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Careplan

ARDS (Acute Respiratory Distress Syndrome) Pediatric

Oct.01.2020

ARDS (Acute Respiratory Distress Syndrome) (Pediatric Inpatient)

Clinical Description

  • Care of the hospitalized child experiencing new onset of respiratory failure within 7 days of the initial insult, including bilateral infiltrates, an acute deterioration in oxygenation from baseline and refractory hypoxemia that cannot be explained by cardiac failure or fluid overload.

Key Information

  • Volume-targeted ventilation allows for consistent lung volumes and real-time pressures as lung compliance changes.
  • Higher PEEP (positive end expiratory pressure) and prone positioning may be more beneficial for those with moderate-severe ARDS (acute respiratory distress syndrome).
  • Refractory hypoxemia, lung compliance and respiratory mechanics may be used to guide an optimal PEEP (positive end expiratory pressure) strategy.
  • Evidence does not support routine use of inhaled nitric oxide, beta-2 agonist medication or high-frequency oscillatory ventilation in the pediatric population.

Clinical Goals

By transition of care

A. The patient will achieve the following goals:
  • Effective Oxygenation

B. Patient, family or significant other will teach back or demonstrate education topics and points:
  • Education: Overview
  • Education: ARDS: Self-Management
  • Education: When to Seek Medical Attention

Correlate Health Status

  • Correlate health status to:

    • history, comorbidity, congenital anomaly
    • age, developmental level
    • sex, gender identity
    • baseline assessment data
    • physiologic status
    • response to medication and interventions
    • psychosocial status, social determinants of health
    • barriers to accessing care and services
    • child and family/caregiver:
      • health literacy
      • cultural and spiritual preferences
    • safety risks
    • family interaction
    • plan for transition of care

ARDS (Acute Respiratory Distress Syndrome)

Signs/Symptoms/Presentation

  • breath sounds abnormal
  • breath sounds diminished
  • lung compliance decreased
  • minute volume increased
  • oxygen demand increased
  • oxygen index increased
  • PaO2/FiO2 ratio less than or equal to 300 mmHg
  • plateau pressure (lung) increased
  • work of breathing increased

Vital Signs

  • heart rate increased
  • respiratory rate increased
  • blood pressure increased or decreased
  • SpO2 (peripheral oxygen saturation) decreased

Laboratory Values

  • ABG (arterial blood gas) abnormal
  • PaO2 (partial pressure of arterial oxygen) decreased

Diagnostic Results

  • CXR (chest x-ray) abnormal

Problem Intervention

Optimize Oxygenation, Ventilation and Perfusion

  • Provide oxygen therapy judiciously to maintain prescribed oxygen saturation level.
  • Use low tidal volume-targeted (e.g., 3 to 6 mL/kg predicted body weight) and low pressure (e.g., less than 28 cm H2O plateau) ventilation strategies to minimize the risk of lung overdistension and progression of lung injury.
  • Apply PEEP (positive end expiratory pressure) to improve oxygenation and lung compliance; consider higher PEEP for moderate-severe ARDS (acute respiratory distress syndrome).
  • Promote conservative fluid strategy to achieve net even fluid balance once hemodynamically stable.
  • Monitor hemodynamic status closely to evaluate the effects of fluid volume expansion and impact of ventilation and disease on cardiac function; anticipate the need for vasoactive medication.
  • Maintain head of bed elevation with regular position changes to improve ventilator/perfusion mismatch; consider prone positioning to maximize alveolar recruitment and functional residual capacity.
  • Consider the use of sedation and short-term neuromuscular blockade to optimize oxygen delivery and tolerance to ventilation strategies.
  • Prepare for adjunctive therapy, such as corticosteroids, alveolar recruitment maneuvers and ECLS (extracorporeal life support).

Associated Documentation

  • Airway/Ventilation Management
  • Lung Protection Measures
  • Stabilization Measures

