1) The document provides guidelines for managing pediatric respiratory distress and failure in 4 parts, with Part 3 focusing on assessment, causes, and treatment of respiratory distress and failure. 2) Key signs of respiratory distress include tachypnea, retractions, and hypoxia; respiratory failure is indicated by bradypnia, cyanosis, and decreased consciousness. Causes include upper airway obstruction, lower airway obstruction, lung disease, and control disorders. 3) For upper airway emergencies like croup and epiglottitis, humidified oxygen, nebulized adrenaline, steroids, and intubation may be needed. For lower airway issues like asthma and bronchiolitis

1. PEDIATRIC ADVANCED
LIFE SUPPORT 2017
GUIDELINES
DR. SAYED ISMAIL,MD
PROFESSOR AND CONSULTANT OF PEDIATRIC
ALAZHAR UNIVERISITY

2. Objectives
• Pediatric advanced life support 2017 guidelines are
presented in 4 parts presentations
• To provide up to date management of life threatening
conditions
• To help the pediatricians and emergency physicians to
pass the PALS examination

3. Part 3
Respiratory Distress
And Failure

4. Assessment of respiration
1. Respiratory rate
2. Chest retractions
3. Chest Sounds , stridor , wheezing , grunting
4. Air entry
5. O2 saturation by oximetry

5. Respiratory distress and failure
Signs of tissue hypoxia / resp. distress /failureEarly signs = resp distress Late signs = resp failure
Tachypnea Bradypnea
Increased resp. efforts , chest
retraction
Head bobbing , seesaw breathing
Tachycardia Bradycardia
Irritability Decreased level of consciousness
O2 sat > 94% <94% with high flow O2
Pallor , mottling , cyanosis are early and late signs
Hypoxia cause catecholamine release pallor

6. Effects of respiratory inadequacy on other organs
• Heart rate
– Hypoxia produces tachycardia. Severe or prolonged hypoxia leads to
bradycardia. This is a pre‐terminal sign.
• Skin colour
– Hypoxia (via catecholamine release) produces vasoconstriction and skin
pallor.
– Cyanosis is a late and pre‐terminal sign of hypoxia
• Mental status
– The hypoxic or hypercapnic child will be agitated and/or drowsy.
Gradually drowsiness increases and eventually consciousness is lost.

7. Exceptions
There may be absent or decreased evidence of increased effort
of breathing in three circumstances:
1. fatigue . Exhaustion is a pre‐terminal sign.
2. cerebral depression
3. Children who have neuromuscular disease
The diagnosis of respiratory failure in such children is made by
observing the efficacy of breathing,
Efficacy of breathing
– Observations of the degree of chest expansion
– auscultation of the chest. A silent chest is an extremely worrying sign.
– Pulse oximetry

8. Causes of Respiratory distress /failure
Upper Airway obstruction
Lower Airway obstruction
Lung parenchymal diseases
Disordered control of breathing

9. Causes of breathing difficulty in children,
• Upper airway obstruction
– Croup/epiglottitis
– Foreign body
• Lower airway obstruction
– Asthma/episodic viral wheeze
– Bronchiolitis
• Disorders affecting lungs
– Pneumonia
– Pulmonary oedema (e.g. in cardiac disease)
– Pneumothorax
– Pleural effusion or empyema ,Rib fractures
– Disorders of the respiratory muscles Neuromuscular disorders
– Disorders below the diaphragm Peritonitis ,Abdominal distension

10. • Central causes of respiratory distress :
• Diabetic ketoacidosis
• Shock
• Poisoning (e.g. salicylates)
• Anxiety attack and hyperventilation
• Decreased respiratory drive Coma
• Convulsions
• Raised intracranial pressure
• Poisoning

11. Upper Airway obstruction
Common causes:
FB
Thick secretion
Adenotonsilar hypertrophy
Croup
Anaphylaxis

12. Lower airway obstruction
Signs and symptoms are charcterized :
Prolonged expiration and wheezing
Marked RD
Affect the expiratory cycle of respiration :
1- Asthma
2- bronchiolitis

13. Lung parenchymal diseases
Caused by alveolar collapse or edema e.g.
pneumonia , CHF
Marked hypoxia
Grunting , Rales
Severe respiratory distress

14. Disordered control of breathing
Abnormal breathing
pattern rapid or slow
but ineffective
Hypoventilation
Due to:
- Trauma
- Hypoxia
- Encephalopathy
- seizures
- CNS infections
- Drug overdose

15. Clinical presentations of the child with breathing difficulty
• Respiratory
– Breathlessness
– Cough
– Change of voice
– Drooling
– Noisy breathing (stridor or wheeze), Grunting
– Rales , poor air entry , chest pain ,
– Hypoxia
• Non‐respiratory
– Poor feeding
– Abdominal pain
– Change in color
– conscious level

16. Features suggesting cardiac cause of respiratory
inadequacy
– Cyanosis, not correcting with oxygen therapy
– Tachycardia out of proportion to respiratory difficulty
– Raised jugular venous pressure
– Gallop rhythm/murmur
– Enlarged liver
– Absent femoral pulses

