Original Article

Acute Respiratory Distress Syndrome in Pediatric

Intensive Care Unit
G. Chetan, R. Rathisharmila, P. Narayanan and S. Mahadevan
Department of Pediatrics, Jawaharlal Institute of Post Graduate Medical Education and Research (JIPMER),
Pondicherry, India

ABSTRACT
Objective. To report causes, clinical feature and outcome of children with Acute Respiratory Distress Syndrome (ARDS).
Methods. The case records of children admitted with ARDS from June 2003 to June 2006 were retrospectively reviewed
and the data collected was analyzed.
Results. A total of 17 children were diagnosed as ARDS during study period giving an incidence of 22.7/1,000 admissions.
The mean (SD) age was 74.5 (56.32) mo [range 6 -144 mo]. Primary lung pathology contributed to a (53%) cases of ARDS
while the rest (47%) had non pulmonary causes.There was not any significant different in mortality between these two
groups. Similarly when infections and non infections conditions were considered separately there was no difference in
survival. All children were ventilated using Pressure Controlled Ventilation. The mean (SD) duration of ventilation was 5.0
days [range 1-10 days]. The maximum PEEP (SD) used during the course of ventilation was 10 (3.37) cm H2O [range 718], while the maximum PIP (SD) used was 31 (3.75) cm H2O (range 25-36). The overall mortality was 70%; highest in
children less than 2 years of age. Majority of the children had shock as the most common comorbid factor and had a high
mortality (73.3%).
Conclusion. The high incidence and mortality of ARDS and the presence of a large proportion of potentially preventable
accidents and poisoning cases in the study group underline the need for health education measures addressing
preventive strategies among the rural population. [Indian J Pediatr 2009; 76 (10) : 1013-1016] E-mail: drnarayananp@
gmail.com

Key words: Acute respiratory distress syndrome; ARDS; Children; PICU

Acute respiratory distress syndrome (ARDS) is a

devastating inflammatory lung condition with high
mortality being the end result of a wide variety of
inciting events. 1 Despite a large number of initiating
factors, the pathophysiologic hallmark is the increased
permeability of the alveolar capillary membrane leading
to non cardiogenic pulmonary edema. This syndrome
was first described in adults and is now increasingly
being recognized in children.2-9 Almost all the pediatric
data available are from the developed countries where
the epidemiology of this complex clinical entity is well
characterized. 3-10 There is scant clinical data about
ARDS in children from our country. Barring isolated
reports, there is a large gap in our understanding of the
magnitude of this problem in Indian children, the
predisposing factors and outcome. 11, 12 The present
Correspondence and Reprint requests : Dr. P. Narayanan,
Assistant Professor, Department of Pediatrics, JIPMER,
Podicherry-605006, India
[Received November 08, 2007; Accepted February 25, 2009]

Indian Journal of Pediatrics, Volume 76October, 2009

study was undertaken to examine the incidence of

ARDS in our pediatric intensive care unit (PICU), to
determine the predisposing factors and the outcome.
MATERIAL AND METHODS
This retrospective study was conducted in the (PICU) of
a tertiary care referral hospital in South India. The 6
bedded PICU predominantly handles children with
medical problems. The records of the children admitted
to the PICU of our hospital during June 2003 to June
2006 were reviewed. The American European
Consensus Conference Committee criteria were used to
diagnose ARDS: (a) acute onset, (b) bilateral infiltrates
on chest radiography, (c) arterial oxygen tension/
fraction of O2 in the inspired gases, i.e., PaO2/FiO2
ratio less than 200, and (d) absence of clinical evidence
of left atrial hypertension. 10 The medical records of all
children so identified were scrutinized to collect
relevant information based on a proforma and the data
1013

