ACUTE RESPIRATORY DISTRESS SYNDROME IN CHILDREN IN SRINAGARIND HOSPITAL: A 5 YEAR RETROSPECTIVE STUDY Amnuayporn Apiraksakorn 1, MD Jamaree Teeratakulpisarn 1, MD Jiraporn Srinakarin 2, MD Department of Pediatrics 1 and Radiology 2,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 ARDS Protein rich edema fluid

Diagnostic criteria The 1994 American European Concensus Conference (AECC) criteria 1.Acute onset 2.PaO 2 /FiO 2 ratio < 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:

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

Literature review Erickson S et al. Acute lung injury in pediatric intensive care in Australia and New Zealand.Pediatr Crit Care Med 2007; 8: DescriptionsGoh et al. (1998) Costil et al. (1995) Dahlem et al. (2003) Flori et al. (2005) ANZICS PSG (2007) Incidence (% admissions) 4.2 %2 %4 %NA2.2 % EtiologySepsis 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% Mortality62 %60 %31 %29 %39 %

Objectives incidence predisposing factors mechanical ventilatory settings outcomes complications mortality To assess

Methods Retrospective descriptive study Approved by The Khon Kaen University Ethics Committee For Human Research All charts of ARDS admitted to Pediatric Intensive Care Unit (PICU), Srinagarind Hospital, Thailand, from 2004 to 2008 were reviewed

Inclusion criteria 1. All pediatric patients age 1 month to 16 years admitted to PICU in Srinagarind Hospital during 1 January 2004 to 31 December Diagnosed with ARDS according to AECC criteria (reviewed CXR by radiologist)

Exclusion criteria 1.cyanotic congenital heart diseases 2.chronic hypoxemic lung diseases 3.unavailable or incomplete medical records

Results J80: ARDS 34 cases Unavailable medical 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 cases Year

ARDSPICUTotal admissions N (cases) Deaths (cases) Mean LOS (days) N (cases) Deaths (cases) N (cases) Deaths (cases) Mean LOS (days) , , , , , Total2319-1, , Mean ,

Results 23 cases met AECC criteria for ARDS Male : female = 1 : 1.6 average age 7.4 years ( 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 cmH 2 O, PEEP cmH 2 O, FiO The mortality rate: 82.6% 8.0% PICU mortality 7.1% all hospitalized pediatric mortality Causes of death: sepsis (52%) severe pneumonia(42%)

Underlying diseases in ARDS Underlying diseasesN (%) Hemato-oncologic diseases7 (30.4%) Neuromuscular diseases5 (21.7%) Systemic lupus erythematosus3 (13.0%) End stage renal diseases2 (8.7%) Immunodeficiency2 (8.7%) Obstructive sleep apnea1 (4.3%) None3 (13.0%)

Maximum ventilatory settings of non-survived patients No Age (yr) Sex Predisposing factors Duration (days) FiO 2 PEEP (cmH 2 O) PIP (cmH 2 O) cause of death 17.8MPneumonia Pneumonia 23.2MPneumonia311234Pneumonia 32.7FPneumonia PCP 413.1MSepsis11832Sepsis 55.8FSepsis Sepsis 612.5MPneumonia141540Pneumonia 73FSepsis Sepsis 810.1FSepsis11628Sepsis 91.9MSepsis Sepsis 103.4FPneumonia811232Pneumonia

NoAge (yr) SexPredisposing factors Duration (days) FiO 2 PEEP (cmH 2 O) PIP (cmH 2 O) cause of death 1113FSepsis Sepsis 129.8FPneumonia Pneumonia 130.9MPneumonia31936Sepsis 146.8FPneumonia411024Sepsis 151.5MSepsis211032Sepsis 162.1FAspiration180.6MAP25dP 60Pneumonia 178.5FPneumonia251832Staph IE FSepsis311024Sepsis FPneumonia Pneumonia Non-survived patients(cont.)

Survived patients NoAge (yr) SexPredisposing factors Duration (days) FiO 2 PEEP (cmH 2 O) PIP (cmH 2 O) 19.8MPneumonia FAspiration FPneumonia FAspiration221836

Complications in ARDS ComplicationsN Air leak7 Organ failureN Hypotension6 Acute renal failure4 DIC4 Seizure3 Hepatitis1

Factors associated with mortality in ARDS Total organ failure 4 Survived Patients (%) 19 Non-survived patients (%) None4 (100%)2 (10.5%) 1 organ failure011 (58.0%) 2 organ failure04 (21.0%) ≥ 3 organ failure (Multi-organ failure)02 (10.5%)

ARDSPICUTotal admission Number (cases)231,05013,333 Deaths (cases) Mean LOS (days)23NA8.1 Median LOS (days)18NA Mean cost (Bahts)96,374NA23,981 Median cost (Bahts)77,400NA ARDS: Prolonged hospital stay was 2.8 folds of average LOS High hospital cost was 4 folds of average hospital cost

Discussion This studyThailand 1,2 Erickson et al 3 Incidence2.2% % % Predisposing factors Pneumonia 52% Sepsis 35% Submersion 26.7% Sepsis 13.3% Pneumonia % Sepsis % Air leak30% %8 - 42% Mortality rate82.6% % % 1 T. Prasanphanich et al. ARDS in children at Prapokklao Hospital. J Prapokklao Hosp Clin Med Educat Center 2005; 22: Ekasilp C et al. Acute severe hypoxemic respiratory failure in pediatric patients. J Ped Crit Care Med 2000: 1(suppl): Erickson S et al. Acute lung injury in pediatric intensive care in Australia and New Zealand.Pediatr Crit Care Med 2007; 8:

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

Suggestions Multi-centered prospective trials should be performed to include more patients, to reduce missing cases and collect complete data Patients who survived ARDS should be followed up to determine long-term outcomes and late complications Evidence-based national guidelines for treatment of ARDS should be developed

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

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