Pediatric Acute Respiratory Distress Syndrome (PARDS)
1. What is the decision or change you are facing or struggling with where a summary of the evidence would be helpful?
Our overarching goal is to update clinical practice guidelines (CPG) for the diagnosis and management of Pediatric Acute Respiratory Distress Syndrome (PARDS). PARDS is a clinical syndrome which originates from an acute inflammatory injury of the lungs1. PARDS affects 3% of patients admitted to Pediatric Intensive Care Units and the related mortality exceeds 30% in severe cases 2,3. Over 5 decades following the initial description of ARDS in adults, there has been little specific attention to the unique pathobiology or treatment strategies for children with ARDS. The management of children with PARDS has therefore long been based on definitions and therapeutic strategies derived from those of adults. This was associated with significant underdiagnosis4 and variability in care5. The Pediatric Acute Lung Injury Consensus Conference (PALICC) was convened between 2012-2015 to establish, for the first time, a pediatric specific definition for PARDS, as well as generate pediatric recommendations for clinical care. The PALICC conclusions were published in 2015, with nearly 100 recommendations for clinical care 6. Many of these recommendations were consensus based, lacking pediatric specific evidence. PALICC was successful at engaging the pediatric critical care community by identifying PARDS knowledge gaps. Since publication of the PALICC recommendations in 2015, there have been nearly 1000 indexed publications related to PARDS, from over 20 countries. Furthermore, as science and clinical practice have evolved over the past 10 years, there are crucial new areas which were not specifically addressed by the initial PALICC recommendations such as driving pressure, strength of respiratory effort and self-inflicted lung injury, common respiratory support modalities such as High Flow Nasal Cannula, and early mobilization7-11. There is now a wealth of new data which needs to be synthesized to provide current, evidence-based recommendations for clinical care. We are proposing a comprehensive update to PALICC which will conduct detailed systematic review of the literature. We have assembled a diverse, international panel of approximately 50 multi-disciplinary experts in PARDS to update recommendations related to the diagnosis and management of PARDS.
Main question: How should Pediatric ARDS be diagnosed, and what is the optimal management?
This overall question will be addressed through the following 11 key sub-questions. Nine of them will be an update of the 2015 recommendations (Literature search years: 2012-2020), and 2 of them will be new questions (Literature search years: 1950-2020).
Question 1. How should PARDS be defined, and how to report its epidemiology? (Update)
Question 2. What are the pediatric specificities of the pathophysiology of ARDS, and how are the pathophysiology and co-morbidities associated with severity in PARDS? (Update)
Question 3. What are optimal ventilator strategies for children with PARDS? (Update)
Question 4. What pulmonary-specific treatments should be used in children with PARDS? (Update)
Question 5. What non-pulmonary treatments should be used in children with PARDS? (Update)
Question 6. How should patients with PARDS be monitored? (Update)
Question 7. What is the role of non-invasive respiratory support in PARDS? (Update)
Question 8. What is the role of extra-corporeal support in PARDS? (Update)
Question 9. How should morbidity and long-term outcomes be evaluated in PARDS? (Update)
Question 10. How can informatics, data science, and computerized decision support tools improve the diagnosis and management of PARDS? (new question)
Question 11. How should the PALICC2 recommendations be adapted to the context of resource-limited settings? (new question)
2. Why are you struggling with this issue?
PARDS is associated with high mortality in children. In the recent Pediatric ARDS Incidence and Epidemiology (PARDIE) study that we conducted in 145 international PICUs, mortality for severe PARDS is > 35%2. Implementation of PALICC recommendations varies markedly amongst PICUs, even for similar types of patients. From the PARDIE study, we have found that PALICC recommendations for lung protective ventilation such as limitation of tidal volume and use of Positive End Expiratory Pressure are not followed for greater than 60% of children with severe PARDS (PARDIE V.2 study, manuscript in preparation). Furthermore, failure to comply with these recommendations is associated with higher mortality. (PARDIE V.2 study, manuscript in preparation)12. Hence, all of these reasons apply related to CPG in PARDS. There is uncertainty about benefits and harms in some areas of treatment for PARDS, there is incredibly high variability in practice, and there is under-utilization of even low risk interventions with sound evidence base.
3. What do you want to see changed? How will you know that your issue is improving or has been addressed?
The PALICC2 update of PARDS CPG will lead to clinical teams being better informed regarding treatments for children with PARDS and the evidence supporting them. Besides CPG development, our project contains a plan for implementation and dissemination of the PALICC2 CPG. Plans are underway to replicate the international PARDIE observational study to measure the improvement in PARDS CPG implementation at the bedside and its association with patient outcomes. The PALICC2 group is committed to identify gaps in knowledge and develop study protocols for future randomized controlled trials to test new PARDS therapies. In addition, junior faculty have been invited to serve on PALICC2 to develop the new generation of PARDS scientists and investigators.
4. When do you need the evidence report?
Thu, 07/01/2021
5. What will you do with the evidence report?
Our goal is to generate CPGs for PARDS. An evidence report created with the support of AHRQ EPC will strengthen the validity of our process. Combined to the large diverse international and transdisciplinary team of experts, the independent, objective, and high-quality systematic review process will certainly improve the external acceptability of the recommendations. We know from PALICC that it is possible to have a strong impact in that field. With an optimized process to generate the updated recommendations, we strongly believe that PALICC2 will lead to an improved management of these severely ill children with PARDS.
Supporting Document
References and Group Members (Word)
Title or short description: References and Group Members
Comments or notes about this file: This is a list of key references and a list of the international members of PALICC 2
