Intensive Care Med (2014) 40:1924–1926
DOI 10.1007/s00134-014-3498-y WHAT’S NEW IN INTENSIVE CA RE
Martin C. J. Kneyber
Philippe A. Jouvet
How to manage ventilation in pediatric acute
Peter C. Rimensberger respiratory distress syndrome?
Received: 1 September 2014
Accepted: 13 September 2014
Published online: 20 September 2014
Ó Springer-Verlag Berlin Heidelberg and ESICM 2014
M. C. J. Kneyber ())
Division of Pediatric Intensive Care, Department of Pediatrics,
Beatrix Children’s Hospital, University Medical Center Groningen,
The University of Groningen, Internal postal code CA 80,
P.O. Box 30.001, 9700 RB Groningen, The Netherlands
e-mail: m.c.j.kneyber@umcg.nl
Tel.: (?)3150-3614147
M. C. J. Kneyber
Critical Care, Anesthesiology, Peri-operative Medicine and
Emergency Medicine (CAPE), The University of Groningen,
Groningen, The Netherlands
P. A. Jouvet
Pediatric ICU, Soins Intensifs Pédiatrique, Hôpital Sainte Justine,
Montreal, QC, Canada
P. C. Rimensberger
Division of Neonatology and Pediatric Intensive Care, University
Hospital Geneva, Geneva, Switzerland
Mechanical ventilation (MV) is essential for children with
acute respiratory distress syndrome (ARDS). However, it
may also contribute to lung inflammation and injury via
ventilator-induced lung injury (VILI) [1]. Barotrauma,
volutrauma due to alveolar overdistension, and atelec-
trauma following ventilation at low lung volumes all
contribute to VILI. Understanding these mechanisms has
resulted in lung protective ventilation strategies including
pressure limitation, delivery of low tidal volume (Vt), and
application of positive end-expiratory pressure (PEEP) in
adults with ARDS.
Pediatric intensivists have readily adopted these prac-
tices. However, many uncertainties remain. Numerous
differences in physiological systems between children and
adults may invalidate extrapolation of adult practice to
children. In addition, the susceptibility to VILI may differ
with age [2]. Specifically the association between Vt and
mortality is unclear in pediatric ARDS [3]. Hence, studies
need to be undertaken to understand and improve the
management of pediatric ARDS, during both the acute
and weaning phases (Fig. 1). Various compelling issues
need to be addressed, such as a better definition of pedi-
atric ARDS, individualized titration of ventilator settings,
and the role of non-invasive ventilation (NIV) or high
frequency oscillatory ventilation (HFOV).
The incidence and mortality of pediatric ARDS differ
from those in adults. Pediatric ARDS is relatively rare at
2–12.8 per 100,000 persons per year. Mortality rates are
between 18 and 35 % [4]. Despite this low incidence,
Spanish investigators have shown that a substantial
number of ventilated children may develop ARDS during
their stay in the pediatric intensive care unit (PICU) [4].
To date the North-American European Consensus Con-
ference (NAECC) definition has been used to identify
children with ARDS with the inherent risk of underesti-
mating its true incidence, especially because it requires an
invasive marker of oxygenation (PaO2) [5]. The Berlin
definition of ARDS has replaced the NAECC definition
but does not include specific pediatric considerations.
However, the Section Respiratory Failure of the European
Society for Pediatric and Neonatal Intensive Care (ESP-
NIC) have since demonstrated good performance of the
Berlin definition among infants younger than 24 months
[6]. More recently, the Pediatric Acute Lung Injury
Consensus Conference (PALICC) brought together
investigators from all over the world with the aim of
improving the definition of pediatric ARDS, its manage-
ment, and providing directions for further research [7].
This new definition is based on analysis of observational
data from various pediatric studies, taking primarily into
account the association between hypoxemia/lung injury

Fig. 1 Schematic
representation of mechanical ACUTE PHASE
ventilation (MV) course in
pediatric acute respiratory MV course with additional monitoring (TPP? EIT? EaDi?)
distress syndrome (PARDS).
