TABLE 6.
Synthesis of the Second Pediatric Acute Lung Injury Consensus Conference Clinical Recommendations and Good Practice Statements Related to the Ventilatory Support, Respiratory Monitoring, and Pulmonary Ancillary Treatment
| Topic | Recommendation | Good Practice Statement |
|---|---|---|
| Noninvasive support | ||
| Use of O2/HFNC | Worsening acute respiratory failure → time-limited trial of NIV (7.1.1) | Humidification for HFNC (7.3.3) |
| In RLS, use of HFNC/CPAP vs O2 (7.5.1) | ||
| In RLS, use of CPAP vs HFNC when available (7.5.2) | ||
| Use of NIV (CPAP or bilevel positive airway pressure) | Worsening in 0–6 hr trial → ETT (7.1.2) | Close monitoring and trained staff (7.2) |
| Humidification (7.3.3), optimal interface for synchronization (7.3.1), monitoring for complications (7.3.2) | ||
| Addition of inspiratory support if synchronized (7.3.5) | ||
| Sedation during poor tolerance of NIV (7.3.4) | ||
| Invasive ventilation | ||
| ETT | ETT: use of cuffed tubes (3.11) | |
| Maintain unobstructed airway (4.4.1) | ||
| ETT suction: nonroutine use of instilled saline (4.4.3) | ||
| MV bundle | Use of lung protective ventilation bundle (3.5) | Daily assessment for extubation readiness test and spontaneous breathing trial (6.4.1) |
| Automated monitoring of compliance with Second Pediatric Acute Lung Injury Consensus Conference lung protective strategies (10.2) | In RLS, implement locally adapted protocols (PS 11.5) | |
| Regular training and education of all staff (PS 11.6) | ||
| MV type | Cannot recommend for or against HFOV (3.8.1) | If HFOV used: lung volume optimization strategy (3.8.2) |
| Monitoring | Continuous: respiratory rate, heart rate, Spo2 (6.1.1). Intermittent: noninvasive blood pressure (6.1.1) | |
| Monitor effort of breathing (6.2.5) | ||
| Continuous monitoring of co2 during MV (6.3.3) | ||
| Calculate and monitor dead space (6.3.4) | ||
| Vt | 6–8 mL/kg (3.2) | Scale Vt and Crs to body weight (6.1.2) |
| Use of 4–6 mL/kg if needed to stay below suggested PPlat and DP (3.2) | Continuously monitor Vt (6.2.1) using compensation for circuit compliance (6.2.2) | |
| PIP and PPlat | PPlat ≤ 28 cm H2O (3.3.1) | Monitor PIP and PPlat (6.2.3) |
| PPlat ≤ 32 cm H2O if reduced chest wall compliance (3.3.1) | ||
| DP limit | DP ≤ 15 cm H2O (3.3.2) | Monitor DP (6.2.3) |
| PEEP | Titration: to O2, O2-delivery, hemodynamics, and Crs (3.4.1) | Monitor intrinsic PEEP, flow- and pressure-time curves (6.2.4) |
| Level: at or above level on Acute Respiratory Distress Syndrome Network low PEEP/Fio2 Table (3.4.2) | Titration: attend to PPlat and DP (3.4.3) | |
| Spo2 target | Mild/moderate: 92–97% strategy (3.9.1) | Avoidance of Spo2 < 88% and > 97% (3.9.3) |
| Severe: accept < 92%, with optimized PEEP (3.9.2) | Severe: when Spo2 < 92% → central venous oxygen saturation monitoring (3.9.4) | |
| pH/Paco2 target | Accept pH ≥ 7.2 to remain within PPlat, DP, and Vt ranges during permissive hypercapnia (3.10.1) | Adjust frequency of pH, Paco2 measurement to PARDS severity and stage and to noninvasive co2 monitoring (6.3.2) |
| No routine use of bicarbonate supplementation (3.10.2) | ||
| Ancillary treatment | ||
| Prone positioning | Cannot recommend for or against prone positioning (4.3) | |
| Recruitment maneuver | Cannot recommend for or against recruitment maneuver (3.6) | |
| Inhaled NO | Use of inhaled nitric oxide in selected populations only (4.1) | |
| Surfactant | Against routine use of surfactant (4.2) | |
| Corticosteroids | Use of corticosteroids in selected populations only (4.6) | |
CPAP = continuous positive airway pressure, Crs = compliance of the respiratory system, DP = driving pressure, ETT = endotracheal tube, HFNC = high-flow nasal cannula, HFOV = high-frequency oscillating ventilation, MV = mechanical ventilation, NIV = noninvasive ventilation, PEEP = positive end-expiratory pressure, PIP = peak inspiratory pressure, PPlat = plateau pressure, PS = policy statements, RLS = resource-limited settings, Spo2 = pulse oximeter oxygen saturation, Vt = tidal volume.
The corresponding definition statement numbers are indicated in parentheses.