Purpose of review 

The present review addresses the underlying biology of acute respiratory distress syndrome (ARDS) while recognizing that extracorporeal membrane oxygenation (ECMO) is an increasingly employed technology in the context of severe disease. The review provides the physiologic and molecular foundation for the ventilation strategies most likely to facilitate lung repair and recovery.

Recent findings 

In infants and children, ARDS remains a significant cause of morbidity and mortality. Although any infant or child can develop ARDS, children who have experienced trauma, pneumonia, aspiration, or immune compromise are at increased risk. Though ECMO accomplishes oxygenation and ventilation independent of the lung, rhythmic distention of the lung, maintenance of an air–liquid interface, and strategies that prevent atelectasis are strongly recommended to minimize lung injury and promote recovery. An open-lung ventilation strategy that employs sufficient positive end-expiratory pressure to avoid atelectasis, a tidal volume limited to <5–7 cc/kg per breath, a plateau pressure of 30 cm of water, and driving pressure of <20 cm of water afford the greatest likelihood of lung repair.

Summary 

ECMO can be effective to treat children with severe ARDS. Even with ECMO in place, the principles of physiologically sound mechanical ventilation need to be applied. Collaborative trials and development of well curated international clinical information are needed to better understand which children with ARDS are most likely benefit from ECMO.