Pediatric

Respiratory
Emergencies
Nancy A. Johnson,
RRT/NPS

“Respiratory emergencies are 1 of the most common reasons parents seek

evaluation for their children in the Emergency department”

Emerg Med Clin North Am. 2016 Feb;34(1):77-96. doi:

10.1016/j.emc.2015.08.006.
 Respiratory Disorders
Respiratory Disorders are the 2nd leading cause of ER
visits in children (#1 is Injury and poisoning)

https://www.hcup-us.ahrq.gov/reports/statbriefs/sb157.pdf
 Objectives
• Discuss the differences between pediatric and adult anatomy &
physiology

•How to properly assess a pediatric patient with respiratory distress

and discuss emergency room presentation of common pediatric
respiratory diseases

• ABCDE tool for Assessment

•Discuss Most Common Pediatric Respiratory Emergencies

Kids are
not little
Adults
Airway: Child vs Adult
NOSE: Generally smaller, increased resistance,
Smaller septum & nasal bridge is flat and flexible . . .
Obligatory nose breathers

VOCAL CORDS: located at C3-4 versus C5-6 in

adults . . . Larynx is more anterior
Contributes to aspiration if neck is hyperextended

CRICOID RING Is the narrowest part of the airway

instead of vocal cords

AIRWAY DIAMETER is 4 mm vs.. 20 mm in adult

TRACHEAL RINGS more elastic & cartilaginous,

can easily crimp off trachea

More SMOOTH MUSCLE, makes airway more

reactive or sensitive to foreign substances
Body Surface Area
 Children do not have a
larger body surface area
than adults. They have a
larger PERCENTAGE of
surface area for their
weight than adults do.

This is because children do

not have highly developed
muscle.

Most of their mass is fat and

water which weighs less.
Bones are also less dense at a
younger age. 
 Child vs Adult
• Head to Body ratio and relative
size and location of anatomic
features make children more
susceptible to head and
abdominal injury

• Underdeveloped anatomy leads

to chest pliability and less
protection of thoracic cage and
less effective use of accessory
muscles

• Arrest – Cardiac arrest typically

results from untreated
respiratory arrest
Thorax - Child vs Adult
• Horizontal ribs – more diaphragmatic
breathing
• Flatter Diaphragm
• Ribs & Sternum is cartilage - less stability
of chest wall, requires more use of
diaphragm
• Less pulmonary reserve
• Heart takes up more thoracic space
• Poor accessory muscle development
• Larger abdominal organs - pushes up
diaphragm
 Airway
Urgencies
can quickly
progress to
airway
Emergencies
 ABCDE
Assessment Tool

Underlying Principle - -
•Use a systematic approach
•Complete initial exam and re-assess regularly
•Assess the effects of treatment/interventions
•Correct life-threatening abnormalities before moving
on to the next part of assessment
 Look for signs of airway obstruction
• Paradoxical chest and abdominal
movements (See-Saw)
• Accessory Muscle Use
• Central cyanosis
• Absent to no Breath sounds
• Depressed consciousness

Treat airway obstruction as a medical emergency

• In the majority of cases, simple methods of airway
management are all that is necessary - - Positioning, Chin Lift,
Suctioning, Oral/Nasal Airway - - Tracheal Intubation may be
required where simple measures fail
Give Oxygen
• Keep SpO2 > 90% - - Diminish risk of hypoxic damage
 Look for general signs of respiratory
distress, sweating, cyanosis, accessory
muscle use – It is vital to diagnose and
treat immediately life threatening
conditions (Severe Asthma, Tension
Pneumothorax, Foreign Body)

•Respiratory Rate & rhythm

•Equal chest expansion
•Breath sounds
•Stridor, Rales, Rhonchi, Wheezing
•Air Exchange
•Chest deformity
•Abdominal distension
 In almost all medical/surgical
emergencies, consider hypovolemia to be
the primary cause of shock unless proven
otherwise.
Respiratory pathology that may compromise circulatory state - - - tension
pneumothorax

•Look for signs of poor cardiac output

• Peripheral and central pulses
• Blood Pressure
• Reduced level of consciousness
• Low urine output (less wet diapers)
• Reduced PO intake
• Look for signs of bleeding

