Management of Pediatric ARDS

Dr. A. Sadeghizadeh

Pediatric Intensivist

Assistant professor of IUMS

N0V. 2021

SUPPORTIVE CARE

• Sedatives and neuromuscular blockade• Hemodynamic management• Nutritional support• Control of blood glucose levels• Nosocomial Infection and pneumonia• Fluid Management• Monitoring-Nursing care

• Prophylaxis against gastrointestinal (GI) bleeding.

SUPPORTIVE CARE

Sedatives and neuromuscular blockade

• Minimal yet effective targeted sedation to facilitate their tolerance to mechanical ventilation and to optimize oxygen delivery, oxygen consumption, and work of breathing.

• Narcotics for pain and suppression of the respiratory drive. benzodiazepines for anxiety

• Intermittent injections are preferred, with continuous infusions reserved for patients who require repeated doses

SUPPORTIVE CARE

Sedatives and neuromuscular blockade• Increasing evidence suggests dexmedetomidine

• pain and sedation scales should be used to monitor, target, and titrate sedation

• Avoid excessive sedation by routinely waking patients each day ,using intermittent instead of continuous infusions of sedatives ,following a sedation and analgesia Scales and protocol , avoiding sedation altogether.

SUPPORTIVE CARE

• Sedatives and neuromuscular blockade• Not routinely administering NMBs to patients with moderate to

severe ARDS, unless other indications are present : Severe ventilator desynchrony, or unwanted motor movement refractory to ventilator adjustment and sedation

• Receive minimal yet effective NMB with sedation

• A daily NMB holiday to allow periodic assessment of the patient’s level of NMB and sedation.

SUPPORTIVE CARE

• Hemodynamic management

• To guide volume expansion in the context of fluid restrictive strategy, to evaluate cardiac function, and to assess oxygen delivery.

• Suspected cardiac dysfunction, echocardiography is recommended.

• Not recommended hemodynamic monitoring devices

SUPPORTIVE CARE

• Nutritional support• Enteral feedings are preferred:

fewer intravascular infections

less GI bleeding because of gastric buffering,

Preservation of the intestinal mucosal barrier

• Overfeeding should be avoided to prevent excessive carbon dioxide production.

• To be kept semirecumbent with their heads in the upright position to decrease the risk of ventilator-associated pneumonia

• Nutrition plan to facilitate their recovery, maintain their growth, and meet their metabolic needs.

SUPPORTIVE CARE

• Fluid Management• Receive total fluids to maintain adequate intravascular volume, end-organ

perfusion, and optimal delivery of oxygen.

• Prevent positive fluid balance

• A goal-directed protocol :total fluid intake, output, and net balance

• Combination therapy with albumin solution and furosemide may improve fluid balance, oxygenation, and hemodynamics

SUPPORTIVE CARE

• Nosocomial Infection and pneumonia

• Severe ARDS developed 60 percent nosocomial pneumonia

• An average of 10 days after the onset of ARDS

• The misdiagnosis of pneumonia and Inappropriate treatment :patients without pneumonia promotes the emergence of organisms with antibiotic resistance, while a missed diagnosis may be lethal.

• Follow Guidelines recommended to help prevent, diagnose, and treat VAP

SUPPORTIVE CARE

• Monitoring-Nursing care

• Clinical monitoring :respiratory frequency, heart rate, continuous pulse oximetry, and noninvasive blood pressure.

• Values of ventilator: tidal volume , compliance of the respiratory system,P-peak, plateau pressure, ventilatory inspiratory pressure(interpreted by IBW)

• Monitoring Oxygenation: Fio 2, Spo 2 and/or Pao 2, Paw, and PEEP ( PARDS severity and management of oxygenation failure)

SUPPORTIVE CARE

• Monitoring-Nursing care

• Blood pH and Paco2 measurement frequency

• Peripheral venous blood gas sampling is not recommended

• Continuous monitoring of co2 is recommended in children : invasive mechanical ventilation, using end-tidal co 2/time curves, volumetric capnography, …

SUPPORTIVE CARE

• Monitoring-Nursing care

• oxygenation and ventilation goals :“perceived” risks of the toxicity of the ventilatory support and high concentration of oxygen.

