Pediatric Acute Lung Injury Consensus Research Articles

Pediatric Acute Respiratory Distress Syndrome Severity and Health-Related Quality of Life Outcomes: Single-Center Retrospective Cohort, 2011-2017.

To determine factors associated with health-related quality of life (HRQL) decline among pediatric acute respiratory distress syndrome (PARDS) survivors. Retrospective cohort study. Academic children's hospital. Three hundred fifteen children 1 month to 18 years old with an unplanned PICU admission from December 2011 to February 2017 enrolled in the hospital's Outcomes Assessment Program. None. Pre-admission baseline and median 6-week post-discharge HRQL were assessed using the Pediatric Quality of Life Inventory or the Functional Status II-R. Patients meeting retrospectively applied Second Pediatric Acute Lung Injury Consensus Conference criteria for PARDS were identified, and PARDS severity was classified using binary (mild/moderate, severe) and trichotomous (mild, moderate, severe) categorization for noninvasive ventilation and invasive mechanical ventilation (IMV). PARDS occurred in 41 of 315 children (13.0%). Clinically important HRQL decline (≥ 4.5 points) occurred in 17 of 41 patients (41.5%) with PARDS and 64 of 274 without PARDS (23.4%). On multivariable generalized linear regression adjusted for age, baseline Pediatric Overall Performance Category, maximum nonrespiratory Pediatric Logistic Organ Dysfunction score, diagnosis, length of stay, and time to follow-up, PARDS was associated with HRQL decline (adjusted relative risk [aRR], 1.70; 95% CI, 1.03-2.77). Four-hour and maximum PARDS severity were the only factors associated with HRQL decline. HRQL decline occurred in five of 18 patients with mild PARDS at 4 hours, five of 13 with moderate PARDS (aRR 2.35 vs. no PARDS [95% CI, 1.01-5.50]), and seven of ten with severe PARDS (aRR 2.56 vs. no PARDS [95% CI, 1.45-4.53]). The area under the receiver operating characteristic curve for discrimination of HRQL decline for IMV patients was 0.79 (95% CI, 0.66-0.91) for binary and 0.80 (95% CI, 0.69-0.93) for trichotomous severity categorization. HRQL decline is common among children surviving PARDS, and risk of decline is associated with PARDS severity. HRQL decline from baseline may be an efficient and clinically meaningful endpoint to incorporate into PARDS clinical trials.

Potential risk factors of pediatric acute respiratory distress syndrome in sepsis

Background Sepsis in children is characterized by a dysregulated host response to infection and life-threatening organ dysfunction. Pediatric acute respiratory distress syndrome (PARDS) is a severe complication of sepsis. Several known risk factors of PARDS are immunodeficiency, obesity, source of infection, and genetic factors. Objective To describe the potential risk factors of PARDS in septic children at Haji Adam Malik General Hospital, Medan, North Sumatera. Methods This descriptive study using eligible medical record data from sepsis patients aged 1 month – 18 years was conducted at Haji Adam Malik General Hospital in 2020–2022. A total sampling method was used for subject selection. Patients’ demographic and clinical characteristics, mechanical ventilation modes and parameters, laboratory results, and outcomes were collected from medical records. Patients were classified as having sepsis with PARDS if Pediatric Acute Lung Injury Consensus Conference (PALICC) criteria of ARDS was met. Results Of 112 pediatric sepsis patients, 33.9% developed PARDS. The mortality rates for PARDS was 73.7%. Of the patients with PARDS, 57.9% had immunodeficiency, 60.5% patients had an intrapulmonary infection, 39.5% had an extrapulmonary infection, and 23.7% of patients had a suspected genetic disorder. In addition, 39.5% had good nutritional status, followed by 21.1% with obese. Conclusion The majority of patients with PARDS have intrapulmonary infection and immunodeficiency. Some of patients with PARDS have suspected genetic disorders and well nourished.

