med Educat Center 2005; 22: 113-20.2Ekasilp C et al. Acute severe hypoxemic respiratory failure in pediatric patients. J Ped Crit Care Med 2000: 1(suppl): 144.3Erickson S et al. Acute lung injury in pediatric intensive care in Australia and New Zealand.Pediatr

Crit Care Med 2007; 8: 317-23.

Conclusions• ARDS is a severe form of respiratory

failure in children• The mortality rate in children with

ARDS was very high especially in those with complications or organ failure

• Reducing the mortality rate is very challenging in pediatric critical care

Limitations

Retrospective study • undiagnosed cases• incomplete information • unavailable medical records

Acknowledgement• The Head of Department of Pediatrics,

Faculty of Medicine, Khon Kaen University

• Staff in Medical Record and Biostatistic Unit, Srinagarind Hospital, Khon Kaen

• The Head and Secretary of PICU, Srinagarind Hospital, Khon Kaen

Thank you for your attention