LETTERSTOTHEEDITOR 211
DanieleDeLucaa,b,∗,MartinKneyberc,d,
PeterC.Rimensbergere
aDivisionofPediatricsandNeonatalCriticalCare, DepartmentofFAME,SouthParisUniversityHospitals, MedicalCenter‘‘A.Béclére’’---APHP,Paris,France bInstituteofAnesthesiologyandCriticalCare,Catholic UniversityoftheSacredHeart,Rome,Italy
cDepartmentofPediatrics,DivisionofPediatricIntensive Care,BeatrixChildren’sHospital,UniversityMedical CenterGroningen,Groningen,TheNetherlands
dPeri-operativeMedicineandEmergencyMedicine(CAPE), UniversityofGroningen,Groningen,TheNetherlands eServiceofNeonatologyandPediatricCriticalCare, DepartmentofPediatrics,UniversityHospitalofGeneva, Geneva,Switzerland
∗Correspondingauthor.
E-mail:dm.deluca@icloud.com(D.DeLuca).
http://dx.doi.org/10.1016/j.jped.2013.12.003
ARDS
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DearSir,
It waswith greatinterest and pleasure that we read the Letter tothe Editor entitled ‘‘International collaborative researchforpediatricandneonatallunginjury:theexample of an ESPNIC initiative to validate definitions and formu-latefutureresearchquestions’’byDanieleDeLucaetal.1 The authors commented that the European Society for Pediatric and Neonatal Intensive Care (ESPNIC) published the first validation of the acute respiratory distress syn-drome (ARDS) Berlin Definition (BD) in early childhood.2 MembersoftheESPNICRespiratorySectionperformeda ret-rospective international(Italy,Spain, France,Austria, and theNetherlands)multicenterstudyincludingchildrenaged between30daysand18monthswithARDSaccordingtothe American-EuropeanConsensusConference(AECC)criteria.3 Itelegantlyaddressesourconcerns onthe applicabilityof BDinpediatricswhenwedescribed theevolutionofARDS definitions.4
A time lapse between the two publications prevented exact connections between them; nowis the opportunity todoso.TheBD5foradultsandchildrenisanadvance,in thesensethatARDSstratificationisimportantfordiagnosis andtreatment.However,itwasobvious thatpediatricians workinginclinicalorbasicresearchneededtovalidatethe new datain children. The work performed by The Respi-ratory Section of ESPNIC2 enrolled 221 children, median age6months(range2-13months),whichwerecategorized according to the two definitions. The authors found very interesting andimportantresults. Applying AECC,36 chil-drenwereclassifiedasALIand185asARDS,withmortality ratesof13.9%and17.8%,respectively.Conversely,36were classifiedasmild,97 asmoderate, and88assevereARDS
DOIofreferstoarticle:http://dx.doi.org/10.1016/j.jped.2013.
12.003
夽
Please cite this article as: Fioretto JR, de Carvalho WB.
ARDSdefinitionsinchildren:onestepforward.JPediatr(RioJ).
2014;90:211---2.
when applyingthe BD. The BD described the clinical sit-uationbetterthan AECC, withsimilarresults publishedin adults.Also,themainoutcomesweresignificantlydifferent onlyfor severe ARDS; mortalitywas13.9% for mild ARDS, 11.3%formoderateARDS,and25%forsevereARDS.Theydid notfindsignificantdifferencesbetweenmildandmoderate classes.However,theinclusionofaseverecategoryinthe BDhelpedtoincreaseitsvalidity.Despitenotaimedat iden-tifyingrisk factors andtheir association withARDS, some werepresented (sepsis, near-drowning, congenital immu-nodeficiencies,thoracic trauma, etc.). As expected, they aredifferent than those in the adult population. A prop-erlydesigned study is therefore necessary toaddress this issue.TheauthorsconcludedthatthenewARDS definition correctlyadjustsandisabletodefinethesyndromein 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 inten-sivecare aremuchsmallerthanthoseofadults.Secondly, clinicaldatawasnotcorrelatedwithlungmorphology. How-ever,lungbiopsyisnotcommonlyperformedincriticallyill children.