Acute respiratory distress syndrome in pediatric practice, diagnosis, and intensive care: A review

Acute respiratory distress syndrome is one of the main causes of life-threatening complications and deaths in pediatric intensive care units. This study aimed to analyze the current features of epidemiology, risk factors, and outcomes of acute respiratory distress syndrome in children aged 1 months according to the literature. The analysis included 100 publications extracted from eLibrary and PubMed abstract databases. The search was performed using the following keywords: acute respiratory distress syndrome, epidemiology, pediatric, outcome, and control mechanical ventilation. After the initial study of abstracts, 64 articles containing previously published information were excluded from the review. The recommendations of the Pediatric Acute Lung Injury Consensus Conference, which were published in April 2023, were taken as the main source. The review presents current definitions, risk factors, and criteria for the severity of acute respiratory distress syndrome in pediatric practice, discusses in detail the features of invasive ventilation and adjuvant therapy, and pays special attention to infusion and transfusion therapy, nutrition, and sedation. One of the sections is devoted to monitoring the patient’s condition, assessing the effectiveness of gas exchange and hemodynamics, and emphasizing the importance of a dynamic assessment of delirium in patients and the readiness for extubation. The recommendations of Pediatric Acute Lung Injury Consensus Conference-2 for the treatment of acute respiratory distress syndrome in children make it possible to more accurately stratify the severity of the pathological process, identify patients at risk with a high probability of developing this syndrome, and begin timely protective respiratory support to restore lung parenchyma and optimize oxygen delivery and consumption.

Definition, Incidence, and Epidemiology of Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference: Erratum.

Definition, Incidence, and Epidemiology of Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference: Erratum.

Evaluation of the classifications of severity in acute respiratory distress syndrome in childhood by the Berlin Consensus and the Pediatric Acute Lung Injury Consensus Conference.

To compare two methods for defining and classifying the severity of pediatric acute respiratory distress syndrome: the Berlin classification, which uses the relationship between the partial pressure of oxygen and the fraction of inspired oxygen, and the classification of the Pediatric Acute Lung Injury Consensus Conference, which uses the oxygenation index. This was a prospective study of patients aged 0 - 18 years with a diagnosis of acute respiratory distress syndrome who were invasively mechanically ventilated and provided one to three arterial blood gas samples, totaling 140 valid measurements. These measures were evaluated for correlation using the Spearman test and agreement using the kappa coefficient between the two classifications, initially using the general population of the study and then subdividing it into patients with and without bronchospasm and those with and without the use of neuromuscular blockers. The effect of these two factors (bronchospasm and neuromuscular blocking agent) separately and together on both classifications was also assessed using two-way analysis of variance. In the general population, who were 54 patients aged 0 - 18 years a strong negative correlation was found by Spearman's test (ρ -0.91; p < 0.001), and strong agreement was found by the kappa coefficient (0.62; p < 0.001) in the comparison between Berlin and Pediatric Acute Lung Injury Consensus Conference. In the populations with and without bronchospasm and who did and did not use neuromuscular blockers, the correlation coefficients were similar to those of the general population, though among patients not using neuromuscular blockers, there was greater agreement between the classifications than for patients using neuromuscular blockers (kappa 0.67 versus 0.56, p < 0.001 for both). Neuromuscular blockers had a significant effect on the relationship between the partial pressure of oxygen and the fraction of inspired oxygen (analysis of variance; F: 12.9; p < 0.001) and the oxygenation index (analysis of variance; F: 8.3; p = 0.004). There was a strong correlation and agreement between the two classifications in the general population and in the subgroups studied. Use of neuromuscular blockers had a significant effect on the severity of acute respiratory distress syndrome.

Waiting for the Pediatric Acute Lung Injury Consensus Conference 3.

Waiting for the Pediatric Acute Lung Injury Consensus Conference 3.

The perinatal period should be considered in neonatal acute respiratory distress syndrome: comparison of the Montreux definition vs. the second pediatric acute lung injury consensus conference definition.

The recently developed Montreux definition for neonatal acute respiratory distress syndrome (ARDS) partially differs from the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) definition. Here, we compare the Montreux and PALICC-2 definitions regarding morbidity, mortality, and prognosis of neonatal cases of ARDS in order to evaluate which definition is more appropriate for newborns. Neonates admitted to our neonatal intensive care unit between 1 January 2018 and 30 September 2019 who met the Montreux or PALICC-2 definition of neonatal ARDS were retrospectively analyzed (n = 472). One comparison was made between application of the Montreux and PALICC-2 definitions to neonates outside the perinatal period (> 7 d after birth). A second comparison was made between a diagnosis of neonatal ARDS within (≤ 7 d of birth) and outside (> 7 d after birth) the perinatal period using the Montreux definition. No significant differences in morbidity, mortality, severity, therapies, or prognosis were observed between neonates in the extra perinatal group according to the Montreux and PALICC-2 definitions. However, epidemiology, clinical course, and prognosis of neonatal ARDS within the perinatal period did differ from those outside the perinatal period according to the Montreux definition. Neonates with ARDS within the perinatal period have unique triggers, epidemiology, clinical course, and prognosis, yet a similar pathobiology pattern, to neonates at other ages. Therefore, it may be essential to consider the perinatal period when defining neonatal ARDS.

