Chapter 7: Management of Respiratory Emergencies

Respiratory problems can be classified into two categories based on their severity.

Respiratory Distress:

• Tachypnea
• Increased respiratory efforts (eg, nasal flaring, retractions)
• Inadequate respiratory effort (eg, hypoventilation or bradypnea)
• Abnormal airway sounds (eg, strider, wheezing, grunting)
• Tachycardia
• Pale, cool skin
• Changes in level of consciousness
• Seesawing or “abdominal” breathing
• Head bobbing

Respiratory Failure:

•  Marked tachypnea (early)
• Bradypnea, apnea (late)
• Increased, decreased, or no respiratory efforts
• Poor or absent distal air movement
• Tachycardia (early)
• Bradycardia (late)
• Cyanosis
• Stupor, coma (late)

Respiratory problems are categorized Into FOUR categories based upon type: 

Evaluate by observing symmetric chest expansion and by listening for bilateral breath sounds. Breath sounds should be auscultated over the anterior and posterior chest wall and in the axillary areas. Listen for intensity and pitch of sounds.

Upper Airway Obstruction:

• Croup, Anaphylaxis and Foreign Body Airway Obstruction are common causes.
• Symptoms-

Croup:

• 1. Barking cough
• 2. Hoarseness
• 3. Stridor (high-pitched sound when breathing in)
• 4. Difficulty breathing
• 5. Fever
• 6. Sore throat

Anaphylaxis:

• 1. Difficulty breathing
• 2. Swelling of the face, lips, or tongue
• 3. Hives or rash
• 4. Rapid or weak pulse
• 5. Nausea or vomiting
• 6. Abdominal pain
• 7. Feeling of impending doom
• 8. Loss of consciousness

Foreign Body Airway Obstruction:

• 1. Choking or gagging
• 2. Difficulty breathing or noisy breathing
• 3. Inability to speak or cry
• 4. Cyanosis (bluish skin color)
• 5. Clutching the throat
• 6. Ineffective coughing

Treatment:

• Treatment of choice for Croup- modified oxygen and nebulized epinephrine, corticosteroids
• Treatment of choice for Anaphylaxis- intramuscular (IM) epinephrine or auto injector, albuterol, antihistamines, corticosteroids,
• Treatment of choice for Aspiration of foreign body- allowing position of comfort and specialty consultation.

Lower Airway Obstruction:

• Asthma and bronchiolitis are common causes.
• Symptoms-

Asthma:

• 1. Recurrent episodes of wheezing
• 2. Shortness of breath
• 3. Chest tightness
• 4. Coughing, especially at night or early morning
• 5. Wheezing that may worsen with respiratory infections or exposure to triggers such as allergens or irritants
• 6. Difficulty breathing or rapid breathing
• 7. Fatigue

Bronchiolitis:

• 1. Runny or stuffy nose
• 2. Cough
• 3. Sneezing
• 4. Mild fever
• 5. Rapid or labored breathing
• 6. Wheezing
• 7. Irritability or fussiness
• 8. Difficulty feeding or refusing to feed in infants

Treatment:

• Treatment of choice for Bronchiolitis-nasal suctioning and bronchodilator
• Treatment of choice for Asthma- albuterol, corticosteroids, SQ epinephrine, magnesium sulfate, terbutaline

Lung Tissue (Parenchymal) Disease:

• Pneumonia/Pneumonitis and Pulmonary Edema are common causes
• Symptoms

Pneumonia/Pneumonitis:

• 1. Fever
• 2. Cough
• 3. Shortness of breath
• 4. Chest pain
• 5. Fatigue
• 6. Difficulty breathing
• 7. Rapid breathing
• 8. Increased heart rate
• 9. Bluish discoloration of lips or nails in severe cases

Pulmonary Edema:

• 1. Shortness of breath, especially when lying down
• 2. Persistent coughing with frothy or pink-tinged sputum
• 3. Rapid or irregular heartbeat
• 4. Sweating
• 5. Feeling of anxiety or restlessness
• 6. Chest pain or discomfort
• 7. Wheezing or gasping for breath
• 8. Fatigue

Treatment:

• Treatment of choice for Pneumonia/pneumonitis with albuterol and antibiotics
• Treatment of choice for Pulmonary edema with ventilator and vasoactive support, and consider a diuretic

Disordered control of ventilation:

• Increase ICP, Poisoning/Overdose, and Neuromuscular Disease are common causes
• Symptoms-
• Increased Intracranial Pressure (ICP):
• 1. Severe headache
• 2. Nausea and vomiting
• 3. Blurred or double vision
• 4. Changes in behavior or personality
• 5. Lethargy or confusion
• 6. Seizures
• 7. Pupillary changes (unequal pupil size)
• 8. High-pitched crying in infants

 Poisoning/Overdose:

