eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Respiratory Distress Syndrome: Follow-up

Author: Andrew K Feng, MD, Attending Physician, Division of Pediatric Critical Care, Kapiolani Medical Center for Women and Children, Honolulu
Coauthor(s): Dale Steele, MD, Division of Pediatric Emergency Medicine, Assistant Professor, Department of Emergency Medicine, Brown University School of Medicine and Hasbro Children's Hospital
Contributor Information and Disclosures

Updated: Sep 18, 2009

Follow-up

Further Inpatient Care

  • Noninvasive positive pressure ventilation and/or endotracheal intubation with mechanical ventilation is usually required in patients with clinical and radiographic evidence suggestive of worsening lung disease with a fraction of inspired oxygen (FiO2) of greater than 50%.
    • No gas exchange occurs in collapsed or fluid-filled alveoli. A nearly linear increase in FRC develops as PEEP is increased over a range from 0-15 mm Hg with recruitment of terminal airways and alveoli and improved oxygenation.
    • A physiologic approach to ventilating patients with ARDS includes the use of optimal PEEP to minimize FiO2 while maintaining oxygen delivery, small tidal volumes, and extended inspiratory times to allow more uniform ventilation. Permissive hypercapnia may allow reductions in rate and peak inspiratory pressure (PIP), thereby limiting further barotrauma and volutrauma.
    • Prophylactic application of PEEP has not been shown to improve outcome. As PEEP is increased, cardiac output may fall and volume expansion and/or inotropic/pressor agents may be required.
    • Other techniques include high-frequency oscillatory ventilation and high-frequency jet ventilation.
  • Adjuncts to mechanical ventilation
    • Prone positioning is often utilized in adults and children to improve oxygenation as a recruiting maneuver, but a large multicentered trial failed to demonstrate significant reduction in ventilator-free days or significant impact on other relevant outcome parameters.4
    • Surfactant dysfunction has been documented in ARDS and has led to investigational use of exogenous surfactant. A recent randomized, controlled multicenter study by Willson et al using a natural exogenous surfactant (calfactant) demonstrated significant improvement in oxygenation, as measured by oxygenation index and decreased mortality rate.5 However, earlier clinical trials in adults with sepsis-induced ARDS did not effect overall survival.
    • Inhaled nitric oxide often acutely improves oxygenation and, in the short-term, allows weaning of FiO2 and ventilatory parameters. However, not all patients respond and not all have a sustained response. An association exists between improvement with inhaled nitric oxide and improved clinical outcome.6
    • Extracorporeal membrane oxygenation (ECMO) is used in some institutions as a rescue therapy for children with failure to respond to conventional ventilation. Matched cohort analysis has suggested a lower mortality rate in patients treated with ECMO.7

Transfer

  • Intrahospital transfers: Patients transferred from the ED to the PICU must be accompanied by providers competent to secure and manage the patient's airway. This team often includes a physician, a nurse, and a respiratory therapist.
  • Interhospital transfers: Ideally, a dedicated pediatric transport team transfers the patient to a PICU via ground, rotor, or fixed wing transport.

Complications

  • Complications of treatment
    • Oxygen toxicity
    • Ventilator-induced lung injury
  • Pulmonary barotrauma is common, with air leaks occurring in nearly one half of patients.
  • Death from refractory respiratory failure is relatively uncommon.
  • The major causes of death are sepsis or failure of other major organs, such as the heart, brain, and liver.
  • During the proliferative stage, diffuse interstitial fibrosis may develop.

Prognosis

  • Relatively few long-term survivors of pediatric ARDS have been studied.
  • Because lung growth is not complete until age 8 years, the effect on young children may be worse than in older children or adults.

Patient Education

 


More on Pediatrics, Respiratory Distress Syndrome

Overview: Pediatrics, Respiratory Distress Syndrome
Differential Diagnoses & Workup: Pediatrics, Respiratory Distress Syndrome
Treatment & Medication: Pediatrics, Respiratory Distress Syndrome
Follow-up: Pediatrics, Respiratory Distress Syndrome
Multimedia: Pediatrics, Respiratory Distress Syndrome
References
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References

  1. Flori HR, Glidden DV, Rutherford GW, Matthay MA. Pediatric acute lung injury: prospective evaluation of risk factors associated with mortality. Am J Respir Crit Care Med. May 1 2005;171(9):995-1001. [Medline].

  2. Meduri GU, Headley AS, Golden E, et al. Effect of prolonged methylprednisolone therapy in unresolving acute respiratory distress syndrome: a randomized controlled trial. JAMA. Jul 8 1998;280(2):159-65. [Medline].

