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Pediatr Crit Care Med. Author manuscript; available in PMC 2017 January 22.
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Published in final edited form as:

Pediatr Crit Care Med. 2015 June ; 16(5): 428–439. doi:10.1097/PCC.0000000000000350.

Pediatric Acute Respiratory Distress Syndrome: Consensus

Recommendations From the Pediatric Acute Lung Injury
Consensus Conference
The Pediatric Acute Lung Injury Consensus Conference Group

Abstract
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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
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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

Listen to the iCritical Care podcasts for an in-depth interview on this article. Visit www.sccm.org/iCriticalCare or search “SCCM” at
iTunes.
Dr. Jouvet received grants from the respiratory research network of Fonds de Recherche du Québec-Santé, Réseau mère enfant de la
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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.
For information regarding this article, nthomas@psu.edu
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recommendations addressing the following topics related to pediatric acute respiratory distress
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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.
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Keywords
acute lung injury; acute respiratory distress syndrome; consensus development conference;
guidelines; pediatrics

Since the first description of the “acute respiratory distress syndrome” (ARDS) by Ashbaugh
et al (1) in 1967, pediatric intensivists have recognized that ARDS in children is different
from ARDS in adults. In the absence of identification of these differences, however, children
have been characterized as having acute lung injury (ALI) and ARDS based on the adult
definitions originating from the 1994 American-European Consensus Conference (AECC)
(2). Seventeen years later, a second consensus conference was convened with the intent of
improving the feasibility, reliability, and validity of the ALI/ARDS definitions. As with the
previous AECC, however, this was conducted without specific consideration of children.
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The new Berlin definitions (3) included several significant changes: 1) the ALI category was
eliminated and replaced with a gradation of ARDS severity (mild, moderate, and severe)
based on the degree of oxygenation disturbance; 2) a minimum of 5 cm H2O of positive end-
expiratory pressure (PEEP) was required; and 3) the determination of cardiac failure was
rendered more subjective in view of the decreased utilization of pulmonary artery catheters.

Both the AECC and Berlin ARDS definitions were focused on adult lung injury and have
limitations when applied to children. For example, a major shortcoming is the necessity of
invasive measurement of arterial oxygen. Pulse oximetry is increasingly obviating the use of
arterial blood gas measurement in pediatrics, and consequently, definitions requiring direct
measurement of Pao2 may underestimate ARDS prevalence in children. This may result in
the selection of children with more severe hypoxemia and/or cardiovascular compromise. A
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second limitation is the use of the Pao2/Fio2 (P/F) ratio. In addition to requiring
measurement of Pao2, this ratio is greatly influenced by ventilator pressures (4–7). Although
the Berlin definition requires a minimum PEEP of 5 cm H2O, other ventilator manipulations
and the practice patterns around PEEP management can also alter this ratio. Consequently,
differences in clinical practice may influence the diagnosis, particularly in the PICU where
there is greater variability in ventilator management relative to adult ICUs (8, 9). This has
led some pediatric practitioners to adopt the oxygenation index (OI) ([Fio2 × mean airway
pressure (Paw) × 100]/Pao2) and oxygen saturation index (OSI) ([Fio2 × Paw × 100]/Spo2)

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to assess hypoxemia in children (10, 11). Finally, differences in risk factors, etiologies,
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pathophysiology, and outcomes between adults and children were not considered in either
the AECC or Berlin definitions.

These concerns prompted the organization of the Pediatric Acute Lung Injury Consensus
Conference (PALICC) (12). The concept originated with the Pediatric Acute Lung Injury
and Sepsis Investigators (PALISI) Network but was subsequently supported by the
Australian and New Zealand Intensive Care Society, Canadian Critical Care Trials Group,
World Federation of Pediatric Intensive and Critical Care Societies, European Society for
Pediatric and Neonatal Intensive Care, and French Group for Pediatric Intensive Care and
Emergency Medicine. The goals of the conference were 1) to develop a taxonomy to define
pediatric ARDS (PARDS), specifically predisposing factors, etiology, and pathophysiology;
2) to offer recommendations regarding therapeutic support of the patient with PARDS; and
3) to identify priorities for future research in PARDS, including defining short- and long-
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term outcomes of interest. We also hoped to foster collaborative relationships for future
international research in PARDS.

METHODS
Three members of the organizing committee met in March 2012 to define the methodology,
to select the subtopics for study, and to identify the experts in the field. Experts were invited
based on their record of publications in PARDS in the past 5 years and their participation in
clinical research studies in pediatric critical care. The final list of 27 experts, representing 21
academic institutions and eight countries, constituted the PALICC expert group (Appendix
1). Of note, only one expert declined to participate due to personal reasons; two experts
initially agreed to participate but were subsequently unable for personal reasons.
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The first PALICC meeting took place in Chicago, IL, on October 2, 2012, in conjunction
with the fall meeting of the PALISI Network. At this meeting, we discussed and agreed upon
conference subtopics, the project timeline, and the consensus methodology (Fig. 1). Experts
were also assigned to each of the nine subtopics. The modified Delphi approach previously
employed by the French Society of Pediatric Intensive Care (13) was chosen as the
methodology to achieve consensus. This approach was necessary because of the limited data
and low level of available evidence, as well as the high variability in clinical practice in
PARDS. A detailed description of this methodology is available in the supplement published
in Pediatric Critical Care Medicine (14).

Between the first and second meeting, each group of experts undertook a comprehensive,
standardized literature review. Upon completion, each group drafted their recommendations
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along with detailed arguments to support them. The second meeting occurred in Montreal,
QC, Canada, on April 18–19, 2013. At this 2-day meeting, the recommendations were
discussed and the wording of each agreed upon by the majority of experts. Possible
omissions for any of the nine topics were also discussed. After the second meeting,
recommendations with their respective arguments (long texts) were distributed to each
expert for electronic scoring by the Research ANd Development/University of California
Los Angeles (RAND/UCLA) appropriateness method (15). Experts with a disclosed conflict

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of interest were excluded from voting on areas where any real or perceived conflict was
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identified. After the initial scoring, all recommendations were consolidated by the
organizing committee.

