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A novel oxygenation distension index (ODI): a driving pressure–based metric compared with the oxygenation index in pediatric PARDS

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Abstract

The oxygenation index (OI) is widely used to assess disease severity in pediatric ARDS; however, it relies on mean airway pressure (Pmean), which does not reflect lung-distending forces relevant to ventilator-induced lung injury. Driving pressure (DP) is a determinant of lung strain. We developed and evaluated the oxygenation distension index (ODI) by substituting DP for Pmean in the OI formula. This observational study included children aged 1 month to 18 years with PARDS requiring ≥ 24 h of invasive mechanical ventilation in six centers. Lung ultrasound scores (LUS) and respiratory mechanics, including transpulmonary pressure (PL), transpulmonary driving pressure (DPL), mechanical power (MP), and transpulmonary mechanical power (MPL), were assessed 4–24 h after diagnosis according to PALICC-2 recommendations. Associations of OI and ODI with lung injury markers and clinical outcomes were analyzed. Among 56 patients, 41 (73%) had mild-to-moderate and 15 (27%) had severe PARDS. ODI demonstrated stronger correlations than OI with lung injury markers, including LUS (r = 0.818 vs. 0.501), PL (r = 0.779 vs. 0.697), DPL (r = 0.745 vs. 0.671), MP normalized to predicted body weight (r = 0.518 vs. 0.438), and MPL normalized to predicted body weight (r = 0.634 vs. 0.628). For 30-day mortality prediction, ODI showed higher discriminative performance than OI (AUC 0.740 [95% CI, 0.598–0.866] vs. 0.685 [95% CI, 0.535–0.835]; DeLong p = 0.040).

Conclusions: By incorporating driving pressure, ODI more closely reflects lung injury severity than the conventional oxygenation index and improves discrimination for mortality in PARDS.

What is Known:

• The oxygenation index is the standard metric used for severity classification in pediatric acute respiratory distress syndrome.

• Driving pressure has been increasingly recognized as a key physiological determinant of lung injury and clinical outcomes in ARDS.

What is New:

• A driving pressure–based oxygenation metric, the oxygenation distension index (ODI), shows stronger associations with established markers of lung injury than the conventional oxygenation index in PARDS.

• ODI provides improved discrimination for 30-day mortality compared with the oxygenation index in mechanically ventilated children with PARDS.

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Data availability

The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. Individual patient-level data cannot be shared publicly due to ethical and privacy considerations.

Change history

  • 08 April 2026

    The original online version of this article was revised due to a typographical error in the section heading, where "Discussion" was incorrectly displayed as "Dıscussıon".

Abbreviations

AUC:

Area under the curve

DP:

Driving pressure

DPL:

Transpulmonary driving pressure

ECW:

Chest wall elastance

EL:

Lung elastance

EResp:

Respiratory system elastance

FiO₂:

Fraction of inspired oxygen

LUS:

Lung ultrasound score

MP:

Mechanical power

MPL:

Transpulmonary mechanical power

ODI:

Oxygenation distension index

OI:

Oxygenation index

PALICC:

Pediatric Acute Lung Injury Consensus Conference

PARDS:

Pediatric acute respiratory distress syndrome

PBW:

Predicted body weight

Pes:

Esophageal pressure

PICU:

Pediatric intensive care unit

PL:

Transpulmonary pressure

ROC:

Receiver operating characteristic

VFD:

Ventilator-free days

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Funding

This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations

  1. Pediatric Intensive Care Unit, Aydin Maternity and Children’s Hospital, Ataturk Boulevard No:96, Center, Aydın, Turkey

    Ekin Soydan, Ozlem Demirel & Ece Dorsan Yay

  2. Dr. Behcet Uz Children’s Hospital, Pediatric Intensive Care Unit, University of Health Sciences, Izmir, Turkey

    Gokhan Ceylan, Gulhan Atakul, Ozlem Sarac, Utku Karaarslan & Hasan Agin

  3. Acibadem Altunizade Hospital, Pediatric Intensive Care Unit, Acibadem University, Istanbul, Turkey

    Sevgi Topal

  4. Cam Sakura Research and Training Hospital, Pediatric Intensive Care Unit, University of Health Sciences, Istanbul, Turkey

    Mustafa Colak

  5. Pediatric Intensive Care Unit, Erzurum Regional Research and Training Hospital, Erzurum, Turkey

    Pinar Hepduman

  6. Pediatric Intensive Care Unit, Istanbul Aydin University, Izmir, Turkey

    Ferhat Sari

  7. Research and New Technology Department, Hamilton Medical AG, Bonaduz, Switzerland

    Jean-Pierre Revelly

Authors
  1. Ekin Soydan
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Contributions

Ekin Soydan contributed to conceptualization, methodology, formal analysis, and writing of the original draft. Gokhan Ceylan contributed to conceptualization, supervision, and writing—review and editing. Ozlem Demirel, Ece Dorsan Yay, Gulhan Atakul, Sevgi Topal, Mustafa Colak, and Pinar Hepduman contributed to investigation and data collection. Ozlem Sarac and Ferhat Sari contributed to investigation and data curation. Utku Karaarslan and Hasan Agin contributed to supervision and resources. Jean-Pierre Revelly contributed to writing—review and editing. All authors reviewed and approved the final manuscript.

Corresponding author

Correspondence to Ekin Soydan.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of Dr. Behçet Uz Children’s Hospital, İzmir Health Sciences University (Protocol No: 02021/519; Approval Date: January 21, 2023). The study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from the parents or legal guardians of all enrolled patients prior to participation. All participating centers obtained local institutional approval where required.

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Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Communicated by AKASH DEEP

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The original online version of this article was revised due to a typographical error in the section heading, where "Discussion" was incorrectly displayed as "Dıscussıon".

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Soydan, E., Ceylan, G., Demirel, O. et al. A novel oxygenation distension index (ODI): a driving pressure–based metric compared with the oxygenation index in pediatric PARDS. Eur J Pediatr 185, 224 (2026). https://doi.org/10.1007/s00431-026-06910-w

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