What is the initial approach to managing pediatric respiratory disease?

Initial Management of Pediatric Respiratory Disease

The initial approach to managing pediatric respiratory disease requires immediate assessment of severity through objective measures (oxygen saturation, respiratory rate, work of breathing), followed by targeted interventions based on the specific diagnosis—with oxygen supplementation, bronchodilators for obstructive disease, and antibiotics for bacterial infections forming the cornerstone of acute management.

Immediate Assessment and Stabilization

The first priority is rapid severity assessment using objective clinical parameters rather than subjective impression alone, as severity is frequently underestimated by families and clinicians 1.

Key severity indicators requiring immediate intervention include:

• Oxygen saturation ≤92% on room air, which mandates supplemental oxygen therapy 1
• Respiratory rate: >70 breaths/min in infants, >50 breaths/min in older children 1
• Work of breathing: grunting (indicating impending respiratory failure), nasal flaring, intercostal/subcostal retractions, use of accessory muscles 1
• Altered mental status (agitation may indicate hypoxia; confusion/drowsiness indicates severe hypoxemia or hypercarbia) 1
• Apnea or inability to feed in infants 1

Disease-Specific Initial Management

For Obstructive Airway Disease (Asthma/Bronchospasm)

Administer high-flow oxygen (40-60%) via face mask or nasal cannulae to maintain SpO₂ >92% 2, 3. Nebulized beta-agonists (salbutamol 5 mg for children, 10 mg for adolescents/adults via oxygen-driven nebulizer) should be given immediately 2, 3. Systemic corticosteroids must be administered early—not after "trying bronchodilators first"—with prednisolone 1-2 mg/kg (maximum 60 mg/day) orally or IV hydrocortisone 200 mg 3, 4. For severe exacerbations, add ipratropium bromide 100-500 mcg nebulized to beta-agonist therapy 2, 3.

For Suspected Bacterial Pneumonia

Amoxicillin is the first-choice oral antibiotic for children under 5 years because it effectively targets the majority of causative pathogens (Streptococcus pneumoniae, Haemophilus influenzae), is well-tolerated, and inexpensive 1, 5. For children ≥5 years, consider macrolide antibiotics (erythromycin, clarithromycin, azithromycin) as first-line empirical treatment due to higher prevalence of Mycoplasma pneumoniae in this age group 1. Intravenous antibiotics (co-amoxiclav, cefuroxime, cefotaxime) are indicated when the child cannot absorb oral medications (vomiting) or presents with severe signs and symptoms 1.

For Interstitial Lung Disease (chILD Syndrome)

Before pursuing chILD-specific investigations, exclude more common causes of respiratory disease including cystic fibrosis, infection, cardiac disease, and pulmonary vascular disorders 1. Echocardiography is recommended as part of the initial evaluation to rule out structural cardiovascular disease and pulmonary hypertension, which is associated with worse prognosis 1. The urgency of diagnostic evaluation depends on disease severity, acuity, duration, age at presentation, immunocompetence, and family history 1.

Oxygen Therapy Protocol

Supplemental oxygen should be administered to any child with SpO₂ ≤92% via nasal cannulae, head box, or face mask 1. Patients requiring fraction of inspired oxygen (FiO₂) ≥0.50 to maintain saturation >92% should be cared for in a unit with continuous cardiorespiratory monitoring 1. Oxygen saturation should be monitored at least every 4 hours in patients receiving oxygen therapy 1.

Critical Pitfalls to Avoid

Never administer sedatives to children with acute respiratory distress, as agitation may indicate hypoxia rather than anxiety 1, 4. Chest physiotherapy is not beneficial and should not be performed in children with pneumonia 1. Nasogastric tubes may compromise breathing in severely ill children, especially infants with small nasal passages; if necessary, use the smallest tube in the smallest nostril 1. Avoid aggressive hydration—if intravenous fluids are needed, administer at 80% basal levels and monitor serum electrolytes 1.

Hospital Admission Criteria

Admit to hospital if:

• Oxygen saturation <92% or cyanosis 1
• Respiratory rate >70 breaths/min (infants) or >50 breaths/min (older children) 1
• Difficulty breathing, grunting, or signs of dehydration 1
• Family unable to provide appropriate observation 1

Consider ICU admission if:

• FiO₂ ≥0.50 required to maintain adequate oxygenation 1
• Altered mental status due to hypercarbia or hypoxemia 1
• Recurrent apnea or signs of impending respiratory failure 1

Monitoring and Reassessment

Children managed at home should be reviewed if deteriorating or not improving after 48 hours on treatment 1. For hospitalized patients, re-evaluation is necessary if the child remains febrile or unwell 48 hours after admission, with consideration of possible complications 1. Minimal handling may reduce metabolic and oxygen requirements in severely ill children 1.