Volume I:
First Thirty Minutes
- Section 1
  Acute Care Algorithm/ Treatment Plans/ Acronyms
- Section 2
  Universal Approach
  - CALS Universal Approach To Emergency Advanced Life Support
- Section 3
  Steps 1-6
- Section 4
  Preliminary Impression/Focused Clinical Pathways
Volume II:
Resuscitation Procedures
Volume III:
Definitive Care

Pathway 7: Pediatric Respiratory

The team continues the resuscitation along the pathway suggested by the initial clinical impression. Each pathway includes a complete, thorough, and rapid physical examination with additional history taking. The team leader is wary of conditions that may not be apparent. To obtain additional clinical data or to correct a missed or newly developed condition, the team leader repeats the initial survey if the patient is not responding satisfactorily.

PEDS: Because this entire pathway pertains only to pediatric patients, the convention of underlining has been omitted.

For the purposes of this survey, the pediatric age group ranges from infancy to the attainment of adult size.

Children are not small adults. For further general discussion of this issue, see Vol III—PED1 Physiologic and Anatomic Considerations.

Topics not covered here but found in Pathway 6 Adult Respiratory (Vol I—Pathway 6 Adult Respiratory) may provide immediate insight into respiratory management, especially for older/larger pediatric patients.

Text Number	Diagnosis/Condition	Related Materials
1	Foreign Body Aspiration	Vol II—Air Skills 12 Tracheal Foreign Body Removal, Air Skills 14 Tracheotomy, Air Skills 16 Transtracheal Needle Ventilation
2	Retropharyngeal or Peritonsillar Abscess	Vol II—Air Skills 13 Cricothyrotomy, Air Skills 4 Rapid Sequence Intubation, Air Skills 14 Tracheotomy, Air Skills 15 Tracheotomy in Infants
3	Diphtheria	Vol II—Air Skills 1 Aids to Intubation, Air Skills 4 Rapid Sequence Intubation, Air Skills 13 Cricothyrotomy, Air Skills 14 Tracheotomy, Air Skills 15 Tracheotomy in Infants
4	Epiglottitis	Vol III—PED3 Epiglotittis; Vol II—Air Skills 13 Cricothyrotomy, Air Skills 14 Tracheotomy, Air Skills 15 Tracheotomy in Infants, Air Skills 16 Transtracheal Needle Ventilation
5	Laryngeal Edema Post Extubation	Vol III—AIR3 Heliox Treatment; Vol II—Air Skills 1 Aids to Intubation, Air Skills 13 Cricothyrotomy, Air Skills 14 Tracheotomy, Air Skills 15 Tracheotomy in Infants
6	Anaphylaxis and Angioedema	Vol III—AIR8 Anaphylaxis; Vol II—Air Skills 1 Aids to Intubation, Air Skills 13 Cricothyrotomy, Air Skills 14 Tracheotomy, Air Skills 15 Tracheotomy in Infants, Air Skills 16 Transtracheal Needle Ventilation
7	Laryngotracheobronchitis (Croup)	Vol III—PED4 Laryngotracheobronchitis; Vol II—Air Skills 13 Cricothyrotomy, Air Skills 14 Tracheotomy, Air Skills 15 Tracheotomy in Infants, Air Skills 16 Transtracheal Needle Ventilation; Vol III—AIR3 Heliox Treatment
8	Bacterial Tracheitis	Vol III—PED5 Bacterial Tracheitis; Vol II—Air Skills 13 Cricothyrotomy, Air Skills 14 Tracheotomy, Air Skills 15 Tracheotomy in Infants, Air Skills 16 Transtracheal Needle Ventilation; Vol III—AIR3 Heliox Treatment
9	Bronchiolitis	Vol III—PED6 Bronchiolitis; Vol II—Air Skills Portals
10	Pneumonia	Vol III—PED7 Pneumonia; Vol II—Air Skills Portals
11	Asthma	Vol III—AIR7 Statis Asthmaticus, AIR3 Heliox Treatment, AIR4 Ventilator Management; Vol II—Air Skills Portals
12	Near Drowning	Vol I—Pathway 9 Pediatric Trauma, Pathway 1 Altered Level of Consciousness; Vol II—Air Skills 4 Rapid Sequence Intubation; Vol III—AIR4 Ventilator Management
13	Acute Respiratory Distress Syndrome	Vol I—Pathway 6, #6

Foreign Body Aspiration
Children constantly put objects in their mouths, leading to frequent occurrence of foreign body (FB) aspiration. Strongly consider FB airway obstruction with a history of sudden onset of respiratory difficulty, especially in a previously healthy child. Also consider this diagnosis in a non-resolving respiratory disorder.

If the situation is life threatening or there is a complete obstruction, removal of the object must be attempted. An aggressive approach may be necessary to establish an adequate airway.

