Pediatric Respiratory Distress

Key considerations: Foreign body aspiration, Epiglottitis, Severe croup with impending obstruction

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history: Onset: sudden (foreign body) vs gradual (viral); Barky cough (croup) vs wheezing (asthma/bronchiolitis); Choking episode or witnessed aspiration; Prematurity history, previous intubation; Immunization status (Hib, pertussis); Sick contacts, seasonal pattern; exam: Respiratory rate for age, work of breathing; Stridor (inspiratory = supraglottic, biphasic = subglottic); Wheezing (expiratory = lower airway); Air entry bilaterally; Capillary refill, perfusion; Mental status assessment; labs: ABG/VBG if impending respiratory failure; CBC if bacterial infection suspected; RSV/viral panel in bronchiolitis season; imaging: CXR: hyperinflation, infiltrate, foreign body, air trapping; Lateral neck XR if epiglottitis or retropharyngeal abscess suspected; Inspiratory/expiratory films or bilateral decubitus for suspected foreign body; bedside: Continuous pulse oximetry; Point-of-care glucose; Lung ultrasound for pneumonia or effusion

immediate: Supplemental O2 to maintain SpO2 ≥92%; Keep child calm — minimize agitation (worsens obstruction); Bag-valve-mask ventilation if respiratory failure imminent; Prepare for advanced airway if severe; general: Frequent reassessment of work of breathing; Minimize invasive procedures if upper airway obstruction; specific: diagnosis: Croup; steps: Dexamethasone 0.6mg/kg PO/IM (single dose, max 16mg); Nebulized racemic epinephrine if moderate-severe stridor at rest; Observe 2-4 hours post racemic epi for rebound; Mist therapy NOT recommended; diagnosis: Bronchiolitis; steps: Supportive care: suctioning, hydration, O2 as needed; Trial of albuterol NOT routinely recommended (AAP 2014); Hypertonic saline nebulization if admitted; High-flow nasal cannula if persistent hypoxia or increased work of breathing; diagnosis: Asthma exacerbation; steps: Albuterol nebulization 2.5mg q20min x3 or continuous; Ipratropium 250-500mcg nebulized with first 3 albuterol treatments; Dexamethasone 0.6mg/kg PO (single dose — non-inferior to 5-day prednisone); Magnesium 50mg/kg IV over 20 min (max 2g) if severe/refractory; diagnosis: Foreign body aspiration; steps: If complete obstruction: back blows/chest thrusts (<1yr) or abdominal thrusts (>1yr); If partial obstruction: do NOT attempt blind finger sweep; Urgent bronchoscopy for removal; CXR may be normal — clinical suspicion is key

admit: Persistent hypoxia requiring supplemental O2; Toxic-appearing or clinical dehydration; Severe retractions not improving with treatment; Apneic episodes; Poor feeding in infant; Post racemic epinephrine observation if stridor recurs; discharge: Mild croup responding to dexamethasone; Asthma exacerbation with good response to treatment and home plan; Mild bronchiolitis with adequate feeding, SpO2 ≥92% on room air; consults: Pediatric surgery/ENT for foreign body removal; PICU for impending respiratory failure

In bronchiolitis, deep suctioning and albuterol are NOT routinely helpful — supportive care is the mainstay (AAP 2014)
Croup scoring: Westley Croup Score helps grade severity — most kids improve dramatically with a single dose of dexamethasone
Epiglottitis is rare post-Hib vaccine but still occurs — drooling + stridor + toxic = do NOT examine the throat, go straight to OR
Foreign body aspiration: normal CXR does NOT rule it out — if history is suggestive, get bronchoscopy
Single dose dexamethasone 0.6mg/kg is non-inferior to multi-day prednisone for both croup and asthma (multiple RCTs)

AAP Bronchiolitis Guidelines 2014, GINA Pediatric Asthma 2024, Pediatric Emergency Medicine (Fleisher & Ludwig). Last reviewed: 2024-11-01