Release Date : November 29 2023
Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2)
About the Guideline
- The guideline panel consisted of 52 international, multidisciplinary experts in pediatric acute respiratory distress syndrome (PARDS) and four methodology experts from 15 countries.
- These guidelines are an update from the 2015 Secondary Pediatric Acute Lung Injury Consensus Conference (PALICC-2), which addressed the diagnosis and management of PARDS.
- The literature search included MEDLINE, EMBASE, and CINAHL Complete (EBSCOhost); and Grading of Recommendations, Assessment, Development, and Evaluating (GRADE) methodology was used to evaluate the quality of the evidence.
- This update includes 146 recommendations and statements.
Key Clinical Considerations
Become familiar with the recommendations and best-practice statements provided in this guideline, especially if you work in a pediatric acute care setting.
Diagnosis of PARDS
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- Diagnosis of PARDS includes the following criteria:
- Age—the patient must be younger than 18 years of age without active perinatal lung disease
- Timing—symptoms of hypoxemia and radiographic changes must occur within seven days of a known clinical insult
- Origin of edema—edema not fully explained by cardiac failure or fluid overload must be present
- Chest imaging—the presence of opacity (or opacities) found by chest imaging and consistent with acute pulmonary parenchymal disease that is not explained by effusion or atelectasis
- Oxygenation—disease stratification that is determined by severity of hypoxemia
- For children treated with invasive mechanical ventilation (IMV), oxygenation index (OI) or oxygen saturation index (OSI), rather than arterial partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FIO2) or pulse oximeter oxygen saturation (SpO2)/FIO2, should be utilized to measure lung disease severity.
- For children receiving noninvasive ventilation (NIV) or high-flow nasal cannula (HFNC), PaO2/FIO2 or SpO2/FIO2 should be used to diagnose PARDS or possible PARDS.
- For children with cyanotic heart disease, PARDS is diagnosed using the above criteria, when acute deterioration in oxygenation is present that is not otherwise explained by cardiac disease.
- For children with chronic lung disease, PARDS is diagnosed using the above criteria when acute deterioration in oxygenation from baseline is present.
- After a period of 4 hours, children should be stratified into severity categories according to oxygenation levels and method of ventilation.
- To aid in the bedside assessment and risk stratification, measurement of dead space to tidal volume ratio and/or end-tidal alveolar dead-space fraction is suggested for children with arterial access.
Invasive ventilatory support
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- No recommendation is made regarding the specific ventilator mode preferred for children with PARDS.
- The use of physiologic tidal volumes between 6 and 8 mL/kg is suggested.
- Use of tidal volumes below 6 mL/kg is suggested if children need to stay below suggested plateau and driving pressure limits.
- Tidal volumes less than 4 mL/kg should be used with caution.
- Inspiratory plateau pressure of 28 cmH20 or less is suggested in the absence of transpulmonary pressure measurements.
- For children with reduced chest wall compliance, plateau pressure may be higher.
- Limiting driving pressure to 15 cm H20 is suggested.
- Titrating positive end-expiratory pressure (PEEP) to oxygenation/oxygen delivery, hemodynamics, and compliance measurements under static conditions is suggested.
- Maintaining PEEP levels at or above the lower PEEP/higher FIO2 table from the ARDS Network protocol is recommended.
- Avoid exceeding plateau pressure and/or driving pressure limits when adjusting PEEP levels to achieve the proposed oxygen target range.
- When caring for ventilated children with PARDS, using a lung protective ventilation bundle rather than no bundle is suggested.
- No recommendation is made for or against the use of recruitment maneuvers in children with PARDS.
- Insufficient evidence is available regarding the use of mechanical power calculations to guide pediatric mechanical ventilation.
- No recommendation is made regarding the use of high-frequency oscillatory ventilation (HFOV) over conventional ventilation.
- Optimal lung volume should be attained by exploration of the potential for lung recruitment with a stepwise increase and decrease of the mean airway pressure while continuously monitoring oxygen and CO2 response and hemodynamic parameters when using HFOV.
- For mild/moderate PARDS, maintaining SPO2 between 92% and 97% is suggested.
- For severe PARDS, after optimizing PEEP and in order to reduce FIO2, an SPO2 less than 92% can be accepted.
- While receiving supplemental oxygen, prolonged exposure of an SPO2 less than 88% or more than 97% should be avoided.
- Central venous saturation and markers of oxygen delivery/utilization should be monitored when SPO2 is less than 92%.
- Allowing permissive hypercapnia (lower limit pH of 7.20) is suggested to remain within previously recommended tidal volume and pressure ranges.
- Exceptions include intracranial hypertension, select congenital heart disease lesions, significant ventricular dysfunction, severe pulmonary hypertension, and hemodynamic instability.
