Adjunctive treatments in pediatric acute respiratory distress syndrome

Prone position in the mechanical ventilation of acute respiratory distress syndrome children: a systematic review and meta-analysis

Background

Prone position has been well recognized for the treatment of adult acute respiratory distress syndrome (ARDS). We aimed to evaluate the role of prone position in the mechanical ventilation in children with ARDS, to provide evidence to the treatment and care of children with ARDS.

Methods

We searched the Pubmed et al. databases by computer until January 23, 2024 for randomized controlled trials (RCTs) on the role of prone position in the mechanical ventilation in children with ARDS. We evaluated the quality of included studies according to the quality evaluation criteria recommended by the Cochrane library. RevMan 5.3 software was used for meta-analysis.

Results

7 RCTs involving 433 children with ARDS were included. Meta-analysis indicated that prone position is beneficial to improve the arterial oxygenation pressure [MD = 4.27 mmHg, 95% CI (3.49, 5.06)], PaO2/FiO2 [MD = 26.97, 95% CI (19.17, 34.77)], reduced the oxygenation index [MD = -3.52, 95% CI (-5.41, -1.64)], mean airway pressure [MD = -1.91 cmH2O, 95% CI (-2.27, -1.55)] and mortality [OR = 0.33, 95% CI (0.15, 0.73), all P < 0.05]. There were no statistical differences in the duration of mechanical ventilation between the prone position group and control group [MD = -17.01, 97.27, 95% CI (-38.28, 4.26), P = 0.12]. Egger test results showed that no significant publication bias was found (all P > 0.05).

Conclusions

Prone position ventilation has obvious advantages in improving oxygenation, but there is no significant improvement in the time of mechanical ventilation in the treatment of children with ARDS. In the future, more large-sample, high-quality RCTs are still needed to further analyze the role of prone position in the mechanical ventilation in children with ARDS.

Safety and efficacy of corticosteroids in ARDS patients: a systematic review and meta-analysis of RCT data

Purpose

Acute respiratory distress syndrome (ARDS) is an acute and critical disease among children and adults, and previous studies have shown that the administration of corticosteroids remains controversial. Therefore, a meta-analysis of randomized controlled trials (RCTs) was performed to evaluate the safety and efficacy of corticosteroids.

Methods

The RCTs investigating the safety and efficacy of corticosteroids in ARDS were searched from electronic databases (Embase, Medline, and the Cochrane Central Register of Controlled Trials). The primary outcome was 28-day mortality. Heterogeneity was assessed using the Chi square test and I² with the inspection level of 0.1 and 50%, respectively.

Results

Fourteen RCTs (n = 1607) were included for analysis. Corticosteroids were found to reduce the risk of death in patients with ARDS (relative risk (RR) = 0.78, 95% confidence interval (CI): 0.70–0.87; P < 0.01). Moreover, no significant adverse events were observed, compared to placebo or standard support therapy. Further subgroup analysis showed that variables, such as adults (RR = 0.78; 95% CI: 0.70–0.88; P < 0.01), non-COVID-19 (RR = 0.71; 95% CI: 0.62–0.83; P < 0.01), methylprednisolone (RR = 0.70; 95% CI: 0.56–0.88; P < 0.01), and hydrocortisone (RR = 0.79; 95% CI: 0.63–0.98; P = 0.03) were associated with 28-day mortality among patients who used corticosteroids. However, no association was found, regarding children (RR = 0.21; 95% CI: 0.01–4.10; P = 0.30).

Conclusion

The use of corticosteroids is an effective approach to reduce the risk of death in ARDS patients. However, this effect is associated with age, non-COVID-19 diseases, and methylprednisolone and hydrocortisone use. Therefore, evidence suggests patients with age ≥ 18 years and non-COVID-19 should be encouraged during the corticosteroid treatment. However, due to substantial differences in the use of corticosteroids among these studies, questions still remain regarding the dosage, optimal corticosteroid agent, and treatment duration in patients with ARDS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02186-4.

MANAGEMENT OF ACUTE RESPIRATORY DISTRESS SYNDROME IN A CHILD WITH ADENOVIRUS PNEUMONIA: CASE REPORT AND LITERATURE REVIEW

OBJECTIVE

To report the case of a child who developed acute respiratory distress syndrome (ARDS) from a pulmonary infection by adenovirus.

