History:

 

• Time of onset
• Possibility of foreign body
• Medical history
• Medications
• Fever or respiratory infection
• Other sick siblings/contacts
• History of trauma

 

Significant Findings:

 

• Wheezing/stridor
• Respiratory retractions
• Increased heart rate
• Altered level of consciousness
• Nasal flaring/tripoding
• Anxious appearance

 

Differential:

 

• Asthma/epiglottitis
• Allergic reaction
• Aspiration/foreign body
• Infection
  • Pneumonia
  • Croup
• Congenital heart disease
• Medication/toxin
• Trauma

 

Assessment:

 

• Assess symptom severity;
• allow patient to maintain a position of comfort (usually sitting)

 

Treatment:

 

• Oxygen and pulse oximetry

 

Wheezing ?

 

• Yes

 

• • Combivent (DuoNeb) and/or Albuterol (Ventolin) 2.5 mg via nebulizer may repeat Albuterol once to max 5 mg

 

• • Initiate IV if O2 <92% after first treatment

 

• • OLMC: For severe respiratory distress characterized by difficulty speaking, accessory muscle use, or low O2; request Epinephrine 1:1,000 0.15 mg IM.

 

Stridor ?

 

• Yes

 

• • Consider Racemic Epinephrine 0.5 mL (diluted to 3 mL with Normal Saline) via nebulizer, may NOT be repeated

 

• • Initiate IV if O2  < 92% after first treatment

 

• • OLMC: For severe respiratory distress characterized by difficulty speaking, accessory muscle use, or low O2; request Epinephrine 1:1,1000 0.15 mg IM

 

Notify receiving facility or contact Medical Control

 

PEARLS:

 

• Pediatric = 1 day to less than age 12, or less than 55 kg in ages 12-18.
• Use Handtevy for drug dosages.
• Pulse oximetry should be monitored continuously if initial saturation is less than or equal to 96%, or there is a decline in patient status despite normal pulse oximetry readings.
• Do not force a child into a position.  They will protect their airway by their body position.
• The most important component of respiratory distress is airway control.  Avoid direct laryngoscopy unless intubation is imminent.
• Asthma is the most commonly seen obstructive airway disease in pediatric patients, as with adults, asthma causes outflow obstruction (wheezing) because of narrowing of the lower airways.
• Narrowing of the upper airway, as with croup and acute epiglottitis will present with stridor. These patients have the potential to progress to ventilatory failure.  Direct visualization of the upper airway of these patients should be limited.
• Bronchiolitis is a viral infection typically affecting infants resulting in wheezing which may not respond to beta-agonists.

• Croup typically affects children less than 2 years of age. It is viral, possible fever, gradual onset, no drooling is noted.
• Epiglottitis typically affects children greater than 2 years of age. It is bacterial, with fever, rapid onset, possible stridor, patient wants to sit up to keep airway open, drooling is common. Airway manipulation may worsen the condition.

 

Appearance

 

• Often the first clue to a problem
• Tone
• Interactiveness
• Consolability
• Look/gaze (eye contact)
• Speech/cry

 

Skin Circulation

 

• Reflects overall adequacy of perfusion

 

 Abnormal audible breath sounds

 

• Stridor - upper airway obstruction
• Wheezing - partially blocked small airways
• Grunting - lower airway (pneumonia)
• Retractions - suprasternal, intercostal, or subcostal
• Nasal flaring

 

Positioning

 

• Abnormal appearance + Poor circulation

 

• • • • = SHOCK

 

• Abnormal appearance + Change in work of breathing

 

• • • = RESPIRATORY FAILURE

 

• Normal appearance + Change in work of breathing

 

• • • = RESPIRATORY DISTRESS