Algorithm
graph TD
classDef start fill:#1b5e20,color:#ffffff,stroke:#66bb6a;
classDef step fill:#0d47a1,color:#ffffff,stroke:#42a5f5;
classDef decision fill:#4a148c,color:#ffffff,stroke:#ab47bc;
classDef alert fill:#b71c1c,color:#ffffff,stroke:#ef5350;
A(<b>Pediatric Resp Distress</b><br>Initial Triage):::start
B[<b>Assess PAT</b><br>Appearance Breathing Color]:::step
C{<b>Respiratory Failure</b><br>Cyanosis SpO2 under 94}:::decision
A --> B
B --> C
D1[<b>Immediate Resuscitation</b><br>Airway Breathing Circulation]:::step
D2[<b>Anatomical Localization</b><br>Identify Clinical Etiology]:::step
C -->|Yes| D1
C -->|No| D2
E1{<b>Intubation Indicated</b><br>Neuro or CV Decline}:::decision
D1 --> E1
F1[<b>Endotracheal Intubation</b><br>Secure Airway Rapidly]:::alert
F2[<b>Non-Invasive Support</b><br>CPAP or HFNC Oxygen]:::step
E1 -->|Yes| F1
E1 -->|No| F2
G1[<b>Upper Airway</b><br>Stridor and Retractions]:::step
G2[<b>Lower Airway</b><br>Wheeze and Prolonged Expiration]:::step
G3[<b>Lung Parenchyma</b><br>Grunting and Crepitations]:::step
D2 --> G1
D2 --> G2
D2 --> G3
H1[<b>Croup</b><br>Steroids and Neb Adrenaline]:::step
H2[<b>Acute Asthma</b><br>Salbutamol and Steroids]:::step
H3[<b>Bronchiolitis</b><br>Supportive and Hydration]:::step
H4[<b>Severe Pneumonia</b><br>Empiric IV Antibiotics]:::step
G1 --> H1
G2 --> H2
G2 --> H3
G3 --> H4
Initial assessment and triage
Pediatric assessment triangle
- Triage begins with rapid visual and auditory evaluation.
- Assess child appearance, breathing, and color.
Appearance evaluation
- Utilize Ticls mnemonic: Tone, Interactiveness, Consolability, Look/gaze, Speech.
- Provides rapid clues regarding brain perfusion and oxygenation.
Breathing assessment
- Identify abnormal respiratory rates including tachypnea or bradypnea.
- Detect increased work of breathing via nasal flaring or retractions.
- Note abnormal airway sounds including wheeze, grunt, or stridor.
Color evaluation
- Detect pallor, mottling, or cyanosis.
- Color abnormalities indicate severe hypoxemia or impending cardiorespiratory failure.
Respiratory failure categorization
- Identify patients requiring immediate resuscitation.
- Criteria include tachypnea, increased breathing work, cyanosis, abnormal sensorium, and room air oxygen saturation below 94 percent.
Pathophysiology and anatomical localization
Anatomical localization guide
| Clinical signs | Anatomical localization | Common etiologies |
|---|
| Ala nasi flaring, suprasternal/supraclavicular retractions, stridor | Upper airway obstruction | Croup, Epiglottitis, Foreign body, Diphtheria |
| Subcostal/intercostal retractions, prolonged expiration, wheeze | Lower airway obstruction | Asthma, Acute bronchiolitis |
| Intercostal/subcostal retractions, grunting, crepitations | Lung parenchyma | Community acquired pneumonia, Acute respiratory distress syndrome |
| See-saw breathing, irregular breathing, bradypnea | Central disordered control | Raised intracranial pressure, Brain injury |
Pathophysiological mechanisms
- Upper airway obstruction: Partial obstruction above thoracic inlet causes turbulent airflow and harsh, high-pitched stridor.
- Lower airway obstruction: Small airway obstruction increases resistance, causing air trapping and dynamic hyperinflation.
- Active, prolonged expiration results in audible wheezing.
- Parenchymal disease: Alveolar consolidation or pulmonary edema creates ventilation-perfusion mismatch.
- Results in intrapulmonary shunting and severe hypoxemia.
Primary assessment and stabilization algorithm
Airway management
- Ensure airway remains open and maintainable.
- Utilize simple positioning techniques including head-tilt-chin lift or sniffing position.
- Perform oral suctioning to clear excessive secretions.
- Prepare advanced interventions if airway remains unmaintainable.
Breathing interventions
- Administer heated, humidified 100 percent supplemental oxygen.
- Utilize non-rebreathing face mask targeting oxygen saturation of 94 percent or higher.
- Provide appropriate-sized nasal prongs with 1-2 liters per minute flow rate for infants.
Non-invasive respiratory support
- Initiate continuous positive airway pressure or high flow nasal cannula for severe retractions.
- Indicated when patient fails to maintain oxygen saturation above 94 percent.
- Continuous positive airway pressure provides distending pressure to recruit atelectatic alveoli.
- Reduces overall work of breathing and potentially averts invasive mechanical ventilation.
Circulation assessment
- Monitor heart rate, capillary refill time, and systemic blood pressure.
- Obtain immediate intravenous or intraosseous vascular access.
Shock management
- Suspect concurrent shock with hypotension, prolonged capillary refill, or marked tachycardia.
- Administer rapid isotonic crystalloid fluid boluses of 10-20 milliliters per kilogram.
Disability evaluation
- Continuously monitor baseline level of consciousness.
- Identify worsening hypoxia or hypercarbia presenting as excessive irritability.
- Note progression to lethargy, obtundation, or coma.
Indications for endotracheal intubation
Clinical thresholds for invasive ventilation
| Clinical category | Specific indicators for intubation |
|---|
| Oxygenation failure | Central cyanosis or inability to maintain oxygen saturation above 94 percent despite non-invasive ventilation |
| Neurological decline | Central nervous system signs of severe hypoxia including restlessness, obtunded sensorium, extreme lethargy, seizures, or coma |
| Cardiovascular compromise | Marked tachycardia, profound bradycardia, or hypotension indicating imminent cardiorespiratory arrest |
| Clinical worsening | Severe respiratory distress, exhaustion, or visible worsening of respiratory effort while on non-invasive support |
Disease-specific emergency management
Acute asthma exacerbation
- Administer inhaled salbutamol and repeat inhalation therapy every 20 minutes for the first hour.
- Administer systemic corticosteroids using oral prednisolone or intravenous hydrocortisone.
- Escalate severe exacerbations to continuous salbutamol nebulization.
- Administer intravenous magnesium sulphate at 50 milligrams per kilogram.
- Provide intravenous terbutaline for refractory cases.
Croup protocol
- Provide humidified oxygen in a calm, non-threatening manner.
- Administer single dose oral, intramuscular, or intravenous dexamethasone at 0.6 milligrams per kilogram.
- Deliver nebulized adrenaline utilizing 5 milliliters of 1:1000 undiluted solution for severe respiratory distress.
Acute bronchiolitis care
- Management remains primarily supportive focusing on oxygenation and hydration.
- Consider therapeutic trial of nebulized 3 percent hypertonic saline or adrenaline.
- Routine administration of antibiotics and systemic steroids remains strictly not recommended.
Severe pneumonia treatment
- Initiate empiric intravenous antibiotics immediately upon recognition.
- Administer cefotaxime combined with amikacin for infants aged 1-2 months.
- Administer ampicillin combined with gentamicin for children aged 2-59 months.
- Adjust antibiotic regimen if atypical pathogens or staphylococcal pneumonia suspected clinically.