Agreement was determined by voting using the RAND/UCLA scale (scores range from 1 to
9), with each expert having an equal vote but with the highest and lowest scores discarded
after each vote. “Strong” agreement required that all experts rank the recommendation 7 or
higher. “Weak” agreement meant that at least one more expert ranked the recommendation
below 7, but the median vote was at least 7. Those with strong agreement were considered
complete, and those with weak agreement were revised based on comments by the experts.
These revised recommendations were then distributed for a second round of electronic
voting. After this voting, some reworded recommendations obtained a strong agreement. For
the remaining recommendations with a weak agreement after the second round, the
percentage of experts who rated 7 or above was calculated and is reported after each weak
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recommendation. With this method of calculation, a strong agreement corresponded to a

percentage of agreement more than 95% (no more than one expert rated below 7 on the
RAND/UCLA scale).

The third and final meeting took place on October 9, 2013, in Paris, France. Each group
presented their final recommendations, and a third round of voting was conducted for several
specific but unresolved recommendations related to the definitions. The organizers believed
it was vital to achieve strong agreement regarding definitions, and this was accomplished
after much dialog and debate. Additionally, each group of experts presented their consensus
regarding key areas of controversy and future research.

RESULTS
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The nine topics studied by PALICC resulted in 151 total recommendations, including 132
recommendations with strong agreement and 19 with weak agreement. Once restated, the
final iteration of the recommendations had none with equipoise or disagreement, according
to the predefined definitions by the RAND/UCLA appropriateness methodology. The
recommendations for each topic are listed below, with the justification for these
recommendations detailed in the supplement in this issue of Pediatric Critical Care
Medicine.

Section 1: Definition, Prevalence, and Epidemiology

1.1 Age
1.1.1: We recommend that there should not be age criteria for the definition of PARDS.
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However, exclusion criteria for PARDS should include causes of acute hypoxemia that are
unique to the perinatal period, such as prematurity-related lung disease, perinatal lung injury
(e.g., Meconium Aspiration Syndrome, and pneumonia and sepsis acquired during delivery),
or other congenital abnormalities (e.g., congenital diaphragmatic hernia or alveolar capillary
dysplasia). Strong agreement

1.1.2: We recommend that in the absence of a compelling rationale related to physiology or

feasibility, studies of PARDS should not include age limits. In order to better understand the

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pathobiology of PARDS across the spectrum of age, and in the absence of a clear break
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point in the epidemiology of PARDS, adult and pediatric investigators should engage in
collaborative studies targeting adolescents and young adults. Future studies are needed to
evaluate potential age-dependent differences in the pathophysiology of PARDS across the
entire pediatric age spectrum. Strong agreement

1.2 Timing and Triggers for PARDS

1.2.1: We recommend that symptoms of hypoxemia and radiographic changes must occur
within 7 days of a known clinical insult to qualify for PARDS. Strong agreement

1.3 Defining PARDS in Children With Left Ventricular Dysfunction

1.3.1: We recommend that children with left ventricular heart dysfunction that fulfill all
other PARDS criteria have PARDS if the acute hypoxemia and new chest imaging changes
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cannot be explained by acute left ventricular heart failure or fluid overload. Strong
agreement

1.4 Radiographic Findings

1.4.1: We recommend that chest imaging findings of new infiltrate(s) consistent with acute
pulmonary parenchymal disease are necessary to diagnose PARDS. Strong agreement

1.4.2: We recommend that future clinical trials for PARDS should stratify patients by the
presence or absence of bilateral infiltrates on chest imaging. In order to minimize variability
in these studies, investigators should standardize interpretation of all chest imaging. Strong
agreement
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1.4.3: We recommend that future studies are needed to determine the optimal common
training or effect of automated methodologies to reduce interobserver variability in the
interpretation of chest imaging for PARDS. Strong agreement

1.5 Measures of Oxygenation in the Definition

1.5.1: We recommend that OI, in preference to P/F ratio, should be the primary metric of
lung disease severity to define PARDS for all patients treated with invasive mechanical
ventilation. Strong agreement

1.5.2: We recommend that P/F ratio should be used to diagnose PARDS for patients
receiving noninvasive, full-face mask ventilation (continuous positive airway pressure
[CPAP] or bi-level positive airway pressure [BiPAP]) with a minimum CPAP of 5 cm H2O.
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Strong agreement

1.6 Pulse Oximetry Versus Pao2

1.6.1: We recommend that OSI should be used when an OI is not available for stratification
of risk for patients receiving invasive mechanical ventilation. Strong agreement

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1.6.2: We recommend that oxygen saturation/Fio2 ratio can be used when P/F ratio is not
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available to diagnose PARDS in patients receiving noninvasive full-face mask ventilation

(CPAP or BiPAP) with a minimum CPAP of 5 cm H2O. Strong agreement

1.7 Other Markers of Lung Disease Severity

1.7.1: We recommend that given the limited published data on dead space in PARDS, there
is insufficient evidence to recommend a measure of dead space as part of the diagnostic
criteria for PARDS. Strong agreement

1.7.2: We recommend that future study is needed to determine the potential relevance of
elevated dead space for the definition of PARDS. Strong agreement

1.7.3: We recommend that measures of respiratory system compliance should not be used
for the definition of PARDS. Future studies of respiratory system compliance with reliable
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and standardized methods for measurement are warranted to determine the relevance of
respiratory system compliance to the diagnosis and risk stratification of PARDS. Strong
agreement

1.8 Characterizing Oxygen Delivery for Noninvasive Ventilation

1.8.1: We recommend that to apply Spo2 criteria to diagnose PARDS, oxygen therapy
should be titrated to achieve the Spo2 between 88% and 97%. Strong agreement

1.8.2: We recommend that defining a group of patients at risk for PARDS is necessary to
determine the epidemiology of disease progression and potential avenues for disease
prevention. Strong agreement
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1.9 Defining PARDS in Children With Chronic Cardiorespiratory Disease

1.9.1: We recommend that patients with preexisting chronic lung disease who are treated
with supplemental oxygen, noninvasive ventilation, or invasive ventilation via tracheostomy
should be considered to have PARDS if they have acute changes that meet standard PARDS
criteria (acute onset, a known clinical insult, and chest imaging supporting new onset
pulmonary parenchymal disease) and have an acute deterioration in oxygenation from
baseline which meets oxygenation criteria for PARDS. Strong agreement

1.9.2: We recommend that patients with cyanotic congenital heart disease are considered to
have PARDS if they fulfill standard criteria (acute onset, a known clinical insult, and chest
imaging supporting new onset pulmonary parenchymal disease) and have an acute
deterioration in oxygenation not explained by the underlying cardiac disease. Strong
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agreement

1.9.3: We recommend that children with chronic lung disease who are on mechanical
ventilation at baseline or cyanotic congenital heart disease with acute onset of illness that
satisfy PARDS criteria should not be stratified by OI or OSI risk categories. Future studies
are necessary to determine PARDS risk stratification of patients with acute-on-chronic
hypoxemic respiratory failure. Strong agreement

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1.9.4: We recommend that future studies of PARDS should endeavor to include children
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with preexisting pulmonary and cardiac disease. Strong agreement

Based on the recommendations above, Figure 2 details the proposed definitions of PARDS,
and Figure 3 details the proposed definitions for those children at risk for PARDS.