•IV Fluids for patients that present with tachycardia and/or poor
capillary refill
 Signs of Disability - - coma/convulsion -
-Common causes of unconsciousness include
profound hypoxia, hypercapnea, cerebral
hypoperfusion or recent sedative/analgesic
drug ingestion
•Review ABC’s – exclude hypoxia and hypotension
• Assess tone, Pupil size
• R/O Accidental Ingestion – give appropriate antagonist
where available
• Monitor LOC
• Blood Glucose Level

D can also stand for signs of dehydration

• Signs of shock have already been looked for while
assessing circulation but specific examination for
skin turger, sunken eyes, dry mucus membranes
Check Temperature - - Kids will become
hyper/hypo thermic faster than an adult

Look all over the body - - - back, groin

Assess in well lit area

 Other than Trauma - - -
5 Most Common Respiratory
Emergencies

• Asthma
• Croup
• Bronchiolitis
• Epiglotitis
• Foreign bodies
 Upper
Airway
Disease Lower
Croup
Noise during Inspiration
Airway
Foreign Body
Proximal to Thoracic Inlet
Epiglottitis Disease
Asthma
Bacterial
Nose – Pharynx Tracheitis
– Larynx Bronchiolitis
• Awake/Crying NoisePneumonia
during Exhalation
Distal to Thoracic
Foreign BodyInlet
• It child Improves
• Nose/Pharynx Trachea, Bronchi, Peripheral
• If child Deteriorates Airways
• Larynx
 Upper
Airway
Disease
 Croup
Basics
Upper respiratory viral
infection
Occurs mostly among
ages 6 months to 3 years
More prevalent in fall and
spring
Edema develops,
narrowing the airway
lumen (Steeple Sign)
Severe cases may result
in complete obstruction
 Croup
• Physical exam/Assessment
• Tachycardia, tachypnea
• Skin color - pale, cyanotic,
mottled
• Decrease in activity or
LOC
• Fever
• Breath sounds - wheezing,
diminished breath sounds
• Stridor, barking cough,
hoarse cry or voice
• Any difficulty swallowing?
• Drooling present
Management
Croup
Assess & monitor ABC’s
High flow humidified O2; blow
by if child won’t tolerate mask
Limit exam/handling to avoid
agitation
Be prepared for respiratory
arrest, assist ventilations and
perform CPR as needed
Do not place instruments in
mouth or throat
Rapid transport
 Epiglotitis
Basics
Bacterial infection and
inflammation of the
epiglottis
Usually occurs in children
3-6 years of age
Can occur in infants, older
children, & adults
Swelling may cause
complete airway obstruction
Thumb sign
True medical emergency
 Epiglotitis
Signs & Symptoms
Assessment/History
May be sitting in Tripod
When did child position
become ill?
May be holding mouth
Has it suddenly open, with tongue
worsened after a protruding
couple of days or
Muffled or hoarse cry
hours?
Inspiratory Stridor
Sore throat?
Tachycardia/tachypnea
Will child swallow
liquids or saliva? Pale, mottled, cyanotic
skin
Is drooling present?
Anxious, focused on
High fever (102-103
breathing lethargic
degrees F)
Very sore throat
Onset is usually
sudden Nasal Flaring
Look very sick with high
fever
 Epiglotitis
Management
Assess & monitor ABC’s
Do not make child lie down
Do not manipulate airway
High flow humidified O2; blow
by if child won’t tolerate mask
Limit exam/handling to avoid
agitation
Be prepared for respiratory
arrest, assist ventilations and
perform CPR as needed
Transfer of Children’s Hospital
 Aspirated Foreign Body
• Basics
• Common among the 1-3
age group who like to put
everything in their mouths
• Running or falling with
objects in mouth
• Inadequate chewing
capabilities
• Common items - gum, hot
dogs, grapes and peanuts
 Aspirated Foreign Body

