Waiting for the Pediatric Acute Lung Injury Consensus Conference 3 - Critical Care Science (CCS)

Editorial

Waiting for the Pediatric Acute Lung Injury Consensus Conference 3

Crit Care Sci. 2024;36:e20240114en

DOI: 10.62675/2965-2774.20240114-en

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Since the publication of a case series by Ashbaugh et al. in 1967 involving 11 adult patients and only one child, pediatricians have been trying to define acute respiratory distress syndrome (ARDS) in pediatric patients.() In 1988, Murray et al. created a score for the classification of ARDS using four variables—chest radiography, partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2), end-expiratory airway pressure (PEEP) and lung compliance—but only for adult patients.() Six years later, in 1994, the American-European Consensus Conference (AECC) published the first definition of ARDS, using PaO2 /FiO2, regardless of PEEP, again excluding pediatric patients.() In 2012, a new definition was published resulting from a consensus conducted in the city of Berlin, Germany, using PaO2/FiO2 and the PEEP level, which also did not include children or adolescents.() Nevertheless, pediatricians have begun to adopt the Berlin criteria to define ARDS in the absence of a proper definition. Both definitions of ARDS, that of the AECC and that of Berlin, focus on lung injury in adults and have limitations when applied to children. For example, an important deficiency is the need for invasive measurement of arterial oxygen, which can become a challenge in infants and children who are agitated or uncooperative. A second limitation is the use of PaO2 /FiO2. In addition to the need for the measurement of PaO2, this relationship is influenced by ventilator pressure. Consequently, differences in pediatric clinical practice may influence the diagnosis, particularly because there is greater variability in ventilatory parameters in pediatric intensive care units (ICUs) than in adult ICUs.

In 2015, the idea of a pediatric definition was promoted by the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI), which was later supported by several other research groups around the world. Thus began the Pediatric Acute Lung Injury Consensus Conference (PALICC), in which PaO2 /FiO2 was replaced by the oxygenation index (FiO2 x mean airway pressure/partial arterial oxygen pressure) and oxygen saturation index (FiO2 x mean airway pressure/oxygen saturation), including the management of the patient with pressure on mechanical ventilators, in addition to including a measurement not dependent on arterial blood gas analysis.() In 2023, an improved definition was published, PALICC-2, which started to include noninvasive ventilation modes, among other changes.()

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