Pediatric Emergency Care and Medicine: Open Access

Introduction

Acute Respiratory Distress Syndrome (ARDS) is a life-threatening condition characterized by severe hypoxemia, diffuse alveolar damage, and impaired pulmonary compliance. While ARDS is more commonly described in adults, it also significantly affects pediatric populations, particularly in the context of sepsis, pneumonia, trauma, and aspiration syndromes. In children, the clinical presentation may differ due to age-related anatomical and physiological differences, such as smaller airway caliber, increased chest wall compliance, and immature immune responses. Despite advances in critical care, challenges persist in identifying ARDS early, tailoring ventilatory strategies to small lung volumes, and preventing complications from invasive support. Emergency departments (EDs) and pediatric intensive care units (PICUs) play a central role in stabilizing these patients, emphasizing airway management, oxygenation strategies, hemodynamic support, and infection control. This article explores the emergency approaches to pediatric ARDS, outlining current practices, challenges, and emerging directions in management [1].

Description

ARDS in children is triggered by direct pulmonary insults (such as pneumonia, aspiration, or near-drowning) or indirect systemic insults (like sepsis, severe trauma, or pancreatitis). The underlying mechanism involves inflammatory injury to the alveolarâ??capillary membrane, resulting in increased vascular permeability, pulmonary edema, and impaired gas exchange. In children, this progression can occur rapidly, underscoring the need for vigilant monitoring in high-risk patients. Clinically, pediatric ARDS presents with tachypnea, dyspnea, retractions, nasal flaring, and hypoxemia unresponsive to standard oxygen therapy. Cyanosis, altered mental status, and hemodynamic instability may follow if hypoxemia persists. Diagnosis is guided by the Pediatric Acute Lung Injury Consensus Conference (PALICC) criteria, which emphasize oxygenation indices adapted for children. Chest radiographs often reveal bilateral infiltrates, though imaging findings may lag behind clinical deterioration. Early recognition is essential, as delayed diagnosis can lead to irreversible lung injury, multi-organ dysfunction, and increased mortality risk [2].

Emergency management of pediatric ARDS begins with prompt airway and breathing support. Initial stabilization follows the ABC (Airway, Breathing, Circulation) approach, with high-flow oxygen as the first-line intervention. In cases unresponsive to oxygen therapy, non-invasive ventilation may be trialed, though intubation and mechanical ventilation are often required. Rapid sequence intubation should be carefully performed, with preoxygenation, skilled personnel, and age-appropriate endotracheal tube selection to minimize complications. Once intubated, lung-protective ventilation strategies become the cornerstone of care, focusing on low tidal volumes and limiting plateau pressures to reduce ventilator-induced lung injury. Emergency physicians must strike a delicate balance between fluid administration and lung protection, often guided by dynamic hemodynamic assessments. Empiric antibiotics may be initiated when infection is suspected, given that pneumonia and sepsis are leading triggers. Concurrently, providers must monitor for hypoglycemia, acidosis, and electrolyte imbalances, which can exacerbate respiratory distress and compromise organ function [3].

Mechanical ventilation in pediatric ARDS follows principles adapted from adult guidelines but requires pediatric-specific adjustments. Lung-protective ventilation involves tidal volumes of 5â??7 mL/kg predicted body weight and optimal positive end-expiratory pressure (PEEP) to improve oxygenation while preventing alveolar collapse. Permissive hypercapnia may be tolerated to avoid barotrauma, provided cerebral perfusion is maintained. In severe cases, advanced modalities such as high-frequency oscillatory ventilation (HFOV) may be considered, particularly when conventional ventilation fails. Prone positioning is another emergency intervention shown to improve oxygenation by enhancing dorsal lung recruitment. Adjunctive therapies are sometimes employed in refractory pediatric ARDS. Extracorporeal membrane oxygenation (ECMO) serves as a salvage therapy in select cases of severe, refractory ARDS where conventional strategies fail, though its availability is restricted to specialized centers. Importantly, emergency providers must anticipate complications such as pneumothorax, ventilator-associated infections, and multi-organ dysfunction, requiring close monitoring and early specialist consultation. Advancements in pediatric ARDS care are increasingly focused on precision medicine and early intervention. Biomarkers are being investigated to facilitate early diagnosis and guide individualized therapy. Bedside lung ultrasound is gaining prominence in emergency settings as a non-invasive tool for detecting pulmonary edema and monitoring lung recruitment. Novel ventilatory modes and extracorporeal technologies are being refined to reduce complications and improve survival. Vaccination against respiratory pathogens, early sepsis recognition, and prompt treatment of pneumonia and trauma are critical preventive measures. Training emergency care providers in pediatric-specific resuscitation and ARDS recognition ensures timely, evidence-based interventions. Future models of care emphasize multidisciplinary collaboration among emergency physicians, pediatric intensivists, respiratory therapists, and nurses to optimize outcomes [4,5].

Conclusion

Acute Respiratory Distress Syndrome in children represents a critical emergency requiring rapid recognition, stabilization, and tailored interventions. The emergency approach involves airway management, lung-protective ventilation, hemodynamic support, and vigilant monitoring for complications. Despite challenges, innovations in diagnostics, ventilatory strategies, and extracorporeal support are advancing pediatric ARDS care. Emphasis on early recognition, prevention, and multidisciplinary teamwork can significantly improve survival and long-term outcomes. As research continues, integrating precision medicine and novel therapies into emergency practices holds promise for reducing the burden of ARDS in pediatric populations.

Acknowledgment

None.

Conflict of Interest

None.

References

1. Curley GF, O’Kane CM, McAuley DF, Matthay MA, Laffey JG (2024). Cell-based therapies for acute respiratory distress syndrome: Where are we now?. Am J Respir Crit Care Med209: 789-797.

                                                      Google Scholar Cross Ref Indexed at

2. Liu C, Xiao K, Xie L (2022). Advances in the regulation of macrophage polarization by mesenchymal stem cells and implications for ALI/ARDS treatment. Front Immunol 13: 928134.

                                                      Google Scholar Cross Ref Indexed at

3. Kirkham AM, Bailey AJ, Monaghan M, Shorr R, Lalu MM, et al. (2022). Updated living systematic review and meta-analysis of controlled trials of mesenchymal stromal cells to treat COVID-19: A Framework for Accelerated Synthesis of Trial Evidence for Rapid Approval—FASTER Approval. Stem Cells Transl Med 11: 675-687.

                                                      Google Scholar Cross Ref Indexed at

4. Qu HY, Xiao YW, Jiang GH, Wang ZY, Zhang Y, et al. (2009). Effect of atorvastatin versus rosuvastatin on levels of serum lipids, inflammatory markers and adiponectin in patients with hypercholesterolemia. Pharm Res 26: 958-964.

                                                      Google Scholar Cross Ref Indexed at

5. Kleemann R, Princen HM, Emeis JJ, Jukema JW, Fontijn RD, et al. (2003). Rosuvastatin reduces atherosclerosis development beyond and independent of its plasma cholesterol–lowering effect in APOE* 3-Leiden transgenic mice: Evidence for antiinflammatory effects of rosuvastatin. Circulation 108: 1368-1374.

                                                      Google Scholar Cross Ref Indexed at