Section 2: Pathophysiology, Comorbidities, and Severity

2.1 Pathophysiology
2.1.1: There may be a difference in the progression and outcome from ARDS in children as
compared with adults. We recommend that future studies be designed to examine whether
there are differences in the progression and/or outcome of ARDS between adults and
children or between children of different ages. Strong agreement
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2.1.2: There is a paucity of studies related to the pathophysiology of PARDS. The impact of
postnatal maturational development on the pathophysiology of PARDS is unknown. We
recommend that biomarker and genetic studies that may provide insight into the
pathophysiology of PARDS in children, and study of pathophysiology in animals of different
ages with age cutoffs informed by chronology of postnatal lung and immune system
development, should be a focus of future research protocols. Strong agreement

2.2 Severity of Illness—Disease severity measures can be subdivided into measures that
can be made at the bedside, measures requiring more in-depth calculation, biochemical
measurements, and early responsiveness to therapy.

2.2.1: Of the measures available at the bedside, both oxygenation defect and ventilation
defect have generally been found to be associated with outcome. There is great
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inconsistency in the literature, however, concerning the optimal timing of these

measurements. We recommend evaluating respiratory indices and biomarkers at the onset of
PARDS, within the first 24 hours of onset, as well as serial measures beyond that is
indicated according to treatment and/or clinical studies. Strong agreement

2.2.2: For disease severity measures that can be made at the bedside, we recommend that
future research studies evaluating both trajectory of illness and recovery should use
standardized, minimal datasets with adequately explicit definitions. Strong agreement

2.2.3: Recent adult studies evaluating the effect of dead-space ventilation, thereby reflecting
lung perfusion, have been highly predictive of outcome. We recommend that future
multicenter studies should examine the association of dead space and outcome of PARDS.
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Strong agreement

2.2.4: Studies examining the relationship between tidal volume, peak airway pressures,
PEEP, or mean airway pressure with mortality or length of mechanical ventilation have
resulted in conflicting results; some studies exhibit associations with outcomes while others
do not. We recommend that future studies incorporating variables such as tidal volume, peak
and plateau airway pressures, PEEP, or Paw use explicit protocols and definitions such that
these measures can be more robustly evaluated. Strong agreement

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2.2.5: Among measures requiring more in-depth calculation, we recommend that the use of
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an estimate of multiple organ system failure should be included in any studies of clinical risk
factors associated with outcome in patients with PARDS. Strong agreement

2.2.6: With respect to evaluating risk factors related to organ failure in a research related to
PARDS, caution should be exercised in the use of organ failure scoring systems that include
indices of respiratory failure. We recommend the development of a validated, nonpulmonary
organ failure definition for use in PARDS research. Strong agreement

2.2.7: We recommend further research into the potential use of combinations of biomarker
levels in providing a stronger prediction of outcome. Strong agreement

2.2.8: We recommend that early response to therapy should not be used as a primary
outcome measure in phase III clinical research trials. Future research should explore the
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relationship of early response to therapy as an intermediate process variable linked to more

clinically relevant, long-term outcomes (e.g., ventilator-free days and mortality). Strong
agreement

Section 3: Ventilatory Support

3.1 Modes of Conventional Ventilation
3.1.1: There are no outcome data on the influence of mode (control or assisted) during
conventional mechanical ventilation. Therefore, no recommendation can be made on the
ventilator mode to be used in patients with PARDS. Future clinical studies should be
designed to assess control and assisted modes of ventilation on outcome. Strong agreement

3.2 Tidal Volume/Plateau Pressure Limitations

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3.2.1: In any mechanically ventilated pediatric patient, we recommend in controlled

ventilation to use tidal volumes in or below the range of physiologic tidal volumes for age/
body weight (i.e., 5–8 mL/kg predicted body weight) according to lung pathology and
respiratory system compliance. Weak agreement (88% agreement)

3.2.2: We recommend using patient-specific tidal volumes according to disease severity.

Tidal volumes should be 3–6 mL/kg predicted body weight for patients with poor respiratory
system compliance and closer to the physiologic range (5–8 mL/kg ideal body weight) for
patients with better preserved respiratory system compliance. Weak agreement (84%
agreement)

3.2.3: In the absence of transpulmonary pressure measurements, we recommend an

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inspiratory plateau pressure limit of 28 cm H2O, allowing for slightly higher plateau
pressures (29–32 cm H2O) for patients with increased chest wall elastance (i.e., reduced
chest wall compliance). Weak agreement (72% agreement)

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3.3 PEEP/Lung Recruitment

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3.3.1: We recommend moderately elevated levels of PEEP (10–15 cm H2O) titrated to the
observed oxygenation and hemodynamic response in patients with severe PARDS. Weak
agreement (88% agreement)

3.3.2: We recommend that PEEP levels greater than 15 cm H2O may be needed for severe
PARDS, although attention should be paid to limiting the plateau pressure as previously
described. Strong agreement

3.3.3: We recommend that markers of oxygen delivery, respiratory system compliance, and
hemodynamics should be closely monitored as PEEP is increased. Strong agreement

3.3.4: We recommend that clinical trials should be designed to assess the effects of elevated
PEEP on outcome in the pediatric population. Strong agreement
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3.3.5: We recommend careful recruitment maneuvers in the attempt to improve severe

oxygenation failure by slow incremental and decremental PEEP steps. Sustained inflation
maneuvers cannot be recommended due to lack of available data. Weak agreement (88%
agreement)

