Received: 17 August 2020 | Revised: 21 November 2020 | Accepted: 27 November 2020

DOI: 10.1002/ppul.25194

ORIGINAL ARTICLE: OUTCOMES

Comparison of the OI and PaO2/FiO2 score in evaluating

PARDS requiring mechanical ventilation

Huili Shen MD | Dong Qu MD | Weilan Na MD | Shuang Liu MD |

Siyuan Huang MD | Yi Hui MD

Department of Critical Medicine, Children's

Hospital Affiliated to the Capital Institute of
Pediatrics, Beijing, China
Correspondence
Dong Qu, MD, Department of Critical
Medicine, Children's Hospital Affiliated to the
Capital Institute of Pediatrics, NO. 2 Yabao
Rd, Chaoyang, 100020 Beijing, China.
Email: qudong2012@126.com
Abstract
Aim: To examine the differences between oxygenation index (OI) and arterial partial
pressure of oxygen to the fraction of inspired oxygen (PaO2/FiO2, [P/F]) in evalu-
ating the severity of pediatric acute respiratory distress syndrome (PARDS).
Methods: The severity of PARDS was graded by using the OI score and P/F ratio,
respectively. The data including clinical indexes and prognosis indicators were
recorded and analyzed.

Funding information
The Special Fund of the Pediatric Medical
Coordinated Development Center of Beijing
Hospitals Authority, Grant/Award Number:
XTCX201820
Results: During the 3‐year study period, there were significant differences between
OI and P/F scores in the severity grading of PARDS patients (p < .05). However, in
severe diseases, both the scorings of OI and P/F were consistent (24.6% vs. 25.6%).
The OI scores appeared more accurate when compared with P/F in the correlation
between them and the pediatric critical illness score, multiple organ dysfunction
syndromes (MODS), pressure indexes of ventilators and patients' prognosis. In the
receiver operating characteristic curve, the critical values of OI and P/F were 8.42
and 144.71. Area under the curve of them were 0.839 and 0.853. The sensitivity
values were both 0.854. The specificity values were 0.584 and 0.602.
Conclusions: The OI and P/F were consistent in designating patients with severe
PARDS. Among patients with mild to moderate diseases, the P/F could still be used
for rapid determination given its simple calculation. Combined with the prognostic
factors, the OI score was more accurate.

KEYWORDS
arterial partial pressure of oxygen to the fraction of inspired oxygen (PaO2/FiO2, oxygenation
index (OI), P/F), pediatric acute respiratory distress syndrome (PARDS)

1 | INTRODUCTION factors. It is typically characterized by alveolar capillary endothelial

1
Acute respiratory distress syndrome (ARDS)
progressive respiratory failure caused by various noncardiogenic
pathogenic factors regardless of intrapulmonary or extrapulmonary
injury, alveolar hyperpermeability edema, and inflammatory re-
refers to acute sponses.2 In the intensive care unit (ICU), the incidence of ARDS is
approximately 10% with associated 40% mortality rate.3 While in the
pediatric ICU (PICU), the morbidity rate of pediatric ARDS (PARDS)

Abbreviations: AECC, American‐European Consensus Conference; ARDS, acute respiratory distress syndrome; ICU, intensive care unit; MAP, mean airway pressure; MODS, multiple organ
dysfunction syndrome; OI, oxygenation index; PaCO2, arterial blood carbon dioxide partial pressure; PALICC, Pediatric Acute Lung Injury Consensus Conference; PaO2, arterial partial
pressure of oxygen; PaO2/FiO2, P/F, arterial partial pressure of oxygen to fraction of inspired oxygen; PARDS, pediatric acute respiratory distress syndrome; PCIS, pediatric critical illness
score; PEEP, positive end‐expiratory pressure; PICU, pediatric intensive care unit; PIP, peak inspiratory pressure; ROC, receiver operating characteristic; VT, tidal volume.