The Brazilian Pediatric ARDS Study Group6 performed a prospective, multicentre cohort study from March to Septemberof2013,whichaimed:(1)toevaluatethe preva-lenceofARDS;(2)todetermineriskfactorsforARDS;and (3)toevaluatewhethertheuseofBDincriticallyillchildren canbetterdiscriminatetheseverityofthediseasecompared withtheAECCdefinition.Thedistributionandoutcomesof the patients according to the AECC and BD areshown in
Table1.
TheBDbetterdiscriminatestheseverityofARDSin chil-drenwhen comparedtothe AECCdefinition, asshown by the incremental increase in mortality rates and reduced number of ventilation-free days in patients with severe ARDS.
212 LETTERSTOTHEEDITOR
Table1 DistributionandoutcomesofthepatientsaccordingtotheAmericanEuropeanConsensusConference(AECC)andthe
BerlinDefinition.
AECC(n=58) BerlinDefinition(n=57)
ALI ARDS Mild Moderate Severe
Numberofpatients(%) 10(17) 48(82.7) 9(15.7) 21(36.8) 27(47.3)
MVonly(%) 9(90) 48(100) 9(100) 21(100) 17(100)
ReceivedaditionalNIV 4(40) 16(33.3) 4(44.4) 7(33.3) 9(52)
Ventilatorfreedays(median,IQR) 22(20-24) 14(0-20) 22(0-25) 20(0-27) 5(0-23)
PICULOS 10 12.5 11(8-20) 12(8.7-15.2) 15(11-20)
HospitalLOS 16.5 26 19(13-25.5) 19.5(17.5-35.5) 26(14.7-37)
Mortalityn(%) 0(0) 14(30.4) 0(0) 3(14.3) 11(42.3)
ALI,acutelunginjury;ARDS,acuterespiratorydistress syndrome;LOS,lengthofstay;MV,mechanicalventilation;NIV,noninvasive mechanicalventilation;PICU,pediatricintensivecareunit.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.DeLucaD,Kneyber M,RimensbergerPC.International collab-orative research for pediatric and neonatal lung injury: the exampleofanESPNICinitiativetovalidatedefinitionsand for-mulatefuture researchquestions. JPediatr (Rio J). 2014;90: 209---11.
2.DeLucaD,PiastraM,ChidiniG,TissieresP,CalderiniE,Essouri S,et al.TheuseoftheBerlin definitionfor acuterespiratory distress syndrome during infancy and early childhood: multi-center evaluation and expert consensus. Intensive CareMed. 2013;39:2083---91.
3.BernardGR,ArtigasA,BrighamKL,CarletJ,FalkeK,HudsonL, etal.TheAmerican-EuropeanConsensusConferenceonARDS. AmRevRespirDis.1994;149:818---24.
4.Fioretto JR, de Carvalho WB. Temporal evolution of acute respiratory distress syndrome definitions. J Pediatr (Rio J). 2013;89:523---30.
5.ARDSDefinitionTaskForce,RanieriVM,RubenfeldGD,Thompson BT,FergusonND, Caldwell E,etal. Acuterespiratorydistress syndrome:theBerlinDefinition.JAMA.2012;307:2526---33.
6.Barreira ER, Shieh HH, Suzuki AS, Ortega G, Degaspare N, CavalheiroP,etal.EpidemiologyandoutcomesofARDSin criti-callyillchildrenaccordingtotheBerlindefinition:aprospective study.(unpublisheddata).
JoséR.Fiorettoa,∗,WertherB.deCarvalhob
aDepartmentofPediatrics,UniversidadedoEstadodeSão Paulo(UNESP),Botucatu,SP,Brazil
bSchoolofMedicine,UniversidadedeSãoPaulo(USP),São Paulo,SP,Brazil
∗Correspondingauthor.
E-mail:jrf@fmb.unesp.br(J.R.Fioretto).
