Advancing Pediatric ARDS Management: Integrating Innovative Monitoring Techniques and ECMO for Improved Outcomes

4.1 Descriptive summary of the studies

The reviewed literature presents a progressive evolution in pediatric ARDS management, showing a clear transition from protocol-based ventilation approaches to more integrated frameworks that include ECMO utilization, advanced monitoring, and sustainable system design. As shown in Figure 2, the monitoring and ventilation integration pathway Figure 2(a) illustrates the progression of research findings across three main phases. In Phase 1, studies demonstrated that adherence to lung-protective ventilation protocols, particularly maintaining low tidal volumes and monitoring delta pressure, significantly reduces mortality in moderate to severe PARDS. The introduction of advanced physiological monitoring tools, such as EIT and pleural pressure assessment, enables clinicians to tailor ventilation settings in real-time, thereby minimizing ventilator-induced lung injury and improving oxygenation efficiency. Moreover, the early application of green hospital principles and the implementation of WHO-based pediatric care guidelines underscore how evidence-based clinical strategies can align with sustainable healthcare development.

The research focus distribution Figure 2(b) provides quantitative insight into pediatric ARDS management performance indicators within Indonesian and comparable healthcare settings. The results reveal adherence to lung-protective ventilation at 52.4%, with mortality in moderate-to-severe PARDS recorded at 34.7%. Meanwhile, ECMO availability in tertiary centers remains limited at 18%, and clinician ECMO certification reaches only 9.3%, indicating a need for structured training and certification programs. Utilization of advanced monitoring technologies, including EIT and transpulmonary pressure measurement, stands at 11.8%, showing gradual adoption across pediatric ICUs. The average ICU length of stay (LOS) of 9.6 days further reflects the clinical and logistical challenges of PARDS management. Collectively, these data emphasize that while Indonesian healthcare facilities have made measurable progress in integrating evidence-based pediatric ARDS care, substantial gaps persist in resource accessibility, staff capacity, and the widespread use of monitoring technologies—critical areas that future implementation efforts must continue to strengthen.

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Figure 2. Evolutionary roadmap of pediatric ARDS research and implementation strategies (a) Monitoring and ventilation integration pathway; (b) Research focus distribution across pediatric ARDS domains

A total of 14 studies demonstrated that protocol-based lung-protective ventilation and adherence to ventilation elements significantly reduce mortality and improve clinical outcomes in pediatric ARDS, particularly through lower delta pressure and optimized PEEP strategies [9, 11]. The use of ECMO in severe ARDS also shows notable survival benefits when appropriately indicated, with clinical management guidelines contributing to better patient outcomes [10, 24]. Conversely, nonadherence to lung-protective ventilation principles remains common and is consistently linked to poorer outcomes, emphasizing the urgent need for improved protocol compliance among clinicians [22]. Furthermore, ventilator application in respiratory failure cases has been shown to markedly improve clinical recovery compared to patients managed without mechanical ventilation [17]. Despite these clinical advancements, multiple studies identified persistent logistical, educational, and infrastructural barriers in ECMO deployment, including limited team organization, inadequate training, and low procedural awareness among nursing staff [13, 23]. Resource constraints in Indonesian and other resource-limited healthcare systems also restrict access to mechanical ventilation and advanced therapies [22]. Nevertheless, the implementation of quality improvement initiatives and structured staff education programs has been proven to enhance adherence to clinical guidelines and completion of care processes [21].