3.3.6: We recommend that clinical trials should be designed to assess optimal recruitment
strategies in infants and children with PARDS. Strong agreement

3.4 High-Frequency Ventilation

3.4.1: We recommend that high-frequency oscillatory ventilation (HFOV) should be
considered as an alternative ventilatory mode in hypoxic respiratory failure in patients in
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whom plateau airway pressures exceed 28 cm H2O in the absence of clinical evidence of
reduced chest wall compliance. Such an approach should be considered for those patients
with moderate-to-severe PARDS. Weak agreement (92% agreement)

3.4.2: In HFOV, we recommend that the optimal lung volume be achieved by exploration of
the potential for lung recruitment by a stepwise increase and decrease of the Paw
(continuous distending pressure) under continuous monitoring of the oxygenation and co2
response as well as hemodynamic variables. Strong agreement

3.4.3: We cannot recommend the routine use of high-frequency jet ventilation (HFJV) in
children with PARDS. Strong agreement
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3.4.4: We recommend that, in addition to the use of HFOV, HFJV might be considered in
patients with severe air leak syndrome. Weak agreement (64% agreement)

3.4.5: High-frequency percussive ventilation (HFPV) is not recommended for routine

ventilatory management of PARDS. Strong agreement

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3.4.6: We recommend that HFPV can be considered in patients with PARDS and secretion-
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induced lung collapse, which cannot be resolved with routine clinical care (e.g., inhalational
injuries). Weak agreement (72% agreement)

3.5 Liquid Ventilation

3.5.1: The clinical use of liquid ventilation cannot be recommended. Strong agreement

3.6 Endotracheal Tubes

3.6.1: Cuffed endotracheal tubes (ETTs) are recommended when conventionally ventilating
a patient with PARDS. Strong agreement

3.6.2: We recommend allowing for an ETT air leak during HFOV to augment ventilation, if
needed, assuming Paw can be maintained. Strong agreement
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3.7 Gas Exchange

3.7.1: We recommend that oxygenation and ventilation goals are titrated based on the
“perceived” risks of the toxicity of the ventilatory support required. Strong agreement

3.7.2: We recommend that for mild PARDS with PEEP less than 10 cm H2O, Spo2 should
generally be maintained at 92–97%. Weak agreement (92% agreement)

3.7.3: We recommend that after optimizing PEEP, lower Spo2 levels (in the range of 88–
92%) should be considered for those with PARDS with PEEP at least 10 cm H2O. Strong
agreement

3.7.4: Insufficient data exist to recommend a lower Spo2 limit. Strong agreement
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3.7.5: When Spo2 is less than 92%, monitoring of central venous saturation and markers of
oxygen delivery is recommended. Strong agreement

3.7.6: We recommend that permissive hypercapnia should be considered for moderate-to-

severe PARDS to minimize ventilator-induced lung injury. Strong agreement

3.7.7: We recommend maintaining pH 7.15–7.30 within lung protective strategy guidelines

as previously described. There are insufficient data to recommend a lower limit for pH.
Exceptions to permissive hypercapnia should include intracranial hypertension, severe
pulmonary hypertension, select congenital heart disease lesions, hemodynamic instability,
and significant ventricular dysfunction. Weak agreement (92% agreement)
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3.7.8: Bicarbonate supplementation is not routinely recommended. Strong agreement

Section 4: Pulmonary-Specific Ancillary Treatment

4.1 Inhaled Nitric Oxide
4.1.1: Inhaled nitric oxide is not recommended for routine use in PARDS. However, its use
may be considered in patients with documented pulmonary hypertension or severe right

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ventricular dysfunction. In addition, it may be considered in severe cases of PARDS as a

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rescue from or bridge to extracorporeal life support. When used, assessment of benefit must
be undertaken promptly and serially to minimize toxicity and to eliminate continued use
without established effect. Finally, future study is needed to better define its role, if any, in
the treatment of PARDS. Strong agreement

4.2 Exogenous Surfactant

4.2.1: At this time, surfactant therapy cannot be recommended as routine therapy in PARDS.
Further study should focus on specific patient populations that may be likely to benefit and
specific dosing and delivery regimens. Strong agreement

4.3 Prone Positioning

4.3.1: Prone positioning cannot be recommended as routine therapy in PARDS. However, it
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should be considered an option in cases of severe PARDS. Further pediatric study is

warranted, particular study stratifying on the basis of severity of lung injury. Weak
agreement (92% agreement)

4.4 Suctioning
4.4.1: We recommend that maintaining a clear airway is essential to the patient with
PARDS. However, endotracheal suctioning must be performed with caution to minimize the
risk of derecruitment. Strong agreement

4.4.2: There are insufficient data to support a recommendation on the use of either an open
or closed suctioning system. However, in severe PARDS, consideration should be given to
the technique of suctioning with careful attention to minimize the potential for
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derecruitment. Strong agreement

4.4.3: The routine instillation of isotonic saline prior to endotracheal suctioning is not
recommended. However, the instillation of isotonic saline prior to endotracheal suctioning
may be indicated at times for lavage to remove thick tenacious secretions. Strong agreement

4.5 Chest Physiotherapy

4.5.1: There are insufficient data to recommend chest physiotherapy as a standard of care in
the patient with PARDS. Strong agreement

4.6 Corticosteroids
4.6.1: At this time, corticosteroids cannot be recommended as routine therapy in PARDS.
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Further study should focus on specific patient populations that are likely to benefit from
corticosteroid therapy and specific dosing and delivery regimens. Strong agreement

4.7 Other Ancillary Therapies

4.7.1: No recommendation for the use of the following ancillary treatment is supported:
helium-oxygen mixture, inhaled or IV prostaglandins therapy, plasminogen activators,
fibrinolytics, or other anticoagulants, inhaled β-adrenergic receptor agonists or ipratropium,

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IV N-acetylcysteine for antioxidant effects or intratracheal N-acetylcysteine for mobilizing

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secretions, dornase alpha outside of the cystic fibrosis population, and a cough-assist device.
Strong agreement

4.7.2: No recommendation for the use of stem cell therapy can be supported. It must be
considered experimental therapy at this point. Strong agreement

