Courtney M Rowan1, Margaret J Klein2, Deyin Doreen Hsing3, Mary K Dahmer4, Philip C Spinella5, Guillaume Emeriaud6, Amanda B Hassinger7, Byron E Piñeres-Olave8, Heidi R Flori4, Bereketeab Haileselassie9, Yolanda M Lopez-Fernandez10, Ranjit S Chima11, Steven L Shein12, Aline B Maddux13, Jon Lillie14, Ledys Izquierdo15, Martin C J Kneyber16, Lincoln S Smith17, Robinder G Khemani2, Neal J Thomas18, Nadir Yehya19. 1. Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at IU Health, Indianapolis, Indiana. 2. Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles and University of Southern California, Los Angeles, California. 3. Department of Pediatrics, New York Presbyterian Hospital and Weill Cornell Medical College, New York, New York. 4. Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan. 5. Division of Critical Care, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri. 6. Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine and Université de Montréal, Montreal, Quebec, Canada. 7. Division of Pediatric Critical Care, Department of Pediatrics, Oishei Children's Hospital and University of Buffalo, Buffalo, New York. 8. Hospital Pablo Tobón Uribe, Medellín, Colombia. 9. Division of Pediatric Critical Care, Department of Pediatrics, Stanford University, Palo Alto, California. 10. Department of Pediatrics, Cruces University Hospital, Bizkaia, Basque Country, Spain. 11. Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio. 12. Division of Pediatric Critical Care Medicine, Department of Pediatrics, Rainbow Babies and Children's Hospital and Case Western Reserve University, Cleveland, Ohio. 13. Department of Pediatrics, Children's Hospital Colorado and University of Colorado, Aurora, Colorado. 14. Evelina London Children's Hospital, London, United Kingdom. 15. Department of Pediatrics, Hospital Militar Central, Bogotá, Colombia. 16. Division of Pediatric Critical Care Medicine, Department of Pediatrics, Beatrix Children's Hospital and University of Groningen, Groningen, the Netherlands. 17. Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, Washington. 18. Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children's Hospital, Hershey, Pennsylvania and. 19. Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania.
Abstract
Rationale: Few data exist to guide early adjunctive therapy use in pediatric acute respiratory distress syndrome (PARDS). Objectives: To describe contemporary use of adjunctive therapies for early PARDS as a framework for future investigations. Methods: This was a preplanned substudy of a prospective, international, cross-sectional observational study of children with PARDS from 100 centers over 10 study weeks.Measurements and Main Results: We investigated six adjunctive therapies for PARDS: continuous neuromuscular blockade, corticosteroids, inhaled nitric oxide (iNO), prone positioning, high-frequency oscillatory ventilation (HFOV), and extracorporeal membrane oxygenation. Almost half (45%) of children with PARDS received at least one therapy. Variability was noted in the median starting oxygenation index of each therapy; corticosteroids started at the lowest oxygenation index (13.0; interquartile range, 7.6-22.0) and HFOV at the highest (25.7; interquartile range, 16.7-37.3). Continuous neuromuscular blockade was the most common, used in 31%, followed by iNO (13%), corticosteroids (10%), prone positioning (10%), HFOV (9%), and extracorporeal membrane oxygenation (3%). Steroids, iNO, and HFOV were associated with comorbidities. Prone positioning and HFOV were more common in middle-income countries and less frequently used in North America. The use of multiple ancillary therapies increased over the first 3 days of PARDS, but there was not an easily identifiable pattern of combination or order of use.Conclusions: The contemporary description of prevalence, combinations of therapies, and oxygenation threshold for which the therapies are applied is important for design of future studies. Region of the world, income, and comorbidities influence adjunctive therapy use and are important variables to include in PARDS investigations.
Rationale: Few data exist to guide early adjunctive therapy use in pediatric acute respiratory distress syndrome (PARDS). Objectives: To describe contemporary use of adjunctive therapies for early PARDS as a framework for future investigations. Methods: This was a preplanned substudy of a prospective, international, cross-sectional observational study of children with PARDS from 100 centers over 10 study weeks.Measurements and Main Results: We investigated six adjunctive therapies for PARDS: continuous neuromuscular blockade, corticosteroids, inhaled nitric oxide (iNO), prone positioning, high-frequency oscillatory ventilation (HFOV), and extracorporeal membrane oxygenation. Almost half (45%) of children with PARDS received at least one therapy. Variability was noted in the median starting oxygenation index of each therapy; corticosteroids started at the lowest oxygenation index (13.0; interquartile range, 7.6-22.0) and HFOV at the highest (25.7; interquartile range, 16.7-37.3). Continuous neuromuscular blockade was the most common, used in 31%, followed by iNO (13%), corticosteroids (10%), prone positioning (10%), HFOV (9%), and extracorporeal membrane oxygenation (3%). Steroids, iNO, and HFOV were associated with comorbidities. Prone positioning and HFOV were more common in middle-income countries and less frequently used in North America. The use of multiple ancillary therapies increased over the first 3 days of PARDS, but there was not an easily identifiable pattern of combination or order of use.Conclusions: The contemporary description of prevalence, combinations of therapies, and oxygenation threshold for which the therapies are applied is important for design of future studies. Region of the world, income, and comorbidities influence adjunctive therapy use and are important variables to include in PARDS investigations.
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