Advanced physiological monitoring methods such as EIT and pleural or transpulmonary pressure measurements have shown potential to personalize ventilation strategies, improve PEEP optimization, and better detect changes in lung mechanics [25]. Consensus guidelines further highlight the importance of comprehensive respiratory and cardiovascular monitoring to elevate the quality of PARDS management [7]. At the same time, physiological sub-phenotyping supports the development of individualized respiratory support strategies that may reduce ventilator-induced lung injury [26]. Parallel to these clinical innovations, sustainable hospital design integrating green hospital principles and child-friendly environments has begun to emerge in Indonesian healthcare systems, focusing on environmentally responsible landscape design and operational practices [27]. Evidence-based design frameworks additionally identify critical environmental variables that influence both patient recovery and staff performance [7]. However, no studies have directly addressed the sustainability of ventilation or ECMO resources. From a resource utilization perspective, protocol adherence and quality improvement programs enhance both clinical outcomes and the efficiency of resource allocation [28]. The application of EIT-based monitoring may further optimize resource utilization by preventing ventilator-related injuries and guiding safer ventilation practices. Moreover, ECMO resource efficiency is influenced by the level of team training and patient selection, which directly impact mortality and overall care quality [26]. In contrast, personalized ventilation approaches have been shown to maximize resource utilization by tailoring interventions to individual patient physiology [5].

4.2 Meta-analysis

4.2.1 Protective pulmonary mechanical ventilation

Lung-protective mechanical ventilation (LPMV) with low tidal volumes (4–6 ml/kg), plateau pressures <30 cmH₂O, and optimal PEEP has been shown to reduce mortality in pediatric ARDS, including in Southeast Asia [11]. Consistent adherence to the LPMV protocol during the first week of ARDS is associated with a reduced 60-day mortality rate. Use of PEEP lower than ARDSNet recommendations is associated with higher mortality [29].

4.2.2 Non-invasive support and prone positioning

HFNC and NIV (CPAP/BiPAP) are effective for mild to moderate ARDS, with HFNC showing a lower incidence of hemodynamic failure and the need for invasive ventilation compared to NIV. Prone positioning improves oxygenation and reduces mortality in patients with moderate to severe ARDS, although there is limited evidence in children. The use of these strategies should be accompanied by close monitoring to detect early failure [30-33].

4.2.3 ECMO and advanced support

ECMO is an option for refractory ARDS unresponsive to conventional ventilation, with evidence of benefit in selected cases. However, access and implementation of ECMO in Indonesia remain limited due to resource constraints. After extubation, the majority of pediatric ARDS patients still require continued respiratory support until discharge [34-37].

4.2.4 Fluid management, monitoring, and adjuvant therapy

Conservative fluid management or deresuscitation increases ventilator-free days and decreases ICU length of stay without increasing mortality [38, 39]. Advanced physiological monitoring (transpulmonary pressure, bedside devices) and personalized approaches to therapy are increasingly emphasized [40]. Adjuvant therapies such as corticosteroids, surfactants, inhaled nitric oxide, and vitamin C are still selective and not yet standard [41]. Building on these therapeutic insights, Table 1 provides a comparative overview of key studies that evaluate modern respiratory support strategies in pediatric ARDS secondary to sepsis. The evidence demonstrates that adherence to lung-protective ventilation protocols consistently lowers mortality, while non-invasive approaches, such as HFNC, show favorable hemodynamic outcomes compared to NIV. Conservative fluid management further strengthens recovery prospects by shortening ICU stay, reflecting the importance of integrated supportive care alongside ventilation. As shown in Table 2, the dominance of specific authors and journals in disseminating these findings underscores the global networks that shape consensus in pediatric ARDS care. Strengthening Indonesia’s research engagement within these networks will be essential to contextualize and translate global innovations into local practice.

Table 1. Comparison of key studies on modern respiratory support strategies for pediatric ARDS secondary to sepsis

Table 2. Authors and journals that appear most frequently in the included papers

4.3 Critical analysis and synthesis

The analysis indicates that ventilation protocols achieve the highest strength score of 9, confirming their strong clinical effectiveness in reducing mortality and improving outcomes. ECMO implementation, with a score of 8, and advanced monitoring, scoring 7, demonstrate promising potential but remain hindered by limited infrastructure and inadequate staff training. Sustainable hospital design, also rated 8, highlights progress toward environmentally responsible and child-centered healthcare environments. However, resource limitation is the greatest weakness, as recorded at 9, emphasizing ongoing capacity and accessibility challenges in pediatric intensive care. As shown in Figure 3, both ventilation and ECMO occupy the high-risk zone, underscoring the urgent need to enhance protocol adherence, expand ECMO readiness, and integrate sustainable system strategies to strengthen pediatric ARDS management in Indonesia [9, 12, 16, 22].