Section 5: Nonpulmonary Treatment

5.1 Sedation
5.1.1: We recommend that pediatric patients with PARDS should receive minimal yet
effective targeted sedation to facilitate their tolerance to mechanical ventilation and to
optimize oxygen delivery, oxygen consumption, and work of breathing. Strong agreement
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5.1.2: We recommend that valid and reliable pain and sedation scales should be used to
monitor, target, and titrate sedation and to facilitate interprofessional communication. Strong
agreement

5.1.3: We recommend that sedation monitoring, titration, and weaning should be managed
by a goal-directed protocol with daily sedation goals collaboratively established by the
interprofessional team. Strong agreement

5.1.4: We recommend that clinical trials in PARDS should report their sedation goal,
strategy, and exposures. Strong agreement

5.1.5: We recommend that the reporting of sedation strategy and monitoring in clinical trials
should be adequately explicit to allow comparison across studies. Strong agreement
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5.1.6: We recommend that when physiologically stable, pediatric patients with PARDS
should receive a periodic assessment of their capacity to resume unassisted breathing (e.g.,
extubation) that is synchronized with sedative titration to an aroused state. Strong agreement

5.1.7: We recommend an individualized sedation weaning plan, guided by objective

withdrawal scoring and assessment of patient tolerance that is developed by the clinical team
and managed by the bedside nurse. Strong agreement

5.2 Neuromuscular Blockade

5.2.1: We recommend that if sedation alone is inadequate to achieve effective mechanical
ventilation, neuromuscular blockade (NMB) should be considered. When used, pediatric
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patients with PARDS should receive minimal yet effective NMB with sedation to facilitate
their tolerance to mechanical ventilation and to optimize oxygen delivery, oxygen
consumption, and work of breathing. Strong agreement

5.2.2: We recommend that when used, NMB should be monitored and titrated to the goal
depth established by the interprofessional team. Monitoring may include effective
ventilation, clinical movement, and train-of-four response. Strong agreement

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5.2.3: We recommend that if full chemical paralysis is used, the team should consider a daily
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NMB holiday to allow periodic assessment of the patient’s level of NMB and sedation.
Strong agreement

5.2.4: We recommend that clinical trials in PARDS should report their NMB goal, strategy,
and exposure. Strong agreement

5.2.5: We recommend that the reporting of NMB strategy and monitoring in clinical trials
should be adequately explicit to allow comparison across studies (e.g., type of NMB agent
and use of steroids). Strong agreement

5.2.6: We recommend that further studies are needed to better understand the short- and
long-term outcomes of NMB use. Strong agreement
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5.3 Nutrition
5.3.1: We recommend that pediatric patients with PARDS should receive a nutrition plan to
facilitate their recovery, maintain their growth, and meet their metabolic needs. Strong
agreement

5.3.2: We recommend that enteral nutrition, when tolerated, should be used in preference to
parenteral nutrition. Strong agreement

5.3.3: We recommend that enteral nutrition monitoring, advancement, and maintenance

should be managed by a goal-directed protocol that is collaboratively established by the
interprofessional team. Strong agreement
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5.3.4: We recommend that clinical trials in PARDS should report their nutritional/feeding
goals, strategy, and exposure. Strong agreement

5.3.5: We recommend that the reporting of the nutrition strategy, exposure, and monitoring
in clinical trials should be adequately explicit to allow comparison across studies (e.g., route,
composition, calories delivered, use of additives, and time to reach nutrition goal). Strong
agreement

5.4 Fluid Management

5.4.1: We recommend that pediatric patients with PARDS should receive total fluids to
maintain adequate intravascular volume, end-organ perfusion, and optimal delivery of
oxygen. Strong agreement
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5.4.2: After initial fluid resuscitation and stabilization, we recommend goal-directed fluid
management. Fluid balance should be monitored and titrated to maintain adequate
intravascular volume while aiming to prevent positive fluid balance. Strong agreement

5.4.3: We recommend that fluid titration be managed by a goal-directed protocol that

includes total fluid intake, output, and net balance. Strong agreement

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5.4.4: We recommend that clinical trials in PARDS should report their fluid management
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goals, strategy, and exposure. Strong agreement

5.4.5: We recommend that the reporting of fluid strategy and monitoring in clinical trials
should be adequately explicit to allow comparison across studies (e.g., fluid bolus trigger,
type of fluid, central venous pressure goal, use of ultrasound, or impedance monitoring).
Strong agreement

5.4.6: We recommend that clinical trials in PARDS should use a clinical protocol to guide
fluid management. Strong agreement

5.4.7: We recommend that further studies are needed to definitively determine the optimal
fluid management strategy in pediatric patients with PARDS. Strong agreement
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5.5 Transfusion
5.5.1: In clinically stable children with evidence of adequate oxygen delivery (excluding
cyanotic heart disease, bleeding, and severe hypoxemia), we recommend that a hemoglobin
concentration up to 7.0 g/dL be considered a trigger for RBC transfusion in children with
PARDS. Strong agreement

5.5.2: We recommend that clinical trials in PARDS should report their blood product
transfusion triggers, strategies, and exposures. Strong agreement

5.5.3: We recommend that the reporting of transfusion trigger, strategy, and monitoring in
clinical trials should be adequately explicit to allow comparison across studies (e.g., whole
vs packed RBCs, age of blood, use of leukoreduction, fresh-frozen plasma, and platelets).
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Strong agreement

5.5.4: We recommend that clinical trials in PARDS should use a clinical protocol to guide
blood product transfusion. Strong agreement

5.5.5: We recommend that further studies are needed to definitely determine the risks and
benefits of transfusion in pediatric patients with PARDS. Strong agreement

Section 6: Monitoring
6.1 General Monitoring
6.1.1: We recommend that all children with or at risk of PARDS should receive the
minimum clinical monitoring of respiratory frequency, heart rate, continuous pulse oximetry,
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and noninvasive blood pressure. Strong agreement

6.1.2: We recommend that specific alarms should be available when the monitored variables
are outside predefined ranges. Strong agreement

6.1.3: We recommend that some monitored values (e.g., tidal volume and compliance of the
respiratory system) should be interpreted after standardization to body weight. Hence,

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accurate weight is critical. Predicted body weight should be used, based on calculation from
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gender and from height or length or from ulna length. Strong agreement