CASE DESCRIPTION

A female patient aged 2 years and 6 months, weighting 10,295 grams developed fever, productive cough and vomiting, later on progressing to ARDS despite initial therapy in accordance with the institutional protocol for ARDS treatment. The child evolved to refractory hypoxemia and hypercapnia, requiring high parameters of mechanical pulmonary ventilation and use of vasoactive agents. In the treatment escalation, the patient received steroids, inhaled nitric oxide (iNO), was submitted to the prone position, started oscillatory high-frequency ventilation (HFOV) and extracorporeal membrane oxygenation (ECMO) was indicated due to severe refractory hypoxemia. During this time, the patient's clinical response was favorable to HFOV, improving oxygenation index and hypercapnia, allowing the reduction of vasoactive medications and mechanical ventilation parameters, and then the indication of ECMO was suspended. The patient was discharged after 26 days of hospital stay without respiratory or neurological sequelae.

COMMENTS

Adenovirus infections occur mainly in infants and children under 5 years of age and represent 2 to 5% of respiratory diseases among pediatric patients. Although most children with adenovirus develop a mild upper respiratory tract disease, more severe cases can occur. ARDS is a serious pulmonary inflammatory process with alveolar damage and hypoxemic respiratory failure; Adenovirus pneumonia in children may manifest as severe pulmonary morbidity and respiratory failure that may require prolonged mechanical ventilation. Exclusive pulmonary recruitment and HFOV are advantageous therapeutic options.

Corticosteroids in Acute Lung Injury: The Dilemma Continues

Acute lung injury (ALI) represents a serious heterogenous pulmonary disorder with high mortality. Despite improved understanding of the pathophysiology, the efficacy of standard therapies such as lung-protective mechanical ventilation, prone positioning and administration of neuromuscular blocking agents is limited. Recent studies have shown some benefits of corticosteroids (CS). Prolonged use of CS can shorten duration of mechanical ventilation, duration of hospitalization or improve oxygenation, probably because of a wide spectrum of potentially desired actions including anti-inflammatory, antioxidant, pulmonary vasodilator and anti-oedematous effects. However, the results from experimental vs. clinical studies as well as among the clinical trials are often controversial, probably due to differences in the designs of the trials. Thus, before the use of CS in ARDS can be definitively confirmed or refused, the additional studies should be carried on to determine the most appropriate dosing, timing and choice of CS and to analyse the potential risks of CS administration in various groups of patients with ARDS.

Extracorporeal membrane oxygenation with prone position ventilation successfully rescues infantile pertussis: a case report and literature review

BACKGROUND

Bordetella pertussis can cause fatal illness with severe acute respiratory distress syndrome (ARDS) and pulmonary hypertension (PHT).

CASE PRESENTATION

A 6-month-old non-vaccinated boy with B. pertussis infection who developed ARDS was treated by extracorporeal membrane oxygenation (ECMO). During his ECMO support stage, sudden occurred decreasing of ECMO flow implied increasing intrathoracic pressure. The airway spasm followed caused sudden drop of ventilator tidal volume as well as poor lung compliance. Prone position ventilation and bundle care were conducted as lung protection ventilator strategy. After 297-h of ECMO support, the patient was weaned off ECMO, and extubated one week later.

CONCLUSIONS

In this patient with severe ARDS caused by Bordetella pertussis, ECMO was performed for cardiopulmonary support and rescued the infant with severe pertussis. During ECMO support period, prone position ventilation and care bundle nursing strategy contributed to the relief of continuous airway spasm.

Pathophysiology and Management of Acute Respiratory Distress Syndrome in Children

Acute respiratory distress syndrome (ARDS) is a syndrome of noncardiogenic pulmonary edema and hypoxia that accompanies up to 30% of deaths in pediatric intensive care units. Pediatric ARDS (PARDS) is diagnosed by the presence of hypoxia, defined by oxygenation index or Pao₂/Fio₂ ratio cutoffs, and new chest infiltrate occurring within 7 days of a known insult. Hallmarks of ARDS include hypoxemia and decreased lung compliance, increased work of breathing, and impaired gas exchange. Mortality is often accompanied by multiple organ failure. Although many modalities to treat PARDS have been investigated, supportive therapies and lung protective ventilator support remain the mainstay.

Special considerations for the management of pediatric acute respiratory distress syndrome

INTRODUCTION

Pediatric acute respiratory distress syndrome (ARDS) remains a diagnostic and therapeutic challenge with significant mortality and morbidity. There are limited data to guide identification and management.

AREAS COVERED

The Pediatric Acute Lung Injury Consensus Conference recently proposed pediatric-specific definitions for ARDS and management recommendations. In this review, we discuss aspects of pediatric ARDS that have received more attention over the past few years: high frequency oscillatory ventilation, administration of corticosteroids and functional outcomes. We conducted searches on PubMed, ClinicalKey and Google Scholar using medical subject heading terms and text words related to acute lung injury and ARDS. Expert commentary: The newly proposed definition for pediatric ARDS requires validation for efficacy in diagnosis and risk stratification. At present, there is insufficient evidence to support routine use of high frequency oscillatory ventilation or corticosteroids in pediatric ARDS. Further studies are required to determine the impact of pediatric ARDS on functional outcomes.

