What are the latest guidelines for managing pediatric Acute Respiratory Distress Syndrome (ARDS)?

Latest Guidelines for Managing Pediatric Acute Respiratory Distress Syndrome (pARDS)

The management of pediatric Acute Respiratory Distress Syndrome (pARDS) should follow lung-protective ventilation strategies with specific oxygenation targets, appropriate PEEP levels, and consideration of adjunctive therapies based on disease severity.

Ventilation Strategies

Tidal Volume and Pressure Limits

• Keep tidal volumes ≤10 mL/kg ideal body weight (may need to be lower in lung hypoplasia syndromes) 1
• Limit plateau pressure ≤28 cmH2O in restrictive lung disease or ≤30 cmH2O in obstructive airway disease 1
• Keep driving pressure (plateau pressure minus PEEP) ≤10 cmH2O for healthy lungs 1

PEEP Management

• Use 5-8 cmH2O as baseline PEEP, with higher levels necessary based on disease severity 1
• For pARDS: Consider PEEP titration and lung recruitment maneuvers based on disease severity 1
• Add PEEP in obstructive airway disease when air-trapping is present to facilitate triggering 1
• Use PEEP to stent upper airways in cases of malacia 1

Oxygenation Targets

• For pARDS: Target SpO2 92-97% when PEEP <10 cmH2O and 88-92% when PEEP ≥10 cmH2O 1
• Keep SpO2 ≤97% for all disease conditions 1
• Target PCO2 35-45 mmHg for healthy lungs, with higher PCO2 acceptable for acute pulmonary patients as long as pH >7.20 1
• Maintain normal pH for patients with pulmonary hypertension 1

Monitoring Parameters

Essential Monitoring

• Measure PCO2 in arterial or capillary blood samples 1
• Measure end-tidal CO2 and SpO2 in all ventilated children 1
• Measure arterial PO2, pH, lactate, and central venous saturation in moderate-to-severe disease 1
• Monitor pressure-time and flow-time scalars 1, 2
• Measure peak inspiratory pressure, plateau pressure, mean airway pressure, and PEEP 1
• For children <10 kg, measure flow near Y-piece of patient circuit to improve trigger sensitivity 1, 2

Ventilator Modes and Settings

Mode Selection

• Target patient-ventilator synchrony in all modes 1
• Consider high-frequency oscillatory ventilation (HFOV) when conventional ventilation fails 1
• Do not use high-frequency jet ventilation in obstructive airway disease 1
• Consider extracorporeal life support in reversible disease if conventional ventilation and/or HFOV fails 1

Inspiratory Time and I:E Ratio

• Set inspiratory time based on respiratory system mechanics and underlying disease 1
• Use time constant (observe flow-time scalar) to guide settings 1
• Use higher respiratory rates in restrictive disease to maintain minute ventilation 1

Non-Invasive Respiratory Support

CPAP and HFNC

• Consider in mild-to-moderate cardiorespiratory failure 1
• Should not delay intubation in severe disease 1
• Consider non-invasive ventilation in neuromuscular patients during weaning 1

Weaning and Extubation

Weaning Protocol

• Start weaning as soon as possible 1, 2
• Perform daily extubation readiness testing 1, 2
• Use corticosteroids in patients at increased risk for post-extubation stridor 1

Supportive Measures

Positioning and Airway Management

• Maintain head of bed elevated 30-45° 1
• Use cuffed endotracheal tube with cuff pressure ≤20 cmH2O 1
• Minimize dead space by reducing added components 1
• Use double-limb circuits for invasive ventilation 1

Suctioning and Humidification

• Use humidification for all ventilated patients 1
• Perform endotracheal suctioning only when indicated, not routinely 1
• Avoid routine instillation of isotonic saline prior to suctioning 1

Common Pitfalls to Avoid

• Setting inspiratory trigger too sensitive or too insensitive can increase work of breathing or cause auto-triggering 2
• Inappropriate expiratory trigger settings can lead to air-trapping or premature cycling 2
• Using home ventilators during the acute phase in the intensive care unit 1
• Routine hand ventilation (avoid unless specific conditions dictate otherwise) 1
• Weaning too rapidly, which can lead to fatigue and extubation failure 2, 3
• Failure to recognize variability in ventilator management practices, which may lead to suboptimal outcomes 4

Special Considerations

Cardiac Patients

• Same principles of mechanical ventilation apply as for non-cardiac children 1
• Use sufficient PEEP to maintain end-expiratory lung volume 1
• Consider PEEP titration and lung recruitment maneuvers 1

Neuromuscular Patients

• Consider cough-assist devices 1
• Consider non-invasive ventilation during weaning 1