Pediatric Acute Respiratory Distress Syndrome Clinical Practice Guidelines (PALICC-2, 2023)

Second Pediatric Acute Lung Injury Consensus Conference

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

March 08, 2023

Clinical practice guidelines on pediatric acute respiratory distress syndrome from the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) were published in February 2023 in Pediatric Critical Care Medicine.[1]

For pediatric patients with acute respiratory distress syndrome (ARDS) who require invasive ventilatory support, the use of physiologic tidal volumes (6-8 mL/kg) is suggested.

If transpulmonary pressure measurements are not available, an inspiratory plateau pressure of less than or equal to 28 cm H2O is suggested.

Limiting driving pressure to 15 cm H2O (as measured under static conditions) is suggested.

Titration of positive end-expiratory pressure (PEEP) to oxygenation/oxygen delivery, hemodynamics, and compliance measured under static conditions is suggested.

It is recommended that PEEP levels be maintained at or above the lower PEEP/higher fraction of inspired oxygen (FiO2) table from the ARDS Network protocol.

For pediatric patients with ARDS, the use of a lung protective ventilation bundle is suggested.

For pediatric patients with mild to moderate ARDS, it is suggested that blood oxygen saturation (SpO2) be maintained between 92% and 97%.

After PEEP has been optimized in pediatric patients with severe ARDS, an SpO2 of less than 92% can be accepted in order to reduce exposure to FiO2.

Permissive hypercapnia (to a lower limit pH of 7.20) may be allowed in pediatric patients with ARDS in order to remain within recommended pressure and tidal volume ranges.

It is suggested that the routine use of bicarbonate supplementation be avoided. However, bicarbonate supplementation can be considered for patients in whom severe metabolic acidosis or pulmonary hypertension is adversely affecting cardiac function or hemodynamic stability.

For more information, please go to Pediatric Acute Respiratory Distress Syndrome.


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