Journal Information
Vol. 90. Issue 2.
Pages 211-212 (March - April 2014)
Share
Share
Download PDF
More article options
Vol. 90. Issue 2.
Pages 211-212 (March - April 2014)
Letter to the Editor
Open Access
ARDS definitions in children: one step forward
Definições da SDRA em crianças: um passo adiante
Visits
4370
José R. Fiorettoa,
Corresponding author
jrf@fmb.unesp.br

Corresponding author.
, Werther B. de Carvalhob
a Department of Pediatrics, Universidade do Estado de São Paulo (UNESP), Botucatu, SP, Brazil
b School of Medicine, Universidade de São Paulo (USP), São Paulo, SP, Brazil
Related content
This item has received

Under a Creative Commons license
Article information
Full Text
Bibliography
Download PDF
Statistics
Tables (1)
Table 1. Distribution and outcomes of the patients according to the American European Consensus Conference (AECC) and the Berlin Definition.
Full Text
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 BD5 for adults and children is an advance, in the sense that ARDS stratification is important for diagnosis and treatment. However, it was obvious that pediatricians working in clinical or basic research needed to validate the new data in children. The work performed by The Respiratory Section of ESPNIC2 enrolled 221 children, median age 6 months (range 2‐13 months), which were categorized according to the two definitions. The authors found very interesting and important results. Applying AECC, 36 children were classified as ALI and 185 as ARDS, with mortality rates of 13.9% and 17.8%, respectively. Conversely, 36 were classified as mild, 97 as moderate, and 88 as severe ARDS when applying the BD. The BD described the clinical situation better than AECC, with similar results published in adults. Also, the main outcomes were significantly different only for severe ARDS; mortality was 13.9% for mild ARDS, 11.3% for moderate ARDS, and 25% for severe ARDS. They did not find significant differences between mild and moderate classes. However, the inclusion of a severe category in the BD helped to increase its validity. Despite not aimed at identifying risk factors and their association with ARDS, some were presented (sepsis, near‐drowning, congenital immunodeficiencies, thoracic trauma, etc.). As expected, they are different than those in the adult population. A properly designed study is therefore necessary to address this issue. The authors concluded that the new ARDS definition correctly adjusts and is able to define the syndrome in its population, subdividing it into mild/moderate and severe ARDS.

Some limitations were addressed. Firstly, the number of patients included was not large. This is a difficulty in all pediatric studies, as populations of children in intensive care are much smaller than those of adults. Secondly, clinical data was not correlated with lung morphology. However, lung biopsy is not commonly performed in critically ill children.

The Brazilian Pediatric ARDS Study Group6 performed a prospective, multicentre cohort study from March to September of 2013, which aimed: (1) to evaluate the prevalence of ARDS; (2) to determine risk factors for ARDS; and (3) to evaluate whether the use of BD in critically ill children can better discriminate the severity of the disease compared with the AECC definition. The distribution and outcomes of the patients according to the AECC and BD are shown in Table 1.

Table 1.

Distribution and outcomes of the patients according to the American European Consensus Conference (AECC) and the Berlin Definition.

  AECC (n = 58)Berlin Definition (n = 57)
  ALI  ARDS  Mild  Moderate  Severe 
Number of patients (%)  10 (17)  48 (82.7)  9 (15.7)  21 (36.8)  27 (47.3) 
MV only (%)  9 (90)  48 (100)  9 (100)  21 (100)  17 (100) 
Received aditional NIV  4 (40)  16 (33.3)  4 (44.4)  7 (33.3)  9 (52) 
Ventilator free days (median, IQR)  22 (20‐24)  14 (0‐20)  22 (0‐25)  20 (0‐27)  5 (0‐23) 
PICU LOS  10  12.5  11 (8‐20)  12 (8.7‐15.2)  15 (11‐20) 
Hospital LOS  16.5  26  19 (13‐25.5)  19.5 (17.5‐35.5)  26 (14.7‐37) 
Mortality n (%)  0 (0)  14 (30.4)  0 (0)  3 (14.3)  11 (42.3) 

ALI, acute lung injury; ARDS, acute respiratory distress syndrome; LOS, length of stay; MV, mechanical ventilation; NIV, noninvasive mechanical ventilation; PICU, pediatric intensive care unit.

The BD better discriminates the severity of ARDS in children when compared to the AECC definition, as shown by the incremental increase in mortality rates and reduced number of ventilation‐free days in patients with severe ARDS.

In summary, we congratulate De Luca et al.2 for their timely study, and thank them for their comments. From now on, the pediatric community involved in critical care and emergency medicine, of which we are members, has specific parameters to compare when studying such a serious disease as ARDS in children. Moreover, we look forward to the authors taking a similar initiative in Latin America and other future projects.

Conflicts of interest

The authors declare no conflicts of interest.

References
[1]
D. De Luca, M. Kneyber, P.C. Rimensberger.
International collaborative research for pediatric and neonatal lung injury: the example of an ESPNIC initiative to validate definitions and formulate future research questions.
J Pediatr (Rio J), 90 (2014), pp. 209-211
[2]
D. De Luca, M. Piastra, G. Chidini, P. Tissieres, E. Calderini, S. Essouri, et al.
The use of the Berlin definition for acute respiratory distress syndrome during infancy and early childhood: multicenter evaluation and expert consensus.
Intensive Care Med, 39 (2013), pp. 2083-2091
[3]
G.R. Bernard, A. Artigas, K.L. Brigham, J. Carlet, K. Falke, L. Hudson, et al.
The American‐European Consensus Conference on ARDS.
Am Rev Respir Dis, 149 (1994), pp. 818-824
[4]
J.R. Fioretto, W.B. de Carvalho.
Temporal evolution of acute respiratory distress syndrome definitions.
J Pediatr (Rio J), 89 (2013), pp. 523-530
[5]
ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, et al..
Acute respiratory distress syndrome: the Berlin Definition.
JAMA, 307 (2012), pp. 2526-2533
[6]
Barreira ER, Shieh HH, Suzuki AS, Ortega G, Degaspare N, Cavalheiro P, et al. Epidemiology and outcomes of ARDS in critically ill children according to the Berlin definition: a prospective study.(unpublished data).

Please cite this article as: Fioretto JR, de Carvalho WB. ARDS definitions in children: one step forward. J Pediatr (Rio J). 2014;90:211–2.

Copyright © 2013. Sociedade Brasileira de Pediatria
Download PDF
Idiomas
Jornal de Pediatria (English Edition)
Article options
Tools
en pt
Taxa de publicaçao Publication fee
Os artigos submetidos a partir de 1º de setembro de 2018, que forem aceitos para publicação no Jornal de Pediatria, estarão sujeitos a uma taxa para que tenham sua publicação garantida. O artigo aceito somente será publicado após a comprovação do pagamento da taxa de publicação. Ao submeterem o manuscrito a este jornal, os autores concordam com esses termos. A submissão dos manuscritos continua gratuita. Para mais informações, contate assessoria@jped.com.br. Articles submitted as of September 1, 2018, which are accepted for publication in the Jornal de Pediatria, will be subject to a fee to have their publication guaranteed. The accepted article will only be published after proof of the publication fee payment. By submitting the manuscript to this journal, the authors agree to these terms. Manuscript submission remains free of charge. For more information, contact assessoria@jped.com.br.
Cookies policy Política de cookies
To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here. Utilizamos cookies próprios e de terceiros para melhorar nossos serviços e mostrar publicidade relacionada às suas preferências, analisando seus hábitos de navegação. Se continuar a navegar, consideramos que aceita o seu uso. Você pode alterar a configuração ou obter mais informações aqui.