Pediatric Pulmonology. 2020;1–7. wileyonlinelibrary.com/journal/ppul © 2020 Wiley Periodicals LLC | 1

2 |
is 1%–3%4 and the mortality rate is 26.9%–60%.5–7 The diagnostic
criteria for PARDS have not been defined previously in both The
8
American–European Consensus Conference on ARDS (1994) and
the Berlin definition (2012),9 but the PaO2/FiO2 (P/F) ratio has been
applied to the diagnosis, classification and treatments. In 2015,
PARDS was first defined by the pediatric acute lung injury consensus
10
conference (PALICC). Considering the airway pressure in the
diagnosis and severity grading, OI has been used as a basis for di-
agnosis for the first time. However, the differences between the OI
score and the P/F ratio in determining the severity of PARDS and
other clinical parameters and outcomes remain unclear. This study
aimed to examine and compare the application of the P/F ratio and
OI score in evaluating the severity of PARDS in a cohort of pediatric
patients and correlating the scorings with ventilation, blood gases
and prognosis. The findings of this study would shed light on the
optimal method for determining PARDS severity and guiding
management.
2 | METHODS
2.1 | Study design
This was a single‐center retrospective observational study approved
by the ethics committee of the Capital Institute of Pediatrics (Ethics
number: SHERLLM2020003). From June 1st, 2016 to May 31st,
2019, all children admitted to the department of PICU at the
Children's Hospital Affiliated to the Capital Institute of Pediatrics
were considered for our study, and were determined whether they
met the PALICC diagnostic criteria.
2.2 | Inclusion and exclusion criteria
Inclusion criteria were: (1) children admitted to PICU with PARDS
and met the PALICC diagnostic criteria.10 The PALICC criteria in-
cluded: (a) excluded patients with peri‐natal related disease; (b)
within 7 days of known clinical insults; (c) pulmonary edema not fully
explained by heart failure or fluid overload; (d) imaging findings were
consistent with the pulmonary parenchymal disease; (e) invasive
mechanical ventilation with severity stratification as follows: mild
4 ≤ OI < 8 or 5 ≤ OSI < 7.5, moderate 8 ≤ OI < 16 or 7.5 ≤ OSI < 12.3,
severe OI ≥ 16 or OSI ≥ 12; (f) other patients with chronic lung/heart
diseases, such as cyanotic heart disease, chronic lung disease, and
left ventricular dysfunction could still fulfill the criteria of PALICC.
(2) The P/F ratio was based on the Berlin definition (2012)9 issued by
the European Society of Critical Care Medicine to grade severity as
follows: mild 200 < P/F ≤ 300; moderate 100 < P/F ≤ 200; severe
P/F < 100. (3) The diagnostic code for the multiple organ dysfunction
syndrome (MODS) was in accordance with the expert consensus on
the diagnosis and treatment of septic shock in children (version
2015)11 developed by the Chinese Society of Pediatrics, the Chinese
Medical Association's Emergency Medical Branch, and the Chinese
SHEN ET AL.
Medical Association's Children's Severe Physicians Branch. (4) The
pediatric critical illness score (PCIS)12 as stipulated by the First Aid
Group of the Chinese Academy of Pediatrics, included heart rate,
blood pressure, respiratory rate, arterial partial pressure of blood
oxygen, pH value, blood sodium, blood potassium, urea nitrogen/
blood creatinine, hemoglobin, gastrointestinal system symptoms
(bleeding from stress ulcer or intestinal paralysis). The lower the
score, the worse would be the disease condition. A score of greater
than 80 was noncritical, 71–80 was classified as critical, and ≤70 is
defined as extremely critical. The previous studies12 had confirmed
that PCIS could accurately determine the condition and predict the
risk of death. Also, the PCIS score is better at appeared superior in
evaluating children's conditions and prognosis than the Acute
Physiology and Chronic Health Evaluation II (APACHE II) score at
the PICU.13
Patients who met any of the following exclusion criteria were
excluded: (1) age ≤28 days old or age greater than 18 years old; (2)
noninvasive mechanical ventilation; (3) patients with incomplete
clinical data; (4) length of admission less than 24 h.
2.3 | Data collection
Following the confirmation of diagnosis based on the PALICC cri-
teria, the mechanical ventilation parameters and blood gas indexes
were recorded. The OI scores and P/F ratios were calculated and
used for severity stratification of PARDS. While P/F was simple to
calculate, the formula used for the calculation of OI was FiO2 ×
MAP × 100/PaO210 and MAP = (PIP × Ti PEEP × [Ttot‐Ti])/Ttot.10
Patients’ data were collected and compared as follows: (1) general
demographics, such as age, gender, etiology of ARDS, and blood
gases parameters including arterial partial pressure of oxygen
(PaO2), arterial blood carbon dioxide partial pressure (PaCO2), etc;
(2) prognosis: the PCIS, survival or death at 28‐day after discharged
from PICU numbers and types of organ failure, etc; (3) parameters of
mechanical ventilation: peak inspiratory pressure (PIP); positive end‐
expiratory pressure (PEEP), mean airway pressure (MAP), and tidal
volume; (4) PARDS severity grade. If the patient had multiple values,
the worst value was recorded. For instance, if the patients had two
PCISs, the worst PCIS could be collected for data analysis.
2.4 | Statistical methods
SPSS (version25.0) was used for statistical analysis. Continuous
variables with normal distribution or approximately normal dis-
tribution were expressed as mean ± standard deviation. Quantitative
data were tested by the independent sample t test while qualitative
data were compared with a chi‐square test. If the data had a non‐
normal distribution trend, mean (interquartile range) was used
for describing the central tendency and Mann–Whitney (U test)
was used for data comparison. p < .05 was considered statistically
significant.
SHEN ET AL.
| 3