Initial Management

Initially try the Heimlich maneuver. (Vol II—Air Skills 12 Tracheal Foreign Body Removal)
If the Heimlich maneuver is unsuccessful, try removing the FB using a meconium aspirator, wall suction set at the maximum setting, and a cut-off ET tube. Insert the ET tube until you feel a slight pressure. A meconium aspirator is attached to the cut-off ET tube and to the suction tubing connected to the wall suction. Suction is applied as the ET tube is removed. Even if the FB is not extracted, reattempt ventilation as the FB may have been dislodged or pushed into the right main stem bronchus. If the FB is now in the right main stem bronchus, the patient's left lung can still be ventilated.
If these measures fail, a surgical airway may be necessary. These include TTNV and tracheotomy (Vol II—Air Skills 14 Tracheotomy, Air Skills 16 Transtracheal Needle Ventilation). The success or failure in removing a FB utilizing a surgical airway will depend on the location of the FB in the airway.

If the FB is not removed but the patient is able to breathe (because of partial obstruction or passage of the FB further down the pulmonary tree), closely observe the patient while arranging for emergent rigid bronchoscopy in the operating room. Though flexible bronchoscopy doesn’t need general anesthesia and is useful for diagnosis of FB, it doesn’t have as much capability for FB removal as rigid bronchoscopy. Continue to support the patient, closely observing for any deterioration:

Use Heliox as a temporizing measure to assist oxygenation as needed. (Vol III—AIR3 Heliox Treatment)
Obtain a PA and lateral chest x-ray to identify the presence of an FB or complications such as atelectasis, mediastinal shift, air trapping, pneumothorax, or compensatory contralateral emphysema. Aspirated FBs commonly lodge in the right main stem bronchus or lower lobe.
Prepare the patient for the procedure. Administering a broad-spectrum antibiotic may not be indicated for infection prior to the procedure, but the antibiotic may be given post procedure, depending on what is visualized. Steroids to limit edema from the FB and the procedural manipulations are debatable; discuss this with an endoscopist.

If a child has had difficulty breathing against the FB before removal, continue to observe the patient for appearance of pulmonary edema (see #13 this portal, ARDS).

Retropharyngeal or Peritonsillar Abscess

Patients may present with pain, fever, difficulty swallowing, trismus, drooling, fetid breath, neck stiffness/swelling, and voice changes. On exam, the mouth may not fully open. Red and swollen posterior soft tissue structures may be fluctuant and may be encroaching on or occluding the upper airway. Do not palpate a retropharyngeal bulge. The uvula may be displaced. The patient may be dehydrated due to decreased oral intake and fever-related losses.

Diagnosis may be complicated by patients being unable to open their mouths. Lateral soft tissue cervical x-rays may not definitively show evidence of retropharyngeal abscess as demonstrated by widening prevertebral space, gas, or air fluid level. In a stable patient, if extension of infection is suspected, the diagnosis may be facilitated by either intraoral ultrasound or CT scan.

Management Considerations

The primary goal is to maintain a secure airway. If intubation is indicated, take care not to rupture the abscess. Rupture may cause possible aspiration, dissemination, and/or increased mortality. (Vol II—Air Skills 13 Cricothyrotomy, Air Skills 4 Rapid Sequence Intubation, Air Skills 14 Tracheotomy, Air Skills 15 Tracheotomy in Infants)
Replace fluid deficits with NS.
Start antibiotic coverage prior to drainage procedures: in both of these conditions the microorganism flora is mixed aerobes and anaerobes. One antibiotic regimen is penicillin G benzathine, 12 500 to 25 000 units/kg IV every 6 h and metronidazole (loading dose 15 mg/kg [up to 1 g] over 1 hour, followed by 7.5 mg/kg over 1 h every 6 to 8 h).
In penicillin-allergic patients, administer cephalexin 25 to 50 mg/kg/day PO or cefazolin 25 to 100 mg/kg/day IV.
The definitive treatment for an abscess is incision and drainage, which should be performed in a controlled setting such as the operating room. (Before treating, be sure the abscess is present.) An exception may be the cooperative, non-toxic/non-septicemic patient with a peritonsillar abscess that has no deep neck extension of the infection and can be needle aspirated using a 19-gauge, depth-protected needle on a 10 cc syringe following topical anesthetic spray and submucosal lidocaine injection. The aspirate should be sent for culture.

Diphtheria
Unvaccinated children are at risk for diptheria, a toxin-mediated disease (caused by Corynebacterium diphtheriae), which generally presents as infection of the tonsils and pharynx. A gray-brown, adherent, leather-like pseudo-membrane (a dense coagulum of necrotic debris) can form and obstruct the airway. This membrane can also form lower in the larynx. Peripharyngeal swelling can be significant. The exotoxin affects many different parts of the body; of particular importance during an emergency situation is its paralytic effect on the palate and hypopharynx (further compromising the airway), its effect on the myocardium (inflammation/myonecrosis, dsyrhythmias, heart block, CHF), and various neurologic complications.

If diptheria is suspected, begin treatment. Confirmation is by swab and special culture techniques. (Alert the lab that special cultures are being sent.) Testing is also recommended for toxigenicity.

