Management of acute lung injury and acute respiratory distress syndrome in children

Abstract

PubMed search for clinical trials, selected literature review of other relevant studies on epidemiology and diagnosis. DATA SYNTHESIS AND RECOMMENDATIONS: Lower mortality combined with a relatively lower frequency of ALI/ARDS in children makes performance of clinical trials challenging. Based on expert opinion, the following are recommended: 1) avoid tidal volumes > or =10 mL/kg body weight; 2) keep plateau pressure < or =30 cm H2O, arterial pH at 7.30 to 7.45, and Pao2 60 to 80 torr (8 to 10.7 kPa) (Spo2 > or =90%); 3) provide sedation, analgesia, and stress ulcer prophylaxis; and 4) use a 10 g/dL hemoglobin threshold for packed red blood cell transfusion in unstable patients (shock or profound hypoxia). Evidence supports dropping the hemoglobin transfusion threshold to 7 g/dL once profound hypoxia and shock have resolved. Promising therapies for pediatric ALI/ARDS based on pediatric studies include endotracheal surfactant, high-frequency oscillatory ventilation, noninvasive ventilation, and use of extracorporeal membrane oxygenation as a rescue therapy. Promising therapies based on adult trials include use of corticosteroids for lung inflammation and fibrosis, use of 4 to 6 mL/kg tidal volumes and restrictive fluid management. Prone positioning, bronchodilators, inhaled nitric oxide, tight glucose control, and high-flow nasal cannula (HFNC) oxygen are therapies that require further study before they can be recommended for children with ALI/ARDS.

The use of the Berlin definition for acute respiratory distress syndrome during infancy and early childhood: multicenter evaluation and expert consensus

“…This meant testing BD against the most stringent conditions (i.e., the most relevant age range with distinct characteristics). This adds significantly to the relevance of the data, as these peculiarities lead to differences in terms of epidemiology, prognosis, ventilatory modalities [7], efficacy of surfactant [15,22], and ancillary therapies [23], as well.…”

“…This is clearly a compromise, but it was agreed because these patients are thought to carry underlying conditions and triggering diseases particularly different from adults. Furthermore, the respiratory tree is still under maturational development and this might also influence the clinical expression [7]. Practically, we wanted to test the predictive validity of the BD under extreme conditions.…”

“…However, ARDS is a complex syndrome: any definition is an attempt to categorize the clinical reality and this complexity is partially due to the different underlying conditions and triggering diseases across the ages [7]. Moreover, pediatric ARDS shows differences in epidemiology, prognosis, and management.…”

“…Moreover, pediatric ARDS shows differences in epidemiology, prognosis, and management. These differences especially occur during early pediatric age [7]. Given these dissimilarities, a new ARDS definition should be specifically evaluated for pediatric patients.…”

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012

“…To be effective, these modes can require a mean airway pressure 5 cmH 2 O higher than that used with conventional ventilation. This can reduce venous return leading to greater need for fluid resuscitation and vasopressor requirements [612][613][614][615][616].…”