Avaliação das classificações de gravidade na Síndrome do Desconforto Respiratório Agudo na infância pelo Consenso de Berlim e pelo Pediatric Acute Lung Injury Consensus Conference

Abstract

Introduction: The acute respiratory distress syndrome (ARDS) occurs in 1-4% of the admissions in pediatric intensive care units (PICU) and in 8-10% of children who requires invasive mechanic ventilation, with a high mortality witch varies from 20-75%. Thus, it remains a diagnostic and therapeutic challenge to pediatric intensivists. Objectives: The present study compares two methods for definition and severity classification of pediatric ARDS. They are the Berlin classification, witch uses the PaO2/FiO2 ratio and the PALICC classification, witch uses the oxigenation index (OI). There are few studies that compare the two classifications in pediatrics, with the aim of estabilish an earlier diagnosis and a most suitable classification, enabling targeted therapeutic strategies and improving clinical outcome. Methods: Prospective study with 54 patients from 0-18 years of age, with ARDS diagnosis and in invasive mechanic ventilation, that provided 1-3 samples of arterial blood gas, totaling 140 valid measurements. These measurements were analyzed for correlation by the Spearman test and concordance by the Kappa coefficient between the two classifications, Berlin (PaO2/FiO2 ratio) and PALICC (OI), initially using the general population of the study and after subdividing it in patients with and without bronchospasm and with and without neuromuscular blocker use, being further evaluated the interference of these two factors separated and together on the two classifications by the analysis of variance (ANOVA) for two factors. Results: In the general population, composed of 54 patients aged 0-18 years, it was found a strong negative correlation by the Spearman test (ρ - 0,91; p < 0,001) and strong concordance by the Kappa coefficient (0,62; p < 0,001) in the comparison between Berlin and PALICC. In the populations with and without bronchospasm and with and without neuromuscular blocker use the correlation and concordance coefficients maintained values similar to those of the general population. Nonetheless, for patients that did not use neuromuscular blocker there was greater agreement between classifications when compared to patients that used neuromuscular blocker (Kappa 0,67 versus 0,56 with p < 0,001 to both). It is also added the significant effect of neuromuscular blocker use on PaO2/FiO2 ratio (ANOVA; F: 12,9; p < 0,001) and oxigenation index (OI) (ANOVA; F: 8,3; p = 0,004). Conclusion: There was a strong correlation and concordance between the two classifications on the general population, nonetheless, the findings suggest that there is a significant influence of neuromuscular blocker use on severity classifications, which does not occur with bronchospasm.