Pediatric ARDS common, associated with more severe disease in lower respiratory infections

Pediatric acute respiratory distress syndrome is common in children intubated for lower respiratory tract infections and was associated with increased mortality, mechanical ventilation, and ICU and hospital length of stay, data show.

Researchers performed a secondary analysis of the BACON study, a large international prospective, observational study, to evaluate children with pediatric ARDS on the first study day. The BACON study included 556 children younger than 2 years with lower respiratory tract infection who were intubated for acute respiratory failure at 44 sites from December 2018 to November 2020.

“Pediatric ARDS (PARDS) is present in 6% of all mechanically ventilated children, as found by the PARDS study, and a recent single-center study of patients with bronchiolitis showed that this rate was 27%,” Benjamin R. White, MD, MA, assistant professor of pediatric critical care medicine at Penn State Health Children’s Hospital in Hershey, Pennsylvania, said during a presentation at the virtual Society of Critical Care Medicine Congress. “Even though this population has been well described in an epidemiological sense to clinical management and bronchiolitis and lower respiratory tract infections, especially in the pediatric ICU, has been understudied.”

Lower respiratory tract infection type was determined by the patients’ bedside provider, and bacterial co-detection was defined as any respiratory culture with moderate or greater polymorphonuclear leukocytes and moderate or greater bacterial growth.

On study day one, 41% of patients (median age, 5 months; 60% boys) had PARDS with 51% presenting with mild disease, 36% with moderate and 12% with severe disease.

Both chronic lung disease presence (5.3% vs. 3.6%) and prematurity (31% vs. 29%) were not associated with a statistically increased PARDS frequency between those with and without pediatric ARDS, respectively. Major developmental delay was significantly more common among children with PARDS compared with those without (9.3% vs. 4.9%). Though there was no difference in home medication use between the two groups, researchers observed a trend toward increased steroid use among children with PARDS (8.9% vs. 4.9%).

Mortality in this patient population was more than two times more likely among children with PARDS (8.4% vs. 3.1%; P = .007). PARDS was associated with significantly longer mechanical ventilation duration (168 vs. 134 hours), ICU length of stay (11.4 vs. 8 days) and hospital length of stay (18 vs. 13 days).

In addition, children with comorbidities had longer ICU length of stay (12.3 vs. 10.6 days) and hospital length of stay (18.7 vs. 16.8 days). As PARDS severity increased from mild to moderate to severe, so did mortality (0.9% vs. 7.4% vs. 43%, respectively), mechanical ventilation duration (10 vs. 12.6 vs. 13.5 days, respectively) and ICU length of stay (16.1 vs. 19.9 vs. 21.8 days, respectively).

PARDS was associated with higher rates of moderate or greater polymorphonuclear leukocytes (68 vs. 55; P = .003) and bacterial co-detection (30 vs. 21; P = .014). Researchers observed a significant decrease in culture positivity with increasing PARDS severity, with 59 for mild, 40 for moderate and 25 for severe (P = .001).

“Future prospective investigations will be needed to determine the significance of these relationships and whether they present modifiable effects that interventions, such as lung protective ventilation or early antibiotic administration, can affect,” White said.