There is a need to better define
the PARDS diagnosis criteria NIV?
and use of the ventilation modes
and monitoring methods
available. NIV non-invasive
ventilation, HFOV high Intubation
frequency oscillatory
ventilation, CMV conventional
mechanical ventilation, EaDi CMV to
electrical activity of the HFOV criteria
diaphragm, EIT electrical PARDS
impedance tomography, TPP
diagnosis criteria
transpulmonary pressure
severity scoring and outcome for pediatric ARDS [8]. A
better taxonomy of pediatric ARDS will most likely result
in a better patient selection for randomized controlled
trials.
Specific pediatric guidelines on how to ventilate a child
with ARDS are lacking. As a consequence, pediatric
critical care physicians have adapted to varying degrees
lung-protective ventilation strategies based on adult rec-
ommendations. In general Vt is targeted in the range of
5–7 mL/kg and a certain level of PEEP is applied at the
discretion of the attending physician [9]. The question is
if such a ‘one size fits all’ approach makes sense. The
physiologic Vt is in the range of 6–8 mL/kg body weight,
but patients with more severe lung injury have a smaller
residual inflatable lung available for alveolar ventilation
(i.e., the baby lung). There is no specific threshold for Vt
associated with mortality in pediatrics [3]. Hence, the
optimal Vt might need to be smaller in severe cases, but
perhaps higher in less sick or improving lungs. Thus, the
underlying disease and severity of lung disease need to be
taken into account instead of targeting 6 mL/kg predicted
body weight (PBW) in every patient. This more physio-
logic approach has not been tested in clinical trials but
does make sense. A subgroup analysis of the ARDS
Network trial showed that randomization to 6 mL/kg
PBW was only beneficial in patients with poor respiratory
system compliance at study entry [10]. Likewise, pedi-
atric patients with higher lung injury score managed with
pressure-limited ventilation displayed lower Vt [11].
Simple bedside tools to titrate ventilation are much
needed, such as transpulmonary pressure (TPP) mea-
surements and electrical impedance tomography (EIT).
The esophageal pressure may be used as a surrogate for
the pleural pressure and therefore be used to set PEEP.
TPP-guided PEEP titration resulted in improved oxy-
genation and compliance in adults with ARDS [12]. EIT
is a non-invasive imaging technique displaying real-time
changes in ventilation. It provides information on which
1925
WEANING PHASE
± HFOV MV weaning phase ± NIV
time
End of Extubation
weaning
HFOV to
CMV criteria
weaning spontaneous extubation
stability criteria
readiness testing breathing testing criteria
parts of the lung the Vt is distributed to, and allows for a
quantification of regional overdistension and atelectasis.
It may thus be used to determine the appropriate Vt and
level of PEEP. EIT-guided PEEP titration resulted in
improved respiratory mechanics, improved gas exchange,
and reduced histologic evidence of VILI in an animal
model of acute lung injury [13]. Pediatric clinical studies
are awaited.
Other areas in need of study in pediatric ARDS
include neutrally adjusted ventilator assist (NAVA).
NAVA might result in better oxygenation, less sedation,
and less patient–ventilator asynchrony. Its use is gaining
interest in pediatric critical care as discussed recently in
this journal [14]. However, the PALIVE study showed
that less than 10 % of pediatric ARDS is managed with
NIV [15]. This can most likely be explained by the fact
that the efficacy of NIV in pediatric ARDS is unknown.
HFOV is often used when conventional ventilation fails.
However, the safety and benefit of HFOV are questioned
following the OSCILLATE trial in adult ARDS and a
retrospective observational pediatric study [16, 17].
Hence, a pediatric HFOV trial is eagerly awaited.
Finally, we do not know the optimum weaning strategy
for children with ARDS. A big question is whether we
should use clinical decision-making protocols to
decrease practice variation and standardize patient care.
Recently, a small pediatric study showed that imple-
mentation of such a protocol reduced weaning duration
by 1.5 days [18].
In summary, many uncertainties remain concerning the
ventilation of pediatric ARDS. This should encourage
investigators worldwide to join forces and address these
questions. It is absolutely clear that we need to improve
the scientific basis of one of the most practiced inter-
ventions in pediatric critical care. The challenging
research agenda for the next decades is set.
Conflicts of interest None to disclose.
1926
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