What are the initial steps in managing pediatric respiratory issues?

Initial Management of Pediatric Respiratory Issues

Immediately assess for signs of respiratory distress and provide supplemental oxygen to maintain SpO2 >92%, as this is the critical threshold that determines need for hospitalization and guides initial management. 1, 2, 3

Rapid Assessment of Severity

Identify respiratory distress through these specific clinical signs:

• Retractions (intercostal, subcostal, or sternal) indicating increased work of breathing 1, 2, 4
• Respiratory rate thresholds: >70 breaths/min in infants, >50 breaths/min in older children 1
• Oxygen saturation <92% on room air at sea level 1, 2, 3
• Accessory muscle use, tracheal tug, nasal flaring, or grunting 1
• Agitation or restlessness (may indicate hypoxia) 1
• Cyanosis or apnea 1, 2

Immediate Interventions

Oxygen Therapy

• Apply high-flow oxygen immediately to both the face and tracheostomy (if present) using two oxygen sources when available 1
• Target SpO2 >92% using nasal cannulae, head box, or face mask 1, 2, 3
• Monitor with continuous pulse oximetry and waveform capnography when available, as capnography is a key intervention for airway safety 1, 3

Airway Positioning

• Open the upper airway using chin lift ("sniffing the morning air") with or without jaw thrust 1
• Use neutral positioning in children under 2 years; consider a pillow or rolled towel under shoulders 1
• Assess airflow by looking, listening, and feeling at both mouth/nose and tracheostomy (if present) 1

Call for Help

• Summon additional help immediately if respiratory distress is present, including resuscitation teams, anesthesia, ENT, and pediatric intensive care specialists 1
• Ensure emergency equipment is available, including appropriately sized facemasks, airway adjuncts, laryngoscope blades, videolaryngoscopes, and suction 1

Hospitalization Criteria

Infants

• Oxygen saturation <92% or cyanosis 1, 2, 3
• Respiratory rate >70 breaths/min 1
• Difficulty breathing, grunting, or intermittent apnea 1, 2
• Not feeding 1
• Age <3-6 months with suspected bacterial infection 2, 4
• Family unable to provide appropriate observation 1

Older Children

• Oxygen saturation <92% or cyanosis 1, 3
• Respiratory rate >50 breaths/min 1
• Difficulty breathing or grunting 1
• Signs of dehydration 1
• Family unable to provide appropriate observation 1

Initial Medical Management

Supportive Care

• Provide IV fluids at 80% basal levels if oral intake is inadequate, with daily electrolyte monitoring to prevent SIADH 1, 2, 3
• Avoid nasogastric tubes in severely ill children, especially infants with small nasal passages, as they may compromise breathing 1
• Do NOT perform chest physiotherapy in children with pneumonia, as it is not beneficial 1
• Use antipyretics and analgesics to keep the child comfortable and help with coughing 1
• Minimize handling in ill children to reduce metabolic and oxygen requirements 1

Antibiotic Therapy (When Indicated)

• Amoxicillin is first-line for children under 5 years with community-acquired pneumonia, as it covers the majority of pathogens (S. pneumoniae, H. influenzae) 1, 3, 5
• Macrolide antibiotics (erythromycin, clarithromycin, azithromycin) should be used as first-line in children ≥5 years due to higher prevalence of Mycoplasma pneumonia 1, 3
• Young children with mild symptoms of lower respiratory tract infection do not need antibiotics 1
• IV antibiotics (co-amoxiclav, cefuroxime, cefotaxime) are indicated when the child cannot absorb oral antibiotics or presents with severe signs 1

Bronchodilator Therapy

• Consider albuterol for bronchospasm, with onset of improvement typically within 5 minutes and maximum effect at 1 hour 6
• Avoid routine bronchodilators in bronchiolitis, as performance data shows overuse (19.7% in ED, 34.6% in hospitalized patients) 7

Monitoring Requirements

• Vital signs and oxygen saturation at least every 4 hours for patients on oxygen therapy 1, 3
• Work of breathing, activity level, appetite, and hydration status 3
• Re-evaluate at 48 hours if the child remains pyrexial or unwell, considering possible complications 1

ICU Transfer Criteria

Transfer to intensive care if:

• Requires invasive ventilation via endotracheal tube 2
• Requires noninvasive positive pressure ventilation (CPAP or BiPAP) 2
• Oxygen requirement FiO2 ≥0.50 to maintain saturation >92% 4
• Impending respiratory failure, sustained tachycardia, inadequate blood pressure, or need for pharmacologic support 2, 4
• Development of apnea or altered mental status 4

Common Pitfalls to Avoid

• Do not delay oxygen therapy while obtaining diagnostic tests; oxygenation takes priority 1, 2, 3
• Avoid excessive chest radiographs in bronchiolitis (current overuse at 14.4% in ED, 29.5% in hospitalized patients) 7
• Do not use narrow-spectrum antibiotics reflexively; current performance shows only 57.3% appropriate use in pneumonia 7
• Young infants (<6 months) require aggressive monitoring as they are at highest risk for severe disease and respiratory failure 2, 4
• Agitation may indicate hypoxia, not behavioral issues; reassess oxygenation before sedation 1

Discharge Criteria

Children may be discharged when:

• Afebrile for ≥24 hours 3
• SpO2 >92% on room air with stable oxygen saturation 2, 3
• Normalized respiratory rate with resolution of retractions 2, 3
• Tolerating adequate oral intake 2, 3
• Documented overall clinical improvement in activity level and appetite 2, 3

Home care families need specific information on managing fever, preventing dehydration, and identifying deterioration, with instructions to return if not improving after 48 hours 1.