What are the treatment recommendations for pediatric patients diagnosed with Acute Respiratory Distress Syndrome (ARDS)?

Treatment Recommendations for Pediatric ARDS

The cornerstone of pediatric ARDS management is lung-protective ventilation with tidal volumes ≤10 mL/kg ideal body weight, appropriate PEEP titration, and oxygenation targets of SpO2 92-97% when PEEP <10 cmH2O and 88-92% when PEEP ≥10 cmH2O. 1

Mechanical Ventilation Strategy

Ventilator Settings

• Tidal Volume:

  • Keep ≤10 mL/kg ideal body weight 1
  • Target 6-8 mL/kg ideal body weight for optimal lung protection 2
  • May need to be lower in lung hypoplasia syndromes 1

• PEEP Management:

  • Start with 5-8 cmH2O 1
  • Higher PEEP necessary based on disease severity 1
  • For PARDS with refractory hypoxemia, consider high PEEP strategy 1
  • Use PEEP titration and consider lung recruitment 1

• Plateau Pressure:

  • Keep ≤28 cmH2O in standard cases 1
  • Keep ≤29-32 cmH2O with increased chest wall elastance 1
  • Maintain driving pressure (Plateau pressure - PEEP) <15 cmH2O 2

• Oxygenation Targets:

  • For PARDS: SpO2 92-97% when PEEP <10 cmH2O 1
  • For PARDS: SpO2 88-92% when PEEP ≥10 cmH2O 1
  • Target PaO2 between 70-90 mmHg 2

• Ventilation Targets:

  • Accept higher PCO2 (permissive hypercapnia) unless contraindicated 1
  • Target pH >7.20 1
  • Target normal pH for patients with pulmonary hypertension 1

Advanced Strategies for Refractory Cases

Non-invasive Support

• Consider a trial of non-invasive mechanical ventilation in children with sepsis-induced PARDS without clear indication for intubation 1
• Carefully and frequently re-evaluate when using non-invasive support 1

Prone Positioning

• Suggest prone positioning for children with severe PARDS 1
• Maintain prone position for at least 12 hours per day, as tolerated 1

Neuromuscular Blockade

• Consider in children with severe PARDS 1
• Typically used for 24-48 hours after ARDS onset 1

Inhaled Nitric Oxide (iNO)

• Not recommended for routine use in all children with sepsis-induced PARDS 1
• Consider as rescue therapy in children with refractory hypoxemia after optimizing other oxygenation strategies 1

High-Frequency Oscillatory Ventilation (HFOV)

• Consider in reversible disease if conventional ventilation fails 1
• No definitive recommendation for use versus conventional ventilation in sepsis-induced PARDS 1

Monitoring and Assessment

• Measure PCO2 in arterial or capillary blood samples 1
• Consider transcutaneous CO2 monitoring 1
• Measure end-tidal CO2 in all ventilated children 1
• Measure SpO2 in all ventilated children 1
• Measure arterial PO2 in moderate-to-severe disease 1
• Measure pH, lactate, and central venous saturation in moderate-to-severe disease 1
• Monitor pressure-time and flow-time scalars 1
• Calculate driving pressure and target <15 cmH2O 2

Supportive Measures

• Maintain head of bed elevated 30-45° 1
• Use cuffed endotracheal tube, keep cuff pressure ≤20 cmH2O 1
• Minimize dead space by reducing added components 1
• Use double-limb circuits for invasive ventilation 1
• Avoid hand ventilation unless specific conditions dictate otherwise 1
• Start weaning as soon as possible 1
• Perform daily extubation readiness testing 1

Common Pitfalls and Challenges

1. Poor adherence to lung-protective ventilation:

   • Studies show only 32-33% adherence to tidal volumes ≤6.5 mL/kg ideal body weight 3
   • Even with a more liberal cutoff of ≤8 mL/kg, adherence is only 58-60% 3

2. Incorrect weight calculations:

   • Using actual body weight instead of ideal body weight can lead to harmful ventilation strategies 3
   • Overweight children are less likely to receive appropriate lung-protective ventilation 3

3. Insufficient PEEP:

   • Clinicians often limit PEEP at ~10 cmH2O as oxygenation worsens, which is lower than recommended 4

4. Variability in practice:

   • Substantial variation exists in ventilator management for pediatric ARDS 4
   • Clinicians often make changes opposite to protocol recommendations (12% of the time) or make no changes when indicated (56% of the time) 4

5. Failure to recognize severity:

   • Not adjusting ventilation strategy based on ARDS severity can lead to suboptimal outcomes 2

By following these evidence-based recommendations and avoiding common pitfalls, clinicians can optimize outcomes for pediatric patients with ARDS while minimizing ventilator-induced lung injury.