Initial Management

Establish control of the airway. (Vol II—Air Skills 1 Aids to Intubation, Air Skills 13 Cricothyrotomy, Air Skills 4 Rapid Sequence Intubation) With laryngeal involvement, tracheostomy may be needed. (Vol II—Air Skills 14 Tracheotomy, Air Skills 15 Tracheotomy in Infants)
Replenish fluids.
Determine cardiac involvement (ECG, monitoring, serum aspartate aminotransferase) and potential for circulatory collapse.
Give antitoxin (diptheria antitoxin) to neutralize free toxin. Empiric IV treatment over 30 to 60 minutes: 40 000 to 120 000 U. (Higher dosing depends on the severity of the disease.)
Administer erythromycin to eradicate the bacterium: 40 to 50 mg/kg/d IV divided into four doses over 24 hours.
Consult with cardiology, neurology, and ENT as needed.
Implement strict isolation.

Epiglottitis
Acute inflammation of the epiglottal area (usually by the bacterium Haemophilus influenzae type B) can cause airway obstruction, respiratory arrest, and death. The incidence of this disease has greatly decreased with the introduction of Haemophilus influenzae type B vaccine.¹

Onset is acute, with pain, fever, restlessness/anxiety, sore throat, muffled voice, nasal flaring, drooling, stridor, and tachypnea. Patients look toxic; the child may sit forward with neck extended and mouth open.

With this presentation and suspected diagnosis, do not attempt an exam. Hold an oxygen mask near the child’s face without frightening him or her. (Note: racemic epinephrine, other nebulizers, steroids, or sedation are not recommended.) Prepare all airway equipment and make sure the team members are ready in case the first attempt at intubation fails. The best setting may be the operating room. When preparation has been completed, lay the child down, BVM with oxygen, and have an airway sequence prepared. Consider using ET tubes a size smaller than normal to adapt for airway swelling. If the first attempt at intubation is unsuccessful, perform transtracheal needle ventilation. Definitive airway control may be done once the transtracheal needle is successfully placed. The team leader can now retry to intubate, which may be successful now as the airflow is moving in both directions. If this is still unsuccessful, perform a tracheotomy. (Vol II—Air Skills 1 Aids to Intubation, Air Skills 13 Cricothyrotomy, Air Skills 14 Tracheotomy, Air Skills 15, Tracheotomy in Infants, Air Skills 16 Transtracheal Needle Ventilation)

To rule out epiglottitis in stable, cooperative patients, use direct visualization. This may be done several different ways. One way is to anesthetize the nares with lidocaine and visualize with a fiberoptic laryngoscope. Note that the soft tissue lateral neck x-ray is helpful only if the epiglottis shadow is enlarged (the ‘thumbprint’ sign). An indeterminate or negative x-ray does not rule out epiglottitis.

Once the airway is secured, sedate appropriately, and begin mechanical ventilation. Obtain epiglottal area and blood cultures. Begin antibiotics. One option is ceftriaxone 50 to 75 mg/kg/d IV. (Though other antibiotic options are available, ceftriaxone is probably the most common.) Assess fluid status and treat appropriately. Admit to an appropriate ICU setting.

Remember to arrange to give rifampin chemoprophylaxis to persons who have been exposed.

Laryngeal Edema Post Intubation

An intubated child may develop laryngotracheal edema post intubation. (Corticosteroids may prevent this edema prior to extubation.) Clinical signs include stridor, cough, and respiratory distress. Depending on the severity of the case, mist therapy and/or aerosolized epinephrine may be beneficial. Heliox therapy may be of some benefit. (Vol III—AIR3 Heliox Treatment) Closely observe for improvement or progression. Establish IV access. Fiberoptic nasopharyngoscopy may be helpful in assessing the severity of the upper airway edema or other upper airway problems and the need for re-intubation or other approaches. Be aware that tracheal edema (and cricoid narrowing) won’t be seen but can be inferred if the upper airway isn’t edematous. These patients need a smaller tube than normally used for reintubation. In progressive or severe cases, prepare airway equipment for all possible scenarios, gather team members, and establish control of the airway, starting with intubation. Cricothyrotomy or tracheotomy may be needed. Note that RSI may not be indicated in cases where the patient’s edema-compromised airway is being maintained by their muscle tone/positioning. (Vol II—Air Skills 1 Aids to Intubation, Air Skills 13 Cricothyrotomy, Air Skills 14 Tracheotomy, Air Skills 15 Tracheotomy in Infants)

Anaphylaxis and Angioedema
Anaphylaxis (literally meaning ‘without protection’) is a multi-systemic allergic reaction to an inciting agent or event. This is a clinical diagnosis.
Anaphylactoid reactions are similar in nature and treatment to allergic reactions.
Angioedema (localized soft tissue swelling involving deeper layers) of the upper aero-digestive tract is a common local manifestation of anaphylactic/ anaphylactoid reactions. Angioedema because of other mechanisms, such as hereditary angioedema or acquired angioedema are responsive to different treatment regimens. However, it looks the same, and angioedema may be impossible to distinguish by history, especially if it is the first episode. (Vol III—AIR8 Anaphylaxis)

A common sense approach to the respiratory aspect of these conditions is to treat these patients as if the episode is an anaphylactic/anaphylactoid reaction while keeping in mind that hereditary angioedema or acquired angioedema will respond poorly or not at all to epinephrine, antihistamines, and steroids. Therapy is directed at reversing current effects and preventing further progression. Like many emergency conditions, assessment and treatment occur simultaneously in this setting. Epinephrine (a physiologic antagonist to the effects of the biochemical mediators) is the drug of choice and should be given as soon as the diagnosis is suspected, whatever system(s) is involved.

