ARDS definitions in children: one step forward

ARDS definitions in children: one step forward

Daniele De Luca, Martin C. J. Kneyber, Peter C. Rimensberger

01 Jan 2014-

TL;DR: enrolled 221 children, medianage 6 months (range 2-13 months), which were categorized according to the two deﬁnitions, and the authors found veryinteresting and important results.

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Abstract: enrolled 221 children, medianage 6 months (range 2-13 months), which were categorizedaccording to the two deﬁnitions. The authors found veryinteresting and important results. Applying AECC, 36 chil-dren were classiﬁed as ALI and 185 as ARDS, with mortalityrates of 13.9% and 17.8%, respectively. Conversely, 36 wereclassiﬁed as mild, 97 as moderate, and 88 as severe ARDS

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Journal Article•DOI•

Acute respiratory distress syndrome: the Berlin Definition.

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Ards Definition Task Force¹, V. Marco Ranieri¹, Gordon D. Rubenfeld², B. Taylor Thompson², Niall D. Ferguson³, Ellen Caldwell², Eddy Fan⁴, Luigi Camporota², Luigi Camporota⁵, Arthur S. Slutsky² - Show less +6 more•Institutions (5)

University of Turin¹, University of Toronto², Harvard University³, University of Washington⁴, Guy's and St Thomas' NHS Foundation Trust⁵

20 Jun 2012-JAMA

TL;DR: The updated and revised Berlin Definition for ARDS addresses a number of the limitations of the AECC definition and may serve as a model to create more accurate, evidence-based, critical illness syndrome definitions and to better inform clinical care, research, and health services planning.

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Abstract: The acute respiratory distress syndrome (ARDS) was defined in 1994 by the American-European Consensus Conference (AECC); since then, issues regarding the reliability and validity of this definition have emerged. Using a consensus process, a panel of experts convened in 2011 (an initiative of the European Society of Intensive Care Medicine endorsed by the American Thoracic Society and the Society of Critical Care Medicine) developed the Berlin Definition, focusing on feasibility, reliability, validity, and objective evaluation of its performance. A draft definition proposed 3 mutually exclusive categories of ARDS based on degree of hypoxemia: mild (200 mm Hg < PaO2/FIO2 ≤ 300 mm Hg), moderate (100 mm Hg < PaO2/FIO2 ≤ 200 mm Hg), and severe (PaO2/FIO2 ≤ 100 mm Hg) and 4 ancillary variables for severe ARDS: radiographic severity, respiratory system compliance (≤40 mL/cm H2O), positive end-expiratory pressure (≥10 cm H2O), and corrected expired volume per minute (≥10 L/min). The draft Berlin Definition was empirically evaluated using patient-level meta-analysis of 4188 patients with ARDS from 4 multicenter clinical data sets and 269 patients with ARDS from 3 single-center data sets containing physiologic information. The 4 ancillary variables did not contribute to the predictive validity of severe ARDS for mortality and were removed from the definition. Using the Berlin Definition, stages of mild, moderate, and severe ARDS were associated with increased mortality (27%; 95% CI, 24%-30%; 32%; 95% CI, 29%-34%; and 45%; 95% CI, 42%-48%, respectively; P < .001) and increased median duration of mechanical ventilation in survivors (5 days; interquartile [IQR], 2-11; 7 days; IQR, 4-14; and 9 days; IQR, 5-17, respectively; P < .001). Compared with the AECC definition, the final Berlin Definition had better predictive validity for mortality, with an area under the receiver operating curve of 0.577 (95% CI, 0.561-0.593) vs 0.536 (95% CI, 0.520-0.553; P < .001). This updated and revised Berlin Definition for ARDS addresses a number of the limitations of the AECC definition. The approach of combining consensus discussions with empirical evaluation may serve as a model to create more accurate, evidence-based, critical illness syndrome definitions and to better inform clinical care, research, and health services planning.

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7,731 citations

Journal Article•DOI•

The American-European Consensus Conference on ARDS: Definitions, mechanisms, relevant outcomes, and clinical trial coordination

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Gordon R. Bernard¹, Antonio Artigas¹, Kenneth L. Brigham¹, J. Carlet¹, K. Falke¹, L. Hudson¹, M. Lamy¹, J. R. LeGall¹, Alan H. Morris¹, Roger G. Spragg¹ - Show less +6 more•Institutions (1)

Vanderbilt University¹

27 Feb 1994-American Journal of Respiratory and Critical Care Medicine

TL;DR: The acute respiratory distress syndrome (ARDS), a process of nonhydrostatic pulmonary edema and hypoxemia associated with a variety of etiologies, carries a high morbidity, mortality, and financial cost.

