What is the pharmacological treatment for respiratory failure in pediatric patients?

Pharmacological Treatment of Respiratory Failure in Pediatric Patients

The pharmacological management of respiratory failure in pediatric patients primarily involves high-flow oxygen, bronchodilators (salbutamol/terbutaline), corticosteroids, and in life-threatening cases, intravenous aminophylline. 1

Initial Assessment and Recognition

Signs of Severe Respiratory Distress in Children:

• Too breathless to talk or feed 1
• Respiratory rate >50 breaths/min 1
• Pulse >140 beats/min 1
• Peak Expiratory Flow (PEF) <50% predicted (if measurable) 1

Life-Threatening Features:

• PEF <33% predicted or poor respiratory effort 1
• Cyanosis, silent chest, fatigue, or exhaustion 1
• Agitation or reduced level of consciousness 1

Immediate Pharmacological Treatment

First-Line Medications:

• High-flow oxygen via face mask to maintain SaO₂ >92% 1
• Intravenous hydrocortisone immediately 1
• Nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer (use half doses in very young children) 1
• Add ipratropium 100 μg nebulized every 6 hours 1

For Life-Threatening Respiratory Failure:

• Intravenous aminophylline 5 mg/kg over 20 minutes followed by maintenance infusion of 1 mg/kg/hour 1
• Omit loading dose if child is already receiving oral theophyllines 1

Subsequent Management

If Patient Shows Improvement:

• Continue high-flow oxygen 1
• Prednisolone 1-2 mg/kg body weight daily (maximum 40 mg) 1
• Nebulized β-agonist (salbutamol/terbutaline) every 4 hours (maximum 40 mg/day) 1

If Patient Is Not Improving After 15-30 Minutes:

• Continue oxygen and steroids 1
• Increase frequency of nebulized β-agonist up to every 30 minutes 1
• Add ipratropium to nebulizer and repeat every 6 hours until improvement starts 1

Monitoring Treatment Response

• Repeat measurement of PEF 15-30 minutes after starting treatment 1
• Maintain oxygen saturation >92% using pulse oximetry 1
• Chart PEF before and after β-agonist administration 1
• In severe cases, repeat blood gas measurements within 2 hours of starting treatment if:
  • Initial PaO₂ <8 kPa (60 mm Hg) 1
  • Initial PaCO₂ was normal or raised 1
  • Patient's condition deteriorates 1

Special Considerations

Albuterol (Salbutamol) Safety in Pediatric Patients:

• Safety and effectiveness established in children 2 years of age or older 2
• Dose recommendations based on studies in children 5-17 years 2
• Safety in children under 2 years not established 2

Alternative Approaches:

• For severe respiratory failure during status asthmaticus, some protocols use high-flow oxygen and sodium bicarbonate to avoid mechanical ventilation 3
• Blood gas estimations are rarely helpful in deciding initial management in children 1

Indications for ICU Transfer

Transfer to intensive care unit with a doctor prepared to intubate if:

• Deteriorating PEF or worsening exhaustion 1
• Feeble respirations 1
• Persistent hypoxia or hypercapnia despite treatment 1
• Coma, respiratory arrest, confusion, or drowsiness 1

Common Pitfalls and Caveats

• Avoid excessive oxygen administration as it can lead to hyperoxia and oxygen toxicity 4
• Target oxygen saturation should be 94-98% in most cases 4
• Children with severe attacks may appear distressed; assessment in very young children may be difficult 1
• Aminophylline should be used with caution due to potential for toxicity; omit loading dose if already on oral theophyllines 1
• Children with ALI/ARDS generally have better outcomes than adults, but may still have long-term physiologic respiratory compromise 5