Question
What does PALICC 2 recommend about the use of noninvasive ventilation in children with PARDS?
Answer
PALICC 1 contained no guidance on noninvasive ventilation (NIV). PALICC 2 added a dedicated section reflecting the significant expansion of NIV use in pediatric critical care over the intervening years.
Meta-analytic data reviewed by PALICC 2 consistently showed that noninvasive approaches, including CPAP and high-flow nasal cannula, favor outcomes compared to standard oxygenation therapy. PALICC 2 recommends a time-limited trial of NIV, specifically CPAP or BiPAP, for patients who do not have a clear indication for immediate intubation. There was 88 percent agreement on this recommendation.
However, the time-limited nature of this trial must be taken seriously. If a patient on NIV does not demonstrate clinical improvement within four to six hours, or shows signs of deterioration, intubation should occur. There was 94 percent agreement on this point. The rationale is important: even patients who are never intubated can develop chronic lung disease if they struggle on noninvasive support for too long. Prolonged effort without adequate mean airway pressure to maintain an open lung strategy leads to ongoing injury through a different mechanism.
For resource-limited settings, PALICC 2 suggests using CPAP or high-flow nasal cannula over standard oxygen therapy for patients at risk for PARDS (92 percent agreement), and CPAP over high-flow nasal cannula for patients with possible PARDS (83 percent agreement).
This Ask the Expert is an edited excerpt from the course, An RT Overview of the Revised PARDS Guidelines from PALICC II, presented by Evan Richards, BSc, RT.
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