Upper Airway Considerations

A. Examine the airway for signs of angioedema. If immediate airway intervention is not indicated, give epinephrine while mobilizing the team and equipment for intervention if the situation worsens. Initially, use a BVM with oxygen, then attempt to intubate. If the first attempt at intubation is unsuccessful perform transtracheal needle ventilation. Definitive airway control can be done once the transtracheal needle is successfully placed. The team leader can now retry to intubate, which may be successful now as the airflow is moving in both directions. If you are still not successful, then perform a tracheotomy. Fiberoptic exam can assist in determining the severity of the edema, especially in patients who are not responding or progressing rapidly and whose laryngeal involvement is not readily apparent. RSI may not be indicated in cases where the patient’s edema-compromised airway is being maintained by their muscle tone/positioning. (Vol II—Air Skills 1 Aids to Intubation, Air Skills 13 Cricothyrotomy, Air Skills 14 Tracheotomy, Air Skills 15 Tracheotomy in Infants, Air Skills 16 Transtracheal Needle Ventilation)

B. Utilize O₂ as indicated. Heliox (80% helium and 20% oxygen) may also be helpful. (Vol III—AIR3 Heliox Treatment)

C. Unless the patient has hereditary angioedema or acquired angioedema for certain, give the following medications:

Epinephrine IM, IV, or IO. Choice of route depends on the severity:

For mild-to-moderate cases: Administer epinephrine IM: 0.01 mL/kg (up to 0.3 mL) of 1:1000 solution. Repeat every 10 to 20 minutes (up to 3 doses prn). Epinephrine IM may result in higher, more rapid, and more predictable peak plasma epinephrine concentrations than the SQ route.^2,3
In life-threatening situations or when patient is unresponsive: Administer epinephrine IV/IO: 1 mg in 500 mL NS (2 μg/mL) given by IV drip at rate determined by the seriousness of the situation and patient’s response. Usual doses are from 2 to 10 μg/minute IV (or 1 to 5 mL/minute of the solution of 1 mg of epinephrine/500 mL of NS). Higher doses may be needed if the patient is clinically unresponsive to lower doses but the dose must be carefully titrated under direct supervision while monitoring BP and cardiac rhythm. If continuous infusion is necessary, switch to a pump-controlled regimen when feasible/available.

H1 and H2 Antihistamines (Give both; choice of route depends on severity.)

H1 antagonist: diphenhydramine (Benadryl), 1 mg/kg PO/IM/IV/IO
H2 antagonist: cimetidine (Tagamet), 10 mg/kg PO/IM/IV/IO

Corticosteroids

methylprednisolone, 1 to 2 mg/kg PO/IV/IO

D. Hereditary angioedema and acquired angioedema treatment options (C₁ esterase inhibitor concentrate, fresh frozen plasma, nebulized heparin, androgen steroids) have unclear/unestablished pediatric doses/indications. Consult with a specialist when the airway is secure and/or stable.

Lower Airway Considerations

Examine the lungs for bronchospasm (wheezing, increased expiratory phase, difficulty breathing). If symptoms persist despite epinephrine, give nebulized albuterol: 2.5 mg in 2 to 3 mL NS every 15 to 20 minutes; continuous nebs may be indicated at 2 to 3 mg/kg/h.

Other Considerations

A. Treat shock and/or cardiovascular collapse with epinephrine, fluids, and pharmacologic vasopressor support if hypotension does not respond to fluid therapy. See Vol III—Trau Care 2 Shock; Vol II—Circ Skills 1 Arterial and Venous Catheter Insertion if the patient is hemodynamically unstable.

B. Remove allergen source from patient:

Remove stinger from insect bite with a blade to avoid injection of more allergen.
If an ingested substance has caused the reaction, give activated charcoal 1 g/kg PO/NG. (If a patient has charcoal in the stomach, give medications via a non-oral route.

C. Monitor the patient carefully for response to therapy, adverse results, or disease progression.

Laryngotracheobronchitis (Croup)
Laryngotracheobronchitis (also called croup) is a viral disease that commonly affects infants and children from 6 months to 3 years of age. Laryngotracheobronchitis is associated with a barking (seal-like) cough, hoarseness, fever, and mild wheezing. The majority of patients recover well. In severe cases, the patient exhibits stridor, retractions, tachypnea, tachycardia (out of proportion to fever), and various degrees of respiratory distress. This is due to luminal narrowing of the larynx and trachea secondary to edema and/or fibrin exudate. In more severe cases, respiratory failure may ensue. Epiglottitis and/or tracheitis may mimic or complicate laryngotracheobronchitis; fiberoptic exam helps to distinguish between these and other entities. X-rays are not diagnostic but may provide guidance for treatment.

