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[Lancet Respir Med发表论文]:儿童ARDS发病率及流行病学
2019年03月11日 时讯速递, 进展交流 暂无评论

ARTICLES

Paediatric acute respiratory distress syndrome incidence and epidemiology (PARDIE): an international, observational study

Robinder G Khemani, Lincoln Smith, Yolanda M Lopez-Fernandez, et al

Lancet Respir Med 2019; 7: 115-128

Background 背景

Paediatric acute respiratory distress syndrome (PARDS) is associated with high mortality in children, but until recently no paediatric-specific diagnostic criteria existed. The Pediatric Acute Lung Injury Consensus Conference (PALICC) definition was developed to overcome limitations of the Berlin definition, which was designed and validated for adults. We aimed to determine the incidence and outcomes of children who meet the PALICC definition of PARDS.

儿童ARDS (PARDS)病死率高,但至今为止没有针对儿童的诊断标准。柏林定义系针对成年患者制定并验证,儿童急性肺损伤共识会议(PALICC)标准的制定旨在克服柏林定义的局限性。我们的目的是确定满足PALICC的PARDS定义儿童的发病率及临床预后。

Methods 方法

In this international, prospective, cross-sectional, observational study, 145 paediatric intensive care units (PICUs) from 27 countries were recruited, and over a continuous 5 day period across 10 weeks all patients were screened for enrolment. Patients were included if they had a new diagnosis of PARDS that met PALICC criteria during the study week. Exclusion criteria included meeting PARDS criteria more than 24 h before screening, cyanotic heart disease, active perinatal lung disease, and preparation or recovery from a cardiac intervention. Data were collected on the PICU characteristics, patient demographics, and elements of PARDS (ie, PARDS risk factors, hypoxaemia severity metrics, type of ventilation), comorbidities, chest imaging, arterial blood gas measurements, and pulse oximetry. The primary outcome was PICU mortality. Secondary outcomes included 90 day mortality, duration of invasive mechanical and non-invasive ventilation, and cause of death.

在这项国际前瞻横断面观察研究中,27个国家145个儿科ICU (PICU)参加,在10周期间连续5天内对所有患者进行筛查。在研究期间满足PALICC诊断标准的PARDS患儿入选。排除标准包括筛查前满足PARDS标准超过24小时,紫绀性心脏病,活动性围产期肺疾病以及心脏干预治疗的准备或恢复阶段。收集PICU特征,患者人口统计学资料,及PARDS各项标准(即PARDS危险因素,低氧血症严重程度,通气种类),基础疾病,胸部影像,动脉血气及脉搏氧饱和度。主要预后指标为PICU病死率。次要预后指标包括90天病死率,有创机械通气及无创机械通气时间,死亡原因。

Findings 结果

Between May 9, 2016, and June 16, 2017, during the 10 study weeks, 23 280 patients were admitted to participating PICUs, of whom 744 (3·2%) were identified as having PARDS. 95% (708 of 744) of patients had complete data for analysis, with 17% (121 of 708; 95% CI 14–20) mortality, whereas only 32% (230 of 708) of patients met Berlin criteria with 27% (61 of 230) mortality. Based on hypoxaemia severity at PARDS diagnosis, mortality was similar among those who were non-invasively ventilated and with mild or moderate PARDS (10–15%), but higher for those with severe PARDS (33% [54 of 165; 95% CI 26–41]). 50% (80 of 160) of non-invasively ventilated patients with PARDS were subsequently intubated, with 25% (20 of 80; 95% CI 16–36) mortality. By use of PALICC PARDS definition, severity of PARDS at 6 h after initial diagnosis (area under the curve [AUC] 0·69, 95% CI 0·62–0·76) discriminates PICU mortality better than severity at PARDS diagnosis (AUC 0·64, 0·58–0·71), and outperforms Berlin severity groups at 6 h (0·64, 0·58–0·70; p=0·01).

在2016年5月9日至2017年6月16日期间,在为期10周的研究期间,共有23280名患者收入参研PICU,其中744名(3.2%)罹患PARDS。95%的患者(708/744)数据完整可供分析,其中17%死亡(121/708; 95% CI 14–20),且仅有32% (230/708)满足柏林标准,病死率27% (61/230)。根据PARDS诊断时低氧血症的严重程度,接受无创通气的轻中度PARDS患者的病死率相似(10–15%),但重度PARDS患者病死率较高(33% [54/165; 95% CI 26–41])。50% (80/160)接受无创通气的PARDS患者需要气管插管,病死率为25% (20/80; 95% CI 16–36)。根据PALICC PARDS定义,诊断后6小时PARDS严重程度(曲线下面积[AUC] 0·69, 95% CI 0·62–0·76)较PARDS诊断当时的严重程度(AUC 0·64, 0·58–0·71)与PICU病死率更为相关,且优于6小时柏林定义严重程度分组(0·64, 0·58–0·70; p=0·01)。

Interpretation 结论

The PALICC definition identified more children as having PARDS than the Berlin definition, and PALICC PARDS severity groupings improved the stratification of mortality risk, particularly when applied 6 h after PARDS diagnosis. The PALICC PARDS framework should be considered for use in future epidemiological and therapeutic research among children with PARDS.

与柏林定义相比,PALICC定义能够发现更多PARDS患儿,PALICC PARDS严重程度分组能够改进病死率风险分层,尤其是使用PARDS诊断后6小时的数据。PALICC PARDS可用于今后有关PARDS患儿流行病学及诊断研究。

Funding

University of Southern California Clinical Translational Science Institute, Sainte Justine Children's Hospital, University of Montreal, Canada, Réseau en Santé Respiratoire du Fonds de Recherche Quebec-Santé, and Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care Medicine.

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