This practice guideline contains changes related to COVID-19.
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 can consist of a foreign body, tissue swelling, subglottic stenosis from previous intubation trauma, and the development of a tumour. Lower airway obstructions, by contrast, result from obstructive problems below the thorax: foreign bodies, and bronchial swelling or constriction.
Restrictions in the lower airways are a result of “stiffening” of lung tissue, caused by increased fluid accumulation from pulmonary edema, toxic exposure, allergic reactions, infiltration, and inflammation. Abdominal structures can also push on lung tissue, creating a restrictive condition.
Dysfunction within the respiratory center of the brain is responsible for the development of disordered breathing. These are more properly neurological problems with respiratory effects, and can include problems such as increased intracranial pressure, neuromuscular disease, and some poisonings and overdoses.
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.
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.
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).
Emergency Medical Responder (EMR) & All License Levels Interventions
Provide supplemental oxygen to maintain SpO2 ≥ 94%
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
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.
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.