Prevalence and Incidence of Pediatric Acute Respiratory Distress Syndrome in a Tertiary Academic PICU in South Africa.

To determine the prevalence and incidence of pediatric acute respiratory distress syndrome (pARDS) among infants and children admitted to the PICU. A single-center descriptive point prevalence study with twice weekly data collection over a 6 months (August 2020 to February 12, 2021). Red Cross War Memorial Children's Hospital, Cape Town, South Africa. All infants and children admitted to the PICU on study days were included. Data were captured electronically on a standardized case record form using a Research Electronic Data Capture electronic database. The Pediatric Acute Lung Injury Consensus Conference criteria were used to define pARDS cases. Prevalence was calculated as the total number of pARDS cases/1,000 PICU bed days. The study included 354 patients (median [interquartile range]) 10.1 months old (1.5-61.3 mo old), with 204 males (57.6%), who occupied 879 bed days. Of these 879 bed days, 266 (30.3%; 95% CI, 27.2-33.3%) were occupied by pARDS cases, with a calculated prevalence and incidence of 302.6 of 1,000 bed days (30.3%) and 29.7% (95% CI, 26.7-32.7%), respectively. Three cases from the cohort were defined using the oxygen saturation index calculation. In cases receiving invasive ventilation ( n = 494; 56.2%), pARDS severity was classified as mild ( n = 143; 16.3%), moderate ( n = 44; 5.0%), and severe ( n = 29, 3.3%). A further 205 beds (23.3%) were occupied by patients classified as being at risk of pARDS. The prevalence and incidence of pARDS in a South African PICU appears substantially higher than findings described in international reports. Further investigation of risk factors and outcomes is warranted.

Interrater Reliability of the 2015 Pediatric Acute Lung Injury Consensus Conference Criteria for Pediatric ARDS

Diagnostic guidelines for pediatric acute respiratory distress syndrome (PARDS) were developed at the 2015 Pediatric Acute Lung Injury Consensus Conference (PALICC). Although this was an improvement in creating pediatric-specific diagnostic criteria, there remains potential for variability in identification of PARDS. What is the inter-rater reliability of the 2015 PALICC criteria for diagnosing moderate-severe PARDS? What clinical criteria and patient factors are associated with diagnostic disagreements? Patients with acute hypoxic respiratory failure admitted from 2016-2021 who received invasive mechanical ventilation were retrospectively reviewed by two PICU physicians. Reviewers evaluated whether the patient met the 2015 PALICC definition of moderate-severe PARDS and rated their diagnostic confidence. Inter-rater reliability was measured using Gwet's Agreement Coefficient (AC1). 37 of 191 encounters had a diagnostic disagreement. Inter-rater reliability was "substantial" (AC1=0.74, 95% CI [0.65 - 0.83]). Disagreements were due to different interpretations of chest radiographs (56.8%), ambiguity in origin of pulmonary edema (37.8%), or lack of clarity if patient's current condition was significantly different from baseline (27.0%). Disagreement was more likely in patients who were chronically ventilated (OR 4.66, 95% CI [2.16-10.08], p<0.001), had a primary cardiac admission diagnosis (OR 3.36, 95% CI [1.18 - 9.53], p=0.02), or underwent cardiothoracic surgery during the admission (OR 4.90, 95% CI [1.60 - 15.00], p=0.005). Reviewers were at least moderately confident in their decision 73% of the time, however were less likely to be confident if the patient had cardiac disease or chronic respiratory failure. The inter-rater reliability of the 2015 PALICC criteria for diagnosing moderate-severe PARDS in this cohort was substantial, with diagnostic disagreements commonly due to differences in chest radiograph interpretations. Patients with cardiac disease or chronic respiratory failure were more vulnerable to diagnostic disagreements. More guidance is needed on interpreting chest radiographs and diagnosing PARDS in these subgroups.

CLINICO-ETIOLOGICAL PROFILE AND OUTCOME OF ACUTE RESPIRATORY DISTRESS SYNDROME IN PAEDIATRIC INTENSIVE CARE UNIT (PICU) IN A TERTIARY CARE HOSPITAL IN BHUBANESWAR.