6.2 Respiratory System Mechanics

6.2.1: We recommend that during invasive ventilation in children with PARDS, the exhaled
tidal volume should be continuously monitored to prevent injurious ventilation. Strong
agreement

6.2.2: We recommend that monitoring of ventilatory inspiratory pressure is important to

prevent ventilator-induced lung injury. It should be based on peak pressure in pressure-
regulated modes and plateau pressure during ventilation in volume-control modes. It should
be interpreted with caution in patients with suspected abnormal chest wall compliance or
with spontaneous breathing. Strong agreement
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6.2.3: We recommend the monitoring of flow-time and pressure-time curves to assess the
accuracy of respiratory timings and to detect expiratory flow limitation or patient-ventilator
asynchrony. Strong agreement

6.2.4: We recommend that in infants and smaller children, the exhaled tidal volumes should
be monitored at the end of the endotracheal tube and/or with appropriate compensation for
circuit compliance. Strong agreement

6.2.5: There is insufficient evidence to recommend the systematic monitoring of the

following variables of respiratory system mechanics: flow-volume loop, static pressure-
volume loop, dynamic pressure-volume loop, dynamic compliance and resistance, stress
index, intrinsic PEEP, esophageal manometry and transpulmonary pressure, work of
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breathing, corrected minute ventilation, functional residual capacity, dead space/tidal volume
ratio, assessment of respiratory muscle activity using airway occlusion pressure (P0.1),
esophageal pressure rate product, electrical activity of diaphragm, ultrasonography of the
diaphragm, or thoracoabdominal asynchrony quantification by respiratory inductance
plethysmography. Weak agreement (92% agreement)

6.3 Oxygenation Variables, Severity Scoring, and co2 Monitoring

6.3.1: Monitoring of Fio2, Spo2 and/or Pao2, Paw, and PEEP is recommended to detect
PARDS, to assess PARDS severity, and to guide the management of oxygenation failure.
Strong agreement

6.3.2: We recommend that blood pH and Paco2 measurement frequency should be adjusted
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according to PARDS severity, noninvasive monitoring data, and stage of the disease. Strong
agreement

6.3.3: Peripheral venous blood gas sampling is not recommended. Weak agreement (83%
agreement)

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6.3.4: Continuous monitoring of co2 is recommended in children with invasive mechanical

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ventilation, using end-tidal co2/time curves, volumetric capnography, and/or transcutaneous

co2 measurements. Strong agreement

6.4 Specific Weaning Considerations

6.4.1: We recommend at least daily assessment of predefined clinical and physiologic
criteria of extubation readiness in order to avoid unnecessary prolonged ventilation. Strong
agreement

6.4.2: We recommend that Spontaneous Breathing Trials and/or Extubation Readiness Tests
should be performed. Strong agreement

6.4.3: We recommend that for research studies, Spontaneous Breathing Trials and
Extubation Readiness Tests should be standardized. Strong agreement
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6.5 Imaging
6.5.1: We recommend that chest imaging is necessary for the diagnosis of PARDS and to
detect complications such as air leak or equipment displacement. Frequency of chest
imaging should be predicated on patient clinical condition. Strong agreement

6.5.2: There is insufficient evidence to recommend the systematic use of chest CT scan, lung
ultrasonography, and electrical impedance tomography. Strong agreement

6.6 Hemodynamic Monitoring

6.6.1: Hemodynamic monitoring is recommended during PARDS, in particular, to guide
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volume expansion in the context of fluid restrictive strategy, to evaluate the impact of
ventilation and disease on right and left cardiac function, and to assess oxygen delivery.
Strong agreement

6.6.2: In patients with suspected cardiac dysfunction, echocardiography is recommended for

noninvasive evaluation of both left and right ventricular function, the preload status, and
pulmonary arterial pressures. Strong agreement

6.6.3: We recommend that a peripheral arterial catheter should be considered in patients

with severe PARDS for continuous monitoring of arterial blood pressure and arterial blood
gas analysis. Strong agreement

6.6.4: There is insufficient evidence to recommend the systematic use of the following
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hemodynamic monitoring devices: pulse contour with transpulmonary dilution technology,

pulmonary artery catheters, alternative devices to monitor cardiac output (ultrasonic cardiac
output monitoring, transesophageal aortic Doppler, and noninvasive monitoring of cardiac
output based on changes in respiratory co2 concentration caused by a brief period of
rebreathing), central venous oxygenation monitoring, and B-type natriuretic peptide
measurements. Strong agreement

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Section 7: Noninvasive Support and Ventilation

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7.1 Indications for Noninvasive Support Ventilation

7.1.1: We recommend that noninvasive positive pressure ventilation (NPPV) is considered
early in disease in children at risk for PARDS to improve gas exchange, decrease work of
breathing, and potentially avoid complications of invasive ventilation. Weak agreement (88%
agreement)

7.1.2: We recommend that selected populations of children, such as children with

immunodeficiency who are at greater risk of complications from invasive mechanical
ventilation, may benefit more from earlier NPPV to avoid invasive mechanical ventilation.
Weak agreement (80% agreement)

7.2 Team Training

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7.2.1: We recommend that although noninvasive, NPPV should be delivered in a setting with
trained experienced staff and where close monitoring is available to rapidly identify and treat
deterioration. Strong agreement

7.3 Noninvasive Support Ventilation Management

7.3.1: We recommend that intubation should be considered in patients receiving NPPV who
do not show clinical improvement or have signs and symptoms of worsening disease,
including increased respiratory rate, increased work of breathing, worsening gas exchange,
or an altered level of consciousness. Strong agreement

7.3.2: We recommend the use of an oronasal or full facial mask to provide the most efficient
patient-ventilator synchronization for children with PARDS. Weak agreement (84%
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agreement)

7.3.3: We recommend that children using NPPV should be closely monitored for potential
problems, such as skin breakdown, gastric distention, barotrauma, and conjunctivitis. Strong
agreement

7.3.4: Heated humidification is strongly recommended for NPPV in children. Strong

agreement

7.3.5: We recommend that to allow the most efficient patient-ventilator synchronization and
tolerance, sedation should be used only with caution in children receiving NPPV for
PARDS. Weak agreement (88% agreement)
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7.3.6: To reduce inspiratory muscle effort and improve oxygenation, we recommend

noninvasive pressure support ventilation combined with PEEP in patients with PARDS.
Continuous positive airway pressure alone may be suitable for those children who are unable
to attain patient ventilatory synchrony or when using nasal interface. Weak agreement (92%
agreement)

