To the Editor:

We read with interest the 2023 International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PARDS) from the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) (1). We note that the recommendations and expert statements were based on literature reviews through to March 2022 (2), which was a follow-up to the methodology (1992 to 2013) used in the first guidelines (3). That is, a 9-year evidence cycle between PALICC-1 and PALICC-2.

In this context, our main question is how the PALICC group intends to update recommendations and statements as new evidence appears?

As a corollary, by way of illustration, is an amendment planned for Clinical Recommendation 7.1.1, which states, “We suggest that in patients with possible PARDS or at risk of PARDS on conventional oxygen therapy or HFNC (high-flow nasal cannula) who are showing signs of worsening respiratory failure, a time-limited trial of NIV (noninvasive ventilation)… should be used if there are no clear indication for intubation” (1)? For example, the physiology underlying risk of patient self-inflicted lung injury in patients with moderate to severe PARDS supported with noninvasive ventilation (NIV) was recently reviewed in the Pediatric Critical Care Medicine journal (4). We also have a planned ancillary study of the PARDS Incidence and Epidemiology (PARDIE) 2016/2017 cohort, which shows that while the use of NIV is associated with some positive outcomes, other findings call for caution (5). The accompanying editorial calls the PARDIE work a “game changer” and says that “we now have some basis for using a time-limited (i.e., 6 hr) NIV trial before transitioning to invasive mechanical ventilation” (6). So, is there a mechanism for incorporating the 6-hour limit into the PALICC guidances?

REFERENCES 1. Emeriaud G, Lopez-Fernandez YM, Iyer NP, et al.; Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) Group on behalf of the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: Executive summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2). Pediatr Crit Care Med. 2023; 24:143–168 2. Iyer N, Khemani R, Emeriaud G, et al.; Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) Group on behalf and the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: Methodology of the second pediatric acute lung injury consensus conference. Pediatr Crit Care Med. 2023; 24(12 Suppl 2):S76–S86 3. Bembea M, Jouvet P, Willson D, et al.: Methodology of the pediatric acute lung injury consensus conference. Pediatr Crit Care Med. 2015; 16(5 Suppl):S1–S5 4. Cruces P: Pediatric acute respiratory distresss syndrome: Approaches in mechanical ventilation. Pediatr Crit Care Med. 2023; 24:e104–e114 5. Emeriaud G, Pons-Odena M, Bhalla AK, et al.; Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology (PARDIE) Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network: Noninvasive ventilation for pediatric acute respiratory distress syndrome: Experience from the 2016/2017 Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology prospective cohort study. Pediatr Crit Care Med. 2023; 24:715–726 6. Milesi C, Baleine J, Mortamet G, et al.: Noninvasive ventilation in pediatric acute respiratory distress syndrome: “Another dogma bites the dust.” Pediatr Crit Care Med. 2023; 24:783–785