12 The PALICC guidelines were developed based on peer-reviewed, pediatric-specific data, as available. In 2015, PALICC, a group of 27 experts from 8 countries, published their recommendations for the definition of pediatric PARDS after a 2-y consensus conference process, which included 3 face-to-face meetings. Special considerations are often necessary to optimize management approaches across the heterogeneous pediatric spectrum ranging from neonates to adolescents. An additional ongoing concern of the adult-based definitions to the pediatric clinician is the inclusion of P aO 2/F IO 2, which can be influenced by alterations in the applied mean airway pressure (eg, PEEP), as the marker of oxygenation failure. Previous application to pediatrics of the adult-based ARDS definitions, with the requirement to measure arterial oxygenation, may have led to an underestimation of the prevalence of ARDS in pediatrics, given the less common use of arterial lines in infants and children. Furthermore, younger patients have a greater metabolic demand and less cardiopulmonary reserve than adolescents and adults. 9 Anatomic and physiologic differences ( Table 1) render infants and children more vulnerable to a severe respiratory insult as compared with adults, 10, 11 potentially necessitating a lower threshold for intervention in the pediatric patient. It is important to stress that the adult-based definitions of ARDS may not be applicable to pediatrics for a variety of reasons. 8 Although these diagnostic criteria were developed primarily for use in the adult population, until recently, they have generally also been employed in the pediatric setting. Over the past 5 decades, there have been multiple revisions of the ARDS definition for adult patients, including the Murray acute lung injury score (1998), 5 American-European Consensus Conference definition (1994), 6 Delphi Consensus definition (2005), 7 and Berlin definition (2012). 4 Since then, ARDS has remained a diagnostic and management challenge for clinicians caring for infants, children, adolescents, and adults. 2, 3 In 1967, a description of ARDS was first provided by Ashbaugh et al. The pathophysiology of this clinical syndrome is characterized by, in progression, inflammatory, proliferative, and fibrotic phases. Infectious etiologies, including sepsis and pneumonia, represented approximately half of these clinical conditions.ĪRDS manifests as pulmonary inflammation, alveolar edema, and hypoxemic respiratory failure. In a comprehensive description of pediatric ARDS, 1 the primary etiologies were pneumonia (35%), aspiration (15%), sepsis (13%), near-drowning (9%), concomitant cardiac disease (7%), and other clinical conditions (21%). ARDS is an acute lung injury that can be triggered by a heterogeneous set of pulmonary (direct lung injury) and extrapulmonary (indirect ling injury) etiologies. Hopefully, the recommendations provided by PALICC, in terms of defining and managing ARDS, will stimulate additional research to better guide therapy and further improve outcomes for critically ill infants and children with ARDS.Īlthough representing a relatively small percentage of the total number of pediatric ICU admissions, ARDS is often considered as one of the most challenging patient populations for a clinician to manage. Improved comparisons between patients and studies may help to promote future clinical investigations. Improvements in prognostication and stratification of disease severity may help to guide therapeutic interventions. Pediatric-specific criteria may provide the ability to more promptly recognize and diagnose PARDS in clinical practice. Although outcomes for PARDS have improved over the past decade, mortality and morbidity remain significant. The PALICC recommendations provide guidance on conventional ventilator management, gas exchange goals, use of high-frequency ventilation, adjunct management approaches, and the application of extracorporeal membrane oxygenation for pediatric ARDS (PARDS). The Pediatric Acute Lung Injury Consensus Conference (PALICC) has provided the critical care community with the first pediatric-focused definition for ARDS.
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