TABLE 1 The etiologies of PARDS Of 358 patients who met the PALICC diagnostic criteria,

Number (%) of 51 patients could not be evaluated further by OI given that non-
Position Etiology 207 patients invasive mechanical ventilator was used to treat those patients,
while 100 patients were excluded according to the other exclusion
Intrapulmonary Infection 152 (73.43)
Virus 94 (45.41) criteria. Eventually, 207 patients managed with invasive mechan-

Bacteria 52 (25.12) ical ventilation were included in our analyses.

Others (e.g. mycoplasma, 6 (2.90) In our study, included patients were aged 9.50 (3.87, 30.30)
fungi, et al) months while the youngest was 30 days old and the oldest was
Pneumorrhagia 3 (1.45) 17 years and 3 months old. The majority were infants and toddlers.
Others 2 (0.97) Males accounted for 65.7% (136/207) and the ratio of boys to

Extrapulmonary Shock 21 (10.14) girls was 1.92:1. The average body weight of patients was 9.00
Septic shock 15 (7.25) (5.5, 13.28) KG. The mean length of hospitalization was 13.00
Hemorrhagic shock 3 (1.45) (8.00, 19.00) days. The most common intrapulmonary etiology was
Tumor 4 (1.93) infection while shock was the major extrapulmonary factor. See
Epilepsy 2 (0.97) Table 1 for more etiologies details.
Apnea 1 (0.48)
Others 25 (12.08)

Abbreviation: PARDS, pediatric acute respiratory distress syndrome.

3.2 | Comparisons of severity grade of PARDS by
OI and P/F

TABLE 2 Grouping situation of 207 patients In the P/F evaluation, patients with mild, moderate, and severe
PARDS were 16.91%, 57.49%, and 25.60%, respectively. On the
Mild Moderate Severe
Project (number [%]) (number [%]) (number [%]) p Value other hand, the frequencies were 47.83%, 27.54%, and 24.64%,
respectively in the evaluation using the OI score (Table 2).
OI group 99 (47.83) 57 (27.54) 51 (24.64) <.001
A total of 65.22% (135/207) patients were at the same OI severity
P/F group 35 (16.91) 119 (57.49) 53 (25.60)
grade as for P/F. Only 1.45% (3/207) patients were graded higher in OI
Abbreviations: OI, oxygenation index; P/F, arterial partial pressure of than in P/F with one patient graded as moderate severity by OI score
oxygen to fraction of inspired oxygen.
(mild ARDS by P/F ratio) and two other patients graded as severe
(moderate ARDS by P/F ratio). However, there were 33.33% (69/207)
patients in OI score at lower severity grade than those in the P/F score.
3 | RESULTS Of these, 4 patients were determined as moderate by OI score (severe
by P/F score) and 65 were graded as mild by OI score (moderate by
3.1 | General demographics and characteristics of P/F ratio), as demonstrated in Figure 1.
PARDS

