What medications are used to treat respiratory distress in pediatric patients?

Medications for Respiratory Distress in Pediatrics

For acute respiratory distress in children, initiate high-flow oxygen immediately, followed by nebulized short-acting beta-agonists (salbutamol 5 mg or terbutaline 10 mg, half doses in very young children) and intravenous or oral corticosteroids as first-line therapy. 1

Immediate Pharmacologic Management

Oxygen Therapy

• Administer high-flow oxygen via face mask to maintain SpO2 >92% in all children with acute respiratory distress 1
• Target oxygen saturation of 90-94% is appropriate once stabilized, with evidence suggesting thresholds as low as 88-90% may be safe and reduce unnecessary hospitalization 2, 3

Bronchodilators

Short-Acting Beta-Agonists (First-Line)

• Nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer (use half doses in very young children) 1
• Onset of improvement typically occurs within 5 minutes, with maximum effect at 1 hour 4
• Repeat every 15-30 minutes if patient not improving 1
• Once improving, continue every 4-6 hours 1

Anticholinergics (Adjunctive Therapy)

• Add ipratropium 100-250 mcg (0.1-0.25 mg) to nebulizer if patient not improving after initial beta-agonist 1
• Repeat every 6 hours until improvement begins 1
• Particularly beneficial in severe or life-threatening presentations 1

Corticosteroids

Systemic Steroids (Essential)

• Intravenous hydrocortisone for immediate treatment in acute severe cases 1
• Oral prednisolone 1-2 mg/kg daily (maximum 40 mg) for continuing management 1
• Initiate early in the course of respiratory distress 1

Inhaled Corticosteroids

• For children with post-prematurity respiratory disease (PPRD) who have chronic cough or recurrent wheezing, trial inhaled corticosteroids with monitoring for clinical improvement 1
• Do NOT routinely prescribe for PPRD patients without chronic symptoms 1

Disease-Specific Considerations

Asthma/Bronchospasm

• Follow the bronchodilator and steroid regimen outlined above 1
• For life-threatening features (PEF <33% predicted, cyanosis, silent chest, altered consciousness): add intravenous aminophylline 5 mg/kg over 20 minutes, followed by 1 mg/kg/h maintenance infusion 1
• Omit aminophylline loading dose if child already receiving oral theophyllines 1

Post-Prematurity Respiratory Disease

• Trial short-acting inhaled bronchodilators only for those with recurrent respiratory symptoms (cough, wheeze) 1
• Do NOT routinely prescribe bronchodilators for asymptomatic PPRD patients 1
• Avoid routine diuretic therapy; for infants discharged from NICU on chronic diuretics, discontinue judiciously 1

Neonatal Respiratory Distress Syndrome

• Surfactant therapy is standard for RDS 5
• For uncomplicated RDS, retreatment can be delayed until higher respiratory support thresholds (FiO2 >40%, mean airway pressure >7 cm H2O) 5
• For complicated RDS (perinatal compromise, sepsis), use low-threshold retreatment strategy (FiO2 >30%) 5

Advanced Therapies for Severe Cases

Mechanical Ventilation Support

• Helium-oxygen mixtures (heliox) may be considered for mechanically ventilated children with severe asthma to reduce peak inspiratory pressures and improve gas exchange 6
• Set helium flow at 5-7 L/min with oxygen titrated to maintain desired saturation 6

Noninvasive Respiratory Support (Post-Extubation)

• For high-risk children after extubation, use noninvasive respiratory support (HFNC, CPAP, or NIV) over conventional oxygen 1
• For children <1 year, prefer CPAP over HFNC as it has lower reintubation rates and mortality 1
• For children >1 year, CPAP, HFNC, and NIV are all appropriate first-line options 1

Critical Monitoring Parameters

• Measure peak expiratory flow (PEF) 15-30 minutes after starting treatment 1
• Maintain continuous oximetry with SpO2 >92% 1
• Monitor at least every 4 hours for patients on oxygen therapy 1
• Repeat blood gas measurements within 2 hours if initial PaO2 <60 mmHg or patient deteriorates 1

Common Pitfalls to Avoid

Do NOT:

• Use chest physiotherapy—it provides no benefit and may prolong fever duration 1
• Routinely prescribe bronchodilators or inhaled corticosteroids for asymptomatic PPRD patients 1
• Use nasogastric tubes in severely ill children as they compromise breathing; if necessary, use smallest tube in smallest nostril 1
• Provide intravenous fluids at full maintenance—give at 80% basal levels after correcting hypovolemia and monitor electrolytes 1

ICU Transfer Criteria

Transfer to intensive care with physician prepared to intubate if:

• Deteriorating PEF, worsening hypoxia, or respiratory effort 1
• Exhaustion, confusion, drowsiness, coma, or respiratory arrest 1
• Persistent hypoxia or hypercapnia despite maximal therapy 1