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7.4 Other Modes of Noninvasive Support Ventilation

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7.4.1: We recommend that further studies are needed to identify clinical indications for high-
flow nasal cannula in patients at risk of PARDS. High-flow nasal cannula has not been
demonstrated to be equivalent to NPPV. Strong agreement

7.4.2: NPPV is not recommended for children with severe disease. Strong agreement

Section 8: Extracorporeal Support

8.1 Indications for Extracorporeal Membrane Oxygenation in Children With
PARDS
8.1.1: We recommend that extracorporeal membrane oxygenation (ECMO) should be
considered to support children with severe PARDS where the cause of the respiratory failure
is believed to be reversible or the child is likely to be suitable for consideration for lung
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transplantation. Strong agreement

8.1.2: It is not possible to apply strict criteria for the selection of children who will benefit
from ECMO in PARDS. We recommend that children with severe PARDS should be
considered for ECMO when lung protective strategies result in inadequate gas exchange.
Strong agreement

8.1.3: We recommend that decisions to institute ECMO should be based on a structured

evaluation of case history and clinical status. Strong agreement

8.1.4: We recommend that serial evaluation of ECMO eligibility is more useful than single-
point assessment. Strong agreement
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8.1.5: We recommend that careful consideration of quality of life and likelihood of benefit
should be assessed. Strong agreement

8.2 Contraindications to ECMO in Children With Severe PARDS

8.2.1: We recommend that ECMO should not be deployed in patients in whom life-
sustaining measures are likely to be limited. Strong agreement

8.3 Team Training and Organization

8.3.1: We recommend that ECMO programs should have clearly defined leadership
structure, including administrative support. Strong agreement
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8.3.2: We recommend that all personnel directly caring for the patient should have an
understanding of the ECMO circuit and the physiologic interactions between it and the
patient. Competencies for physicians with primary patient care duties and ECMO specialists
should be required. Strong agreement

8.3.3: We recommend that all centers providing ECMO support should belong to The
Extracorporeal Life Support Organization (ELSO) and report all patient activity to ELSO or
similar organization. Strong agreement

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8.3.4: We recommend that ECMO programs should benchmark themselves against other
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programs via the ELSO registry or similar. Strong agreement

8.4 Other Modes of Extracorporeal Lung Support

8.4.1: We recommend that patients suffering from extreme hypercarbia and mild-to-
moderate hypoxia may benefit from new extracorporeal devices which provide partial
respiratory support. Such devices may be effective in removing all carbon dioxide and may
not require a pump to provide blood flow but may instead use the patient’s own generated
systemic blood pressure to drive blood through a low-resistance oxygenator. Weak
agreement (63% agreement)

Section 9: Morbidity and Long-Term Outcomes

9.1 Pulmonary Function
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9.1.1: We recommend screening for pulmonary function abnormalities within the first year
after discharge, including a minimum of respiratory symptom questionnaires and pulse
oximetry for all children with PARDS who undergo invasive mechanical ventilation. Strong
agreement

9.1.2: We recommend that for all children with PARDS who undergo invasive mechanical
ventilation and are of sufficient developmental age and capabilities, spirometry should also
be performed for the screening for pulmonary function abnormalities within the first year
after discharge. Strong agreement

9.1.3: We recommend that when deficits in pulmonary function are identified, patients
should be referred to a pediatric pulmonologist for further assessment, treatment, and long-
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term pulmonary follow-up. Strong agreement

9.2 Neurocognitive Development

9.2.1: We recommend that physical, neurocognitive, emotional, family, and social function
be evaluated within 3 months of hospital discharge for children who survive moderate-to-
severe PARDS. Strong agreement

9.2.2: We recommend that for younger patients (infants and toddlers), additional evaluation
of physical, neurocognitive, emotional, family, and social function should be performed
prior to entering school. Strong agreement

9.2.3: We recommend that when abnormalities are identified, children should be treated or
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referred for more in-depth assessment and treatment by appropriate subspecialists and
educators (e.g., when learning deficits are identified). Strong agreement

9.3 Outcome Measures

9.3.1: Given decreasing mortality among children with PARDS, we recommend research
into the following potential alternative endpoints for clinical trials: longer term mortality
(e.g., 90 d), rates of new or progressive organ dysfunction, organ failure- or treatment-free
days, ventilator-free days (with and without noninvasive ventilation), duration of oxygen

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therapy (or a higher concentration of oxygen for subjects on chronic supplemental oxygen),
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risk-adjusted hospital and PICU lengths of stay, hospital and PICU readmissions (e.g.,
within 30 d of discharge), quality of life, neurocognitive function, and emotional health.
Strong agreement

DISCUSSION
The PALICC was convened to identify and articulate differences between adult and pediatric
ARDS. The conference made important first steps in this process. We recognize that further
work is required to build on these initial efforts, and we hope these recommendations
provide a roadmap to future areas of investigation. The details of each section along with the
extensive literature researched are presented in the supplement to this issue of Pediatric
Critical Care Medicine published with this article. The Conference identified many areas of
agreement, but its primary benefit may well be in illustrating how little is known about this
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relatively common condition in children.

The process by which the recommendations were developed was based on previously
published methods (13) and was chosen due to the relative paucity of data in PARDS. The
experts in each group were tasked with synthesizing the data on their specific topic and
developing recommendations based on peer-reviewed, pediatric-specific data. If no pediatric
data were available, experts were directed to use data generated from either adults with
ARDS or neonates with lung injury, to solidify their recommendations. Finally, expert
opinion was used when no data were available. Once the initial recommendations were
presented, each of the PALICC members had equal input on each recommendation. One
advantage of the RAND/UCLA appropriateness method is that it diminishes the “leader
effect” and provides every member an equal vote (15), which was felt to be extremely
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important to the process.