Objective:-To study the clinical profile of the patients of acute respiratory distress syndrome (ARDS) in terms of etiology and clinical course &amp; to evaluate the outcome of the patients with ARDS in term of mortality. :- Study design Prospective observational study. Study was conducted in PICU of HI-Tech medical college, Bhubaneswar. Study group:- All children aged between 3months to 12yrs admitted in PICU from 1st sep 2020 to 31 august 2022,with a diagnosis of pediatric acute respiratory distress syndrome as per pediatric acute lung injury consensus conference definition (PLICC). - Out of 130 patients having acute respiratory distress syndrome, 64.6% Measurements &amp; main results: expired in PICU during stay &amp; 35.3% were discharged. Out of admitted 60% were male &amp; 40 % were female. Most common primary etiology was Pneumonia followed by sepsis, other causes may be drowning, trauma, burns, transfusion related acute lung injury. Pediatric acute respiratory distress syndrome contributes to a significa Conclusion:- nt burden in the PICU of developing country and is associated with significant high mortality. Infection remains the most common etiology.

Association of Interventions With Outcomes in Children At-Risk for Pediatric Acute Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study.

Describe the frequency with which transfusion and medications that modulate lung injury are administered to children meeting at-risk for pediatric acute respiratory distress syndrome (ARF-PARDS) criteria and evaluate for associations of transfusion, fluid balance, nutrition, and medications with unfavorable clinical outcomes. Secondary analysis of the Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology study, a prospective point prevalence study. All enrolled ARF-PARDS patients were included unless they developed subsequent pediatric acute respiratory distress syndrome (PARDS) within 24 hours of PICU admission or PICU length of stay was less than 24 hours. Univariate and multivariable analyses were used to identify associations between therapies given during the first 2 calendar days after ARF-PARDS diagnosis and subsequent PARDS diagnosis (primary outcome), 28-day PICU-free days (PFDs), and 28-day ventilator-free days (VFDs). Thirty-seven international PICUs. Two hundred sixty-seven children meeting Pediatric Acute Lung Injury Consensus Conference ARF-PARDS criteria. None. During the first 2 days after meeting ARF-PARDS criteria, 55% of subjects received beta-agonists, 42% received corticosteroids, 28% received diuretics, and 9% were transfused. Subsequent PARDS (15%) was associated with platelet transfusion (n = 11; adjusted odds ratio: 4.75 [95% CI 1.03-21.92]) and diuretics (n = 74; 2.55 [1.19-5.46]) in multivariable analyses that adjusted for comorbidities, PARDS risk factor, initial oxygen saturation by pulse oximetry:Fio2 ratio, and initial type of ventilation. Beta-agonists were associated with lower adjusted odds of subsequent PARDS (0.43 [0.19-0.98]). Platelets and diuretics were also associated with fewer PFDs and fewer VFDs in the multivariable models, and TPN was associated with fewer PFDs. Corticosteroids, net fluid balance, and volume of enteral feeding were not associated with the primary or secondary outcomes. There is an independent association between platelet transfusion, diuretic administration, and unfavorable outcomes in children at risk for PARDS, although this may be related to treatment bias and unmeasured confounders. Nevertheless, prospective evaluation of the role of these management strategies on outcomes in children with ARF-PARDS is needed.

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

To examine associations between early enteral nutrition (EN) and PICU outcomes in a cohort of children meeting the 2015 Pediatric Acute Lung Injury Consensus Conference "at-risk" for pediatric acute respiratory distress syndrome (ARF-PARDS) criteria. This was a single-center, electronic health record-based retrospective chart review. We included children less than or equal to 18 years-old admitted to our mixed medical-surgical PICU from January 2017 to December 2018 who met ARF-PARDS criteria within 48 hours of admission. Children were categorized as receiving "early" EN if feeds were initiated within 48 hours of admission. All others were categorized as "delayed" EN. Extracted data included demographics, illness characteristics including primary diagnosis and Pediatric Risk of Mortality (PRISM) III score, respiratory support and oxygenation indices, nutritional data, and PICU length of stay (LOS). The primary outcome of interest was subsequent diagnosis of PARDS. Of 201 included children, 152 (75.6%) received early EN. The most common admission diagnoses were pneumonia, bronchiolitis, and influenza. Overall, 21.4% (n = 43) of children developed PARDS. Children receiving early EN had a subsequent diagnosis of PARDS less often then children receiving delayed EN (15.1% vs 40.8%; p < 0.001), an association that persisted after adjusting for patient demographics and illness characteristics, including PRISM III and diagnosis (adjusted odds ratio, 0.24; 95% CI, 0.10-0.58; p = 0.002). Early EN was also associated with a shorter PICU LOS in univariate analysis (2.2 d [interquartile range, 1.5-3.4 d] vs 4.2 d [2.7-8.9 d]; p < 0.001). In this single-center, retrospective cohort study, compared with children with ARF-PARDS who received late EN, those who received early EN demonstrated a reduced odds of subsequent diagnosis of PARDS, and an unadjusted reduction in PICU LOS when compared with delayed EN. Prospective studies should be designed to confirm these findings.