4.4 Thematic review of literature

The current synthesis of literature identifies a diverse thematic landscape in pediatric ARDS research, encompassing both clinical and systemic dimensions of care. As shown in Figure 4, the thematic distribution in Figure 4(a) demonstrates that the most frequently explored topic is the Effectiveness and Safety of Protocol-Based Lung Protective Ventilation (22 papers), followed by the Role of Advanced Physiological Monitoring in Personalizing Therapy (12 papers). Themes addressing Barriers and Solutions in ECMO Implementation (9 papers) and Variability in Mechanical Ventilation Practices (10 papers) highlight ongoing challenges in operational capacity and protocol adherence, particularly within resource-limited hospitals. Other research areas, such as Sustainable Development and Planning Strategies (4 papers) and Integration of Clinical Decision Support and Data Science (3 papers), emphasize the growing recognition of systemic innovation, sustainability, and digital transformation in pediatric critical care. Collectively, these findings indicate that pediatric ARDS research has evolved beyond clinical parameters, incorporating infrastructure, technology, and policy considerations as integral components of holistic management [47, 51, 52].

Complementing the thematic overview, the quantitative indicators in Figure 4(b) provide empirical evidence of progress and remaining gaps in pediatric ARDS management across hospitals in Indonesia. The data show adherence to lung-protective ventilation at 52.4% and mortality in moderate-to-severe PARDS at 34.7%, underscoring both the clinical impact of standardized protocols and the persistence of outcome disparities. ECMO availability remains limited at 18%, while clinician ECMO certification stands at only 9.3%, reflecting capacity and training deficiencies [53-55]. Meanwhile, the use of advanced monitoring (11.8%) and an average ICU length of stay (LOS) of 9.6 days suggest that, despite improved adherence to guidelines, the optimization of monitoring tools and care efficiency is still in development. Together, these findings underscore the need for enhanced protocol implementation, technology adoption, and capacity building to achieve equitable and evidence-based management of pediatric ARDS across Indonesia’s healthcare system.

In this thematic synthesis, the literature distinctly differentiates between the clinical indications and the implementation barriers of ECMO in pediatric ARDS management. Clinically, ECMO is indicated for severe refractory hypoxemia (PaO₂/FiO₂ < 60 mmHg for over six hours despite optimal ventilation), uncompensated hypercapnia with acidosis, or hemodynamic instability unresponsive to conventional therapy, demonstrating significant survival benefits when performed in specialized centers with trained multidisciplinary teams [54, 56, 57]. In Indonesia, however, ECMO use remains primarily confined to tertiary hospitals, mainly for post-viral and sepsis-related refractory cases, reflecting limited access and uneven capabilities. Significant barriers include limited equipment availability, insufficient clinician certification, and high operational costs, compounded by logistical challenges such as perfusionist shortages, inconsistent disposable supplies, and the absence of a national ECMO registry. These factors collectively underscore that while ECMO provides clear clinical value, its sustainable integration within Indonesia’s pediatric intensive care system necessitates coordinated investments in infrastructure, workforce training, and health policy development.

