OBJECTIVES: We sought to update our 2015 work in the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) guidelines for the diagnosis and management of pediatric acute respiratory distress syndrome (PARDS), considering new evidence and topic areas that were not previously addressed. DESIGN: International consensus conference series involving 52 multidisciplinary international content experts in PARDS and four methodology experts from 15 countries, using consensus conference methodology, and implementation science. SETTING: Not applicable. PATIENTS: Patients with or at risk for PARDS. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Eleven subgroups conducted systematic or scoping reviews addressing 11 topic areas: 1) definition, incidence, and epidemiology; 2) pathobiology, severity, and risk stratification; 3) ventilatory support; 4) pulmonary-specific ancillary treatment; 5) nonpulmonary treatment; 6) monitoring; 7) noninvasive respiratory support; 8) extracorporeal support; 9) morbidity and long-term outcomes; 10) clinical informatics and data science; and 11) resource-limited settings. The search included MEDLINE, EMBASE, and CINAHL Complete (EBSCOhost) and was updated in March 2022. Grading of Recommendations, Assessment, Development, and Evaluation methodology was used to summarize evidence and develop the recommendations, which were discussed and voted on by all PALICC-2 experts. There were 146 recommendations and statements, including: 34 recommendations for clinical practice; 112 consensus-based statements with 18 on PARDS definition, 55 on good practice, seven on policy, and 32 on research. All recommendations and statements had agreement greater than 80%. CONCLUSIONS: PALICC-2 recommendations and consensus-based statements should facilitate the implementation and adherence to the best clinical practice in patients with PARDS. These results will also inform the development of future programs of research that are crucially needed to provide stronger evidence to guide the pediatric critical care teams managing these patients.

Objective Determine the feasibility of pulmonary function (PFT) and quality of life (QOL) evaluations in children after Acute Respiratory Distress Syndrome (ARDS). Design A prospective follow-up feasibility study Setting A tertiary pediatric intensive care unit Patients Children <18 year old with ARDS admitted between 2000 and 2005. Measurements and Main Results PFTs and QOL questionnaires performed approximately 12-months post-illness were analyzed and correlated to in-hospital clinical parameters. QOL data was compared to published pediatric chronic asthma and general pediatric norms. 180 patients met ARDS criteria; 37 (20%) died, 90 (51%) declined participation, 28 (16%) consented but did not return, and 24 (13%) returned for follow up visit. Twenty-three patients completed QOL testing and 17 completed PFTs. Clinical characteristics of those who returned were no different from those who did not except for age (median age 4.9 vs. 1.8 years). One third had mild to moderate pulmonary function deficits. QOL scores were marginal with general health perception, physical functioning, and behavior being areas of concern. These scores were lower than scores in children with chronic asthma. Parental QOL assessments report lower scores in single parent homes but no differences were noted by race or parental employment status. Conclusion Valuable information may be discerned from ARDS patients who return for follow-up evaluation. In this pilot study up to one-third of children with ARDS exhibit pulmonary function deficits and 12-month post-illness QOL scores are lower than in children with chronic asthma. Parental perceptions of post-illness QOL may be negatively impacted by socioeconomic constraints. Long term follow of children with ARDS is feasible and bears further investigation.

Prior criteria for organ dysfunction in critically ill children were based mainly on expert opinion. We convened the Pediatric Organ Dysfunction Information Update Mandate (PODIUM) expert panel to summarize data characterizing single and multiple organ dysfunction and to derive contemporary criteria for pediatric organ dysfunction. The panel was composed of 88 members representing 47 institutions and 7 countries. We conducted systematic reviews of the literature to derive evidence-based criteria for single organ dysfunction for neurologic, cardiovascular, respiratory, gastrointestinal, acute liver, renal, hematologic, coagulation, endocrine, endothelial, and immune system dysfunction. We searched PubMed and Embase from January 1992 to January 2020. Study identification was accomplished using a combination of medical subject headings terms and keywords related to concepts of pediatric organ dysfunction. Electronic searches were performed by medical librarians. Studies were eligible for inclusion if the authors reported original data collected in critically ill children; evaluated performance characteristics of scoring tools or clinical assessments for organ dysfunction; and assessed a patient-centered, clinically meaningful outcome. Data were abstracted from each included study into an electronic data extraction form. Risk of bias was assessed using the Quality in Prognosis Studies tool. Consensus was achieved for a final set of 43 criteria for pediatric organ dysfunction through iterative voting and discussion. Although the PODIUM criteria for organ dysfunction were limited by available evidence and will require validation, they provide a contemporary foundation for researchers to identify and study single and multiple organ dysfunction in critically ill children.

Objectives To determine if weight extremes impact clinical outcomes in pediatric ARDS (PARDS). Design Post-hoc analysis of a cohort created by combining 5 multicenter PARDS studies Setting 43 academic pediatric intensive care units worldwide Patients 711 subjects prospectively diagnosed with PARDS Intervention Subjects >2 years were included and categorized by CDC BMI z-score criteria: underweight (<−1.89), normal weight (−1.89 to +1.04), overweight (+1.05 to +1.64), and obese (≥+1.65). Subjects were stratified by direct vs. indirect lung injury leading to PARDS. The primary outcome was in-hospital mortality. In survivors, secondary analyses included duration of mechanical ventilation (DMV) and ICU length of stay (LOS). Measurements and Main Results 331 patients met inclusion criteria; 12% were underweight, 50% normal weight, 11% overweight, and 27% obese. Overall mortality was 20%. By multivariate analysis, BMI category was independently associated with mortality (p=0.004). When stratified by lung injury type, there was no mortality difference between BMI groups with direct lung injury; however, in the indirect lung injury group, the odds of mortality in the obese were significantly lower than normal weight subjects (OR=0.11, 95%CI 0.02–0.84). Survivors with direct lung injury had no difference in DMV or ICU LOS; however, those with indirect lung injury, the overweight required longer DMV than other groups (p<0.001). Conclusions These data support the obesity paradox in PARDS. Obese children with indirect lung injury PARDS have a lower risk of mortality. Importantly, among survivors the overweight with indirect lung injury require longer DMV. Our data require prospective validation to further elucidate the pathobiology of this phenomenon.