Assessment
Complete obstruction will
present as apnea
Partial obstruction may present
as labored breathing,
retractions, and cyanosis
Objects can lodge in the lower
or upper airways depending on
size
Object may act as one-way
valve allowing air in, but not
out
 Aspirated Foreign Body
Partial obstruction
Make child comfortable
Administer humidified oxygen
Encourage child to cough
Have intubation equipment
available
Transport to hospital for removal
with bronchoscope

Complete Obstruction
Attempt to clear using BLS
techniques
Attempt removal with direct
laryngoscopy and Magill forceps
Cricothyrotomy may be indicated
 Stridor
https://www.uptodate.com/contents/assessment-of-stridor-in-children?
source=search_result&search=stridor&selectedTitle=1~150

Supraglottic Area (Insp. Stridor)

• Anaphylaxis
• Epiglottitis
• Retropharyngeal/Peritonsillar Absess
• Laryngomalacia
• Congenital Malformation
• Tumor of oral cavity or pharynx

Glottic & Subglottic Area (Insp. Stridor)

•Laryngotracheitis (croup)
•Tracheomalacia • Subglottic Stenosis
•Anaphylaxis • Bacterial tracheitis
•Foreign Body in Airway • Vocal Cord Paralysis

Intrathoracic Area (Exp Stridor and/or Wheezing)

•Infection (bacterial tracheitis, bronchitis)
•Foreign Body in Airway or Esophagus)
•Anaphylaxis
•Congenital Malformation
•Tumor
Lower
Airway • Narrower trachea and bronchi
• Poiseulle’s Law - Edema
Disease
If radius is halved,
resistance increases
16x
 Asthma

Discussed this morning my Dr. Rotta

 Bronchiolitis
Basics
Respiratory infection of the
bronchioles
Occurs in early childhood
(younger than 1 yr)
Caused by viral infection

Assessment/History
Length of illness or fever
Has infant been seen by a doctor
Taking any medications
Any previous asthma attacks or
other allergy problems
How much fluid has the child been
drinking
 Bronchiolitis
Management
Signs & symptoms
Assess & maintain
Acute respiratory airway
distress
When appropriate let
Tachypnea child pick POC
May have intercostal Clear nasal passages
and suprasternal if necessary
retractions
Prepare to assist with
Cyanosis ventilations
Fever & dry cough IV LR or NS TKO rate
May have wheezes - Intubate if airway
inspiratory & expiratory management
Confused & anxious becomes difficult or
mental status fails
Possible dehydration
 Other than the 5 Most Common
Respiratory Emergencies
• Dehydration/
Shock
• Ingestions
• Anaphylaxis
• Seizures
 Dehydration
Mild, Moderate & Severe
• Physical
Assessment/ Vital
signs
• Capillary refill
• Skin color
• Alertness, activity
level
 Dehydration
Mild, Moderate & Severe
Mild dehydration
Infants lose up to 5% of their body weight
Child lose up to 3-4% of their body weight
Physical signs of dehydration are barely visible

Moderate Dehydration
Infants lose up to 10% of their body weight
Children lose up to 6-8% of their body weight
Poor skin color & turgor, dry mucous membranes,
decreased urine output & increased thirst, no tears

Severe Dehydration
Infants lose up to 15% of their body weight
Children lose up to 10-13% of their body weight
Danger of life-threatening hypovolemic shock
 Dehydration
Mild, Moderate & Severe
Management
If mild or moderate
Give fluids orally if there is no
abdominal pain, vomiting or
diarrhea and is alert
Severe
High flow O2
IV/IO with NS or LR
Fluid bolus of 20 ml/kg IV/IO
push
Repeat fluid bolus if no
improvement
 Ingestions/Poisonings
• Ingestion of a potentially
toxic substance, drug,
household or industrial
chemical, plant or waste
products

History
Home environment
Medications in home
Where are chemicals stored?
Hobby-related exposures
Physical clues (open bottles, plants
with missing leaves, etc)
 Unknown Ingestions
Laboratory workup.
Physical exam
Every child should
• Vital signs
have…
• Excitation or Acetaminophen level
•Depression Salicylate level
• Pupils Ethanol level
Chemistry panel including
• Mental Status
LFT’s
• Skin Calculate anion gap
• Management Urinalysis
• ABC’s
Consider urine toxicology
• Decontamination screen, ABG, urine, pregnancy,
imaging (CXR or KUB),
Osmolality
 Ingestion Management
Management:
• Stabilize and ABC’s as needed
• Oxygen as needed
• IV with Normal Saline (keep Hydrated)
• NG if unconscious or will not drink

