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

Intensive Care Medicine, Oct 2013

Purpose 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. Methods 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. Results 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)]. Conclusions 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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The use of the Berlin definition for acute respiratory distress syndrome during infancy and early childhood: multicenter evaluation and expert consensus

0 A. Medina Villanueva A. Vivanco Allende Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Universitario de Asturias , Oviedo, Spain 1 A. Tridente Intensive Care Unit, Whiston Hospital, St. Helen's and Knowsley Teaching Hospitals NHS Trust, UK and academic Unit of Medical Education, Sheffield Medical School, University of Sheffield , Sheffield, UK 2 Partial results were presented as a late- breaking oral communication at the 24th P. Tissieres S. Essouri Annual Meeting of the European Society of Pediatric Intensive Care Unit , Pediatric and Neonatal Intensive Care, CHU Kremlin-Bicetre, South Paris Rotterdam (NL), June 2013. University Teaching Hospitals , Paris, France 3 G. Chidini E. Calderini M. Antonelli Pediatric Intensive Care Unit, General Intensive Care Unit, Department of Department of Anesthesia and Critical Care , Anesthesia and Intensive Care, University Fondazione IRCCS Ca' Granda, Hospital ''Agostino Gemelli'', Catholic Ospedale Maggiore Policlinico, University of the Sacred Heart , Rome , Italy Milan, Italy 4 M. Hermon Division of Neonatology, Intensive Care and Neuro-pediatrics, Medical University of Vienna , Vienna, Austria 5 Respiratory Section of the European Society for Pediatric Neonatal Intensive Care (ESPNIC) 1-3 Rue de Chantepoulet , P.O. Box 1726, 1211 Geneva 1, Switzerland 6 M. Pons-Odena L. Perez-Baena Pediatric Intensive Care and Intermediate Care Unit, Department of Pediatrics, Hospital Universitari Sant Joan de Deu , Barcelona, Spain 7 D. De Luca Neonatal Intensive Care Unit , CHU Antoine Becle`re, South Paris University Teaching Hospitals , Paris, France 8 D. De Luca M. Piastra G. Conti Pediatric Intensive Care Unit, Department of Anesthesia and Intensive Care, University Hospital ''Agostino Gemelli'', Catholic University of the Sacred Heart , Rome, Italy 9 M. Kneyber Pediatric Intensive Care Unit, Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen , Groningen, The Netherlands Purpose: 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 (13.9 % for mild ARDS; 11.3 % for concordance between raters evaluat(risk factors list and illustrative moderate ARDS; 25 % for severe ing radiographs [ICC 0.6 (95 % CI radiographs) to help the application of ARDS, p = 0.04) and the composite 0.20.8)] and risk factors [ICC 0.92 BD. Methods: This was an interna- outcome extracorporeal membrane (95 % CI 0.80.97)]. Conclutional, multicenter, retrospective oxygenation (ECMO)/mortality sions: BD validity for children is study enrolling 221 children [aged (13.9 % for mild ARDS; 11.3 % for similar to that already reported in greater than 30 days and less than moderate ARDS; 28.4 % for severe adults and mainly due to the intro18 months; median age 6 (range ARDS, p \ 0.01) were different duction of a severe ARDS 213) months], admitted to seven across the BD classes, whereas they category. We provided clinical tools European pediatric intensive care were similar using the previous defi- to use BD for clinical practice, units (PICU) with acute lung injury nition. Mortality [HR 2.7 (95 % CI research, and health services planning (ALI) or ARDS diagnosed with the 1.17.1)] and ECMO/mortality [HR 3 in pediatric critical care. earlier definition. Results: Patients (95 % CI 1.17.9)] were increased were categorized according to the two only for the severe ARDS class and Keywords ARDS Children definitions, as follows: ALI, 36; remained significant after adjustment Diagnostic criteria ARDS, 185 (for the AmericanEuro- for confounding factors. PICU stay pean Consensus Conference (AECC) was not different across severity definition); mild, 36; moderate, 97; classes, irrespective of the definition severe ARDS, 88 (for BD). Mortality used. There was significant Introduction BD has been issued through a formal consensus process, followed by an empirical evaluation over a large The AmericanEuropean Consensus Conference (AECC) cohort of patients coming from different databases, defined acute respiratory distress syndrome (ARDS) demonstrating that the BD predicts mortality and venti19 years ago [1]: since then, this definition has not been latory requirements better than the AECC definition [2]. modified and has been used worldwide for clinical and Finally, illustrative clinical pictures for ARDS identifiresearch purposes. In the meantime, accumulating data cation have also been produced. led to criticisms of the AECC definition, and thus ARDS The Respiratory Section of the European Society for has been recently redefined according to an international Pediatric and Neonatal Intensive Care (ESPNIC) c (...truncated)


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Daniele De Luca, Marco Piastra, Giovanna Chidini, Pierre Tissieres, Edoardo Calderini, Sandrine Essouri, Alberto Medina Villanueva, Ana Vivanco Allende, Marti Pons-Odena, Luis Perez-Baena, Michael Hermon, Ascanio Tridente, Giorgio Conti, Massimo Antonelli, Martin Kneyber, On behalf of Respiratory Section of the European Society for Pediatric Neonatal Intensive Care (ESPNIC). The use of the Berlin definition for acute respiratory distress syndrome during infancy and early childhood: multicenter evaluation and expert consensus, Intensive Care Medicine, 2013, pp. 2083-2091, Volume 39, Issue 12, DOI: 10.1007/s00134-013-3110-x