Respiratory Emergencies and Airway Management
Respiratory failure remains the most common pathway to pediatric cardiopulmonary arrest. Assess using the pediatric assessment triangle (appearance, work of breathing, circulation) and then quantitate work of breathing: tachypnea, nasal flaring, suprasternal and intercostal retractions, grunting, head bobbing, and accessory muscle use. Grunting is a high-risk sign; so is a silent chest, which indicates inadequate air movement rather than improvement. Also weigh mental status and color - a tired, quiet child with stridor is deteriorating.
Upper airway
Croup has a barking cough and inspiratory stridor; treat with a single dose of dexamethasone 0.6 mg/kg (oral or IM) and nebulized epinephrine for moderate-to-severe distress. Epiglottitis presents with drooling, tripod positioning, muffled voice, and high fever - do not inspect the throat, do not force recumbency, and bring the airway team to the child.
Foreign body aspiration: for a choking infant under 1 year, give 5 back blows alternating with 5 chest thrusts; abdominal thrusts are for children over 1 year and adults.
Lower airway
Asthma: albuterol nebulized or 4–8 puffs by MDI with spacer, ipratropium for severe episodes, systemic corticosteroids, magnesium sulfate 25–50 mg/kg IV in refractory cases, and IM epinephrine 0.01 mg/kg of 1:1000 for impending failure. Bronchiolitis is supportive care - no routine bronchodilators, steroids, or antibiotics; heated high-flow nasal cannula is often the escalation step before intubation.
Worked example: A 10-month-old with 3 days of rhinorrhea, wheeze, and subcostal retractions, RR 60, SpO2 89% on room air. The diagnosis is bronchiolitis; the correct action is oxygen and hydration support, with a trial of high-flow, not repeated racemic epinephrine.