Guideline sources The following summarized guidelines for the evaluation and management of pediatric acute respiratory distress syndrome (PARDS) are prepared by our editorial team based on guidelines from the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2/PALISI 2023). 1 Calculator Wang Respiratory Score WRS Guidelines 1. Screening and diagnosis https://web.pathway.md/diseases/recMNw2AqnIDcbAIl 1/6 6/29/23, 10:56 PM Pediatric acute respiratory distress syndrome Pathway Diagnostic criteria (patients without chronic cardiorespiratory disease): use the PALICC-2 criteria for the diagnosis of pediatric ARDS in < 18 years old patients without active perinatal lung disease. Show 6 more Diagnostic criteria (patients with chronic cardiorespiratory disease): consider diagnosing pediatric ARDS in patients with cyanotic congenital heart disease if meeting standard pediatric ARDS criteria and having an acute deterioration in oxygenation (relative to baseline) not fully explained by the underlying cardiac disease. Show 2 more 2. Classification and risk stratification Risk stratification: use oxygenation index or oxygen saturation index, in preference to PaO /FiO or SpO /FiO , as the primary metric of lung disease severity to define pediatric ARDS in all patients treated with invasive mechanical ventilation, with PaO used preferentially when available. Show 4 more 3. Diagnostic investigations Diagnostic imaging: Obtain chest imaging for the diagnosis of pediatric ARDS, to detect complications (such as air leak or equipment displacement) and to assess severity. B Insufficient evidence to support the routine use of chest CT, lung ultrasound, and electrical impedance tomography. I Laboratory tests: Assess FiO , SpO and/or PaO , mean airway pressure, and PEEP for the diagnosis of pediatric ARDS. B Assess PaO /FiO or SpO /FiO for the diagnosis of pediatric ARDS. 4. Respiratory support Prone positioning: insufficient evidence to recommend for or against prone positioning in patients with pediatric ARDS. I Airway clearance: insufficient evidence to recommend specific methods of airway clearance, such as chest physiotherapy and mucolytics, in patients with pediatric ARDS. I Endotracheal suctioning: maintain an unobstructed airway in intubated patients with pediatric ARDS. B Show 2 more Noninvasive ventilation (indications): consider initiating a time-limited trial of noninvasive ventilation (CPAP or bilevel positive airway pressure) in patients with, or at risk for, possible https://web.pathway.md/diseases/recMNw2AqnIDcbAIl 2/6 6/29/23, 10:56 PM Pediatric acute respiratory distress syndrome Pathway pediatric ARDS on conventional oxygen therapy or high-flow nasal cannula showing signs of worsening respiratory failure, in the absence of clear indications for intubation. C Show 2 more Noninvasive ventilation (technical considerations): deliver noninvasive ventilation in a setting with trained experienced personnel and where close monitoring is available to rapidly identify and treat deterioration. B Show 5 more Invasive ventilation (indications): consider performing intubation over continuing noninvasive ventilation in patients on noninvasive ventilation not showing clinical improvement within the first 6 hours of treatment or having signs and symptoms of worsening disease, including increased respiratory/HR, increased work of breathing, and worsening gas exchange (SpO /FiO ratio). C Invasive ventilation (technical considerations): use cuffed endotracheal tubes in patients with pediatric ARDS. B Show 16 more Invasive ventilation (weaning): obtain daily assessments of predefined clinical and physiologic criteria of extubation readiness to avoid unnecessarily prolonged ventilation. Perform a spontaneous breathing trial to test extubation readiness in patients meeting extubation readiness criteria. B Extracorporeal membrane oxygenation (indications): consider assessing patients with a potentially reversible cause of severe pediatric ARDS for ECMO when lung protective strategies result in inadequate gas exchange. C Show 3 more Extracorporeal membrane oxygenation (technical considerations): consider performing venovenous ECMO over venoarterial ECMO in patients with adequate cardiac function. C Show 5 more Extracorporeal membrane oxygenation (follow-up): obtain short- and long-term neurodevelopmental and physical functioning evaluations