- Routine use of bicarbonate supplementation is not suggested.
- When ventilating a child with PARDS, cuffed endotracheal tubes should be utilized.
Ancillary pulmonary treatment
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- Routine use of inhaled nitric oxide is not suggested.
- Routine use of surfactant therapy is not suggested.
- Insufficient evidence is available to endorse or oppose the use of prone positioning.
- An unobstructed airway should be maintained in intubated children.
- No recommendation can be made regarding the use of a closed versus an open suctioning system.
- Instillation of isotonic saline prior to endotracheal suctioning should not be performed routinely.
- No recommendation can be made regarding the use of specific methods of airway clearance.
- Routine use of corticosteroids is not suggested.
- No recommendation can be made regarding the following treatments:
- Inhaled or intravenous (IV) prostaglandins therapy
- Inhaled β-adrenergic receptor agonists or ipratropium
- IV N-acetylcysteine for antioxidant effects
- Helium-oxygen mixture
- Fibrinolytics or other anticoagulants
- Plasminogen activators
Nonpulmonary treatments
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- Validated assessment scales for pain, sedation, delirium, and withdrawal should be utilized to monitor and adjust therapies and to facilitate communication among the care team.
- Sedation should be titrated to attain the appropriate mechanical ventilation plan that promotes oxygen delivery, oxygen consumption, and work of breathing goals.
- The care team should utilize a validated protocol to establish daily sedation goals when monitoring, titrating, and weaning sedation.
- Providers weaning children from five or more days of sedation should incorporate a plan that facilitates weaning and assessment of the child for iatrogenic withdrawal syndrome using a validated assessment tool.
- Assess children for delirium daily utilizing a validated pediatric delirium screening tool.
- To prevent and treat delirium, incorporate nonpharmacologic interventions as first-line tools.
- No recommendation can be made for the use of melatonin, typical or atypical antipsychotics, or other medications for the routine prevention and treatment of delirium.
- The use of neuromuscular blockade (NMB) in conjunction with sedation is suggested over the use of sedation alone if effective mechanical ventilation cannot be attained.
- The NMB should be monitored and titrated to the goal prescribed by the care team.
- Early initiation of enteral nutrition is suggested over parenteral nutrition or delayed enteral nutrition.
- Nutrition plan goals should include promoting recovery, maintaining growth, and meeting the child's metabolic needs.
- A minimum intake of 1.5 g/kg/day of protein is suggested.
- Maintaining optimal oxygen delivery and preserving end-organ function while preventing fluid overload should be the focus of daily fluid goals and the administration of fluids.
- Except in the case of hemolytic anemia, critically ill children with respiratory failure who have a hemoglobin of less than 5g/dL should receive packed red blood cells (PRBCs).
- For critically ill, hemodynamically stable children with a hemoglobin of 7 g/dL or more (without a chronic cyanotic condition, severe PARDS, or hemolytic anemia), the transfusion of PRBCs is not suggested.
- For critically ill children who have severe hypoxemia or who are hemodynamically unstable, no recommendation can be made regarding the optimal PRBC transfusion threshold.
- Nonpharmacologic approaches should be utilized to enhance day-night activities and rest patterns.
- Activity and mobility goals should be assessed and determined daily.
- Physical therapy and/or occupational therapy evaluation should be performed within the first 72 hours of admission to establish baseline function and rehabilitation goals.
Monitoring
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- At a minimum, all children with PARDS should have continuous monitoring of respiratory rate, heart rate, and pulse oximetry, and regular intermittent monitoring of noninvasive blood pressure.
- Lung volume metrics, such as tidal volume, should be interpreted after standardization to body weight.
- Tidal volume should be continuously monitored during invasive ventilation.
- Adjust as needed, either manually or via ventilator settings, using compensation for circuit compliance.
- Monitor ventilator inspiratory pressures, including driving pressure and plateau pressure.
- Assess the accuracy of respiratory timings by monitoring flow-time, pressure-time curves, and intrinsic PEEP.
- Clinical assessment should include monitoring the child's effort of breathing.
- No recommendation can be made regarding routine monitoring of the following parameters of respiratory system mechanics:
- Flow-volume loop
- Pressure-volume loop
- Dynamic compliance and resistance
- Strain
- Stress index
- Esophageal manometry and transpulmonary pressure
- Functional residual capacity
- Ventilation index
- Mechanical power
- Mechanical energy
- Electrical activity of diaphragm
- Thoraco-abdominal asynchrony quantification by respiratory inductance plethysmography
- Adjust the frequency of blood pH and PaCO2 measurement according to PARDS severity, noninvasive monitoring data, and stage of disease.
- During IMV, continuous monitoring of CO2 should be used to assess adequacy of ventilation.
