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Pediatric acute respiratory distress syndrome

Key sources
The following summarized guidelines for the evaluation and management of pediatric acute respiratory distress syndrome are prepared by our editorial team based on guidelines from the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2/PALISI 2023).


1.Screening and diagnosis

Diagnostic criteria, patients without chronic cardiorespiratory disease: use the PALICC-2 criteria for the diagnosis of PARDS in < 18 years old patients without active perinatal lung disease.
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  • Diagnostic criteria (patients with chronic cardiorespiratory disease)

2.Classification and risk stratification

Risk stratification: use oxygenation index or oxygen saturation index, in preference to PaO2/FiO2 or SpO2/FiO2, as the primary metric of lung disease severity to define PARDS in all patients treated with invasive mechanical ventilation, with PaO2 used preferentially when available.
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3.Diagnostic investigations

Diagnostic imaging
Obtain chest imaging for the diagnosis of PARDS, to detect complications (such as air leak or equipment displacement) and to assess severity.
Insufficient evidence to support the routine use of chest CT, lung ultrasound, and electrical impedance tomography.

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  • Laboratory tests

4.Respiratory support

Prone positioning: insufficient evidence to recommend for or against prone positioning in patients with PARDS.

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  • Airway clearance

  • Endotracheal suctioning

  • Noninvasive ventilation (indications)

  • Noninvasive ventilation (technical considerations)

  • Invasive ventilation (indications)

  • Invasive ventilation (technical considerations)

  • Invasive ventilation (weaning)

  • ECMO (indications)

  • ECMO (technical considerations)

  • ECMO (follow-up)

5.Medical management

Fluid management: consider administering fluids with a daily goal collaboratively established by the interprofessional team to maintain optimal oxygen delivery and preserve end-organ function while preventing fluid overload in patients with PARDS.

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  • Sedation

  • Prevention of delirium

  • Neuromuscular blockade

  • Therapies with no evidence for benefit

6.Inpatient care

Clinical monitoring: obtain clinical monitoring of continuous respiratory frequency, HR, pulse oximetry, and regular intermittent noninvasive BP in all patients with PARDS.

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  • Hemodynamic monitoring

  • Respiratory monitoring

7.Nonpharmacologic interventions

Nutritional support: consider initiating enteral nutrition early (< 72 hours) when feasible over parenteral nutrition or delayed enteral nutrition in patients with PARDS.
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  • Rehabilitation

8.Therapeutic procedures

Blood transfusion: administer PRBC transfusion in critically ill patients with respiratory failure and a hemoglobin concentration < 5 g/dL.
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9.Follow-up and surveillance

Follow-up: advise the patient's primary care providers to screen for post-ICU morbidities within 3 months of discharge from the hospital. Use a stepwise approach to clinical evaluation of post-ICU morbidities with initial screening by a primary care provider or electronic/telephonic screen.
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