Morbidity and Mortality Among Critically Injured Children With Acute Respiratory Distress Syndrome

Abstract

Objectives: To evaluate morbidity and mortality among critically injured children with acute respiratory distress syndrome.

Design: Retrospective cohort study.

Setting: Four-hundred sixty Level I/II adult or pediatric trauma centers contributing to the National Trauma Data Bank.

Patients: One hundred forty-six thousand fifty-eight patients less than 18 years old admitted to an ICU with traumatic injury from 2007 to 2016.

Interventions: None.

Measurements and main results: We assessed in-hospital mortality and need for postdischarge care among patients with and without acute respiratory distress syndrome and hospital resource utilization and discharge disposition among survivors. Analyses were adjusted for underlying mortality risk (age, Injury Severity Score, serious brain or chest injury, and admission heart rate and hypotension) and year, transfer status, and facility trauma level designation. Acute respiratory distress syndrome occurred in 2,590 patients (1.8%). Mortality was 20.0% among acute respiratory distress syndrome patients versus 4.3% among nonacute respiratory distress syndrome patients, with an adjusted relative risk of 1.76 (95% CI, 1.52-2.04). Postdischarge care was required in an additional 44.8% of acute respiratory distress syndrome patients versus 16.0% of patients without acute respiratory distress syndrome (adjusted relative risk, 3.59; 2.87-4.49), with only 35.1% of acute respiratory distress syndrome patients discharging to home versus 79.8% of patients without acute respiratory distress syndrome. Acute respiratory distress syndrome mortality did not change over the 10-year study period (adjusted relative risk, 1.01/yr; 0.96-1.06) nor did the proportion of acute respiratory distress syndrome patients requiring postdischarge care (adjusted relative risk, 1.04/yr; 0.97-1.11). Duration of ventilation, ICU stay, and hospital stay were all significantly longer among acute respiratory distress syndrome survivors. Tracheostomy placement occurred in 18.4% of acute respiratory distress syndrome survivors versus 2.1% of patients without acute respiratory distress syndrome (adjusted relative risk, 3.10; 2.59-3.70).

Conclusions: Acute respiratory distress syndrome development following traumatic injury in children is associated with significantly increased risk of morbidity and mortality, even after adjustment for injury severity and hemodynamic abnormalities. Outcomes have not improved over the past decade, emphasizing the need for new therapeutic interventions, and prevention strategies for acute respiratory distress syndrome among severely injured children.

Figure 1:. Frequency of discharge outcomes in patients with and without ARDS

Figure 2:. Trends in mortality and need for ongoing care among ARDS patients from 2007–2016.

Dark blue lines represent mortality and need for ongoing care among ARDS patients. Light blue lines represent mortality and need for ongoing care among non-ARDS patients.

Figure 3:. Duration of mechanical ventilation, ICU length of stay, and hospital length of stay among patients with and without ARDS who survived to hospital discharge.

Box-plots demonstrate median and interquartile range, with whiskers representing upper and lower adjacent values (1.5x the interquartile range). Outliers are included in calculations but not illustrated; the range of data points are indicated in parentheses. Black diamonds represent the average number of additional days for ARDS patients compared to non-ARDS patients after risk adjustment, with error bars representing 95% confidence intervals.