Nonpulmonary Treatments for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

Abstract

The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Twenty-five studies were identified for fulltext extraction. Five clinical practice recommendations were generated, related to neuromuscular blockade, nutrition, fluid management, and transfusion. Thirteen good practice statements were generated on the use of sedation, iatrogenic withdrawal syndrome, delirium, sleep management, rehabilitation, and additional information on neuromuscular blockade and nutrition. Three research statements were generated to promote further investigation in nonpulmonary therapies for PARDS. CONCLUSIONS:These recommendations and statements about nonpulmonary treatments in PARDS are intended to promote optimization and consistency of care for patients with PARDS and identify areas of uncertainty requiring further investigation.

Neuromuscular Blocker Use in Critically Ill Children: Assessing Mortality Risk by Propensity Score–Weighted Analysis

“…Our results confirm the findings of previous studies in which NMBAs were mainly used in patients presenting with respiratory disease and ventilated with nonconventional ventilatory support (4,9,19). The findings are also consistent with the Pediatric Acute Lung Injury Consensus Conference recommendation for the management of acute PARDS, in which NMBAs are indicated once MV is ineffective with sedation alone (7). Similarly, adult guidelines based on strong evidences suggest a trial of NMBAs when sedation alone is inadequate to achieve effective MV for patients with acute respiratory distress syndrome associated with profound hypoxemia, respiratory acidosis, or hemodynamic compromise and a Pao 2 /Fio 2 ratio less than 150 (5).…”

“…Similarly, adult guidelines based on strong evidences suggest a trial of NMBAs when sedation alone is inadequate to achieve effective MV for patients with acute respiratory distress syndrome associated with profound hypoxemia, respiratory acidosis, or hemodynamic compromise and a Pa o 2 /F io 2 ratio less than 150 (5). Our high rate of NMBA use in patients with respiratory disease confirms that, even in the setting of a limited consensus pediatric guidelines, the principal indications for their utilization seems to optimize ventilation and asynchrony when sedation alone cannot achieve effective MV, particularly when using nonconventional ventilatory support (1, 7). However, there are limited high-quality data on the use of NMBAs in pediatric patients receiving MV and no randomized controlled studies in children evaluating their use with PARDS.…”

“…The only other recommendations for the use of NMBAs can be found for pediatric acute respiratory distress syndrome (PARDS) patients in the Pediatric Acute Lung Injury and Sepsis Investigators Network Consensus, published in 2015. A panel of 27 experts recommended the use of NMBAs if sedation alone is inadequate to achieve an effective MV, also suggesting daily NMBAs discontinuation to allow periodic assessment of the patient's paralysis and sedation level (7).…”

Nutritional Support in Children Meeting the At-Risk for Pediatric Acute Respiratory Distress Syndrome Criteria

“…The potential to modulate the intestinal immune system and reduce downstream inflammatory signaling in the lung through maintenance of the intestinal epithelial barrier is an area of active investigation. For now, judicious use of EN remains a promising therapeutic means of preventing intestinal epithelial barrier dysfunction, although the key constituents and minimal critical volume (so called “trophic feeds”) is not yet known ( 14 , 22 – 24 ). The role EN plays within these complex immune interactions may potentially explain the improved outcomes seen in children with respiratory failure, including in our study.…”

“…In multivariate analysis, however, early EN was the only factor associated with decreased odds of subsequent PARDS. There is prior evidence to suggest an association between EN and improved patient outcomes for children in acute hypoxic respiratory failure (22)(23)(24). The nutritive benefits of food in a critically ill child with altered metabolism are well described and inform current practice guidelines (14).…”