4.5 Chronological review of literature

The chronological trajectory of pediatric ARDS research from 2012 to 2024 reveals a steady and data-supported progression in both clinical management and healthcare system development. The evidence compiled in Figure 5 demonstrates that the 2012-2014 period laid the foundation, marked by early studies on pediatric ARDS care, policy formulation, and child-friendly healthcare initiatives. Research conducted between 2017 and 2018 began examining variability in ventilation practices, patient outcomes, and mortality patterns across resource-limited hospitals, establishing essential benchmarks for improvement [48, 49]. The 2019-2021 phase emphasized protocol-based ventilation and standardized weaning strategies, which enhanced survival rates and reduced mechanical ventilation duration. During 2022-2023, the focus expanded to advanced physiological monitoring, noninvasive ventilation, and the operational barriers of ECMO implementation [16, 52]. By 2024, the research direction had evolved toward personalized ventilation and sustainable pediatric care, integrating ECMO training programs, precision monitoring, and environmentally conscious hospital design—representing a mature synthesis of technology, policy, and patient-centered innovation in pediatric intensive care.

4.6 Agreement and divergence across studies

The comparative evaluation in Figure 6 reveals that the highest level of consensus exists around protocol-based lung-protective ventilation (LPV), with an agreement score of 7, reflecting strong alignment among studies regarding its clinical effectiveness and survival benefits. In contrast, moderate agreement scores of 6 for both ECMO implementation barriers and advanced physiological monitoring indicate shared recognition of their importance but highlight ongoing challenges in consistent application and accessibility within Indonesian hospitals [38, 39]. Sustainable hospital design and resource and cost efficiency record slightly lower agreement levels at 5, suggesting that while these topics are emerging in pediatric critical care discussions, empirical validation remains limited. Divergence values ranging from 3 to 4 demonstrate variability in evidence interpretation, particularly concerning ECMO readiness and the integration of advanced monitoring technologies. Overall, the findings emphasize that while consensus supports the clinical value of LPV and ECMO, differing resource capacities and institutional priorities continue to shape implementation outcomes across pediatric ARDS research contexts [7, 10].

4.7 Theoretical and practical implications

The theoretical synthesis of findings reinforces the pivotal role of lung-protective ventilation strategies in pediatric ARDS, emphasizing the importance of adhering to parameters such as low tidal volume, controlled peak inspiratory pressure, and appropriate PEEP titration to minimize ventilator-induced lung injury [22]. These observations validate existing theoretical models, which suggest that ventilation mechanics have a direct influence on morbidity and mortality in PARDS. Furthermore, the application of advanced physiological monitoring techniques—such as electrical tomography EIT and transpulmonary pressure measurement provides a theoretical extension toward personalized ventilation management. These modalities offer real-time visualization of regional lung function, facilitating individualized PEEP adjustment and minimizing atelectrauma or overdistension. Thus, theoretical frameworks increasingly acknowledge patient-specific lung mechanics as essential to optimizing respiratory support in children [13].

The evidence further underscores the heterogeneity of pediatric ARDS pathophysiology and the theoretical necessity of age-specific approaches rather than applying adult-derived ventilation models [5]. This recognition challenges the one-size-fits-all paradigm and supports the principles of precision medicine in pediatric respiratory care. ECMO’s theoretical position as a salvage therapy is supported by multicenter reviews demonstrating survival benefits when appropriately indicated and managed within specialized units [14]. Despite this, questions remain regarding optimal ventilatory parameters during ECMO, which continue to drive theoretical inquiry in pediatric critical care. Consequently, ECMO is conceptualized not merely as a rescue therapy but as an integral component of lung-protective strategies that prevent further injury during severe disease progression [11].

From a practical perspective, the implementation of protocol-based lung-protective ventilation in Indonesian pediatric intensive care units has shown potential to improve outcomes; yet, consistent adherence remains a significant challenge. Capacity-building efforts, including structured training and dissemination of standardized protocols, are essential to ensure uniform clinical application across facilities [10]. The introduction of advanced monitoring technologies, though promising, necessitates investments in equipment, clinician training, and workflow integration to realize their full potential. In parallel, barriers to ECMO implementation, such as limited staff certification, high costs, and logistical obstacles, require targeted national strategies and multidisciplinary coordination. Collectively, these findings underscore the urgent need for multidimensional initiatives that integrate technology adoption, education, and system-level reforms to enhance pediatric ARDS care in Indonesia [25].

