• Shan L Ward, Virginia Gildengorin, Stacey L Valentine, Anil Sapru, Martha A Q Curley, Neal Thomas, Douglas F Willson, and Heidi R Flori.
• 1Division of Critical Care, Department of Pediatrics, UCSF Benioff Children's Hospital San Francisco, San Francisco, CA. 2Department of Critical Care, UCSF Benioff Children's Hospital Oakland, Oakland, CA. 3Department of Pediatric Critical Care, UMass Memorial Medical Center, Worcester, MA. 4Department of Family and Community Health, University of Pennsylvania, School of Nursing, Philadelphia, PA. 5Division of Pediatric Critical Care Medicine, Departments of Pediatrics and Public Health Sciences, Penn State Hershey Children's Hospital, Hershey, PA. 6Division of Pediatric Critical Care, Children's Hospital of Richmond at VCU, Richmond, VA. 7Division of Pediatric Critical Care Medicine, C.S. Mott Children's Hospital, Ann Arbor, MI.
• Crit. Care Med. 2016 Nov 1; 44 (11): 2052-2059.

ObjectivesTo determine whether weight extremes impact clinical outcomes in pediatric acute respiratory distress syndrome.DesignPost hoc analysis of a cohort created by combining five multicenter pediatric acute respiratory distress syndrome studies.SettingForty-three academic PICUs worldwide.PatientsA total of 711 subjects prospectively diagnosed with pediatric acute respiratory distress syndrome.InterventionSubjects more than 2 years were included and categorized by Center for Disease Control and Prevention body mass index z score criteria: underweight (< -1.89), normal weight (-1.89 to +1.04), overweight (+1.05 to +1.64), and obese (≥ +1.65). Subjects were stratified by direct versus indirect lung injury leading to pediatric acute respiratory distress syndrome. The primary outcome was in-hospital mortality. In survivors, secondary analyses included duration of mechanical ventilation and ICU length of stay.Measurements And Main ResultsA total of 331 patients met inclusion criteria; 12% were underweight, 50% normal weight, 11% overweight, and 27% obese. Overall mortality was 20%. By multivariate analysis, body mass index category was independently associated with mortality (p = 0.004). When stratified by lung injury type, there was no mortality difference between body mass index groups with direct lung injury; however, in the indirect lung injury group, the odds of mortality in the obese were significantly lower than normal weight subjects (odds ratio, 0.11; 95% CI, 0.02-0.84). Survivors with direct lung injury had no difference in the duration of mechanical ventilation or ICU length of stay; however, those with indirect lung injury, the overweight required longer duration of mechanical ventilation than other groups (p < 0.001).ConclusionsThese data support the obesity paradox in pediatric acute respiratory distress syndrome. Obese children with indirect lung injury pediatric acute respiratory distress syndrome have a lower risk of mortality. Importantly, among survivors, the overweight with indirect lung injury requires longer duration of mechanical ventilation. Our data require prospective validation to further elucidate the pathobiology of this phenomenon.

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