Management Considerations

Assess severity of airway and carefully monitor to detect early hypoxia. Severe croup that is unresponsive to therapy and/or progressive may require intubation with a smaller ET tube than is normally used. (Vol II—Air Skills 1 Aids to Intubation, Air Skills 13 Cricothyrotomy, Air Skills 14 Tracheotomy, Air Skills 15 Tracheotomy in Infants, Air Skills 16 Transtracheal Needle Ventilation)

Humidified O₂delivery. Heliox (80% helium and 20% oxygen) may help. (Vol III—AIR3 Heliox Treatment)
Racemic epinephrine nebs: 0.05 mL/kg/dose (of 2.25% solution) in 3 mL NS; repeat every 20 min (up to 3 doses prn). Observe any patient given this treatment for at least 3 hours.
Dexamethasone 0.15 to 0.6 mg/kg IM/PO.
Rehydration
Assess toxicity. Administer empiric antibiotics if bacterial tracheitis is suspected. Obtain blood and tracheal cultures.
Admit severe cases to an ICU. Severe cases include those patients who continue to have respiratory distress, have a relapse of signs and symptoms of respiratory distress, and/or require administration of multiple epinephrine nebs.

Bacterial Tracheitis (Vol III—PED5 Bacterial Tracheitis)
Bacterial tracheitis is an occasional complicating factor of an upper respiratory infection such as croup, signified by toxicity, high fever, and severe respiratory distress/failure. Prompt diagnosis is essential. At this time it seems that the only means to distinguish this entity from other pediatric upper airway diseases is direct laryngo-tracheo-broncoscopy. Therefore, maintain a high index of suspicion. Endoscopy is diagnostic (direct visualization and cultures) and therapeutic (removal of secretions and airway control). Treatment priorities include aggressive airway management and antibiotics.

Airway

Managing and securing the airway of children in respiratory distress is of paramount importance (and should not be delayed while waiting for endoscopy).

Management Considerations

Assess severity of airway difficulty and carefully monitor to detect early signs of hypoxia. Severe croup that is unresponsive to therapy and/or progressive may require intubation using endotracheal tubes that are smaller than recommended. (Vol II—Air Skills 1 Aids to Intubation, Air Skills 13 Cricothyrotomy, Air SKills 14 Tracheotomy, Air Skills 15 Tracheotomy in Infants, Air Skills 16 Transtracheal Needle Ventilation)
Humidified O₂ delivery. Heliox (80% helium and 20% oxygen) may be helpful. (Vol III—AIR3 Heliox Treatment)
Racemic epinephrine nebs: 0.05 mL/kg/dose (of 2.25% solution) in 3 mL NS; repeat every 20 min prn as many as three times. Observe any patient given this treatment for at least 3 hours.
Dexamethasone 0.15 to 0.6 mg/kg IM/IV
Rehydration
Assess toxicity. Empiric antibiotics should be administered if you suspect bacterial tracheitis. Obtain blood and tracheal cultures.
Admit severe cases to ICU. Severe cases may include those patients who continue to have respiratory distress, have a relapse of signs and symptoms of respiratory distress, and/or require administration of multiple epinephrine nebs.

Antibiotics

Polymicrobial flora may be present; Staphylococcus aureus and Hemophilus influenzae most likely predominate. A reasonable empiric choice is ampicillin/sulbactam (Unasyn) 25 to 75 mg/kg IV every 6 h or ceftriaxone 50 to 75 mg/kg/d. (Note that these do not cover resistant Staphylococcus aureus. Vancomycin may be used for Staphylococcus in this situation, 10 to 15 mg/kg every 6 h.)

Bronchiolitis (Vol III—PED6 Bronchiolitis)
Bronchiolitis is a viral infection (usually caused by the respiratory syncytial virus, RSV) of the 2- to 24-month-old age group, which starts as an URI and progresses to the lower and smaller airways (bronchioles). Mucous, debris, and edema cause obstruction, airway resistance, hyperinflation, and hypoxia, which is evidenced by dyspnea, wheezing, and tachypnea. Progression leads to respiratory failure, hypercapnia, acidosis, and apnea. Other signs include low-grade fever, grunting, poor feeding, irritability, and post-tussive vomiting. Chest x-ray is necessary for assessment of other diseases, but isn‘t diagnostic for bronchiolitis. Nasal washing may be done for RSV antigen testing (rapid turnaround) and/or cultures.

Initial Management

Isolation from other children (RSV is very contagious.)
Humidified O₂
Rapid identification of those at severe risk: underlying cardiopulmonary disease, prematurity, bronchopulmonary dysplasia, immunodeficiency, age < 6 weeks.
Beta agonists (not proven to help but not thought to be harmful and still a standard of care) for wheezing: nebulize albuterol 2.5 mg in 2 to 3 mL NS every 15 to 20 min (up to 3 doses prn). May switch to continuous nebulization if needed.
Ipratropium 250 μg may be added to the albuterol neb.
Assessment of need to secure airway for respiratory support of (near) failure (hypoxia not responding to O₂, tiring child, worsening vital signs, etc.): See Vol II—Air Skills Portals, Air Skills 3 Orotracheal Intubation, Air Skills 4 Rapid Sequence Intubation.
Fluid management: restoration and maintenance.