A total of 2675 patients were admitted to our hospital during the
study period. Of these, 358 patients met the PALICC diagnostic
criteria, and thus, the incidence rate of PARDS in our center was
13.38% (358/2675). There were 83 patients that died on the 28th
of discharge from PICU, with a mortality rate of 23.18% (83/358).
The direct cause of death for 26 patients was progressive hy-
poxemia. hence the mortality rate of PARDS was 7.26% (26/358).
3.3 | Differences in mechanical ventilatory
parameters and clinical outcomes between P/F
and OI scores
All patients were treated with a lung‐protection ventilation strategy.
The PaO2 (Table 3) and PCIS (Figure 2A) decreased with the in-
creased disease severity, while the PIP (Figure 2D), PEEP (Figure 2E),

F I G U R E 1 The specific rating of oxygenation index (OI) and arterial partial pressure of oxygen to fraction of inspired oxygen (P/F)
group This figure shows how the patients were rated by these two methods exactly. The largest difference is there were 65 patients graded as
mild by OI score (moderate by P/F ratio)
4 | SHEN ET AL.

Note: ”*”means the p value between P/F group and OI group is less than .05. There are statistical differences between P/F group and OI group in PaO2 at mild PARDS and coagulation failure at moderate
MAP (Figure 2C), MODS (Figure 2B), and 28‐day mortality (Table 3)

37.00 (25.10, 46.90)

55.70 (43.50, 78.00)

increased when the disease condition worsened. In patients with

OI group (n = 51)
mild disease, the PaO2 (Table 3) of OI scoring was lower than that in

34 (66.67%)

24 (47.06)

22 (43.14)

23 (45.10)
the P/F group (p < .05). In moderate disease, PCIS (Figure 2A) of OI

8 (15.69)

Abbreviations: IQR, interquartile range; OI, oxygenation index; PARDS, pediatric acute respiratory distress syndrome; P/F, arterial partial pressure of oxygen to fraction of inspired oxygen.
scoring was also significantly lower (p < .05), but the proportion of
MODS (Figure 2B) involvement was higher (p < .05), with the re-
quirement of higher ventilator pressure support (p < .05,
Figure 2C–E)] when compared with P/F group.
35.60 (24.70, 44.50)

55.70 (43.35, 77.90)

P/F group (n = 53)

The OI score showed significant consistency in PCIS, MODS, and

ventilator pressure index (p > .05, Figure 2) in the group of patients
38 (71.70)

26 (49.06)

10 (18.87)

22 (41.51)

24 (45.28)
with the mild disease and severe disease group compared with P/F
Severe

score. The P/F score showed no difference in the all the mechanical
ventilation and prognosis indexes (p > .05, Table 3 and Figure 2),
suggesting that this scoring was as accurate as the OI score in the
assessments of severe diseases.
58.10 (50.60, 61.10)

44.30 (36.85, 53.55)

OI group (n = 57)

19 (33.33)*

3.4 | Receiver operating characteristic curve

25 (43.86)

13 (22.81)
7 (12.28)
4 (7.02)

curves of the two evaluation methods in PARDS

The mortality was used to construct the receiver operating char-

acteristic curve (ROC) separately for the OI score and P/F ratio. Both
58.50 (54.20, 61.80)

44.50 (39.40, 59.90)

P/F group (n = 119)

the evaluation methods were highly similar at ROC sensitivity and

specificity, as demonstrated in Figure 3 and Table 4.
22 (18.49)

39 (32.77)

22 (18.49)
Moderate

10 (8.40)
5 (4.20)

4 | DISCUSS ION

In our study, pneumonia was the main pulmonary cause of PARDS,

61.60 (56.80, 66.10)*

45.00 (39.70, 49.50)

and septic shock was the major non‐pulmonary factor. The majority
OI group (n = 99)

of PARDS were among infants and toddlers. These findings were

consistent with previous studies.14–16 The overall morbidity of
15 (15.15)