• Mild PARDS with PEEP less than 10 cm H2O, Spo2 :92–97%• PARDS with PEEP at least 10 cm H2O, lower Spo2 levels :88– 92%

• Spo2 less than 92%: monitoring of central venous saturation and markers of oxygen delivery

SUPPORTIVE CARE

• Monitoring-Nursing care

• Permissive hypercapnia considered for moderate-to severe PARDS

• PH 7.15–7.30 within lung protective strategy

• Exceptions to permissive hypercapnia :intracranial hypertension, severe pulmonary hypertension, select congenital heart disease lesions, hemodynamic instability, and significant ventricular dysfunction

• Bicarbonate supplementation is not routinely recommended.

SUPPORTIVE CARE

• Monitoring-Nursing care

• Tachypnea

• Dyspnea

• Decrease breath sounds

• Deteriorating gas levels

• Hypoxemia despite high concentration of oxygen

• Decreased pulmonary compliance

• Ineffective Airway Clearance

• Deteriorate perfusion

• Excess Fluid Volume

• Impaired Physical Mobility

• Impaired Skin Integrity

Anxiety

Risk for aspiration

• Sleep Pattern Disturbance

SUPPORTIVE CARE

• Monitoring-Nursing care

• Cuffed endotracheal tubes (ETTs) :conventionally ventilating a patient with PARDS.

• Maintaining a clear airway is essential to the patient with PARDS.

• Endotracheal suctioning with caution to minimize the risk of derecruitment

• There are insufficient data to support a recommendation on the use of either an open or closed suctioning system.

• Isotonic saline is not recommended: may be indicated at times for lavage to remove thick tenacious secretions.

MANAGEMENT OF HYPOXEMIA

MANAGEMENT OF HYPOXEMIA

Oxygen supplement

• High Flow Nasal Canula in patients with ARDS who are alert, hemodynamically stable, and do not require immediate intubation.

• Noninvasive positive pressure ventilation (NPPV) is considered early to improve gas exchange, decrease work of breathing, and potentially avoid complications of invasive ventilation.

• Immunodeficiency who are at greater risk of complications from invasive mechanical ventilation, may benefit

MANAGEMENT OF HYPOXEMIA

Oxygen supplement

• Use of an oronasal or full facial mask to provide the most efficient patient-ventilator synchronization

• Closely monitored for skin breakdown, gastric distention, barotrauma, and conjunctivitis

• Heated humidification is strongly recommended for NPPV in children

• To allow the most efficient patient-ventilator synchronization and tolerance, sedation used only with caution in children receiving NPPV

MANAGEMENT OF HYPOXEMIA

Oxygen supplement

• Continuous positive airway pressure alone may be suitable for those children who are unable to attain patient ventilatory synchrony or when using nasal interface.

• NPPV is not recommended for children with severe disease.

• Intubation considered in patients receiving NPPV who do not show clinical improvement or have signs and symptoms of worsening disease.

MANAGEMENT OF HYPOXEMIA

Oxygen supplement

• FiO2 should be decreased to the 50 to 60 percent range as soon as safely possible

• Goal PaO2 of 55 to 80 mmHg or SaO2 88 to 95 percent as used in studies performed by the ARDSNET investigators

MANAGEMENT OF HYPOXEMIA

Decrease oxygen consumption

• Common causes of increased oxygen consumption include fever, anxiety and pain, and use of respiratory muscles.

• Arterial saturation may improve after treatment with anti-pyretics, sedatives, analgesics, or paralytics

MANAGEMENT OF HYPOXEMIA

Increase oxygen delivery

• DO2 dependent to cardiac output, hemoglobin concentration, arterial oxygen saturation(Sao2), partial pressure of oxygen in arterial blood(Pao2)

• In clinically stable children with evidence of adequate oxygen delivery (excluding cyanotic heart disease, bleeding, and severe hypoxemia,Shock), a hemoglobin concentration up to 7.0 g/dL be considered

• Cardiac output may be augmented by raising filling pressures or by using inotropic agents.