Steroids are not proven to help. Ribavirin therapy shows no clinical benefit but may still be used in selected/severe inpatient cases.

Pneumonia
The causes and presentations of infection of the lower respiratory tract are variable, depending on age and underlying medical condition(s). Newborns may be hypothermic, and they don’t cough. Pneumonia may present in the very young infant with nonspecific signs and symptoms, such as poor feeding, vomiting, and/or low-grade temperature. Signs such as grunting, severe tachypnea, cyanosis, nasal flaring, and retractions are ominous. Auscultation is difficult; however, until proven otherwise, focal inspiratory crackles indicate pneumonia in a febrile child with previously normal lungs. Obtain a rectal temperature (more accurate in this setting). A chest x-ray is necessary for work-up but not necessarily diagnostic, as pneumonia may lag in appearance on film.

Initial Management Considerations

Use oxygen to keep saturations > 92%. Treat bronchospasm with inhaled albuterol: 2.5 mg in 2 to 3 mL NS every 15 to 20 min (up to 3 doses prn). May switch to continuous nebulization, if needed. Ipratropium (Atrovent) 250 μg may be added to the albuterol neb.
Watch closely for worsening respiratory status. Severe respiratory distress unresponsive to oxygen therapy needs intubation and mechanical ventilation. (Vol II—Air Skills Portals, Air Skills 3 Orotracheal Intubation, Air Skills 4 Rapid Sequence Intubation) Intubated patients may benefit from tracheal suction; send the secretions for culture.
Monitor hydration status carefully; fluid management is a critical aspect of care. Pediatric patients become dehydrated easily. However, overaggressive fluid overload may cause pulmonary edema and worsen the patient’s respiratory status. (Vol II—Circ Skills 2 Central Venous Access, Circ Skills 3 Central Venous Pressure Measurement) For hypotensive patients, administer a bolus with 20 mL/kg of NS and monitor closely. Patients not responding may be in septic shock and require invasive monitoring of fluid replacement therapy. (Vol III—IN3 Sepsis in Adults, Trau Care 2 Shock)
Arrange to have a thoracentesis done if a pleural effusion is present. Empyemas need ongoing drainage. Note: this procedure is not an emergency procedure, should not interfere with ongoing evaluation and treatment, and can be done hours after antibiotics have been started.
Purulent pericarditis may occur as a complication of pneumonia. Perform echocardiography and tap any significant accumulation of fluid (send for culture). (Vol II—Circ Skills 6 Pericardiocentesis)
Certain viruses are common causes of pneumonia at different ages: CMV, rubella, and herpes in neonates; RSV and others in infants; adeno, influenza, and parainfluenza in children/adolescents.
Start empiric antibiotics once the working diagnosis of bacterial pneumonia has been established; diagnostic testing should not delay antibiotic administration. If possible, draw blood cultures before starting antibiotics. Culture the tracheo-bronchial secretions of intubated patients. The following drug choices are from The Sanford Guide to Antimicrobial Therapy 2011⁴:

Outpatient treatment of stable, nontoxic, well-hydrated, and nourished patients:

3 months to 5 years: Consider Streptococcus pneumoniae, chlamydia, mycoplasma. Choose between erythromycin, clarithromycin, or azithromycin.
5 years to 18 years: Consider mycoplasma, chlamydia, Streptococcus pneumoniae. Choose between clarithromycin or azithromycin. Doxycycline is acceptable if the patient is > 8 years old.
If drug-resistant Streptococcus pneumoniae is suspected, look up local susceptibility patterns in your community and treat accordingly.

Initial inpatient treatment regimens. (See doses immediately following.)

Neonates: Consider group B Streptococcus, Listeria, coliforms, Staphylococcus aureus, P aeruginosa (also chlamydia and syphilis). Treatment: Ampicillin and gentamycin or ampicillin and cefotaxime (Claforan). Substitute vancomycin for ampicillin if resistant Staphylococcus aureus is of concern. Add erythromycin to any of the above if chlamydia is a possibility.
1 to 3 months afebrile pneumonia syndrome: Consider chlamydia, Bordetella. Treatment: erythromycin.
1 to 24 months: Consider Streptococcus pneumoniae, Hemophilus influenza, chlamydia, mycoplasma, Staphylococcus aureus (rare). Non-ICU treatment: cefuroxime (and erythromycin for chlamydia). ICU setting treatment: cefotaxime and cloxacillin (and erythromycin for chlamydia) or ceftriaxone and cloxacillin (and erythromycin for chlamydia).
3 months to 5 years: Consider Streptococcus pneumoniae, mycoplasma, chlamydia. Treatment: cefuroxime and erythromycin.
5 to 18 years: Consider Streptococcus pneumoniae and mycoplasma. Treatment: ceftriaxone and azithromycin. Consider vancomycin as a substitute for ceftriaxone if you suspect drug-resistant Streptococcus pneumoniae.

