Table 2:
PALICC recommendations for the management of PARDS
| Summary of evidence from paediatric studies | PALICC recommendations | |
|---|---|---|
|
| ||
| Lung-protective ventilation | • Threshold for injurious tidal volume not established (systematic review11) • Higher mortality with lower PEEP relative to FiO2 than that recommended by the ARDS Network12 (observational study13) • Improved oxygenation but no improvement in clinical outcomes with HFOV (small RCTs,14–17 systematic review,18 observational study19); PROSpect 2 × 2 factorial, response-adaptive RCT (prone positioning and HFOV; NCT03896763) ongoing |
• Use tidal volume of 5–8 mL/kg predicted bodyweight if respiratory system compliance preserved (3–6 mL/kg predicted bodyweight if respiratory system compliance reduced)20 • Maintain plateau pressure of ≤28 cm H2O (29–32 cm H2O if chest wall elastance increased)20 • Consider HFOV as an alternative approach if lung-protective ventilation targets cannot be maintained20 • Maintain SpO2 at 92–97% (88–92% for severe PARDS and PEEP ≥10 cm H2O)20 • Allow permissive hypercapnia: target pH 7–15-7–3020 |
| Recruitment manoeuvres | No paediatric studies | Use incremental and decremental PEEP titration, with monitoring of markers of oxygen delivery, respiratory system compliance, and haemodynamics20 |
| Fluid management | Fluid overload associated with worse outcomes (oxygenation and fewer ventilator-free days; systematic review21) | Use a goal-directed fluid-management protocol to maintain intravascular volume while minimising fluid overload22 |
| Prone positioning | No reduction in ventilator-free days (RCT23); PROSpect RCT ongoing | Not recommended for routine use; consider in patients with severe PARDS24 |
| Nitric oxide | Improved oxygenation but no improvement in survival (RCTs, observational studies, literature review24) | Not recommended for routine use; consider in patients with documented pulmonary hypertension or severe right ventricular failure, or as rescue from or bridge to ECMO24 |
| Surfactant | Improved oxygenation but no improvement in survival (RCTs, observational studies, literature review24) | Not recommended for routine use24 |
| Steroids | No effect on survival or duration of ventilation (RCT25); longer duration of mechanical ventilation with prolonged steroid administration (observational study26) | Not recommended for routine use24 |
| Neuromuscular blockade | Improved oxygenation27 but longer duration of mechanical ventilation and paediatric ICU stay28 (observational studies) | Consider if sedation alone is deemed to be inadequate to achieve effective mechanical ventilation22 |
| Sedation | No effect on duration of mechanical ventilation with reduced sedation exposure (RCT29) | • Use minimal yet effective targeted sedation to facilitate tolerance to mechanical ventilation and to optimise oxygen delivery, oxygen consumption, and work of breathing22 • Use validated pain and sedation scales22 |
| ECMO | No paediatric RCTs | Consider in patients with severe PARDS when lung-protective ventilation strategies result in inadequate gas exchange; disease process must be deemed reversible30 |
PALICC recommendations from the Pediatric Acute Lung Injury Consensus Conference Group.10 ARDS=acute respiratory distress syndrome. ECMO=extracorporeal membrane oxygenation. FiO2=fraction of inspired oxygen. HFOV=high-frequency oscillatory ventilation. PALICC=Paediatric Acute Lung Injury Consensus Conference. PARDS=paediatric acute respiratory distress syndrome. PEEP=positive end-expiratory pressure. PROSpect=Prone and Oscillation Pediatric Clinical Trial. RCT=randomised controlled trial. SpO2=pulse-oximetric oxygen saturation.