Pediatric acute respiratory distress syndrome: consensus recommendations from the Pediatric Acute Lung Injury Consensus Conference

Abstract

Objective: To describe the final recommendations of the Pediatric Acute Lung Injury Consensus Conference.

Design: Consensus conference of experts in pediatric acute lung injury.

Setting: Not applicable.

Subjects: PICU patients with evidence of acute lung injury or acute respiratory distress syndrome.

Interventions: None.

Methods: A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. When published, data were lacking a modified Delphi approach emphasizing strong professional agreement was used.

Measurements and main results: A panel of 27 experts met over the course of 2 years to develop a taxonomy to define pediatric acute respiratory distress syndrome and to make recommendations regarding treatment and research priorities. When published data were lacking a modified Delphi approach emphasizing strong professional agreement was used. The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 151 recommendations addressing the following topics related to pediatric acute respiratory distress syndrome: 1) Definition, prevalence, and epidemiology; 2) Pathophysiology, comorbidities, and severity; 3) Ventilatory support; 4) Pulmonary-specific ancillary treatment; 5) Nonpulmonary treatment; 6) Monitoring; 7) Noninvasive support and ventilation; 8) Extracorporeal support; and 9) Morbidity and long-term outcomes. There were 132 recommendations with strong agreement and 19 recommendations with weak agreement. Once restated, the final iteration of the recommendations had none with equipoise or disagreement.

Conclusions: The Consensus Conference developed pediatric-specific definitions for acute respiratory distress syndrome and recommendations regarding treatment and future research priorities. These are intended to promote optimization and consistency of care for children with pediatric acute respiratory distress syndrome and identify areas of uncertainty requiring further investigation.

Conflict of interest statement

Dr. Jouvet received grants from the respiratory research network of Fonds de Recherche du Québec-Santé, Réseau mère enfant de la francophonie, and Research Center of Ste-Justine Hospital related to the submitted work; and received equipment on loan from Philips and Maquet outside the submitted work. Dr. Thomas served on the Advisory Board for Discovery Laboratories and Ikaria outside the submitted work; received a grant from United States Food and Drug Administration Office of Orphan Product Development outside the submitted work. Dr. Willson served on the Advisory Board for Discovery Laboratories outside the submitted work. Drs. Khemani, Smith, Dahmer, and Watson received grants from the National Institutes of Health (NIH) outside the submitted work. Dr. Zimmerman received research grants from the NIH, Seattle Children’s Research Institute, and ImmuneXpress outside the submitted work. Drs. Flori and Sapru received grants from the NIH related to the submitted work. Dr. Cheifetz served as a consultant with Philips and Hill-Rom outside the submitted work; and received grants from Philips, Care Fusion, Covidien, Teleflex, and Ikaria outside the submitted work. Drs. Rimensberger and Kneyber received travel support from the European Societiy of Pediatric and Neonatal Intensive Care (ESPNIC) related to this work. Dr. Tamburro received a grant from United States Food and Drug Administration Office of Orphan Product Development outside the submitted work. Dr. Emeriaud received a grant from Respiratory Health Network of the Fonds de la Recherche du Québec – Santé outside the submitted work. Dr. Newth served as a consultant for Philips Medical outside the submitted work. Drs. Erickson, Quasney, Curley, Nadkarni, Valentine, Carroll, Essouri, Dalton, Macrae, Lopez-Cruces, Santschi, and Bembea have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1

Plan for the three meetings of the Pediatric Acute Lung Injury Consensus Conference (PALICC). The timeline, including the tasks, that has been completed by the PALICC experts. PALISI = Pediatric Acute Lung Injury and Sepsis Investigators.

Figure 2

Pediatric acute respiratory distress syndrome definition. OI = oxygenation index, OSI = oxygen saturation index. 1Use Pao2-based metric when available. If Pao2 not available, wean Fio2 to maintain Spo2 ≤ 97% to calculate OSI or oxygen saturation/Fio2 ratio. 2For nonintubated patients treated with supplemental oxygen or nasal modes of noninvasive ventilation, see Figure 3 for at-risk criteria. 3Acute respiratory distress syndrome severity groups stratified by OI or OSI should not be applied to children with chronic lung disease who normally receive invasive mechanical ventilation or children with cyanotic congenital heart disease. OI = (Fio2 × mean airway pressure × 100)/Pao2. OSI = (Fio2 × mean airway pressure × 100)/Spo2.

Figure 3

At risk of pediatric acute respiratory distress syndrome definition. 1Given lack of available data, for patients on an oxygen blender, flow for at-risk calculation = Fio2 × flow rate (L/min) (e.g., 6 L/min flow at 0.35 Fio2 = 2.1 L/min). 2If Pao2 not available, wean Fio2 to maintain Spo2 ≤ 97% to calculate oxygen saturation index.