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Abstract: The acute respiratory distress syndrome (ARDS), a process of nonhydrostatic pulmonary edema and hypoxemia associated with a variety of etiologies, carries a high morbidity, mortality (10 to 90%), and financial cost. The reported annual incidence in the United States is 150,000 cases, but this figure has been challenged, and it may be different in Europe. Part of the reason for these uncertainties are the heterogeneity of diseases underlying ARDS and the lack of uniform definitions for ARDS. Thus, those who wish to know the true incidence and outcome of this clinical syndrome are stymied. The American-European Consensus Committee on ARDS was formed to focus on these issues and on the pathophysiologic mechanisms of the process. It was felt that international coordination between North America and Europe in clinical studies of ARDS was becoming increasingly important in order to address the recent plethora of potential therapeutic agents for the prevention and treatment of ARDS.

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6,233 citations

"ARDS definitions in children: one s..." refers methods in this paper

...Members of the ESPNIC Respiratory Section performed a retrospective international (Italy, Spain, France, Austria, and the Netherlands) multicenter study including children aged between 30 days and 18 months with ARDS according to the American-European Consensus Conference (AECC) criteria.(3) It elegantly addresses our concerns on the applicability of BD in pediatrics when we described the evolution of ARDS definitions....
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Journal Article•DOI•

The use of the Berlin definition for acute respiratory distress syndrome during infancy and early childhood: multicenter evaluation and expert consensus

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Daniele De Luca¹, Daniele De Luca², Marco Piastra², Giovanna Chidini³, Pierre Tissieres¹, Edoardo Calderini³, Sandrine Essouri¹, Alberto Medina Villanueva, Ana Vivanco Allende, Martí Pons-Òdena, Luis Perez-Baena, Michael Hermon⁴, Ascanio Tridente⁵, Giorgio Conti², Massimo Antonelli², Martin C. J. Kneyber⁶ - Show less +12 more•Institutions (6)

University of Paris¹, Catholic University of the Sacred Heart², Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico³, Medical University of Vienna⁴, University of Sheffield⁵, University Medical Center Groningen⁶

08 Oct 2013-Intensive Care Medicine

TL;DR: BD validity for children is similar to that already reported in adults and mainly due to the introduction of a “severe ARDS” category.

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Abstract: A new acute respiratory distress syndrome (ARDS) definition has been recently issued: the so-called Berlin definition (BD) has some characteristics that could make it suitable for pediatrics. The European Society for Pediatric Neonatal Intensive Care (ESPNIC) Respiratory Section started a project to evaluate BD validity in early childhood. A secondary aim was reaching a consensus on clinical tools (risk factors list and illustrative radiographs) to help the application of BD. This was an international, multicenter, retrospective study enrolling 221 children [aged greater than 30 days and less than 18 months; median age 6 (range 2–13) months], admitted to seven European pediatric intensive care units (PICU) with acute lung injury (ALI) or ARDS diagnosed with the earlier definition. Patients were categorized according to the two definitions, as follows: ALI, 36; ARDS, 185 (for the American–European Consensus Conference (AECC) definition); mild, 36; moderate, 97; severe ARDS, 88 (for BD). Mortality (13.9 % for mild ARDS; 11.3 % for moderate ARDS; 25 % for severe ARDS, p = 0.04) and the composite outcome extracorporeal membrane oxygenation (ECMO)/mortality (13.9 % for mild ARDS; 11.3 % for moderate ARDS; 28.4 % for severe ARDS, p < 0.01) were different across the BD classes, whereas they were similar using the previous definition. Mortality [HR 2.7 (95 % CI 1.1–7.1)] and ECMO/mortality [HR 3 (95 % CI 1.1–7.9)] were increased only for the severe ARDS class and remained significant after adjustment for confounding factors. PICU stay was not different across severity classes, irrespective of the definition used. There was significant concordance between raters evaluating radiographs [ICC 0.6 (95 % CI 0.2–0.8)] and risk factors [ICC 0.92 (95 % CI 0.8–0.97)]. BD validity for children is similar to that already reported in adults and mainly due to the introduction of a “severe ARDS” category. We provided clinical tools to use BD for clinical practice, research, and health services planning in pediatric critical care.

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100 citations

"ARDS definitions in children: one s..." refers methods in this paper

...Dear Sir, It was with great interest and pleasure that we read the Letter to the Editor entitled ‘‘International collaborative research for pediatric and neonatal lung injury: the example of an ESPNIC initiative to validate definitions and formulate future research questions’’ by Daniele De Luca et al.1 The authors commented that the European Society for Pediatric and Neonatal Intensive Care (ESPNIC) published the first validation of the acute respiratory distress syndrome (ARDS) Berlin Definition (BD) in early childhood.2 Members of the ESPNIC Respiratory Section performed a retrospective international (Italy, Spain, France, Austria, and the Netherlands) multicenter study including children aged between 30 days and 18 months with ARDS according to the American-European Consensus Conference (AECC) criteria.3 It elegantly addresses our concerns on the applicability of BD in pediatrics when we described the evolution of ARDS definitions.4 A time lapse between the two publications prevented exact connections between them; now is the opportunity to do so....
[...]
...The authors commented that the European Society for Pediatric and Neonatal Intensive Care (ESPNIC) published the first validation of the acute respiratory distress syndrome (ARDS) Berlin Definition (BD) in early childhood.(2) Members of the ESPNIC Respiratory Section performed a retrospective international (Italy, Spain, France, Austria, and the Netherlands) multicenter study including children aged between 30 days and 18 months with ARDS according to the American-European Consensus Conference (AECC) criteria....
[...]
...In summary, we congratulate De Luca et al.(2) for their timely study, and thank them for their comments....
[...]
...In summary, we congratulate De Luca et al.2 for their timely study, and thank them for their comments....
[...]

