PALICC-2 (2023) refines the 2015 criteria to improve early detection and standardize care for Pediatric Acute Respiratory Distress Syndrome (PARDS).
Onset must be acute, occurring strictly within seven days of the known clinical insult.
Bilateral opacities must be present on chest radiography or computed tomography.
Respiratory failure cannot be fully explained by cardiac failure or fluid overload.
For resource-limited settings (RLS), diagnosis relies on specific clinical criteria if radiological imaging is unavailable.

Severity Stratification and "Possible PARDS"

Severity classification is now strictly assessed at least four hours post-diagnosis.
Stratification categorizes PARDS into mild, moderate, or severe based on the Oxygenation Index (OI) and Oxygen Saturation Index (OSI).
The new category of "Possible PARDS" captures children receiving High-Flow Nasal Cannula (HFNC) therapy at $\ge$ 2 L/kg/min with an SpO2/FiO2 ratio $\le$ 264.
Identifying "Possible PARDS" increases case capture by 20 to 30% without altering overall outcome patterns.

Lung-Protective Ventilation Strategies

Ventilation Parameter	PALICC-2 Recommendation
Tidal Volume	4 to 8 mL/kg of predicted body weight (PBW).
Plateau Pressure	Maintained at $\le$ 28 cmH2O.
Driving Pressure	Targeted to remain < 15 cmH2O to actively minimize ventilator-induced lung injury.
PEEP Titration	Titrated carefully according to established lower/higher PEEP tables.
Gas Exchange	Permissive hypercapnia is recommended.

Early Non-Invasive Ventilation (NIV) or HFNC is advised for mild PARDS, with rapid escalation if clinical failure occurs.
Prone positioning is recommended for a minimum of 16 hours per day in moderate to severe PARDS cases.
Neuromuscular blockade is indicated for a 48-hour duration in severe PARDS.
High-Frequency Oscillatory Ventilation (HFOV) and Extracorporeal Membrane Oxygenation (ECMO) act exclusively as rescue therapies for refractory cases.
Strict fluid restriction and optimized nutritional support are critical adjunctive measures.
Serial monitoring of OI, OSI, and driving pressure is mandated, utilizing data science for clinical decision support systems.

PARDS contributes heavily to Indian Pediatric Intensive Care Unit (PICU) mortality, frequently exacerbated by fluid overload and delayed recognition.
The Indian Academy of Pediatrics (IAP) and Indian Council of Medical Research (ICMR) integrate PALICC-2 principles into their standard treatment workflows and training modules.
Successful implementation requires structured adherence bundles, as real-world compliance to plateau pressure goals and PEEP tables remains below 50% in many centers.