Case Discussion

1. PEDIATRIC ACUTE RESPIRATORY
DISTRESS SYNDROME
(PARDS)
Dr Farha Khan
MBBS, MD (Pediatrics)
PICU Consultant, Max Super speciality Hospital, Patparganj, Delhi, India
PICU Fellow- Royal Brompton & Harefield (NHS London, UK)
ECMO (PCICU) Fellow- Great Ormond Street Hospital (NHS London, UK)
PCICU Fellow – Apollo Hospital (Delhi, India)

2. CASE HISTORY
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3. ER examination
GC very sick & critical
GCS E4V4M5
Pallor present
Temp 100.2 F HR 176/min RR 68/min, Irregular NIBP 88/50
Severe respiratory distress with nasal flaring and use of supra sternal muscles
SPO2 77% on oxygen by mask at 10 LPM
Peripheral pulses feeble but palpable
Cool peripheries
CHEST markedly reduced air entry on left with bilateral crepts
CVS S1S2 normal
CNS deteriorating sensorium
P/A soft, non-distended, Liver 3cm BCM

4. Treatment in ER –
Fluid bolus
NIBP improved to 100/60mmHg
Urine output improved
Patient tried on NIV Bi-pap for an hour with no improvement in saturation, worsening respiratory
efforts, worsening blood gases and deteriorating sensorium
IV antibiotic
Admitted to PICU

5. Patient was Intubated and put on mechanical ventilation as per ARDS vent strategy
Permissive hypoxemia and hypercarbia
Target Spo2 >=88%
Target PH>7.2
Target PaO2 > 55 mmHg
TV 75-80ml
low I-time
high RR

6. Treatment escalation plan
 Mechanical ventilation –ARDS strategy
 IV antibiotics
 steroids
 prone position
 Sildenafil due to non-availability of inhaled nitric oxide (iNO)
 oscillatory high-frequency ventilation (HFOV) and extracorporeal
membrane oxygenation (VV-ECMO) was indicated due to severe refractory
hypoxemia

7. 
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 Respiratory BIOFIRE – pseudomonas and influenza B detected
 Blood culture
 ET culture

8. PICU
 Mechanically ventilated with appropriate sedation and paralyses
 Vent settings:
PRVC Fio2 80% TV 95 Rate 35 PEEP 8
 Increased ventilatory parameters were required, with PEEP titration up to 12
and Fio2 100%
 The child evolved to refractory hypoxemia and hypercapnia with hemodynamic
stability, requiring high parameters of mechanical pulmonary ventilation

9.  Prone ventilated for 4-5 days with intermittent supination for 2 hours
each day
 Serial Blood gases showed permissive hypoxemia and hypercapnia
 Barely able to maintain Pao2 between 55-60mmHg
 Steroid therapy with methylpred used

10.  Pediatric pulmonology referral
 Pediatric bedside ECHO performed
normal intracardiac morphology , minimal pleural effusion, normal LV function, fair RV
function, mild TR, CI 4.6 L/min/m2, SVRI 1337dynes sec/m2
 Nutrition – NG feeds established and optimized
 improving oxygenation index and hypercapnia, allowing the reduction of mechanical
ventilation parameters, and then the indication of ECMO was suspended.

11.  During this time, the patient’s clinical response was favourable to ARDS
ventilation strategy, prone positioning and sildenafil use, steroid therapy (which
was gradually tapered off)
 Progressive improvement and haemodynamic stability and improving gas
exchange with radiological improvement
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12. CXR
showing improvement of
acute respiratory distress
syndrome
Day 20 of hospitalization

13. Recovery
 Family involved in patient care for TLC, which lead to quicker
recovery and rehabilitation
 The patient was discharged after 23 days of hospitalization, with
adequate saturation in ambient air without respiratory or
neurological sequelae (no apparent neurological impairment)
 Paediatric follow-up for pneumonia because of severity of the
condition.

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