25 (43.86)

17 (17.17)
7 (7.07)

8 (8.08)

PARDS was 13.38%, and the mortality rate was 23.8% that was also
consistent with previous studies.17,18 However, the incidence rate of
The difference of mechanical ventilation and prognosis

PARDS in our study was higher than a previous report,19 though the
patients with PARDS in this study comprised of both the adult and
63.80 (61.70, 74.10)

43.80 (38.00, 49.20)

pediatric ARDS.20 The following were considered to account for this

P/F group (n = 35)

disparity observed. First, patients who were evaluated as having mild

disease severity had less than 80 scores at PCIS, which indicated a
20 (20.20)
8 (22.86)

4 (11.43)

5 (14.29)

7 (20.00)

critical condition.12 The study by the Chinese Medical Association21

Mild

that involved the application of PCIS in the PICU of 14 hospitals

found that the PCIS could accurately determine the severity of the
disease. The study demonstrated that the lower the score, the more
Gastrointestinal failure (number [%])

severe the condition, which involved organ failures and higher

Coagulation failure (number [%])

mortality. Furthermore, the incidence of PARDS using PALICC

28‐Day mortality (number [%])
Hepatic failure (number [%])

criteria appeared higher than that using Berlin criteria.14,15

Renal failure (number [%])
PaCO2 (M [IQR], mmHg)

In a study consisted of a smaller sample size of 65 patients by

PaO2 (M [IQR], mmHg)

Gupta et al.,20 a consistent rate of 85% between the PALICC

criterion and Berlin definition was identified. In our study, approxi-
mately two‐thirds of patients were assigned in the same disease se-
Parameters
TABLE 3

verity group by both OI score and the P/F ratio. Particularly, for
PARDS.

patients with severe disease, the consistency rate between the

2 scoring systems was 96.22%. As demonstrated in Table 3 and
SHEN ET AL.
| 5

F I G U R E 2 The differences about pressure parameters of ventilator and prognosis in OI and P/F group. (A) PCIS, pediatric critical illness
score. (B) MODS, multiple organ dysfunction syndrome. (C) MAP, mean airway pressure. (D) PIP, peak inspiratory pressure. (E) PEEP, positive
end‐expiratory pressure. (F) Vt, tidal volume. OI, oxygenation index; P/F, arterial partial pressure of oxygen to fraction of inspired oxygen

Figure 1, several differences existed between the OI and P/F scores in
the grading of mild and moderate disease severities. With the OI
scoring, the proportion of patients decreased gradually with the
increase of disease severity, while the proportion of patients with a
moderate disease was the largest and the proportion with a mild
disease was the smallest by the P/F method. This was consistent with
the study by Dowell et al.15 using the Berlin definition that included a
total of 798 patients. Furthermore, when comparing with the fre-
quencies in the mild disease group, the P/F method revealed only
about one‐third (16.91%) of patients while the OI method indicated a
total of 47.83%, suggesting that the P/F evaluation method tends to
upstage the disease from mild to moderate. In reality, the number
of patients should decrease with the increase of disease severity.22
Interesting, other studies have also shown that in patients graded as
mild‐to‐moderate disease severity, there were higher proportions of
patients in the moderate disease category by the P/F score than the
OI score method,4 while the PCIS in patients graded by the OI method
was lower than that of P/F method, but the MODS and ventilator
pressure support appeared higher. In our study, a similar trend was
observed in the PCIS, MODS and ventilator pressure supported by the
OI method but no difference was observed in these clinical para-
meters by the P/F score. These observations also suggested that the
OI score was more accurate in the assessments of mild and moderate
disease severity than the P/F score, which was consistent with the
findings by Khemani et al.4 In their study, 1833 PARDS children were
included and showed that OI score is superior to that of P/F in di-
agnostic significance. Besides severe ARDS accounted for 45% of
deaths in our study, approximately 2–3 times higher than that of mild
or moderate disease, which was also found in the previous studies.5
Therefore, patients classified in this category would warrant a tailored
6 | SHEN ET AL.