Biomarkers in Pediatric ARDS: Future Directions

Acute respiratory distress syndrome (ARDS) is common among mechanically ventilated children and accompanies up to 30% of all pediatric intensive care unit deaths. Though ARDS diagnosis is based on clinical criteria, biological markers of acute lung damage have been extensively studied in adults and children. Biomarkers of inflammation, alveolar epithelial and capillary endothelial disruption, disordered coagulation, and associated derangements measured in the circulation and other body fluids, such as bronchoalveolar lavage, have improved our understanding of pathobiology of ARDS. The biochemical signature of ARDS has been increasingly well described in adult populations, and this has led to the identification of molecular phenotypes to augment clinical classifications. However, there is a paucity of data from pediatric ARDS (pARDS) patients. Biomarkers and molecular phenotypes have the potential to identify patients at high risk of poor outcomes, and perhaps inform the development of targeted therapies for specific groups of patients. Additionally, because of the lower incidence of and mortality from ARDS in pediatric patients relative to adults and lack of robust clinical predictors of outcome, there is an ongoing interest in biological markers as surrogate outcome measures. The recent definition of pARDS provides additional impetus for the measurement of established and novel biomarkers in future pediatric studies in order to further characterize this disease process. This chapter will review the currently available literature and discuss potential future directions for investigation into biomarkers in ARDS among children.

Rationale for Prolonged Glucocorticoid Use in Pediatric ARDS: What the Adults Can Teach Us

Based on molecular mechanisms and physiologic data, a strong association has been established between dysregulated systemic inflammation and progression of acute respiratory distress syndrome (ARDS). In ARDS patients, glucocorticoid receptor-mediated downregulation of systemic inflammation is essential to restore homeostasis, decrease morbidity and improve survival and can be significantly enhanced with prolonged low-to-moderate dose glucocorticoid treatment. A large body of evidence supports a strong association between prolonged glucocorticoid treatment-induced downregulation of the inflammatory response and improvement in pulmonary and extrapulmonary physiology. The balance of the available data from eight controlled trials (n = 622) provides consistent strong level of evidence for improving patient-centered outcomes and hospital survival. The sizable increase in mechanical ventilation-free days (weighted mean difference, 6.48 days; CI 95% 2.57-10.38, p < 0.0001) and intensive care unit-free days (weighted mean difference, 7.7 days; 95% CI, 3.13-12.20, p < 0.0001) by day 28 is superior to any investigated intervention in ARDS. For treatment initiated before day 14 of ARDS, the increased in hospital survival (70 vs. 52%, OR 2.41, CI 95% 1.50-3.87, p = 0.0003) translates into a number needed to treat to save one life of 5.5. Importantly, prolonged glucocorticoid treatment is not associated with increased risk for nosocomial infections (22 vs. 27%, OR 0.61, CI 95% 0.35-1.04, p = 0.07). Treatment decisions involve a tradeoff between benefits and risks, as well as costs. This low-cost, highly effective therapy is familiar to every physician and has a low risk profile when secondary prevention measures are implemented.

Pediatric Acute Respiratory Distress Syndrome: Fibrosis versus Repair

Clinical and basic experimental approaches to pediatric acute lung injury (ALI), including acute respiratory distress syndrome (ARDS), have historically focused on acute care and management of the patient. Additional efforts have focused on the etiology of pediatric ALI and ARDS, clinically defined as diffuse, bilateral diseases of the lung that compromise function leading to severe hypoxemia within 7 days of defined insult. Insults can include ancillary events related to prematurity, can follow trauma and/or transfusion, or can present as sequelae of pulmonary infections and cardiovascular disease and/or injury. Pediatric ALI/ARDS remains one of the leading causes of infant and childhood morbidity and mortality, particularly in the developing world. Though incidence is relatively low, ranging from 2.9 to 9.5 cases/100,000 patients/year, mortality remains high, approaching 35% in some studies. However, this is a significant decrease from the historical mortality rate of over 50%. Several decades of advances in acute management and treatment, as well as better understanding of approaches to ventilation, oxygenation, and surfactant regulation have contributed to improvements in patient recovery. As such, there is a burgeoning interest in the long-term impact of pediatric ALI/ARDS. Chronic pulmonary deficiencies in survivors appear to be caused by inappropriate injury repair, with fibrosis and predisposition to emphysema arising as irreversible secondary events that can severely compromise pulmonary development and function, as well as the overall health of the patient. In this chapter, the long-term effectiveness of current treatments will be examined, as will the potential efficacy of novel, acute, and long-term therapies that support repair and delay or even impede the onset of secondary events, including fibrosis.