Pediatric Acute Respiratory Distress Syndrome Management

Ventilation Strategies

• The American Thoracic Society recommends keeping tidal volumes ≤10 mL/kg ideal body weight (may need to be lower in lung hypoplasia syndromes) 1, 2
• Limit plateau pressure ≤28 cmH2O in restrictive lung disease or ≤30 cmH2O in obstructive airway disease 1, 2, 3
• Keep driving pressure (plateau pressure minus PEEP) ≤10 cmH2O for healthy lungs 1
• Use 5-8 cmH2O as baseline PEEP, with higher levels necessary based on disease severity 1, 3
• For pARDS: Consider PEEP titration and lung recruitment maneuvers based on disease severity 1, 2
• Add PEEP in obstructive airway disease when air-trapping is present to facilitate triggering 3
• Use PEEP to stent upper airways in cases of malacia 1
• Target SpO2 92-97% when PEEP <10 cmH2O and 88-92% when PEEP ≥10 cmH2O 1, 3
• Keep SpO2 ≤97% for all disease conditions 1
• Target PCO2 35-45 mmHg for healthy lungs, with higher PCO2 acceptable for acute pulmonary patients as long as pH >7.20 1, 3
• Maintain normal pH for patients with pulmonary hypertension 1

Monitoring Parameters

• Measure PCO2 in arterial or capillary blood samples 1
• Measure end-tidal CO2 and SpO2 in all ventilated children 1, 3
• Measure arterial PO2, pH, lactate, and central venous saturation in moderate-to-severe disease 1
• Monitor pressure-time and flow-time scalars 1, 4
• Measure peak inspiratory pressure, plateau pressure, mean airway pressure, and PEEP 1
• For children <10 kg, measure flow near Y-piece of patient circuit to improve trigger sensitivity 1, 4

Ventilator Modes and Settings

• Target patient-ventilator synchrony in all modes 1, 3
• Consider high-frequency oscillatory ventilation (HFOV) when conventional ventilation fails 1
• Do not use high-frequency jet ventilation in obstructive airway disease 1
• Consider extracorporeal life support in reversible disease if conventional ventilation and/or HFOV fails 1
• Set inspiratory time based on respiratory system mechanics and underlying disease 1, 2
• Use time constant (observe flow-time scalar) to guide settings 1
• Use higher respiratory rates in restrictive disease to maintain minute ventilation 2

Non-Invasive Respiratory Support

• Consider CPAP and HFNC in mild-to-moderate cardiorespiratory failure 3
• Should not delay intubation in severe disease 3
• Consider non-invasive ventilation in neuromuscular patients during weaning 1

Weaning and Extubation

• Start weaning as soon as possible 1, 4
• Perform daily extubation readiness testing 1, 4
• Use corticosteroids in patients at increased risk for post-extubation stridor 1

Supportive Measures

• Maintain head of bed elevated 30-45° 1
• Use cuffed endotracheal tube with cuff pressure ≤20 cmH2O 1
• Minimize dead space by reducing added components 1
• Use double-limb circuits for invasive ventilation 1
• Use humidification for all ventilated patients 1
• Perform endotracheal suctioning only when indicated, not routinely 1
• Avoid routine instillation of isotonic saline prior to suctioning 1

Special Considerations

• Same principles of mechanical ventilation apply to cardiac children as for non-cardiac children 3
• Use sufficient PEEP to maintain end-expiratory lung volume in cardiac patients 3
• Consider PEEP titration and lung recruitment maneuvers in cardiac patients 1, 3
• Consider cough-assist devices in neuromuscular patients 1
• Consider non-invasive ventilation during weaning in neuromuscular patients 1