•  1. Nausea and vomiting
•  2. Confusion or altered mental status
• 3. Difficulty breathing
• 4. Chest pain
• 5. Seizures
• 6. Unconsciousness
• 7. Abdominal pain
• 8. Sweating

Neuromuscular Disease:

• 1. Muscle weakness or fatigue
• 2. Difficulty with coordination and balance
• 3. Tremors or involuntary movements
• 4. Numbness or tingling in extremities
• 5. Changes in muscle tone
• 6. Difficulty swallowing
• 7. Fatigue
• 8. Progressive loss of motor function

Treatment:

• Treatment of choice for Increased ICP by avoiding hypoxemia, hypercarbia, and hyperthermia
• Treatment of choice for Poisoning/overdose with antidote and call poison control center
• Treatment of choice for Neuromuscular disease with ventilator support

Steps for Management of Respiratory Emergencies for PALS

The management of respiratory emergencies in Pediatric Advanced Life Support (PALS) involves a structured approach to assess and treat children with respiratory distress or failure. Here’s a comprehensive guide to managing respiratory emergencies in pediatric patients:

1. Initial Assessment

• Initial Impression: Quickly assess the child’s overall appearance, work of breathing, and circulation. Look for signs of respiratory distress such as nasal flaring, retractions, grunting, or cyanosis.

2. Primary Assessment (ABCs)

• Airway (A):
• Ensure the airway is open and clear.
• Use head tilt-chin lift or jaw thrust maneuver if needed.
• Suction secretions if there is an obstruction.
• Consider advanced airway management if the airway is compromised.
• Breathing (B):
• Assess respiratory rate, effort, and chest movement.
• Listen for abnormal breath sounds such as wheezing, stridor, or crackles.
• Monitor oxygen saturation using pulse oximetry.
• Provide supplemental oxygen to maintain SpO2 ≥ 92%.
• For severe respiratory distress or failure, consider non-invasive ventilation or mechanical ventilation.
• Circulation (C):
• Check heart rate, capillary refill, and skin color.
• Establish intravenous (IV) or intraosseous (IO) access if needed.
• Administer fluids or medications as indicated.

3. Secondary Assessment

• Focused History (SAMPLE):
• Signs/Symptoms: Onset, duration, and progression of symptoms.
•  Allergies: Any known allergies, especially to medications.
• Medications: Current medications and recent changes.
• Past Medical History: Relevant medical history, including chronic respiratory conditions.
• Last Meal: Time of the last meal (important for sedation/intubation).
• Events: Events leading up to the respiratory emergency.
• Focused Physical Examination: Perform a detailed examination to identify the cause of respiratory distress, including a head-to-toe assessment and auscultation of lung sounds.

4. Management of Specific Respiratory Conditions

• Upper Airway Obstruction:
• Croup: Administer nebulized epinephrine and dexamethasone.
• Anaphylaxis: Administer intramuscular epinephrine, antihistamines, and corticosteroids. Ensure airway protection and prepare for possible intubation.
• Foreign Body Aspiration: Perform back blows and chest thrusts for infants, or abdominal thrusts for older children. Prepare for advanced airway management if obstruction persists.
• Lower Airway Obstruction:
• Asthma: Administer short-acting bronchodilators (example albuterol) and systemic corticosteroids. Consider magnesium sulfate and continuous nebulized bronchodilators for severe cases.
• Bronchiolitis: Provide supportive care with oxygen therapy and hydration. Consider high-flow nasal cannula (HFNC) or CPAP for severe cases.
• Parenchymal Disease:
• Pneumonia: Administer appropriate antibiotics and provide supportive care with oxygen and fluids.
• Pulmonary Edema: Administer diuretics, provide oxygen, and consider positive pressure ventilation.
• Disordered Control of Breathing:
• Central Nervous System (CNS) Depression: Ensure airway protection and provide ventilatory support as needed. Address the underlying cause, such as infections,increased ICP, poisoning/overdose, or neuromuscular disease.

5. Ongoing Monitoring and Reassessment

• Continuously monitor vital signs, oxygen saturation, and clinical status.
• Reassess the effectiveness of interventions and adjust the treatment plan accordingly.
• Prepare for potential deterioration and the need for advanced airway management.

6. Transport and Handoff

• Ensure safe transport to an appropriate facility if needed.
• Provide a detailed handoff to the receiving healthcare team, including the child’s condition, interventions performed, and response to treatment.

Summary:

Effective management of respiratory emergencies in PALS involves a thorough and systematic approach, starting with initial assessment and primary ABCs, followed by a focused history and physical examination. Specific conditions like upper airway obstruction, lower airway obstruction, parenchymal disease, and disordered control of breathing require targeted interventions. Continuous monitoring, reassessment, and proper handoff are crucial for ensuring the best outcomes for pediatric patients experiencing respiratory emergencies.