1️⃣ MANAGEMENT OF RESPIRATORY DISTRESS (Compensation Phase)

Goal → Support oxygenation & ventilation BEFORE fatigue sets in.

A. Airway Opening Maneuvers

• Positioning is everything
  • Infants: sniffing position
  • Older kids: tripod or chin lift / jaw thrust
• Avoid hyperextension in infants (soft trachea collapses)

B. Oxygen Administration 🫧

Start low → escalate:

1. Blow-by (infants, mild)
2. Nasal cannula
3. Simple mask / NRB
4. Humidified O₂ for croup

Target SpO₂ ≥ 94% unless chronic lung disease.

C. Treat the Underlying Problem

• Upper airway (stridor):
  • Racemic epi neb
  • Dexamethasone
  • Avoid upsetting the child ❗
• Lower airway (wheezing):
  • Albuterol ± ipratropium
  • Magnesium sulfate (severe)
  • Steroids
• Parenchymal (pneumonia):
  • Antibiotics
  • High-flow nasal cannula if hypoxemic
• Fluid overload: diuretics
• Foreign body: encourage cough; prepare for removal

D. Monitoring

• Continuous pulse ox
• Reassess work of breathing q5–10 min
• Cap refill, mental status, perfusion
• Prepare airway equipment early

E. Red Flags That Require Escalation

• Increased fatigue
• Declining retractions (NOT improvement)
• Rising CO₂ signs: headache, confusion, lethargy
• SpO₂ not improving with O₂

2️⃣ MANAGEMENT OF RESPIRATORY FAILURE (Decompensation Phase)

Goal → Ventilate & oxygenate NOW. Fatigue → arrest in minutes.

A. Call for Help / Activate PALS Team 🚨

Failure means the child cannot compensate. You need backup.

B. Immediate Bag-Mask Ventilation (The #1 lifesaving step)

• Correct size mask → seal with “EC clamp”
• Rate: 12–20/min (1 breath q3–5 sec)
• Use PEEP valve if available
• Watch chest rise and SpO₂
• Avoid over-ventilation (↓ venous return → ↓ BP)

C. Consider Airway Adjuncts

• OPA if no gag
• NPA if gag intact
• Suction PRN

D. Prepare for Intubation

Indications:

• Fatigue
• Worsening hypoxemia
• Hypercarbia
• Apnea / bradypnea
• Diminished or silent chest

Setup:

• Appropriate ETT size
• Stylet
• Suction
• BVM with PEEP
• Confirm with waveform capnography

E. Ventilation Strategy Post-Intubation

• Use lowest pressures needed
• Avoid breath stacking
• Adjust rate for CO₂ goals
• Reassess every few minutes

F. Treat the Cause (Critical)

• Anaphylaxis → IM epi, fluids
• Asthma → continuous albuterol, steroids, mag, possible ketamine
• Croup → racemic epi, steroids
• Bronchiolitis → suction, high-flow