• If opiate poisoning
• Narcan
• If acetaminophen poisoning
• N-acetylcysteine
 Anaphylaxis
Usually begins within a few minutes after
exposure evident within 15”
• Causes
• Vaccines
• Drugs
• Insect bites
• Food
• Latex
• Venoms
Symptoms – Sneezing, Coughing, Itching, Flushing
of skin, Facial edema

Anxiety, Palpitations, Nausea, Vomitting, Respiratory

Distress, Hypotesnion
Anaphylaxis Management
•Recumbent Position
• Elevate Feet
• Establish and maintain
airway
• Oxygen
• Start IV – Normal Saline
• Epinephrine per
protocol
 Seizures
Common Age Range - 6 mos - 6 yrs

The CNS of children is more

immature, making children more General considerations
likely to seize
• Stabilize and ABC’s as
• 1% of all patients in ED are Pediatric
seizure patients needed
• Oxygen as needed
• Occurs in 2-5% of pediatric
• Watch for aspiration
patients
• 80% are febrile • Watch glucose
• Other causes • Treat fever
• Infection
• CNS
• Immunizations Febrile seizures that
continue for more than five
minutes should be treated.
Pediatric Trauma
 Pediatric Trauma
• Trauma is leading cause of
death in children Most
common mechanisms
• MVA 43%
• Burns 15%
• Drowning 15%
• Firearms 3%
• Falls 2%

• Most commonly injured body

areas-head, trunk, extremities
Head 48%
Abdomen 11%
Chest 9%
Extremities 32%
 Anatomic Characteristics of the Pediatric
Patient and Significance to Trauma Care
Large Volume of Blood in Head
Cerebral edema develops rapidly
Poor Muscular support in neck
Flexion/extension injuries occur
Decreased Alveolar surface area
Injury leads to rapid compromise
Increased Metabolic rate
Higher oxygen demand
Decreased airway caliber
Increased airway resistance
 Anatomic Characteristics of the Pediatric
Patient and Significance to Trauma Care
Heart higher in chest & Small pericardial sac
Prone to injury and cardiac tamponade

Thin walled, small abdomen

Organs not well protected

Bones soft and pliable

Fractures less common

Renal function not well developed

Prone to develop acute renal failure

Large % body surface area

Prone to hypothermia
 Multi-System Injuries
• Multi-system injury is the rule rather than the exception
• Because of the smaller body mass, energy from linear forces (e.g. fenders,
bumpers, falls) results in greater force applied per unit body area
• Children have less fat, less elastic connective tissue and close proximity of
organs, which leads to more multi-system organ injuries

• The skeleton is incompletely calcified and more

pliable

• If the bones are broken, assume that a

massive amount of energy was applied

• Internal organs may be damaged without

evidence of overlying bone fractures
Head, Face, and Neck Injuries
Children prone to head
injuries
Be alert for signs of
child abuse
Facial injuries common
secondary to falls
Always assume a spinal
injury with head injury

Children are susceptible to the secondary effects of brain injury

produced by hypoxia, hypotension, seizures and hyperthermia
Open fontanels and mobile cranial suture lines are more tolerant of
expansion of intracranial mass lesions, decompensations may not
occur until the mass lesion has become large
Thermal Injuries & Burns
Burns
Second leading cause of pediatric deaths
Scald burns are most common
Rule of nine is different for children
Each leg worth 13.5%
Head worth 18%