Initial Dosages

Ampicillin: 50 mg/kg IV; see age and weight for specific interval (every 6/8/12 h).
Azithromycin: 10 mg/kg PO for first day (up to 500 mg)
Cefotaxime: 66 mg/kg IV every 8 h
Ceftriaxone: 50 to 75 mg/kg IV every 24 h (to max of 2 g/d)
Cefuroxime: 50 mg/kg IV every 8 h
Clarithromycin: 7.5 mg/kg PO q 12 h (max 1 g/d)
Cloxacillin: 50 mg/kg IV every 6 h
Erythromycin: 10 mg/kg IV every 6 h (every 8 to 12 h in neonates)
Gentamycin: 2.5 mg/kg IV; see age and weight for interval (every 6, 8, or 12 h)
Nafcillin: neonates, 25 to 37 mg/kg IV (dose and interval depends on neonatal age and size); 1 month and older, 37 mg/kg IV every 6 h
Vancomycin: neonates, 12.5 to 22 mg/kg IV (dose and interval depends on age and size); 1 month and older, 10 to 15 mg/kg every 6 h

Asthma^5,6
There are numerous reasons for a pediatric patient to wheeze besides asthma, including anaphylaxis, foreign bodies, bronchiolitis, CHF, pneumonia, acute respiratory distress syndrome, or any other cause of thick secretions. If you suspect any of these, proceed to the appropriate sections. A chest x-ray may be invaluable in determining other causes and/or complications. Suspect an increase in mortality risk in patients who have steroid dependence, syncope, history of ICU admission/mechanical ventilation, more than two asthma hospitalizations per year, more than three asthma emergency visits per year, or are worse at night.

For the potentially unstable asthma patient who is not yet intubated: Prepare for intubation while performing the following:

Oxygen or Heliox therapy to keep saturation> 95%. (Vol III—AIR3 Heliox Treatment)

Continuous beta agonist therapy: albuterol neb 0.5 mg/kg/h not to exceed 15 mg/h.
Nebulized ipratropium bromide, 0.25 to 0.5 mg. May repeat every 20 minutes prn to a total of three doses.
Epinephrine (1:1000 solution) 0.01 mg/kg (up to 0.3 mg) IM/SQ every 20 min up to 3 doses or terbutaline 0.01 mg/kg SQ (up to 0.3 mg) every 20 minutes prn for a total of three doses. (Epinephrine IM may result in higher, more rapid, and more predictable peak plasma epinephrine concentrations than the SQ route.^3,4)
Magnesium 25 mg/kg IV over 5 to 10 minutes (not to exceed 2 g).
Methylprednisolone 2 mg/kg IV.
Proceed with RSI/airway management, if the patient is not improving. Consider ketamine as the sedative for its bronchodilator properties. (Vol II—Air Skills 4 Rapid Sequence Intubation; Vol III—AIR4 Ventilator Management, AIR7 Status Asthmaticus)

If ventilating the patient, allow extra time for exhalation. Patients with severe asthma have a problem with hyperinflation. Ventilate slowly, 8 to 10 times/minute.

For a stable patient:

Oxygen to keep saturation > 95%.
Albuterol neb, 0.15 mg/kg/dose (up to 5 mg; minimum dose 2.5 mg). Repeat every 20 minutes prn for a total of three doses.
Ipratropium bromide neb, 0.25 to 0.5 mg. Repeat every 20 minutes prn for a total of three doses.
Start steroids as soon as evaluation has been completed. Oral prednisone (or prednisolone) 1 to 2 mg/kg; methylpresnisolone 2 mg/kg IV.⁷
Consider pulmonary function tests (PEFR/FEV₁) in older children to help guide further management:

Asymptomatic/resolved symptoms and PEFR/FEV₁ > 70% predicted: Evaluate for outpatient management. (Vol III—AIR7 Status Asthmaticus)
Continued symptoms and PEFR/FEV₁ >70% predicted: Continue inhalation therapy while reassessing for alternative conditions. (Vol I—Pathway 6 Adult Respiratory Emergencies)
Moderate symptoms and PEFR/FEV₁ from 40% to 70% predicted: Continue inhalation therapy, Consider continuous beta agonist therapy: albuterol neb 0.5 mg/kg/hour not to exceed 15 mg/h. (Vol III— AIR7 Status Asthmaticus)
Severe symptoms and PEFR/FEV₁ <40% predicted: Continue inhalation therapy.
Consider magnesium 25 mg/kg IV (not to exceed 2 g) over 20 minutes. Consider Heliox. (Vol III—AIR3 Heliox Treatment) Closely assess response, and see Vol III—AIR7 Status Asthmaticus for other considerations.