MANAGEMENT OF HYPOXEMIA

Prone positioning

Reducing ventral-dorsal

transpulmonary pressure difference

Reduced lung compression

Improved lung perfusion

MANAGEMENT OF HYPOXEMIA

Prone positioning

MANAGEMENT OF HYPOXEMIA

Prone positioning

• Severe ARDS-a PaO2:FiO2 ratio <100 mmHg.

• Refractory hypoxemia due to ARDS – An alternative reasonable definition is a PaO2:FiO2 of ≤100 mmHg with a PaO2 ≤60 mmHg despite optimization of the ventilator settings on FiO2 of 1

MANAGEMENT OF HYPOXEMIA

MANAGEMENT OF HYPOXEMIA

Prone positioning

• After a 12 to 24 hour stabilization period of supine ventilation, we maintain a low threshold for initiating prone ventilation early (up to 36 hours)

• Repeated sessions of prone ventilation lasting six to eight hours per day or prolonged prone ventilation lasting 17 to 20 hours per day

• Minimizing the frequency of turning severely ill patients decreases the likelihood of complications

MANAGEMENT OF HYPOXEMIA

Prone positioning-nursing care

Turn the patient from the supine position toward the ventilator, using the chest and pelvic area to allow for better diaphragm motion and lung mechanics.

Depending on the size of the patient, the turn may take four to eight nurses.

Place the patient in the prone position with pillows or cushions supporting the chest and pelvis to allow the abdomen to hang free.

When the patient is in the prone position, arrange the arms in the swimmer’s pose—one at the side of the body and the other extended above the head.

Align all tubes and drains at the head or foot of the bed to prevent dislodgement.

Rotate the patient’s head from side to side to relieve pressure and prevent skin breakdown.

Reposition the patient every couple of hours and assess the pressure points.

Prone Position

MANAGEMENT OF HYPOXEMIA

Prone positioning-nursing care

The delivery of invasive mechanical ventilation is similar to supine.

Peak and plateau airway pressures may increase immediately after a patient is placed in the prone position, but typically decline with time.

Endotracheal suctioning should be assessed ,because large quantities of pulmonary secretions may drain into the endotracheal tube

Electrocardiographic leads should be placed on the back.

All patients in prone ventilation require increased sedation and some require neuromuscular blockade

MANAGEMENT OF HYPOXEMIA

Prone positioning-nursing care

• Enteral tube feeds and usual mouth and skin care can be resumed.

• Enteral feeding can be complicated by emesis and/or increased residual gastric volumes

continuous feeding

25 degree head elevation

prophylactic erythromycin

• Tube feeds should be temporarily switched off and the stomach emptied before repositioning back to the supine position

MANAGEMENT OF HYPOXEMIA

• Ventilatory Support

• High-Frequency Ventilation

• Extracorporeal Support

Ancillary Treatment

Inhaled Nitric Oxide

• Not recommended for routine use in PARDS.

• May be considered in patients with documented pulmonary hypertension or severe right ventricular dysfunction.

• May be considered in severe cases of PARDS as a rescue from or bridge to extracorporeal life support

• Risk of renal impairment/methemoglobinemia

Ancillary Treatment

Corticosteroids

Not recommended as routine therapy in PARDS

Some adult studies recommended:

Non-ARDS-related indications for systemic glucocorticoid therapy Moderate to severe ARDS who are early in the disease course (within 14 days of onset) and persistent or

refractory

Not recommended

Patients with less severe ARDS

Patients late in the disease course

Patients with certain viral infections

Methylprednisolone 1 mg/kg per day for 21 to 28 days followed by a taper

Ancillary Treatment

Exogenous Surfactant

• Not recommended as routine therapy in PARDS.

• Further study should focus on specific patient populations that may be likely to benefit and specific dosing and delivery regimens

Not Recommended…

• Chest Physiotherapy

• Helium-oxygen mixture,

• Inhaled or IV prostaglandins therapy,

• Plasminogen activators, fibrinolytics, or other anticoagulants,

• Inhaled β-adrenergic receptor agonists or ipratropium,

• N-acetylcysteine

• Cough-assist device