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M03: Pediatrics - Respiratory Emergencies

Heather Rose

Updated:

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The respiratory system is responsible for the exchange of oxygen and carbon dioxide in the body. It consists of organs and structures that work together to facilitate breathing and ensure the body receives the oxygen it needs while eliminating waste carbon dioxide.

Respiratory conditions in children can be categorized into upper airway obstructions, lower airway obstructions, lower airway restrictive pathology, and disordered control of breathing.

Upper airway obstructions occur when there is an increased work of breathing due to an obstruction above the thorax. This is demonstrated in croup and epiglottitis. Lower airway obstructions, by contrast, result from obstructive problems below the thorax such as increased swelling, or bronchospasm. Obstructions can originate from multiple causes, a few common ones being foreign bodies, infections, or anaphylaxis.

Restrictions in the lower airways can be a result of “stiffening” of lung tissue, caused by increased fluid accumulation, toxic exposure, allergic reactions, infiltration, or inflammation.  These situations can be best managed with a staged approach of oxygenation and/or ventilation strategies.

Dysfunction within the respiratory center of the brain is responsible for the development of disordered breathing.  These situations typically stem from neurological disfunction and secondarily affect respiratory patterns. This can include problems such as increased intracranial pressure, neuromuscular disease, and some poisonings and overdoses.

Respiratory failure occurs when a patient’s breathing becomes inadequate and results in ineffective oxygenation and/or ventilation. 

  • The PAT is designed to be a quick and efficient assessment tool. In emergency situations, where time is crucial, healthcare providers can rapidly observe a child's appearance, breathing, and circulation to gather essential primary assessment information about the patient's condition in a short amount of time.
  • The PAT relies on visual observation and doesn't require any specialized equipment or extensive medical knowledge
  • The component of appearance can be assessed utilizing the mnemonic TICLS, which stands for Tone, Interactiveness, Consolability, Look and Speech.
  • Upper airway obstruction can be an uncomfortable call to attend as many patients may look ill or unwell, but require purely comfort levels for treatment.
  • Lower airway obstruction results in an inability for the patient to get air out of the chest.  This is usually due to excessive swelling or bronchospasm.
  • Lower airway restrictive pathologies consist of numerous conditions that result in decreasing lung compliance or stiffening of the lung.  The general management of these conditions concern correcting oxygenation and ventilation utilizing an escalation pathway of increasing FiO2 via nasal cannula, face mask, heated HiFlow nasal cannula (2 L/min to a max of 60 L/min), NIV therapy, then intubation.  Bronchospasm can be treated with a B2 agonist.
  • Disordered Control of Breathing are a series of conditions affecting the respiratory control center in the brain or neuromuscular diseases.

Refer to the additional clinical practice guidelines for symptom-specific treatment planning:

  • Continuous salbutamol can decrease serum potassium.
  • Ventilating the lower airway restrictive disease patient may require high peak inspired pressure of up to 32 cmH2O and high PEEP of up to 10-15 cmH2O.  Diligent monitoring for the development of a pneumothorax is required.
  • Succinylcholine should be avoided in the patient with neuromuscular disease due to the possibility of triggering hyperkalemia or malignant hyperthermia.

Interventions

  • Provide reassurance and a calming environment
  • Keep the patient warm and protect from further heat loss
  • Place the patient in a position of comfort, as permitted by clinical condition.  In general, limit patient movement.
  • Provide supplemental oxygen as required to maintain oxygen saturation ≥97%
  • Conduct ongoing assessment and gather collateral information, such as medications and identification documents
  • Establish ingress and egress routes from the patient's location
  • Communicate patient deterioration to follow-on responders
  • Manual airway maneuvers as required
    • → B01: Airway Management
    • Most pediatric airways can be effectively managed with proper positioning and an OPA/NPA (as per license level) and BVM without any requirements for further airway interventions.  The gold standard for airway management is a self-maintained airway.  Bag-valve mask is the preferred technique for airway management in pediatric respiratory emergencies and is reasonable compared with advanced airway interventions (endotracheal intubation or supraglottic airway).
  • Supraglottic airway devices may be used to support oxygenation and ventilation in a staged approach, following confirmation of the ability to ventilate the patient with a bag-valve mask and oropharyngeal airway:
  • For bronchospasm, reactive airway disease, and asthma: 
    • Salbutamol via MDI
    • ⚠️ Requires completion of PCP scope expansion education:
    • Consider intramuscular EPINEPHrine; epinephrine via intramuscular injection should be considered for a patient with SpO2 < 90% and moderate to severe symptoms of asthma that are unresolved with the use of salbutamol administered by MDIs
    • See → B03: Asthma and Bronchospasm for additional information
  • For croup and epiglottitis
  • Consider vascular access and fluid administration (in patients ≥ 12 years of age) 
  • Consider addition of ipratropium to supplement salbutamol
  • Consider magnesium sulfate for significant and protracted bronchospasm
  • Consider intraosseous cannulation if peripheral access is unavailable
  • Consider procedural sedation to facilitate airway management.  Where SGAs and/or bag-valve mask ventilation fail to provide adequate oxygenation, tracheal intubation may be permissible in cases where paramedics are otherwise unable to obtain and maintain a patent airway.  To be clear, this is for actual or immediately impending failure of airway patency unable to be managed by any other means other than intubation. CliniCall consultation required prior to attempting intubation.
  • Consider intubation in patients whose airways cannot be managed through less invasive means
  • Decompress suspected tension pneumothorax
    • Out-of-hospital needle thoracentesis should be considered AGMP.  Although this is a low occurrence procedure, it does potentially expose the paramedic to an increased risk of exposure.  If this procedure is needed, crews are directed to proceed with airborne PPE including face-shield, EHFR/N95 mask, gown, and gloves.
    • → PR21: Needle Thoracentesis 
  • Mechanical ventilation (NIV and invasive)
  • Chest tube maintenance
  • Osmotic agents
  • 3% Saline
  • Infusion medication
  • Antibiotic therapy
  • Steroid therapy
  • Nonselective adenosine receptor antagonist and phosphodiesterase inhibitor

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