Derivation and Validation of an Objective Effort of Breathing Score in Critically Ill Children

Objectives: To derive and validate a score that correlates with an objective measurement of a child’s effort of breathing. Design: Secondary analysis of a previously conducted observational study. Setting: The pediatric and cardiothoracic ICUs of a quaternary-care children’s hospital. Patients: Patients more than 37 weeks gestational age to age 18 years who were undergoing extubation. Interventions: Effort of breathing was measured in patients following extubation using esophageal manometry to calculate pressure rate product. Simultaneously, members of a multidisciplinary team (nurse, physician, and respiratory therapist) assessed respiratory function using a previously validated tool. Elements of the tool that were significantly associated with pressure rate product in univariate analysis were identified and included in a multivariate model. An Effort of Breathing score was derived from the results of the model using data from half of the subjects (derivation cohort) and then validated using data from the remaining subjects (validation cohort) by calculating the area under the receiver operator characteristic curve for pressure rate product greater than 90th percentile and for the need for reintubation. Measurements and Main Results: Among 409 subjects, the median age was 5 months, and nearly half were cardiac surgery patients (49.1%). Retractions, stridor, and pulsus paradoxus were included in the Simple Score. Area under the receiver operator characteristic curve for pressure rate product greater than 90th percentile was 0.8359 (95% CI, 0.7996–0.8722) in the derivation cohort and 0.7930 (0.7524–0.8337) in the validation cohort. Area under the receiver operator characteristic curve for reintubation was 0.7280 (0.6807–0.7752) when all scores were analyzed individually and was 0.7548 (0.6644–0.8452) if scores from three clinicians from different disciplines were summated. Results were similar regardless of provider discipline or training. Conclusions: A scoring system was derived and validated, performed acceptably to predict increased effort of breathing or need for advanced respiratory support and may function best when used by a team. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (https://ift.tt/2gIrZ5Y). Supported, in part, by National Institutes of Health/Eunice Kennedy Shriver National Institute of Child Health and Human Development grant 1K23HL103785 (to Dr. Khemani) and the Los Angeles Basin Clinical Translational Science Institute. Dr. Shein received funding from Accelerate Diagnostic. Drs. Shein and Khemani received support for article research from the National Institutes of Health (NIH). Dr. Khemani’s institution received funding from the NIH. Mr. Hotz has disclosed that he does not have any potential conflicts of interest. This work was performed at Children’s Hospital of Los Angeles. For information regarding this article, E-mail: steven.shein@uhhospitals.org ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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