Intensive Care Medicine

, Volume 44, Issue 8, pp 1230–1239 | Cite as

Subtypes of pediatric acute respiratory distress syndrome have different predictors of mortality

  • Nadir YehyaEmail author
  • Garrett Keim
  • Neal J. Thomas



Acute respiratory distress syndrome (ARDS) is heterogeneous in etiology, which may affect outcomes. Stratification into biologically-defined subtypes may reduce heterogeneity. However, it is unknown whether pediatric ARDS has clinically relevant subtypes. We aimed to determine whether clinical characteristics and predictors of mortality differed between direct and indirect ARDS, and separately between infectious and non-infectious ARDS.


This was a single center, prospective cohort study of 544 children with ARDS (Berlin) between July 2011 and June 2017, stratified into direct versus indirect ARDS, and separately into infectious versus non-infectious ARDS. Multiple logistic regression was used to test for predictors of mortality in the entire cohort, and separately within subtypes. Effect modification by subtype was assessed using interaction tests.


Direct ARDS had lower severity of illness (p < 0.001) but worse oxygenation (p < 0.001), relative to indirect. Predictors of mortality were similar for direct and indirect ARDS. When comparing infectious and non-infectious ARDS, infectious ARDS had lower severity of illness (p < 0.001), worse oxygenation (p = 0.014), and lower mortality (p = 0.013). In multivariable analysis, immunocompromised status demonstrated effect modification between infectious and non-infectious ARDS (p = 0.005 for interaction), with no association with mortality in non-infectious ARDS.


In children, direct and indirect ARDS have distinct clinical characteristics, but similar outcomes and similar predictors of mortality. In contrast, infectious and non-infectious ARDS demonstrate heterogeneity of clinical characteristics, mortality, and predictors of mortality, with traditional predictors of ARDS mortality only applicable to infectious ARDS.


ARDS PARDS Children Direct ARDS Infectious ARDS 


Compliance with ethical standards

Conflicts of interest

Dr. Yehya’s institution receives funding from the NIH (K12-HL-136688). Dr. Thomas reports personal fees from Therabron and Carefusion, all outside of the submitted work.

Supplementary material

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Kaplan–Meier survival curves for the outcomes of survival, ECMO-free survival, or probability of extubation given the competing risk of death, stratified by PALICC severity categories, at ARDS onset and at 24 h. All curves are censored at 28 days. Supplementary material 1 (TIFF 578 kb)
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Supplementary material 11 (DOCX 16 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature and ESICM 2018

Authors and Affiliations

  1. 1.Department of Anesthesiology and Critical Care MedicineChildren’s Hospital of Philadelphia and University of PennsylvaniaPhiladelphiaUSA
  2. 2.Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health SciencePenn State Hershey Children’s HospitalHersheyUSA

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