G. Chetan et al
collected was analyzed. The clinical diagnosis at the
time of satisfying the study criteria was considered as
the predisposing factor for development of ARDS.
Complications like shock, renal failure, disseminated
intravascular coagulation (DIC) etc which developed
subsequently were taken as co morbid factors for final
analysis.
Statistical analysis was done using a computer
software GraphPad InStat version 3.06. Mean and
standard deviation were calculated whenever
necessary. For comparison between survivors and non
survivors, Fishers exact test (discrete variables) and
students t test (continuous variables) were used to test
the significance of differences.
RESULTS
During the study period, 748 children were admitted in
the PICU. In these three years, 17 (6 girls) children
satisfied the diagnostic criteria for ARDS. The incidence
of ARDS in our PICU was 22.7/ 1,000 admissions. The
mean (SD) age of these children was 74.5 (56.32) mth
[range 6 -144 mth].These children had been acutely ill
for a mean duration of 5.05 days. Underlying chronic
illness was present in 4 children - 2 were undergoing
treatment for systemic lupus erythematosis, 1 had
disseminated tuberculosis, and one, epilepsy.
Primary lung pathology contributed to 9 (53%) cases
of ARDS while in 8(47%) children the ARDS was the
TABLE 1. Clinical Characteristics of Study Patients

6 months 2 years
3yr-5yr
>5yr

AGE
No. (%)

Mortality (%)

6 (35.2)
3 (17.6)
8 (47.0)

5(83.3)
1(33.3)
6(75.0)

PREDISPOSING FACTORS
Primary lung Pathology (n=9) No (%)
Mortality (%)
Bronchopneumonia
3 (17.6)
1(33.3)
Hydrocarbon Poisoning
3 (17.6)
3(100)
Aspiration pneumonia
1(5.8)
0
Drowning
1(5.8)
1(100)
Lupus Pneumonia
1(5.8)
0
Non pulmonary Causes (n=8)
Sepsis
5 (29.4)
4(80)
Snake bite
2 (11.6) 2(100)
Wasp sting
1 (5.8)
1(100)
CO MORBID FACTORS*
Shock
Sepsis
Acute renal failure
DIC**

No (%)
15(88.2)
8(47)
3(17.6)
1(5.8)

Mortality (%)
11 (73.3)
5 (62.5)
3(100)
1(100)

*some children had more than one co morbid factor.

**Disseminated Intravascular Coagulation.

1014

result of non pulmonary causes. We did not find any

significant difference in mortality between these two
groups. Similarly when infectious and non infectious
conditions were considered separately, both had equal
representation among the etiologies with no difference
in outcome (Table 1).
All children were mechanically ventilated using
Pressure Controlled Ventilation. The mean duration of
ventilation was 5.0 days [range 1-10 days]. The
maximum PEEP (SD) used during the course of
ventilation was 10 (3.37) cm H2O [range 7-18], while
the maximum peak inspiratory pressure (PIP) (SD) used
was 31 (3.75) cm H2O (range 25-36). All children
received 100% oxygen in the beginning. The minimum
FiO2 (SD) used during ventilation was 68% (22%)
[range 30-100%]. In four children inverse ratio
ventilation was also used to optimize the oxygenation.
The mean PaO2/FiO2 ratio (SD) during the beginning
of ventilator support was 155.24 (28.2) [range 84.2
194.1].
During ventilatory support, 4 children developed
pneumothorax. They included 1 child each with
kerosene aspiration, post measles staphylococcal
pneumonia, disseminated tuberculosis and lupus
pneumonitis. The maximum PEEP used in these
patients was 7, 8, 8, and 16 cm, respectively. Of these,
only one child (lupus pnemonitis) survived.
Among the 17 children in the study population, 12
(70%) did not survive. The mortality was highest in
children less than 2 yr of age. Majority of the children
had shock as the most common comorbid factor and
had a high mortality (73.3%). Sepsis was the next
common comorbid factor with 66.6% mortality. Those
children who developed acute renal failure and
disseminated intravascular coagulopathy had 100%
mortality.
Various clinical and ventilator parameters were
compared between survivors and non survivors (Table
2). None of the factors studied were significantly
different among the two groups.
TABLE 2. Comparison of Survivors and Non-survivors
Parameter
Mean age (months)
Sex (male: female)
Predisposing cause
Pulmonary
Non pulmonary
Average duration of
ventilation (days)
Maximum PEEP in
cm H2 O (SD)
Maximum PIP in
cm H2 O (SD)

