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. 2020 Nov 4;10:19049. doi: 10.1038/s41598-020-76122-1

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© The Author(s) 2020

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

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Airway neutrophils are activated in intubated children with compared to children without PARDS. Surface expression of the primary granule exocytosis marker, CD63, and the lipid signaling G protein-coupled receptor, sphingosine-1-phosphate receptor 3 (S1PR3), are higher in children with versus without PARDS. The type I interferon (IFN) signaling pathway transcription factor, STAT1, is upregulated and phosphorylated, and transcript levels of ISG15 is increased in children with versus without PARDS. Neutrophil extracellular trap (NET) release is regulated by a NADPH oxidase (NOX) respiratory burst (reactive oxygen species (ROS) triggered mechanism and an intracellular calcium-dependent trigger. It is not known which trigger dominates in the airways of children with PARDS. Children with PARDS have elevated levels of NETs in their airways as detected by myeloperoxidase (MPO)-DNA complexes in our study. Elevated NET levels are associated with a higher number of ventilator-free days (VFD) over 20 days in a 28-day period (i.e. if the child survived, then they were more likely to spend ≥ 7 days endotracheally intubated and mechanically ventilated). Created with BioRender.com using the web version, which may be accessed at https://biorender.com/, with a paid individual subscription granting permission to publish in journals.