This document provides guidance on assessing and managing pediatric respiratory emergencies. It defines respiratory distress, failure, and arrest and outlines how to use the Pediatric Assessment Triangle (PAT) including examining the child's appearance, work of breathing, and circulation. Specific conditions discussed include croup, epiglottitis, foreign body aspiration, asthma, and bronchiolitis. Treatment recommendations are provided for different severity levels. The document stresses the importance of proper assessment to determine if a child needs on-scene treatment or rapid transport to definitive care.

1. “RESPIRATORY EMERGENCIES”
Moh supriatna TS
PICU RS Dr.Kariadi/FK UNDIP
SEMARANG

2. INTRODUCTION
• Respiratory disease is the most frequent medical
emergency in out hospital pediatrics  asthma
bronchial is the most common
• Several important physical sign and symptom can
help distinguish respiratory distress from respiratory
failure.
• Using the PAT is an important first step in
determining the severity of the disease & beginning
treatment.
• Good assessment and care are important for the pre
hospital professional (by early intervention).

3. DEFINITIONS
Respiratory distress
• abnormal physiologic condition  increased WOB 
effectively compensating.
Respiratory failure
• exhaust the energy reserves  begin to decompensate.
Respiratory arrest
• absence of effective breathing  rapidly progress to full
cardiopulmonary arrest  low probability of survival.

4. EVALUATING THE PRESENTING COMPLAINT
Key Question :
Has your child ever had this
kind of problem before ?
Is your child taking any
medications ?
Has your child had a fever?
Did your child suddenly start
coughing / chocking / gagging ?
Has your child had an injury to
this chest ?
Possible Medical problem :
Asthma, chronic lung disease.
Asthma, chronic lung
disease, congenital heart
disease.
Pneumonic, bronchiolitis,
croup.
Foreign body aspiration or
ingestion.
Pulmonary contusion,
pneumothorax.

5. ASSESSMENT OF RESPIRATORY STATUS
THE PEDIATRIC ASSESSMENT TRIANGLE ( P.A.T)
appearance work of breathing
circulation to skin
These parts of the general impression will determine weather
the child is in respiratory distress or in respiratory failure.

6. APPEARANCE
Characteristic of Appearance:The “tickles”(TICLS) Mnemonic
Characteristic Features to look for.
Tone Is she moving or resisting examination vigorously ? Does
she have good muscle tone.
Interactiveness How alert is she? How readily does a person, object, or
sound distract her or draw her attention? Will she reach
for, grasp, and play with a toy or exam instrument, like a
pen light or tongue blade? Or is she uninterested in
playing or interacting with the caregiver or pre hospital
professional?
Consolability Can she be consoled or comforted by the caregiver or by
the pre hospital professional?
Look / Gaze Does she fix her gaze on a face ? Or is there a “nobody
home” glassy-eyed state.
Speech / Cry Is her speech or cry strong and spontaneous? Or is it weak,
muffled, or hoarse.

8. WORK OF BREATHING (WOB)
Characteristic of Work of Breathing
Characteristic Features to look for
Abnormal airway Snoring, muffled or hoarse speech, stridor,
sounds grunting, wheezing.
Abnormal positioning Sniffing position, tripoding, refusing to lie down.
Retractions Supraclavicular, intercostal, or substernal
retractions of chest wall, head bobbing in
infants.
Flaring Nasal flaring
These indications of breathing effort will help identify :
1. The anatomic locations of problem.
2. The severity of the physiologic dysfunction.
3. The urgency for treatment.

10. CIRCULATION TO SKIN
Characteristic of Circulation to skin
Characteristic Features to look for
Pallor White or pale skin or mucous membrane coloration
from inadequate blood flow.
Mottling Patchy skin discoloration due to vasoconstriction.
Cyanosis Bluish discoloration of skin and mucous membrane.