Perhaps, the most controversial recommendations will be those regarding definitions. Much
like the Berlin Conference (3), we abandoned the previous category of “ALI” in favor of
grading PARDS by severity (16). Unlike the Berlin group, however, we chose to use the OI
(or, if an arterial blood gas is not available, the OSI) rather than the P/F ratio because of the
less standardized approach to positive pressure ventilation in children relative to adults. We
also chose to eliminate the requirement for “bilateral” pulmonary infiltrates as the distinction
between bilateral and unilateral is often difficult, and there is no evidence that etiology,
treatment, or outcomes are different between patients with and without bilateral infiltrates.
We also chose not to state specific age criteria for PARDS, as described in recommendation
1.1.1. However, the purpose was clearly to define PARDS in the patient population generally
cared for by pediatric intensivists. The inclusion of nonintubated children within the
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definition of PARDS (or at risk) acknowledges the increasing use of noninvasive positive
pressure support and focuses appropriate attention on possible early intervention in PARDS.
Finally, we have offered definitions for PARDS in patients with congenital heart disease and
chronic lung disease. Undoubtedly, this will prove controversial, but we recognize that many
of the patients we care for in the PICU have underlying chronic conditions, and chronic
disease does not preclude the possibility of superimposed ARDS.

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The therapeutic recommendations from the group are also likely to provoke argument, some
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because they are too generic and others because they are too prescriptive. As these
recommendations are clearly a starting point, we expect that few of these recommendations
will weather the test of time, being replaced with higher levels of evidence. All
recommendations were made after a thorough review of the current literature, but high levels
of evidence were often lacking. Nonetheless, it was the purpose of the conference to offer
recommendations based on the best available evidence. When only insufficient evidence was
available expert opinion or expert interpretation of the available data was utilized.

The final purpose of the Conference was to increase interest in research in PARDS.
Although it appears as if mortality has steadily improved over the last 2–3 decades, PARDS
remains a relatively common clinical problem in the PICU with few effective therapies.
Indeed, the failures of many therapies are addressed specifically in the conference
recommendations not to use them for patients with PARDS. By identifying the deficiencies
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in our understanding, the failure of multiple past clinical trials, and the paucity of
information on outcomes other than mortality, we hoped to identify the key areas for future
investigation. The experts in each area have highlighted the lack of published data, and in
doing so, hopefully, they have illuminated the initial way forward. It is clear that we have a
long way to go.

These recommendations represent the consensus achieved by 27 experts from eight different
countries. Although each of the recommendations is based on a thorough review of the
existing literature, given the paucity of science on many of these topics some undoubtedly
contain a large element of interpretation and opinion. Precisely because consensus was
required, some of the recommendations may also appear pedestrian and even
commonsensical. We would urge the clinician searching for more detail, more controversy,
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or perhaps more prescriptive recommendations to read the supporting evidence in the

supplement. The conference identified more questions than answers, and this is evident in
the supplement. It is our hope that identifying the questions will lead others to pursue
research in this area to address some of the limitations in our current understanding of
PARDS.

In summary, the PALICC developed pediatric-specific definitions for ARDS and

recommendations regarding treatment and future research priorities. These are intended to
initiate discussion regarding optimization and consistency of care for children with PARDS
and to identify areas of controversy requiring further investigation.

Acknowledgments
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Supported, in part, by the Department of Pediatrics, The Pennsylvania State University College of Medicine; Health
Outcome Axis–Ste Justine Research Center, Montreal, Canada; Respiratory Research Network of Fonds de
Recherche du Québec-Santé, QC, Canada; Mother and Children French-Speaking Network; French-Speaking
Group in Pediatric Emergency and Intensive Care, French-Speaking Intensive Care Society (SRLF); European
Society for Pediatric and Neonatal Intensive Care Society (travel support for European experts); Australian and
New Zealand Intensive Care Society (travel support for Australian expert); Children’s Hospital of Richmond of
Virginia Commonwealth University; Division of Critical Care Medicine, CS Mott Children’s Hospital at the
University of Michigan; and Department of Anesthesia and Critical Care, Children’s Hospital of Philadelphia.

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APPENDIX 1. PEDIATRIC ACUTE LUNG INJURY CONSENSUS

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CONFERENCE GROUP
Organizing Committee: Philippe Jouvet, University of Montreal, Canada; Neal J. Thomas,
Pennsylvania State University; Douglas F. Willson, Medical College of Virginia.

Section 1: Definition, prevalence, and epidemiology: Simon Erickson, Princess Margaret

Hospital for Children, Australia; Robinder Khemani, University of Southern California;
Lincoln Smith, University of Washington; Jerry Zimmerman, University of Washington.

Section 2: Pathophysiology, comorbidities, and severity: Mary Dahmer, University of

Michigan; Heidi Flori, Children’s Hospital & Research Center Oakland; Michael Quasney,
University of Michigan; Anil Sapru, University of California San Francisco.
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Section 3: Ventilatory support: Ira M. Cheifetz, Duke University; Peter C. Rimensberger,

University Hospital of Geneva, Switzerland.

Section 4: Pulmonary-specific ancillary treatment: Martin Kneyber, University Medical

Center Groningen, The Netherlands; Robert F. Tamburro, Pennsylvania State University.

Section 5: Nonpulmonary treatment: Martha A. Q. Curley, University of Pennsylvania;

Vinay Nadkarni, University of Pennsylvania; Stacey Valentine, Harvard University.

Section 6: Monitoring: Guillaume Emeriaud, University of Montreal, Canada; Christopher

Newth, University of Southern California.

Section 7: Noninvasive support and ventilation: Christopher L. Carroll, University of

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Connecticut; Sandrine Essouri, Université Pierre et Marie Curie, France.

Section 8: Extracorporeal support: Heidi Dalton, University of Arizona; Duncan Macrae,

Royal Brompton Hospital, England.

Section 9: Morbidity and long-term outcomes: Yolanda Lopez-Cruces, University Hospital,

Spain; Michael Quasney, University of Michigan; Miriam Santschi, Université de
Sherbrooke, Canada; R. Scott Watson, University of Pittsburgh.

Literature Search Methodology: Melania Bembea, Johns Hopkins University.

References
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2:319–323. [PubMed: 4143721]

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[PubMed: 23842587]
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13. Société de Réanimation de Langue Française. Recommandations d’Experts (RE) et Formalisée
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et-rfe/index.phtml. Accessed May 18, 2014
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15. The RAND/UCLA Appropriateness Method User’s Manual. Available at: http://www.rand.org/
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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.
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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.
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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.
Author Manuscript
Author Manuscript

Pediatr Crit Care Med. Author manuscript; available in PMC 2017 January 22.