Diagnostic, Management, and Research Considerations for Pediatric Acute Respiratory Distress Syndrome in Resource-Limited Settings: From the Second Pediatric Acute Lung Injury Consensus Conference

Abstract

OBJECTIVES:Diagnosis of pediatric acute respiratory distress syndrome (PARDS) in resource-limited settings (RLS) is challenging and remains poorly described. We conducted a review of the literature to optimize recognition of PARDS in RLS and to provide recommendations/statements for clinical practice and future research in these settings as part of the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2). DATA SOURCES: MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION:We included studies related to precipitating factors for PARDS, mechanical ventilation (MV), pulmonary and nonpulmonary ancillary treatments, and long-term outcomes in children who survive PARDS in RLS. DATA EXTRACTION: Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS: The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Seventy-seven studies were identified for full-text extraction. We were unable to identify any literature on which to base recommendations. We gained consensus on six clinical statements (good practice, definition, and policy) and five research statements. Clinicians should be aware of diseases and comorbidities, uncommon in most high-income settings, that predispose to the development of PARDS in RLS. Because of difficulties in recognizing PARDS and to avoid underdiagnosis, the PALICC-2 possible PARDS definition allows exclusion of imaging criteria when all other criteria are met, including noninvasive metrics of hypoxemia. The availability of MV support, regular MV training and education, as well as accessibility and costs of pulmonary and nonpulmonary ancillary therapies are other concerns related to management of PARDS in RLS. Data on long-term outcomes and feasibility of follow-up in PARDS survivors from RLS are also lacking. CONCLUSIONS: To date, PARDS remains poorly described in RLS. Clinicians working in these settings should be aware of common precipitating factors for PARDS in their patients. Future studies utilizing the PALICC-2 definitions are urgently needed to describe the epidemiology, management, and outcomes of PARDS in RLS. KEY WORDS: acute hypoxemic respiratory failure; developing countries; lowand middle-income countries; oxygen therapy; pediatric acute respiratory distress syndrome; resource limited T he epidemiology and outcomes of pediatric acute respiratory distress syndrome (PARDS) in resource-limited settings (RLS) remains poorly described in the current medical literature. Based on known common

Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2)

“…There were another 112 statements: 18 related to the definition of PARDS and patients at risk for PARDS, 55 GPS, seven PS, and 32 RS. The evidence tables and rationale supporting CR are presented in the corresponding subgroup manuscripts (13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24).…”

“…Other substantial changes with PALICC-2 include two new sections focused on informatics and data science ( 23 ), as well as implementation in RLS ( 24 ). The informatics section provides specific recommendations on systems to screen for PARDS and monitor compliance with lung protective ventilation recommendations.…”

“…Nevertheless, we believe these clinical practice guidelines will be valuable at the bedside, as we took into consideration feasibility, safety, equity, and implementation for all recommendations. Detailed considerations for all of these recommendations can be found in the supplemental articles (13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24). These guidelines have also identified many gaps that offer opportunities for the future PARDS research agenda.…”

“…We used a combination of medical subject heading terms and text words for concepts related to PARDS and each of the 11 sections. Search strategies are detailed in the methods article and supplemental digital files for each of the individual articles (13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24). References included in previous PALICC reviews were systematically added to the extracted evidence.…”

Methodology of the Second Pediatric Acute Lung Injury Consensus Conference

“…We developed Patient/Intervention/Comparator/ Outcome (PICO) questions specific to each topic, which are described in each of the articles in this supplement (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17). Although writing the manuscript, the authors reviewed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines for systematic reviews and scoping reviews, as applicable (18,19).…”