Survivors
(n=5)

Non-survivors
(n=12)

79.2
4:1

72
7:5

4
1

5
7

6.8

3.7

11.2 (2.71)

10.4 (3.4)

30.2 (3.2)

30.8 (3.8)

Indian Journal of Pediatrics, Volume 76October, 2009

Acute Respiratory Distress Syndrome in Pediatric Intensive Care Unit

DISCUSSION
The incidence of ARDS in our PICU was 22.7/1000
admissions. Sepsis was the most common predisposing
factor. The overall mortality rate was 70%. The reported
incidence of ARDS in PICUs varies between 8.5-27
cases per 1000 PICU admissions. 5-9 In a case series of
ARDS patients from New Delhi, Lodha R et al had a
similar incidence of 20.1 per 1000 PICU admissions.11
Our PICU caters to children from predominantly rural
population who have poor access to medical facilities
and are often received at an advanced stage of illness.
Moreover we also receive common rural emergencies
like poisonings and stings. That may account for the
high incidence rates compared to western PICUs.
We encountered a variety of predisposing factors in
the present study population including accidents,
stings, infections and autoimmune diseases.
Traditionally the etiological factors of ARDS are
classified as those causing direct injury to the lungs and
those that cause injury indirectly in the setting of a
systemic process.1 The common causes associated with
direct lung injury are pneumonia and aspiration; near
drowning, pulmonary embolism and pulmonary
contusion are less common.4-9 We observed that direct
lung injury was the risk factor in 9(53%) children.
Pneumonia and hydrocarbon aspiration accounted for
35.2% in the present study. Sepsis is the commonest
cause of indirect lung injury. 1 Severe trauma and
multiple transfusions are less commonly associated
causes. Sepsis accounted for 29.4% of children
developing ARDS in the present study. Bites and stings
accounted for 17.6% of the study population. When
hydrocarbon aspiration and near drowning were also
considered, a total of 41% of children developed ARDS
due to accidents, stings and poisoning. This
demonstrates the burden of potentially preventable
causes of this serious life threatening entity in the
present study group. When infectious and non
infectious conditions were considered separately, both
had equal representation among the etiologies with no
difference in outcome.
Shock followed by sepsis was the most common
accompanying feature and was associated with high
mortality. This may be due to involvement of other organ
systems as part of a more serious multiorgan
dysfunction syndrome (MODS). Children with acute
renal failure and disseminated intravascular
coagulopathy had 100% mortality. Available literature
suggests that presence of sepsis, the initial severity of
arterial hypoxemia, non-pulmonary organ dysfunction
and chronic diseases increase the risk of mortality
significantly.1, 14, 16 Ventilatory variables and indexes of
lung severity were also reported to be significantly
associated with mortality in children.14,17
Indian Journal of Pediatrics, Volume 76October, 2009

The mortality of ARDS has decreased over the years

as a result of better ventilator strategies and
improvements in supportive care. 1, 12, 13, 15 The high
mortality in the present study may have multiple
reasons. Most (88%) of our patients developed shock in
addition to ARDS and nearly half (41%) the children
were poorly resuscitated victims of accidents/
poisonings from distant rural areas. Health education
strategies aiming at prevention of accidents and
poisonings and access to basic medical care with
appropriate referral may improve the survival of these
children. Constant refinement of management
protocols of common illnesses based on well conducted
studies done in our patient population is the need of the
hour.
CONCLUSION
The high incidence of ARDS and the fact that nearly
half of the cases were due to accidents and poisonings
point towards the potential role of preventive strategies
in decreasing the incidence of this life threatening
clinical entity in our population.
Contributions : G. Chetan, was involved in collection of data,
analysis and initial drafting of the manuscript; R. Rathisharmila,
was involved in collection and compilation of data; P. Narayanan,
was involved in data analysis and drafting the manuscript; S.
Mahadevan, was involved in conceptualizing the study, critical
apparaisal of the initial draft and finalizing the manuscript.
Conflicts of Interest : None
Funding Source : None

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Indian Journal of Pediatrics, Volume 76October, 2009