Invasive Ventilatory Support in Patients With Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference.

To provide evidence for the Second Pediatric Acute Lung Injury Consensus Conference updated recommendations and consensus statements for clinical practice and future research on invasive mechanical ventilation support of patients with pediatric acute respiratory distress syndrome (PARDS). MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). We included clinical studies of critically ill patients undergoing invasive mechanical ventilation for PARDS, January 2013 to April 2022. In addition, meta-analyses and systematic reviews focused on the adult acute respiratory distress syndrome population were included to explore new relevant concepts (e.g., mechanical power, driving pressure, etc.) still underrepresented in the contemporary pediatric literature. Title/abstract review, full text review, and data extraction using a standardized data collection form. The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize relevant evidence and develop recommendations, good practice statements and research statements. We identified 26 pediatric studies for inclusion and 36 meta-analyses or systematic reviews in adults. We generated 12 recommendations, two research statements, and five good practice statements related to modes of ventilation, tidal volume, ventilation pressures, lung-protective ventilation bundles, driving pressure, mechanical power, recruitment maneuvers, prone positioning, and high-frequency ventilation. Only one recommendation, related to use of positive end-expiratory pressure, is classified as strong, with moderate certainty of evidence. Limited pediatric data exist to make definitive recommendations for the management of invasive mechanical ventilation for patients with PARDS. Ongoing research is needed to better understand how to guide best practices and improve outcomes for patients with PARDS requiring invasive mechanical ventilation.

Monitoring in Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference.

Monitoring is essential to assess changes in the lung condition, to identify heart-lung interactions, and to personalize and improve respiratory support and adjuvant therapies in pediatric acute respiratory distress syndrome (PARDS). The objective of this article is to report the rationale of the revised recommendations/statements on monitoring from the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2). MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). We included studies focused on respiratory or cardiovascular monitoring of children less than 18 years old with a diagnosis of PARDS. We excluded studies focused on neonates. Title/abstract review, full-text review, and data extraction using a standardized data collection form. The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize evidence and develop recommendations. We identified 342 studies for full-text review. Seventeen good practice statements were generated related to respiratory and cardiovascular monitoring. Four research statements were generated related to respiratory mechanics and imaging monitoring, hemodynamics monitoring, and extubation readiness monitoring. PALICC-2 monitoring good practice and research statements were developed to improve the care of patients with PARDS and were based on new knowledge generated in recent years in patients with PARDS, specifically in topics of general monitoring, respiratory system mechanics, gas exchange, weaning considerations, lung imaging, and hemodynamic monitoring.

Definition, Incidence, and Epidemiology of Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference.

In 2015, the Pediatric Acute Lung Injury Consensus Conference (PALICC) provided the first pediatric-specific definitions for acute respiratory distress syndrome (pediatric acute respiratory distress syndrome [PARDS]). These definitions have since been operationalized in cohort and interventional PARDS studies. As substantial data have accrued since 2015, we have an opportunity to assess the construct validity and utility of the initial PALICC definitions. Therefore, the Second PALICC (PALICC-2) brought together multiple PARDS experts and aimed to identify and summarize relevant evidence related to the definition and epidemiology of PARDS and create modifications to the definition of PARDS. MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). We included studies of subjects with PARDS, or at risk for PARDS, excluding studies pertaining primarily to adults except as specified for identifying age-specific cutoffs. Title/abstract review, full-text review, and data extraction using a standardized data collection form. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. A total of 97 studies were identified for full-text extraction addressing distinct aspects of the PARDS definition, including age, timing, imaging, oxygenation, modes of respiratory support, and specific coexisting conditions. Data were assessed in a Patient/Intervention/Comparator/Outcome format when possible, and formally summarized for effect size, risk, benefit, feasibility of implementation, and equity. A total of 17 consensus-based definition statements were made that update the definition of PARDS, as well as the related diagnoses of "Possible PARDS" and "At-Risk for PARDS." These statements are presented alongside a summary of the relevant epidemiology. We present updated, data-informed consensus statements on the definition for PARDS and the related diagnoses of "Possible PARDS" and "At-Risk for PARDS."