to assess for impairment in all pediatric extracorporeal CO survivors. B 5. Medical management Fluid management: consider administering fluids with a daily goal collaboratively established by the interprofessional team to maintain optimal oxygen delivery and preserve end-organ function while preventing fluid overload in patients with pediatric ARDS. C Sedation: use valid and reliable assessment scales for pain, sedation, delirium, and withdrawal to monitor, target and titrate comfort therapies and to facilitate interprofessional communication. B Show 3 more Prevention of delirium: obtain daily assessment for delirium using a validated pediatric delirium screening tool in patients with pediatric ARDS. B Show 2 more https://web.pathway.md/diseases/recMNw2AqnIDcbAIl 3/6 6/29/23, 10:56 PM Pediatric acute respiratory distress syndrome Pathway Neuromuscular blockade: Consider administering minimal (yet effective) neuromuscular blockade in conjunction with sedation if effective and protective mechanical ventilation cannot be achieved. C Monitor and titrate neuromuscular blockade to the goal depth established by the interprofessional team. B Therapies with no evidence for benefit: Avoid using inhaled nitric oxide, surfactant therapy, or corticosteroids routinely in patients with pediatric ARDS. D Insufficient evidence to support the use of the following ancillary therapies in patients with pediatric ARDS: helium-oxygen mixture inhaled or IV prostaglandins plasminogen activators fibrinolytics or other anticoagulants inhaled -adrenergic receptor agonists or ipratropium IV N-acetylcysteine. I 6. Inpatient care Clinical monitoring: obtain clinical monitoring of continuous respiratory frequency, HR, pulse oximetry, and regular intermittent noninvasive BP in all patients with pediatric ARDS. B Hemodynamic monitoring: obtain hemodynamic monitoring to evaluate the impact of ventilation and disease on right and left cardiac function and to assess oxygen delivery in all patients with pediatric ARDS. B Show 4 more Respiratory monitoring: interpret metrics using lung volumes (such as tidal volume and compliance of the respiratory system) after standardization to body weight. B Show 10 more 7. Nonpharmacologic interventions Nutritional support: consider initiating enteral nutrition early (< 72 hours) when feasible over parenteral nutrition or delayed enteral nutrition in patients with pediatric ARDS. C Show 3 more Rehabilitation: optimize day-night activity and rest patterns with nonpharmacologic, multicomponent approaches in patients with pediatric ARDS. B Show 2 more 8. Therapeutic procedures Blood transfusion: administer packed RBC transfusion in critically ill patients with respiratory failure and a Hgb concentration < 5 g/dL. B https://web.pathway.md/diseases/recMNw2AqnIDcbAIl 4/6 6/29/23, 10:56 PM Pediatric acute respiratory distress syndrome Pathway Show 2 more 9. Follow-up and surveillance Follow-up: advise the patient's primary care providers to screen for post-ICU morbidities within 3 months of discharge from the hospital. Use a stepwise approach to clinical evaluation of post-ICU morbidities with initial screening by a primary care provider or electronic/telephonic screen. B Show 3 more Clinical findings Symptoms Past medical history Agitation Acute pancreatitis Cough Aspiration pneumonia Fatigue Blood transfusion Fever Bronchiolitis Shortness of breath Burns Malignancy Past events Mechanical ventilation Pneumonia Blunt chest trauma Sepsis Drowning TBI Inhalation exposure Traumatic injury Vital signs Past surgical history Hypoxemia Lung transplantation Signs of shock Tachypnea Neurological exam O2 saturation Altered mental status Respiratory exam Lab findings Aspiration Crackles ESR Intercostal retractions arterial partial pressure of CO2 Respiratory distress serum CRP Hematological findings PaO2 Anemia Imaging findings WBC count Pneumomediastinum blood platelet count Pneumothorax Pulmonary edema Pulmonary infiltrates Subcutaneous emphysema https://web.pathway.md/diseases/recMNw2AqnIDcbAIl 5/6 6/29/23, 10:56 PM Pediatric acute respiratory distress syndrome Pathway References 1. Guillaume Emeriaud, Yolanda M L pez-Fern ndez, Narayan Prabhu Iyer et al. Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome PALICC 2 . Pediatr Crit Care Med. 2023 Feb 1;24 2 143 168. Open https://web.pathway.md/diseases/recMNw2AqnIDcbAIl 6/6