Near Drowning
Pertinent history includes the temperature of the water (cold water immersion carries a better prognosis), submersion time, type of water (although salt water versus fresh water carries little significance), water contaminants, and other scene factors. Determine any secondary causes of drowning such as events around the incident (use of alcohol/drugs, exhaustion, hypothermia, suicide, abuse, trauma, rescue attempts) or underlying disease (seizures, hypoglycemia, cardiac). These can play an important role in immediate and ongoing treatment. For example, a common scenario would be a diving accident with possible head and neck/spine injuries. Unless the patient is reliable in being able to recount the incident or there is a reliable eyewitness account of all details, suspect concomitant trauma. (Vol I—Pathway 9 Pediatric Trauma)

Hypoxia is the main factor contributing to tissue injury, organ failure, and death. Immediate term effects include:

Increased vascular permeability, leading to loss of fluid from the intravascular compartment and hypovolemia/hypotension
Myocardial dysfunction, cardiac arrhythmias, asystole
CNS neuronal injury

Aspiration (usually low volumes due to laryngospasm) causes injury to the alveolar/capillary unit with resultant impaired gas exchange, decrease in functional volume, and possible pulmonary edema.

Acidosis may result from both of these primary insults.
Clinical presentation of submersion injuries can range from no symptoms to death. History and exam guide diagnostic studies. Altered mental status makes complete assessment much more complex. Do not assume its cause but systematically rule out all serious potential and reversible causes. (If the patient has hypoxic neuronal damage, intoxication, or occult closed head trauma, see Vol I—Pathway 1 Altered Level of Consciousness.) Remember that normal c-spine x-rays do not rule out a spinal injury; continue to utilize appropriate protective measures.

Management Considerations

Rapid assessment for and treatment of hypoxia and acidosis while protecting the cervical spine:

If supplemental oxygen isn’t reversing hypoxia, intubation and mechanical ventilation is indicated in order to use PEEP. (Vol II—Air Skills 4 Rapid Sequence Intubation; Vol III—AIR4 Ventilator Management)
If you are intubating and using paralytics/sedatives for management purposes and your patient has altered mental status, use anti-seizure medication unless seizures can be ruled out. (Vol III—NEU1 Status Epilepticus)
Obtain early ABG for assessment and treatment of acidosis: most acidosis responds to correction of hypoxia and dehydration. See Vol III—END/M6 Acid-Base for use of bicarbonate in severe acidosis only after ventilation has been assured.
Early establishment of core temperature with aggressive rewarming measures if patient is hypothermic, as hypothermia prolongs/causes organ dysfunction and changes (and hinders) treatment priorities and efforts. (Vol I—Pathway 1 Altered Level of Consciousness)
Cardiac monitoring for dysfunction and dysrhythmias. Inotropic support may be required if hypotension doesn’t respond to fluid treatment. (Vol I—Pathway 2 Cardiovascular Emergencies)
Treatment of hypovolemia/hypotension while avoiding overhydration and pulmonary edema: consider initial fluid bolus of 20 cc/kg NS IV and invasive monitoring such as CVP and arterial line. (Vol II—Circ Skills 1 Arterial and Venous Catheter Insertion, Circ Skills 3 Central Venous Pressure Measurement)
Decompression of the stomach with NG tube.
Assessment for bronchoscopy for FB, debris, or aspirated food.
Early consultation with an intensivist for appropriate care level. ARDS and multi-system failure can occur and require a high level of intensive care. See # 13 below, ARDS, Acute Respiratory Distress Syndrome.
Close monitoring for progression and complications. Observe a patient who is completely asymptomatic for at least 3 to 6 hours.
Adjunctive measures: empiric antibiotics are controversial and probably not indicated unless the patient was submerged in contaminated water. Early steroid use is not indicated.

Acute Respiratory Distress Syndrome

Acute Respiratory Distress Syndrome (ARDS) is a hypoxemic respiratory failure syndrome of non-cardiogenic pulmonary edema that is associated with numerous precipitating conditions and/or critically ill patients. Treatment for the pulmonary system alone is intensely complex and meticulously supportive. There is no definitive treatment per se. For further discussion, see Vol I—Pathway 6, #6 Acute Respiratory Distress Syndrome. Respiratory and multi-organ system failure are both common in these patients. If the team is caring for a child who fits into the category of someone likely to develop ARDS (such as a severe near drowning victim), consider early transfer to a facility with pediatric ICU capabilities and a readily available pediatric intensivist/ pulmonologist.

References

Adams WG, Deaver KA, Cochi SL, et al. Decline of childhood Haemophilus influenzae type b (Hib) disease in the Hib vaccine era. JAMA 1993; 269(2): 221-226.
Hughes G, Fitzharris P. Managing acute anaphylaxis: New guidelines emphasize importance of intramuscular adrenaline. BMJ. 1999;319:1-2.
Simons FE, Gu X, Simons KJ. Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy Clin Immunol. 2001;108:871-873.
Gilbert DN, et al, eds. The Sanford Guide to Antimicrobial Therapy. 41st ed. Antimicrobial Therapy, Inc.; 2011.
National Institutes of Health. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert Panel Report III: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: U.S. Department of Health and Human Services; 2007.
Institute for Clinical Systems Improvement. Health Care Guideline: Diagnosis and Treatment of Asthma. 9th ed. June 2010. http://www.icsi.org/asthma__outpatient/asthma__diagnosis_management_of__guideline_.html. Accessed October 6, 2010.
Fleisher GR, Ludwig S, Henretig FM, Ruddy RM, Silverman BK (eds). Textbook of Pediatric Emergency Medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.

Pathway 7: Pediatric Respiratory

References

Edition 13-October 2011