- When PaCO2 and either end-tidal CO2 pressure or mixed-expired CO2 pressure are available during IMV, dead space should be calculated and monitored.
- Perform daily assessment of predefined clinical and physiologic criteria of extubation readiness to avoid unnecessary prolonged ventilation.
- Chest imaging is imperative for the diagnosis of PARDS, to assess severity, and to detect complications, such as equipment displacement or an air leak.
- No recommendation can be made regarding the routine use of chest computerized tomography (CT) scans, lung ultrasonography, or electrical impedance tomography.
- Hemodynamic monitoring should be performed to evaluate the effect of ventilation and disease on right and left cardiac function and to assess the delivery of oxygen.
- Monitor cumulative fluid balance.
- Perform echocardiography to provide noninvasive evaluation of both left and right ventricular function, preload status, and pulmonary arterial pressures for children with severe PARDS or suspected cardiac dysfunction.
- Consider an arterial catheter for continuous monitoring of arterial blood pressure and arterial blood gases.
- No recommendation can be made regarding the use of the following hemodynamic monitoring devices:
- Pulse contour with transpulmonary dilution technology
- Pulmonary artery catheters
- Alternative devices to monitor cardiac output, such as an ultrasonic cardiac output monitor
- Central venous pressure monitoring
- B-type natriuretic peptide measurements
Noninvasive respiratory support
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- If no clear indications for intubation are present, a time-limited trial of NIV is suggested for children with possible PARDS or for those who are at risk for PARDS and who are on conventional O2 therapy or on HFNC and showing signs of worsening respiratory failure.
- For children not showing clinical improvement after the first 6 hours of NIV or for those who have signs of worsening illness, intubation is suggested over continuing NIV (including those children at higher risk for complications related to IMV).
- NIV should be utilized in settings with experienced staff, who can perform close monitoring and perform interventions if necessary.
- Monitor children who are receiving NIV for skin breakdown, gastric distension, conjunctivitis, and barotrauma.
- Utilize heated humidification for NIV and HFNC.
- Sedation can be utilized for children with a poor tolerance for NIV and HFNC.
- Inspiratory pressure augmentation with pressure support should be used to reduce inspiratory muscle effort for children managed with NIV. CPAP alone may be appropriate for those unable to attain child-ventilator synchrony or when using a nasal interface.
- No recommendation can be made regarding the use of HFNC for children with possible PARDS or at risk for PARDS.
- For children at risk for PARDS, the use of HFNC or CPAP is suggested over standard oxygen therapy.
- In resource-limited settings, CPAP is suggested over HFNC for children with possible PARDS.
Extracorporeal support
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- When lung protective strategies result in inadequate gas exchange and the child has a potentially reversible cause of severe PARDS, evaluation for extracorporeal membrane oxygenation (ECMO) is suggested.
- Evaluation of case history and clinical status should guide the decision to institute ECMO.
- Decisions regarding ECMO eligibility should be guided by successive evaluations rather than a single assessment.
- For children with adequate cardiac function, venovenous ECMO is suggested over venoarterial ECMO.
- Consider transferring the child to an ECMO center when non-ECMO therapies have failed to stabilize the child.
- Maintaining a normal PAO2 is suggested for a child supported by ECMO.
- A slow decrease of PACO2 is suggested over a rapid decrease, especially in the setting of hypercapnia.
- To avoid additional lung injury in a child supported by ECMO, mechanical ventilator pressure should comply with the lung protective limits that were previously identified.
- No recommendation can be made regarding when to use extracorporeal carbon dioxide removal technology in the child population.
- For all pediatric ECMO survivors, perform short- and long-term neurodevelopmental and physical functioning evaluations to assess for impairment.
Morbidity and long-term outcomes
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- Screening for post-ICU (intensive care unit) morbidities should be performed by the child's primary care provider (PCP) within three months of discharge from the hospital.
- Screening for pulmonary function abnormalities should be performed within the first three months after hospital discharge, and should include a respiratory symptom questionnaire, respiratory examination, pulse oximetry, and if age appropriate, spirometry.
- When pulmonary function deficits are discovered, referral to a specialist is recommended.
Reference
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Emeriaud, G., López-Fernández, Y. M., Iyer, N. P., Bembea, M. M., Agulnik, A., Barbaro, R. P., Baudin, F., Bhalla, A., Brunow de Carvalho, W., Carroll, C. L., Cheifetz, I. M., Chisti, M. J., Cruces, P., Curley, M. A. Q., Dahmer, M. K., Dalton, H. J., Erickson, S. J., Essouri, S., Fernández, A., Flori, H. R., … Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) Group on behalf of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network (2023). Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-
2).
Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies,
24(2), 143–168.
https://doi.org/10.1097/PCC.0000000000003147