Pulmonary Specific Ancillary Treatment for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference.

We conducted an updated review of the literature on pulmonary-specific ancillary therapies for pediatric acute respiratory distress syndrome (PARDS) to provide an update to the Pediatric Acute Lung Injury Consensus Conference recommendations and statements about clinical practice and research. MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). Searches were limited to children, PARDS or hypoxic respiratory failure and overlap with pulmonary-specific ancillary therapies. Title/abstract review, full-text review, and data extraction using a standardized data collection form. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Twenty-six studies were identified for full-text extraction. Four clinical recommendations were generated, related to use of inhaled nitric oxide, surfactant, prone positioning, and corticosteroids. Two good practice statements were generated on the use of routine endotracheal suctioning and installation of isotonic saline prior to endotracheal suctioning. Three research statements were generated related to: the use of open versus closed suctioning, specific methods of airway clearance, and various other ancillary therapies. The evidence to support or refute any of the specific ancillary therapies in children with PARDS remains low. Further investigation, including a focus on specific subpopulations, is needed to better understand the role, if any, of these various ancillary therapies in PARDS.

Editor's Choice Articles for February.

Editor's Choice Articles for February.

Methodology of the Second Pediatric Acute Lung Injury Consensus Conference.

This article describes the methodology used for The Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2). The PALLIC-2 sought to develop evidence-based clinical recommendations and when evidence was lacking, expert-based consensus statements and research priorities for the diagnosis and management of pediatric acute respiratory distress syndrome (PARDS). Electronic searches were conducted using PubMed, Embase, and Cochrane Library (CENTRAL) databases from 2012 to March 2022. Content was divided into 11 sections related to PARDS, with abstract and full text screening followed by data extraction for studies which met inclusion with no exclusion criteria. We used a standardized data extraction form to construct evidence tables, grade the evidence, and formulate recommendations or statements using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. This consensus conference was comprised of a multidisciplinary group of international experts in pediatric critical care, pulmonology, respiratory care, and implementation science which followed standards set by the Institute of Medicine, using the GRADE system and Research And Development/University of California, Los Angeles appropriateness method, modeled after PALICC 2015. The panel of 52 content and four methodology experts had several web-based meetings over the course of 2 years. We conducted seven systematic reviews and four scoping reviews to cover the 11 topic areas. Dissemination was via primary publication listing all statements and separate supplemental publications for each subtopic that include supporting arguments for each recommendation and statement. A consensus conference of experts from around the world developed recommendations and consensus statements for the definition and management of PARDS and identified evidence gaps which need further research.

Noninvasive Respiratory Support for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference.

To develop evidence-based recommendations for the Second Pediatric Acute Lung Injury Consensus Conference (PALICC) regarding the effectiveness of noninvasive respiratory support for pediatric acute respiratory distress syndrome (PARDS). These include consideration of the timing and duration of noninvasive ventilation (NIV) and high-flow nasal cannula (HFNC), whether effectiveness varies by disease severity or by characteristics of treatment delivery, and best practices for the use of NIV. MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). Searches included all studies involving the use of NIV or HFNC in children with PARDS or hypoxemic respiratory failure. Title/abstract review, full-text review, and data extraction using a standardized data extraction form. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Out of 6,336 studies, we identified 187 for full-text review. Four clinical recommendations were generated, related to indications, timing and duration of NIV in patients with PARDS, predictors of NIV failure and need for intubation (signs and symptoms of worsening disease including pulse oximetry saturation/Fio2 ratio), and use of NIV in resource-limited settings. Six good practice statements were generated related to how and where to deliver NIV, the importance of trained experienced staff and monitoring, types of NIV interfaces, the use of sedation, and the potential complications of this therapy. One research statement was generated related to indications of HFNC in patients with PARDS. NIV is a widely used modality for the treatment of respiratory failure in children and may be beneficial in a subset of patients with PARDS. However, there needs to be close monitoring for worsening disease and NIV failure.

Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2).

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. 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. Not applicable. Patients with or at risk for PARDS. None. 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%. 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.