Risk Factors
Excessive sun exposure
Hot water heaters set too high
Exposure to chemicals or electricity
Thin skin
Carelessness with burning cigarettes
Faulty electrical wiring
 Thermal Injuries
Management of Burns
• Stabilize ABC’s
•Primary Survey
•Establish Airway and Assist
Ventilation if needed
•Keep saturations 97%
•Fluid Resuscitation
 Thermal Injuries
Transfer to Burn Center
• Second-degree burn over 10%
BSA or any third degree burn
• Electrical or lightening burns
• Inhalation injury
• Chemical Burn
•Circumferential burn
 Near Drowning
• Leading cause of accidental death
in children under 5 yrs
• Highest incidence in Males & African-
Americans
• Inadequately supervised in swimming
pools, bathtubs or around other liquid-
filled containers
• Children under the age of 1 year most
often drown in toilets, bathtubs and
buckets
• 7% appear related to child abuse or
neglect
• Children that drown in pools were out
of sight for less than 5” and were in the
care of one or both parents at the time
• Second peak is seen in males 15-25 yrs
• Tend to occur at rivers, lakes and
beaches
 Drowning
Management of Near Drowning
• Stabilize ABC’s
• Primary Survey
• Establish Airway and Assist Ventilation if needed
• NG Tube (usually have swallowed lots of water)
• Watch for hypothermia
• R/O Head Injury, Seizure
• Watch for ARDS
• Pulmonary Hypertension
• Stabilize Electrolytes
Pediatric Airway
 Airway Size & Placement
Airway sizes may vary unpredictably among pediatric patients of same
age and weight. Have more equipment available: at least 3 different sized
endotracheal tubes.

The appropriate ETT size may be determined by the following formula

(age in years):

OET Size = Age + 16 / 4

(Size or nare, Diameter of Pinky, Broselow Tape)

Tape at 3 x size of tube

Eg: 4 year old: 16+4 / 4 = 5.0, tape 3 x 5 = 15 cm
Broselow Tape
 Rapid Sequence
Recommended by the Emergency College of Medicine
committee of the American College of Emergency Physicians
for every emergency child intubation with intact upper airway
reflexes
Simultaneous administration of neuromuscular
blockade agent and sedative

Paralytics Succinylcholine, Vecuronium,

Pancuronium, Rocuronium

Sedative Versed, Ketamine, Pentothal,

Etomidate
Analgesics Morphine, Fentanyle,
Katamine
 Pediatric Intubation
• Proper Positioning
• Larger head that flexes forward
• Straight Blade for kids < 4yrs
• Larger Epiglottis/Floppy
• Cuffless OET < 8 yers unless using
microcuff OET
• Different angles
• Larynx is more anterior
• Use cricoid pressure with
caution
Don’t bury the tube!!!

Tape at 3 x OET Size

Children 1-5 months
Common problems
• Bronchiolitis
• Foreign Body
• SIDS
• Vomiting and
diarrhea/dehydration
• Meningitis
• Child abuse
• Household accidents
 Children 6-12 months
Common problems
• Febrile seizures
• Vomiting and
diarrhea/dehydration
• Bronchiolitis or croup
• Car accidents and falls
• Child abuse
• Ingestions and foreign
body obstructions
• Meningitis
 Children 1-3 years
Common problems
• Auto accidents
• Vomiting and diarrhea
• Febrile seizures
• Croup, meningitis
• Foreign body
obstruction
 Children 3-5 years
Common Problems
• Croup, asthma,
epiglottitis
• Ingestions, foreign
bodies
• Auto accidents,
burns
• Child abuse
• Drowning
• Meningitis, febrile
seizures
 Children 6-12 years
Common Problems
• Drowning
• MVA's
• Bike vs Motor
Vehicle
• Fracture
• Sports Injuries
• Abuse
• Burns
 Children 12-15 year
Common Problems
• Asthma
• Auto accidents, sports
injuries
• Drug and alcohol abuse
• Sexual abuse,
pregnancy
• Suicide gestures
 Take-a-ways
• Kids can deteriorate quickly – you
constantly have to be on your toes!

• Anatomy and Physiology is

different than adults - - Be aware
of the differences and the impact
disease can make

• Use the ABCDE Assessment tool

• Do a thorough systematic approach
and reassess often
Take home note:
Remember that an adequate airway
and oxygen-rich approach may be
the difference between life and death

Sick pediatric patients can be terrifying,

but they usually only have one thing
wrong.

Support their airway,

breathing and
cardiovascular status and
their amazing bodies will
usually take care of the
rest