Figure 3. Comparative strength–weakness analysis and risk mapping in pediatric ARDS context

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Figure 4. Research landscape of pediatric ARDS (a) Thematic distribution of ventilation, ECMO, and monitoring studies; (b) Quantitative indicators of pediatric ARDS management and outcomes in Indonesian hospitals

Figure 5. Chronological evolution of pediatric ARDS research (2012–2024)

Figure 6. Comparative agreement and divergence across pediatric ARDS research

Figure 7. Performance comparison between conventional and EIT-Guided pediatric ICU management

The comparative data presented in Figure 7 demonstrate notable performance improvements in pediatric intensive care when EIT-guided ventilation is applied. Compared to conventional methods, EIT-guided management reduced the average ICU stay from 10.2 to 8.1 days and lowered ventilator-related complications from 26 to 19 per 100 patients, representing respective improvements of 20.6% and 26.9% [58, 59]. Average ICU costs decreased by 10.5%, while supportive therapy costs were reduced by 7.6%, indicating enhanced economic efficiency through better ventilatory precision. Additionally, oxygen and ventilator efficiency improved from 84% to 92%, correlating with a reduction in mortality from 27.5% to 25.3% [60, 61]. Overall, these findings highlight that integrating EIT-based monitoring not only enhances clinical outcomes but also improves resource utilization and operational sustainability in pediatric ARDS care.

In Indonesia, the practical implications of sustainable hospital development are reflected in emerging real-world initiatives. One notable example is the redevelopment of Dr. Sardjito Hospital’s pediatric intensive care unit in Yogyakarta, which incorporates an energy-efficient ventilation system, optimized natural lighting, and water recycling to minimize operational costs while maintaining infection control standards. Similarly, the Cipto Mangunkusumo National Hospital in Jakarta has launched a “green ward” pilot project featuring biophilic interior design, sound-absorbing materials, and family-centered spatial layouts that enhance patient comfort and staff performance [42]. These initiatives demonstrate that sustainable design can coexist with advanced pediatric care, even under financial and infrastructural constraints. The integration of environmentally responsible design with clinical functionality represents a transformative step toward child-friendly, resource-efficient healthcare environments that improve both outcomes and resilience [13].

4.8 Limitations of the literature

Despite the growing body of research on pediatric ARDS, several limitations in the existing literature constrain the strength and applicability of current evidence, particularly in the Indonesian context. Many studies continue to rely on adult-derived data or consensus recommendations rather than robust pediatric-specific randomized controlled trials, which weakens external validity. Methodological shortcomings such as small sample sizes, single-center designs, and reliance on observational data further reduce generalizability and causal inference. Additionally, significant gaps remain in Indonesian-focused research, long-term outcome data, and systematic reporting of ventilator parameters. Technical challenges in adopting advanced monitoring tools and insufficient empirical evidence on ECMO implementation barriers also limit the translation of findings into routine clinical practice. To provide a structured overview, Table 3 summarizes the key areas of limitation, their descriptions, and representative studies that exemplify these constraints.

4.9 Gaps and future research directions

While the current body of literature on pediatric ARDS provides valuable insights, it also highlights critical research gaps that must be addressed to strengthen evidence-based practice in Indonesia. Many existing studies are limited by methodological constraints, a lack of pediatric-specific data, or insufficient contextual relevance, particularly in the areas of ECMO implementation, advanced monitoring, and sustainable hospital planning. There is also a pressing need for longitudinal studies, standardized protocols, and structured training programs to ensure consistent quality of care. To guide future research priorities, Table 4 summarizes the key gaps identified, outlines recommended directions, and provides justifications for why these areas warrant urgent attention.