  3. [Best Evidence] Steinberg KP, Hudson LD, Goodman RB, Hough CL, Lanken PN, Hyzy R. Efficacy and safety of corticosteroids for persistent acute respiratory distress syndrome. N Engl J Med. Apr 20 2006;354(16):1671-84. [Medline].

  4. [Best Evidence] Curley MA, Hibberd PL, Fineman LD, Wypij D, Shih MC, Thompson JE. Effect of prone positioning on clinical outcomes in children with acute lung injury: a randomized controlled trial. JAMA. Jul 13 2005;294(2):229-37. [Medline].

  5. Willson DF, Thomas NJ, Markovitz BP, et al. Effect of exogenous surfactant (calfactant) in pediatric acute lung injury: a randomized controlled trial. JAMA. Jan 26 2005;293(4):470-6. [Medline].

  6. Goldman AP, Tasker RC, Hosiasson S, et al. Early response to inhaled nitric oxide and its relationship to outcome in children with severe hypoxemic respiratory failure. Chest. Sep 1997;112(3):752-8. [Medline].

  7. Green TP, Timmons OD, Fackler JC, et al. The impact of extracorporeal membrane oxygenation on survival in pediatric patients with acute respiratory failure. Pediatric Critical Care Study Group. Crit Care Med. Feb 1996;24(2):323-9. [Medline].

  8. Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. May 4 2000;342(18):1301-8. [Medline].

  9. Antonelli M, Conti G, Rocco M, et al. A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med. Aug 13 1998;339(7):429-35. [Medline].

  10. Beaufils F, Mercier JC, Farnoux C, et al. Acute respiratory distress syndrome in children. Curr Opin Pediatr. Jun 1997;9(3):207-12. [Medline].

  11. Brower RG, Ware LB, Berthiaume Y, Matthay MA. Treatment of ARDS. Chest. Oct 2001;120(4):1347-67. [Medline].

  12. Davis SL, Furman DP, Costarino AT Jr. Adult respiratory distress syndrome in children: associated disease, clinical course, and predictors of death. J Pediatr. Jul 1993;123(1):35-45. [Medline].

  13. Fackler JC, Arnold JH, Nichols DG. Acute respiratory distress syndrome. In: Rogers M, Williams, Wilkins, eds Textbook. 1996:197-233.

  14. Flori HR, Pittet JF. Biological markers of acute lung injury: prognostic and pathogenetic significance. New Horiz. 1999;7:287-311.

  15. Levitzky MG. Pulmonary Physiology. New York: McGraw-Hill Health Professions Division; 1999:131.

  16. Nichols DG, McCloskey JJ, Rogers MC. Adult respiratory distress syndrome. In: Rogers MC, ed. Textbook of Pediatric Intensive Care. Baltimore, Md: Williams & Wilkins; 1992:296.

  17. Paulson TE, Spear RM, Peterson BM. New concepts in the treatment of children with acute respiratory distress syndrome. J Pediatr. Aug 1995;127(2):163-75. [Medline].

  18. Poponick JM, Renston JP, Bennett RP, Emerman CL. Use of a ventilatory support system (BiPAP) for acute respiratory failure in the emergency department. Chest. Jul 1999;116(1):166-71. [Medline].

  19. Taylor RW, Zimmerman JL, Dellinger RP. Low-dose inhaled nitric oxide in patients with acute lung injury: a randomized controlled trial. JAMA. Apr 7 2004;291(13):1603-9. [Medline].

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Further Reading

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Keywords

acute respiratory distress syndrome, ARDS, severe acute respiratory syndrome, SARS, acute lung injury, ALI, multiple organ failure syndrome, MOFS, respiratory distress syndrome in children

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Contributor Information and Disclosures

Author

Andrew K Feng, MD, Attending Physician, Division of Pediatric Critical Care, Kapiolani Medical Center for Women and Children, Honolulu
Andrew K Feng, MD is a member of the following medical societies: Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Dale Steele, MD, Division of Pediatric Emergency Medicine, Assistant Professor, Department of Emergency Medicine, Brown University School of Medicine and Hasbro Children's Hospital
Dale Steele, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Garry Wilkes, MBBS, FACEM, Director of Emergency Medicine, Bunbury Hospital, Western Australia; Medical Director, St John Ambulance, WA Ambulance Service; Adjunct Associate Professor, Edith Cowan University; Clinical Associate Professor, Rural Clinical School, University of Western Australia, Australia.
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center
Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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