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

Current Treatment Recommendations for Pediatric ARDS

Begin with lung-protective mechanical ventilation using tidal volumes of 4-8 mL/kg predicted body weight (not actual body weight) and maintain plateau pressures ≤30 cmH₂O as the foundation of PARDS management. 1, 2

Initial Respiratory Support Strategy

• Consider a trial of non-invasive ventilation (NIV) or high-flow nasal cannula (HFNC) only in children without clear intubation indications who are responding to initial resuscitation, starting with HFNC flow of 30-40 L/min and FiO₂ 50-60%. 3, 1, 2

• Proceed immediately to intubation if deterioration occurs within 1 hour, FiO₂ exceeds 70%, or flow exceeds 50 L/min—delaying intubation in patients failing NIV is associated with worse outcomes. 1, 2

• Avoid etomidate when intubating children with septic shock or sepsis-associated organ dysfunction. 3

Lung-Protective Ventilation Parameters

• Set tidal volume at 4-8 mL/kg predicted body weight—never use actual body weight for calculations, as this is a common pitfall that leads to excessive tidal volumes and ventilator-induced lung injury. 3, 1, 2

• Maintain plateau pressure ≤30 cmH₂O at all times to prevent barotrauma, or ≤28-29 cmH₂O with increased chest wall elastance. 3, 1, 2

• Keep driving pressure ≤10 cmH₂O for healthy lungs, though optimal levels for diseased lungs remain undefined. 3

PEEP Strategy and Recruitment

• Use higher PEEP in moderate-to-severe PARDS, guided by the ARDS-network PEEP-to-FiO₂ grid, though be cautious of adverse hemodynamic effects particularly in children with septic shock. 3, 1, 2

• Apply PEEP of 5-8 cmH₂O as baseline, with higher PEEP dictated by underlying disease severity. 3

• Recruitment maneuvers cannot be routinely recommended, but if considered, use a stepwise, incremental and decremental PEEP titration maneuver rather than sustained inflation techniques—all PARDS patients must be carefully monitored for tolerance. 3

Oxygenation and Ventilation Targets

• Target SpO₂ 92-97% when PEEP <10 cmH₂O and 88-92% when PEEP ≥10 cmH₂O—do not exceed SpO₂ 97% to avoid oxygen toxicity. 3, 1, 2

• Target PaO₂ 70-90 mmHg to ensure adequate oxygenation without excessive oxygen exposure. 1, 2

• Accept permissive hypercapnia with target pH >7.20, though maintain normal pH for patients with pulmonary hypertension. 3

Monitoring Requirements

• Measure SpO₂ and end-tidal CO₂ in all ventilated children, with arterial PO₂, pH, lactate, and central venous saturation in moderate-to-severe disease. 3

• Monitor peak inspiratory pressure, plateau pressure, mean airway pressure, and PEEP near the Y-piece of the patient circuit in children <10 kg. 3

• Assess right ventricular function via echocardiography, as RV failure significantly worsens outcomes. 1, 2

• Measure central venous saturation as a marker for cardiac output in moderate-to-severe disease. 3

Adjunctive Therapies for Severe PARDS

Prone Positioning

• Implement prone positioning for at least 12 hours per day in children with severe PARDS, as this has demonstrated significant mortality reduction in both adult and pediatric studies. 3, 1, 2

Neuromuscular Blockade

• Use neuromuscular blockade for 24-48 hours after ARDS onset in children with severe PARDS to improve ventilator synchrony and reduce oxygen consumption. 3, 1, 2

Inhaled Nitric Oxide

• Do not use inhaled nitric oxide (iNO) routinely in all children with sepsis-induced PARDS. 3, 1

• Consider iNO only as rescue therapy for refractory hypoxemia after optimizing all other oxygenation strategies (PEEP, prone positioning, neuromuscular blockade). 3, 1

High-Frequency Oscillatory Ventilation

• No recommendation can be made for or against using HFOV versus conventional ventilation in children with sepsis-induced PARDS, as evidence remains insufficient. 3

• Consider HFOV in reversible disease if conventional ventilation and/or other strategies fail, but do not use high-frequency jet ventilation in obstructive airway disease. 3

Fluid Management

• Implement conservative fluid management once respiratory status is stabilized to minimize pulmonary edema. 1, 2, 4

• Avoid excessive fluid administration, which worsens oxygenation, promotes right ventricular failure, and increases mortality. 1, 2

Supportive Care Measures

• Use humidification for all ventilated patients. 3

• Maintain head of bed elevated 30-45° to reduce aspiration risk and improve lung mechanics. 3

• Use cuffed endotracheal tubes with cuff pressure ≤20 cmH₂O. 3

• Minimize dead space by limiting added components in the ventilator circuit. 3

• Do not perform endotracheal suctioning routinely—only on indication, without routine instillation of isotonic saline. 3

• Do not use chest physiotherapy routinely, but consider cough-assist devices in neuromuscular patients. 3

• Avoid hand ventilation unless specific conditions dictate otherwise. 3

Weaning Strategy

• Start weaning as soon as possible once the patient shows improvement. 3

• Perform daily extubation readiness testing to minimize duration of mechanical ventilation. 3

• Consider non-invasive ventilation in neuromuscular patients during weaning. 3

• Use corticosteroids in patients at increased risk for post-extubation stridor. 3

Nutritional Support

• Do not withhold enteral feeding solely based on vasoactive-inotropic medication administration—enteral feeding is not contraindicated after adequate hemodynamic resuscitation when vasoactive agents are no longer being escalated or weaning has started. 3

• Use enteral nutrition as the preferred method of feeding over parenteral nutrition. 3

Advanced Rescue Therapies

• Consider VV-ECMO only at centers with ECMO expertise for patients with severe ARDS failing conventional management, particularly those with potentially reversible disease. 1, 2

Common Pitfalls to Avoid

• Never calculate tidal volume using actual body weight—always use predicted body weight to prevent excessive tidal volumes. 1, 2

• Do not delay intubation in patients failing NIV—this is associated with significantly worse outcomes. 1, 2

• Do not routinely use inhaled nitric oxide—reserve it strictly for rescue therapy after all other strategies have been optimized. 3

• Monitor hemodynamics closely when using high PEEP—adverse effects may be more prominent in children with septic shock. 3