Education

CPG-Specific Education Topics

Overview

  • description

  • signs/symptoms

ARDS: Self-Management

  • activity

  • fluid/food intake

  • provider follow-up

  • rehabilitation therapy

When to Seek Medical Attention

  • unresolved/worsening symptoms

General Education Topics

General Education

  • admission, transition of care

  • orientation to care setting, routine

  • advance care planning

  • diagnostic tests/procedures

  • diet modification

  • opioid medication management

  • oral health

  • medication management

  • pain assessment process

  • safe medication disposal

  • tobacco use, smoke exposure

  • treatment plan

Safety Education

  • call light use

  • equipment/home supplies

  • fall prevention

  • harm prevention

  • infection prevention

  • MDRO (multidrug-resistant organism) care

  • personal health information

  • resources for support

Population-Specific Considerations

Pregnancy

  • ARDS (acute respiratory distress syndrome) in pregnancy is best managed in a hospital where obstetrics, adult and neonatal intensive care capabilities are available.
  • Medication effects and serum levels may be altered by pregnancy.
  • Medications and diagnostic imaging used to treat ARDS (acute respiratory distress syndrome) should not be withheld from a pregnant mother; however, potential fetal effects should be carefully considered when determining treatment.
  • While prone position is recommended for patients with ARDS (acute respiratory distress syndrome), it should be approached cautiously during pregnancy, taking into consideration gestational stage. Positioning aids may be used to maintain proper maternal alignment, should prone position be used.

References

  • American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 211: Critical Care in Pregnancy. Obstetrics & Gynecology. 2019, May;133(5), e303-e319. doi:10.1097/AOG.0000000000003241 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Annane, D.; Pastores, S. M.; Rochwerg, B.; Arlt, W.; Balk, R. A.; Beishuizen, A.; . . . & Marik, P. E. Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Intensive Care Medicine. 2017;43(12), 1751-1763. doi:10.1007/s00134-017-4919-5 [Quality Measures,Clinical Practice Guidelines]
  • Cheifetz, I. M. Pediatric ARDS. Respiratory Care. 2017;62(6), 718-731. doi:10.4187/respcare.05591 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Cho, Y. J.; Moon, J. Y.; Shin, E. S.; Kim, J. H.; Jung, H.; Park, S. Y.; . . . & Lee, S. J. Clinical practice guideline of acute respiratory distress syndrome. Tuberculosis and Respiratory Diseases. 2016;79(4), 214-233. doi:10.4046/trd.2016.79.4.214 Source[Quality Measures,Clinical Practice Guidelines]
  • Gillies, D.; Wells, D.; Bhandari, A. P. Positioning for acute respiratory distress in hospitalised infants and children (review). Cochrane Database of Systematic Reviews. 2012;(7) doi:10.1002/14651858.CCD003645.pub3 [Metasynthesis,Meta-analysis,Systematic Review]
  • Ingelse, S. A.; Wosten-van Asperen, R. M.; Lemson, J.; Daams, J. G.; Bem, R. A.; van Woensel, J. B. Pediatric acute distress syndrome: Fluid management in the PICU. Frontiers in Pediatrics. 2016;4, 21. doi:10.3389/fped.2016.00021 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Jepsen, S. L.; Haahr, A.; Eg, M.; Jørgensen, L. B. Coping with the unfamiliar: How do children cope with hospitalization in relation to acute and/or critical illness? A qualitative metasynthesis. Journal of Child Health Care. 2018; doi:10.1177/1367493518804097 [Metasynthesis,Meta-analysis,Systematic Review]
  • Lim, J. K. B.; Lee, J. H.; Cheifetz, I. M. Special considerations for the management of pediatric acute respiratory distress syndrome. Expert Review of Respiratory Medicine. 2016;10(10), 1133-1145. doi:10.1080/17476348.2016.1219656 [Quality Measures,Clinical Practice Guidelines]
  • Orloff, K. E.; Turner, D. A.; Rehder, K. J. The current state of pediatric acute respiratory distress syndrome. Pediatric Allergy, Immunology, and Pulmonology. 2019;32(2), 35-44. doi:10.1089/ped.2019.0999 Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Pediatric Acute Lung Injury Consensus Conference Group. Pediatric acute respiratory distress syndrome: Consensus recommendations from the pediatric acute lung injury consensus conference. Pediatric Critical Care Medicine: A Journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2015;16(5), 428-439. doi:10.1097/PCC.0000000000000350 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Silversides, J. A.; Major, E.; Ferguson, A. J.; Mann, E. E.; McAuley, D. F.; Marshall, J. C.; Blackwood, B.; Fan, E. Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: A systematic review and meta-analysis. Intensive Care Medicine. 2017, February;43(2), 155-170. doi:10.1007/s00134-016-4573-3 [Metasynthesis,Meta-analysis,Systematic Review]
  • Troiano, N. H.; Witcher, P. M.; McMurtry Baird, S.. (2019). AWHONN: High-risk & critical care obstetrics. Philadelphia: Wolters Kluwer. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]

Disclaimer

Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.

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