Adjunctive treatments in pediatric acute respiratory distress syndrome

Abstract

Acute respiratory distress syndrome (ARDS) is a devastating process that involves pulmonary inflammation, alveolar damage and hypoxemic respiratory failure. Although advances in management approaches over the past two decades have resulted in significantly improved outcomes, death from pediatric ARDS may still occur in up to 35% of patients. While invasive mechanical ventilation is an essential component of ARDS management, various adjuncts have been utilized as treatment for these patients. However, evidence-based data in infants and children in this area are lacking. In this article, the authors review the available evidence supporting (or not supporting) the use of non-ventilatory adjunctive strategies in the management of pediatric ARDS, including prone positioning, pulmonary vasodilators, β-agonists, steroids and surfactant.

Keywords::

• acute respiratory distress syndrome
• children
• nitric oxide
• pediatric
• prone positioning
• prostaglandin
• pulmonary hypertension
• steroid
• surfactant

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Prone positioning may be considered in children with severe acute respiratory distress syndrome (ARDS). Attention must be given and care taken to ensure that adverse events such as dislodgement of tubes and lines are kept to a minimum.

• Inhaled nitric oxide may transiently improve oxygenation in patients with ARDS, but there is no mortality benefit associated with its use. The routine use of inhaled nitric oxide in ARDS patients is not indicated

• There is no role for steroids in the prevention of ARDS, but a prolonged course of low-dose steroid started within the first 2 weeks may improve the clinical outcomes in select patients. Pediatric data to support this practice are limited.

• While there may be a subset of patients who demonstrate benefit, current data do not support the routine use of surfactant in pediatric ARDS.

Notes

CPAP: Continuous positive airway pressure; F_iO₂: Fraction of inspired oxygen; P_aO₂: Partial pressure of arterial oxygen; PEEP: Positive end-expiratory pressure.

Adapted from [11].