Journal Article•DOI•

Temporal evolution of acute respiratory distress syndrome definitions

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José Roberto Fioretto¹, Werther Brunow de Carvalho²•Institutions (2)

Sao Paulo State University¹, University of São Paulo²

01 Nov 2013-Jornal De Pediatria

TL;DR: The evolution of definitions used to describe the disease shows that studies are needed to validate the current definition, especially in pediatrics, where the data are very scarce.

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Abstract: www.jped.com.br Abstract Objective: to review the evolution of acute respiratory distress syndrome (ARDS) definitions and present the current definition for the syndrome. Data source: a literature review and selection of the most relevant articles on ARDS definitions was performed using the MEDLINE®/PubMed® Resource Guide database (last ten years), in addition to including the most important articles (classic articles) that described the disease evolution.

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23 citations

Journal Article•DOI•

International collaborative research for pediatric and neonatal lung injury: the example of an ESPNIC initiative to validate definitions and formulate future research questions

[...]

Daniele De Luca¹, Daniele De Luca², Martin C. J. Kneyber, Peter C. Rimensberger³•Institutions (3)

University of Paris¹, Catholic University of the Sacred Heart², University of Geneva³

01 Mar 2014-Jornal De Pediatria

TL;DR: The European Society for Pediatric and Neonatal Intensive Care (ESPNIC), together with some members of the original ARDS Task Force, have set up an international collaborative project to validate the new Berlin definition for infants and toddlers.

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Abstract: An interesting review of acute respiratory distress (ARDS) definitions has been recently published in the Jornal de Pediatria, focusing on actual needs in terms of research and clinical care of pediatric ARDS. Unfortunately, timing prevented the consideration of an important step forward in this field. The European Society for Pediatric and Neonatal Intensive Care (ESPNIC), together with some members of the original ARDS Task Force, have set up an international collaborative project to validate the new Berlin definition for infants and toddlers. This project is the first initiative linking different pediatric intensive care units (PICU) in order to reach enough statistical power to address a specific research need. Figure 1 shows the ESPNIC net for this project. Indeed, as Fioretto et al. summarized, no specific pediatric validation had ever been conducted, even though some children were included in the original ARDS definition proposed by Ashbaugh et al. in 1967. Fioretto et al. described several possible limitations of the Berlin definition: however, some of the points raised by these authors should not be considered as a limitation, since the new Berlin definition is not supposed to be a predictive tool, but rather a framework to define a syndrome for epidemiology, clinical care, and research.

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5 citations

"ARDS definitions in children: one s..." refers background in this paper

...Dear Sir, It was with great interest and pleasure that we read the Letter to the Editor entitled ‘‘International collaborative research for pediatric and neonatal lung injury: the example of an ESPNIC initiative to validate definitions and formulate future research questions’’ by Daniele De Luca et al.1 The authors commented that the European Society for Pediatric and Neonatal Intensive Care (ESPNIC) published the first validation of the acute respiratory distress syndrome (ARDS) Berlin Definition (BD) in early childhood.2 Members of the ESPNIC Respiratory Section performed a retrospective international (Italy, Spain, France, Austria, and the Netherlands) multicenter study including children aged between 30 days and 18 months with ARDS according to the American-European Consensus Conference (AECC) criteria.3 It elegantly addresses our concerns on the applicability of BD in pediatrics when we described the evolution of ARDS definitions.4 A time lapse between the two publications prevented exact connections between them; now is the opportunity to do so....
[...]
...In summary, we congratulate De Luca et al.2 for their timely study, and thank them for their comments....
[...]
...It was with great interest and pleasure that we read the Letter to the Editor entitled ‘‘International collaborative research for pediatric and neonatal lung injury: the example of an ESPNIC initiative to validate definitions and formulate future research questions’’ by Daniele De Luca et al.(1) The authors commented that the European Society for Pediatric and Neonatal Intensive Care (ESPNIC) published the first validation of the acute respiratory distress syndrome (ARDS) Berlin Definition (BD) in early childhood....
[...]

ARDS definitions in children: one step forward

References

"ARDS definitions in children: one s..." refers methods in this paper

"ARDS definitions in children: one s..." refers methods in this paper

"ARDS definitions in children: one s..." refers background in this paper

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