F I G U R E 3 The receiver characteristic

operator (ROC) curve in ARDS prognosis
using OI and P/F value separately OI and P/F
group have the similar sensitivity and secifity
as seen from the image. ARDS, acute
respiratory distress syndrome; OI,
oxygenation index; P/F, arterial partial
pressure of oxygen to fraction of inspired
oxygen

TABLE 4 The situation of receiver characteristic operator (ROC) curve

95% CI (confidence interval)

Group AUC Standard error p Value Lower boundary Upper boundary Critical value Sensitivity Specificity
OI group 0.839 0.038 .000 0.764 0.914 8.42 0.854 0.584

P/F group 0.853 0.035 .000 0.784 0.924 144.71 0.854 0.602

Abbreviations: AUC, area under the curve; CI, confidence interval; OI, oxygenation index; P/F, arterial partial pressure of oxygen to fraction of inspired
oxygen.

and aggressive approach in the clinical management given the high
risk of dismal outcomes.23
As demonstrated in the ROC curve by the OI method, the ratio
of the cut‐off value of the mortality of severe ARDS to ARDS in
moderate severity was about 2. On the other hand, the critical value
of the P/F method was attributed to the moderate disease grade,
with the mortality ratio in severe to moderate diseases of 2.5. This
suggested that the OI scoring method would be more suitable in the
clinical application for determining the prognosis of PARDS, which
12,24–26
was consistent with the studies by Bellani et al that the OI
was superior to P/F in predicting mortality. However, there were still
approximately 20% of mortality contributed by the group of patients
with moderate disease severity, and hence, the potential risk of
mortality in these patients should not be underestimated. Given its
simple calculation the P/F score would still be clinically value in rapid
assessment and diagnosis of PARDS.
There were limitations to this study. First, this was a retro-
spective study. Second, given that OI numerical calculation could not
be performed in patients not requiring invasive ventilatory supports,
patients with milder disease were not included in this study. Also,
this was a single‐center study. And the sample size was rather
limited. Therefore, future studies should consider multi‐center
collaboration to allow more patient recruitment.
In conclusion, the OI is consistent with the P/F score in grading
severe PARDS. In mild to moderate disease, OI score is more accu-
rate but the P/F remains valuable with simpler calculation and easier
to apply clinically for rapid assessment. When patients progress from
moderate to severe ARDS, the risk of mortality increases. These
patients, therefore, demand early and aggressive management to
improve clinical outcomes.
ACKNOWLEDGEM ENT
The Special Fund of the Pediatric Medical Coordinated Development
Center of Beijing Hospitals Authority. NO. XTCX201820.
CO N FLI CT O F I N TER E S TS
All authors have completed the article and declared that: (i) no
support, financial or otherwise, has been received from any organi-
zation that may have an interest in the submitted work; and (ii) there
are no other relationships or activities that could appear to have
SHEN ET AL.
influenced the submitted work. All the authors are aware of and
approve the manuscript as submitted to this journal. This article has
not been submitted elsewhere and is not under review by another
journal, has not been published previously.
AUTHOR CONTRIBUTIONS
Huili Shen: conceptualization (equal); data curation (lead); formal
analysis (lead); investigation (equal); methodology (equal); resources
(equal); software (lead); writing original draft (lead); writing review
and editing (equal). Dong Qu: conceptualization (lead); funding ac-
quisition (lead); investigation (equal); resources (equal); supervision
(lead); writing review and editing (equal). Weilan Na: con-
ceptualization (equal); data curation (equal); methodology (equal);
writing review and editing (equal). Shuang Liu: funding acquisition
(equal); investigation (equal); supervision (equal); writing review and
editing (equal). Siyuan Huang: investigation (equal); supervision
(equal); writing review and editing (equal). Yi Hui: project adminis-
tration (equal); writing review and editing (equal).
ORCID
Huili Shen https://orcid.org/0000-0003-3904-1144
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How to cite this article: Shen H, Qu D, Na W, Liu S, Huang S,
Hui Y. Comparison of the OI and PaO2/FiO2 score in
evaluating PARDS requiring mechanical ventilation. Pediatric
Pulmonology. 2020;1–7. https://doi.org/10.1002/ppul.25194