11. THE ABCDEs  Hands-on ABCDE assessment :
RESPIRATORY RATE
 Normal RR varies in children of different ages
Normal Respiratory Rate for Age
Age Respiratory Rate
(breaths/min)
Infant 30 - 60
Toddler 24 - 40
Preschooler 22 - 34
School-aged child 18 - 30
Adolescent 12 - 16

12. AIR MOVEMENT & ABNORMAL LUNG SOUND
Interpretation of Abnormal Breath Sounds
Sound Cause Examples
Stridor Upper airway obstruction Croup, foreign body
aspiration, retro-
pharyngeal abscess.
Wheezing Lower airway obstruction Asthma, foreign body,
bronchiolitis.
Expiratory grunting Inadequate oxygenation Pulmonary contusion,
pneumonia, drowning.
Inspiratory crackles Fluid, mucus, or blood in Pneumonia, pulmonary the
airway. contusion
Absent breath sounds Complete airway Foreign body, severe
despite increased obstruction (upper or asthma, pneumothorax,
work of breathing lower airway) hemothorax.
Physical barrier to Pleural fluid, pneumonia,
transmission pneumothorax.

13. Causes of Poor Air Movement in Children
Functional Problem Possible Causes
Obstruction of airways Asthma, bronchiolitis, croup.
Restriction of chest wall Chest wall injury, severe scoliosis or
movement kyphosis.
Chest wall muscle fatigue Prolonged increased work of breathing,
muscular dystrophy.
Decreased control respiratory Head injury, intoxication.
drive.
Chest injury Rib fractures, pulmonary contusion,
pneumothorax.

14. PULSE OXYMETRI
- is a useful tool for detecting & measuring hypoxia.
- a reading of less than 90% (100% non rebreathing
mask), usually indicates respiratory failure
( Normal : > 94 % ).

15. RESPIRATORY DISTRESS MANAGEMENT
GENERAL NONINVASIVE TREATMENT
• Positioning
• Oxygen

16. Patient with Neurologic impairment
Caused by loss of oropharyngeal muscle tone due to the tongue and
mandible falling back and partially blocking the pharynx.
May relieve the obstruction with head tilt / chin lift or jaw thrust.
Sometimes : secretions, blood, foreign bodies block the proximal
airway.
SUCTIONING !
Maintenance of an adequate airway : Oropharyngeal /
Nasopharyngeal Airway / ET Tube.
UPPER AIRWAY OBSTRUCTION
SPECIFIC TREATMENT

17. C R O U P
A viral disease with inflammation, edema and
narrowing of the larynx, trachea, bronchioles.
Treatment :
Position of comfort, humidified O2 and
avoiding agitation are the best treatments
for suspected croup.
The cool water vapor will help reduce the
inflammation and obstruction of croup.

18. PHARMACOLOGIC TREATMENT :
Nebulized epinephrine – specific treatment
2 formulations :
I. RACEMIC EPINEPHRINE, 2.25% solution  0,5 ml 
4,5 ml N saline  nebulized
II. EPINEPHRINE 1 : 1000 Solution  3 – 5 mg (3 – 5 ml)
 nebulized
 BEWARE OF SIDE EFFECTS !
 NEED OBSERVATIONS IN THE ED FOR 4 – 6 HOURS
INVASIVE AIRWAY MANAGEMENT  VERY FEW
CHILDREN

19. BACTERIAL UPPER AIRWAY INFECTIONS
 Tend to progress rapidly with severe respiratory
compromise developing over hours.
 Several possible causes, epiglotitis, tracheitis, diphteria,
peritonsilar / retropharygeal abscess.
 Treatment :
 Give only general non invasive treatment
• High flow O2.
• Position of comfort.
 Avoid agitating the child by trying to place an IV or
another maneuver.
 Quickly transport !
Except : the child in respiratory failure  initiate BVM
ventilation, consider ET intubation.

20. FOREIGN BODY ASPIRATION
May cause mechanical obstruction anywhere in
the airway
A typical history is the sudden onset of coughing,
chocking, gagging, shortness of breath in a
previously well child without a fever
Treatment :
Never perform airway obstruction procedures
if the child has only incomplete obstruction
and can still cough, cry or speak !
Use only general non invasive treatment
Avoid agitating the child

21. If the child has severe respiratory distress and at risk
for getting worse during transport  perform foreign
body airway obstruction maneuvers.
Foreign Body Airways Obstruction Maneuvers
A g e Technique
Infant ( < 12 months ) Five back blows followed by five chest thrusts
Child ( > 1 year ) Five abdominal thrusts
If fail ?  consider direct laryngoscopy
  using pediatric magill forceps
If fail ? attempt BVM ventilation

