Advances in the Pharmacological Management of Pediatric Acute Respiratory Distress Syndrome

ABSTRACT

Introduction

Noninvasive mechanical ventilation is the main supportive measure used in patients with pediatric ARDS (PARDS), but adjunctive pharmacological therapies (corticosteroids, inhaled nitric oxide [iNO], surfactant replacement therapy and neuromuscular blocking drugs) are also used, although limited data exists to inform of this practice.

Areas covered

The authors review the current challenges in the pharmacological management of PARDS and highlight the few certainties currently available.

Expert opinion

Children with PARDS must not be treated as young adults with ARDS, essentially because children’s lungs differ substantially from those of adults and PARDS occurs in children differently than ARDS in adults. Pharmacological treatments available for PARDS are relatively few and, since there is great uncertainty about their effectiveness also because of the extreme heterogeneity of this syndrome, it is necessary to conduct large clinical trials using currently available definitions and considering recent pathobiological knowledge. The aim is to identify homogeneous subgroups or phenotypes of children with PARDS that may benefit from the specific pharmaceutical approach examined. It will be then necessary to link endotypes and outcomes to appropriately target therapies in future trials, but this will be possible only after it will be possible to identify the different PARDS endotypes.

KEYWORDS:

• Acute respiratory distress syndrome
• corticosteroids
• covid-19
• inhaled nitric oxide
• neuromuscular blocking drugs
• pediatric ards
• pheno-endotypes
• surfactant replacement therapy

Article highlights

• PARDS, which is commonly caused by pneumonia, bronchiolitis, and sepsis, is different from ARDS in adults, with a lower incidence and a relatively lower mortality.

• Non-invasive mechanical ventilation is the main supportive measure used in children with PARDS, but it does not influence the body’s inflammatory response and stress response.

• Adjunctive pharmacological therapies with corticosteroids, iNO, surfactant replacement therapy and neuromuscular blocking drugs are also utilized, although few data exist to inform this practice and, consequently, their use remains controversial.

• Other possible pharmacological approaches have less credibility because information on their use has been generated in too small studies.

• Extrapolating data from adult studies to decide whether to administer a specific class of drugs to children with PARDS is certainly not the most appropriate approach.

• There is an urgent need to identify homogeneous subgroups or phenotypes of children with PARDS in whom therapies can be specifically targeted and are thus more likely to be beneficial.

Declaration of interest

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.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript has not been funded.