If fail ? Perform ET intubation

23. LOWER AIRWAY OBSTRUCTION
 Bronchiolitis and asthma are the most common condition
causing lower lower airway obstruction in children
 Wheezing is the clinical hallmark of lower airway
obstruction of any cause.
ASTHMA
Beware of the following features of the initial assessment
which suggest severe bronchospasm and respiratory
failure :
 Altered appearance
 Exhaustion
 Inability to recline
 Interrupted speech
 Severe retractions
 Decreased air movement

24. Several things suggest that a severe or
potentially fatal attack is to come :
• Prior intensive care unit admissions or intubation.
• More than three ED visits in a year.
• More than two hospital admissions in past year.
• Use of more than one metered dose inhaler ( MDI )
canister in the last month.
• Use of steroids for asthma in the past.
• Use of bronchodilators more frequently than every 4
hours.
• Progressive symptoms despite aggressive home
therapy.

25. ALGORITHM FOR THE MANAGEMENT OF ASTHMA
Assess Severity
Early Intervention
Nebulizer -agonis 1-3 X, 3rd Nebulizer + anticholinergic.
Mild
Clinical observation 
improvement maintained
 discharge
Symptom (+)  moderate
Moderate
Nebulizer 2-3 X : partial response
Oxygen.
Close observation in One Day Care
+ IV line.
Severe
Nebulizer 3 X : no response
Oxygen
Close observation in One Day
Care, IV line, Chest X-ray.
Discharge
Add β-agonist orally,
reevaluation after 24-48
hours (Out patient
Department / Asthma
Clinic)
One Day Care
Oxygen, steroid orally.
Nebulizer every 2 hours.
Clinical improvement (8-12 h) 
go to discharge.
12 h : no clinical response 
admitted
In patient
Oxygen, fluid rescucitation
(rehidration and acidosis),
steroid parenterally every 6-8 h,
nebulizer every 1-2 h,
aminophyllin parenterally initial
and maintenance doses
24 h : clinical improvement (+)
 discharge.
No clinical improvement and
impending respiratory failure 
PICU
Note :
Severe asthma  nebulizer 1 x + -agonist +anticholinergic
(nebulizer (-)  adrenalin SC 0,01 ml/BW/dose (max. 0,3 ml)
Moderate and severe asthma  oxygen 2-4 L/min from the
beginning.

27. THE TRANSPORT DECISION : STAY OR GO ?
 Never transport a child who is in Respiratory failure
without assisted ventilation.
 Never transport a child with an obstructed airway until
after performing foreign body obstruction maneuver.
 If the PAT and ABCDE’s are normal and the child has
no history of serious breathing problems  does not
require urgent treatment or immediate transport.
 If the child has Respiratory distress without sign of
upper airway obstruction  transport indicated after
general non invasive treatment.
 If the child has lower airway obstruction with wheezing
 begin specific treatment with a bronchodilator on
scene, then transport.

28. ADDITIONAL ASSESSMENT
 Focused history and physical exam  has the
objectivities :
To obtain a complete description of the main complaint.
To determine the mechanism of injury or circumstances
of illness.
To perform additional physical exam of specific
anatomic locations.
 These parts of the additional assessment are optional in
the physiologically distressed child.
 To obtain the focused history  use the SAMPLE
mnemonic.

29. SAMPLE components in a child with respiratory distress.
Component Explanation
Signs/Symptoms Onset and nature of shortness of breath
Presence of hoarseness, stridor, or wheezing
Presence and quality of cough, chest pain
Allergies Known allergies
Cigarette smoke exposure
Medications Exact names and doses of ongoing drugs, including
metered dose inhalers
Recent use of steroids
Timing and dose of last dose
Timing and dose of analgesics / antipyretics
Past medical problems History of asthma, chronic lung disease, or heart
problems
Prior hospitalizations for breathing problems
Prior intubations for breathing problems
Immunizations
Last food or liquid Timing of the child’s last food or drink, including
bottle or breast feeding
Events leading to the Evidence of increased work of breathing
injury or illness Fever history