17. Initial management for respiratory distress = ABC
Airway
● A patent airway. If the airway is not patent, an airway‐opening maneuver ( head tilt
● The airway should then be secured with a pharyngeal airway device or by
intubation .
Breathing
● All children with breathing difficulties should receive high‐flow oxygen
● Use a flow of 10–15 l/min via a face mask and reservoir bag to provide the patient
with approaching 100% oxygen. If lower flows maintain adequate SpO2 (94–99%),
then nasal cannulae or nasopharyngeal catheters may be used for rates of <2 l/min.
● If the child has a slow respiratory rate or weak effort, respiration should be
supported with oxygen via a bag–valve–mask device and experienced senior help
summoned.
Circulation
• Monitor heart rate , rhythm and blood pressure
• Establish vascular access , or IO , Consider a fluid bolus (20 ml/kg of 0.9% saline) if there
are signs of circulatory failure

18. Secondary assessment and looking for key features
• A focused history (SAMPLE) and focus examination
Certain key features
• Stridor , point to upper airway obstruction
• Wheeze , point to lower airway obstruction
• Fever and tachypnea suggests pneumonia
• Signs of heart failure point to congenital or acquired heart disease
• Short history, exposure to allergen and urticarial rash point to
anaphylaxis
• Suspicion of ingestion and absence of cardiorespiratory pathology
point to poisoning

19. Specific treatment

20. Specific management of Pediatric Respiratory Emegencies
By Types
• Obtain early consultation

21. Approach to the child with stridor
Obstruction of the upper airway (larynx and trachea) is potentially life
threatening

22. Stridor …Is the airway partially obstructed or narrowed
and what is the likely cause
• Reassess airway
– If ‘bubbly’ noises are heard, the airway is full of secretions
requiring clearance and suggests that the child is very fatigued,
or has a depressed conscious level and is unable to clear the
secretions with their own cough.
– If (snoring) respiratory noises are heard, consider partial
obstruction of the airway due to a depressed conscious level.
– If there is a harsh stridor associated with a barking cough, upper
airway obstruction due to croup should be suspected.
– If a quiet stridor in a sick‐looking child without cough, consider
epiglottitis.
– If stridor was of sudden onset, with no prodromal symptoms or a
history suggestive of inhalation, consider a foreign body
aspiration.

23. Airway emergency treatment in croup
• In the child with a compromised but functioning airway, an
important principle in all cases is to avoid worsening the
situation by upsetting the child.
• Crying and struggling may quickly convert a partially
obstructed airway into a completely obstructed one.
• Administration of oxygen, nebulised adrenaline or the
performance of a radiograph may all require skill. Parents’
help should be enlisted.
• But if child is unstable you have to intervene

24. Croup treatment
1. Give humidified oxygen
2. Give nebulised adrenaline ( 0.4 ml/kg of 1:1000 (maximum 5 ml))
with oxygen through a face mask to patients with severe
respiratory distress. This will produce a transient improvement
beginning within 10–30 minutes and lasting for up to 2 hours. It
may need to be repeated
3. Oral or nebulised steroids, such as oral dexamethasone
0.6mg/kg or prednisolone 1mg/kg ,repeat after 12hr if needed
• Adrenaline reduces the clinical severity of obstruction, although the effect is short
lived, but is usually of sufficient duration for the corticosteroids to take effect.

25. • Patients should be observed closely with continuous ECG and
oxygen saturation monitoring, as they may still deteriorate and
require tracheal intubation.
• Failure to respond to nebulised adrenaline should question the
diagnosis of croup – consider bacterial tracheitis, epiglottitis or
foreign body.
• HYPOXIA is a late sign of croup and reflects alveolar hypoventilation
secondary to airways obstruction and ventilation–perfusion
mismatch.
• Whilst the respiratory rate and the degree of sternal recession are
valuable clinical indicators of severity and response to treatment,
the degree of hypoxia is the best assessment.
• However, hypoventilation may be masked when the child is
receiving high ambient oxygen.

26. Epiglottitis
• Intubation is likely to be required.
Contact a senior anaesthetist
urgently,
• Tracheal intubation may be
difficult because of the intense
swelling and inflammation of the
epiglottis (‘cherry red epiglottis’)
(Figure).
• A smaller tube than the one
usually required for the child’s size
will be necessary.
• An ENT surgeon capable of
performing a tracheotomy should
be present.
normal

27. Larynx with foreign body obstruction,
foreign body aspiration cannot be excluded on either normal physical examination or chest
radiograph. Laryngo‐bronchoscopy is needed for all children with a history suggestive of foreign
body aspiration. contact a senior anaesthetist/ENT surgeon urgently.
● In extreme cases of life threat, immediate direct laryngoscopy with Magills forceps to remove
a visible foreign body may be necessary.

28. Bacterial tracheitis
• Bacterial tracheitis, or pseudomembranous croup, is an
uncommon but life‐threatening form of upper airway infection.
• Infection of the tracheal mucosa with Staphyloccocus aureus,
streptococci or Haemophilus influenzae B (Hib) results in copious,
purulent secretions and mucosal necrosis.
• The child appears toxic, with a high fever and the signs of
progressive upper airway obstruction.
• The croupy cough, absence of drooling and a longer history help
distinguish this condition from epiglottitis.
• Over 80% of children with this illness need intubation and
ventilatory support to maintain an adequate airway, as well as
• intravenous antibiotics (cefotaxime or ceftriaxone plus
flucloxacillin).

29. Other causes of upper airways obstruction
• Marked tonsillar swelling in infectious mononucleosis or acute
tonsillitis can occasionally compromise the upper airway.
• The passage of a nasopharyngeal tube may give instant relief
and steroids are often helpful.
• Retropharyngeal abscess or peritonsillar abscess are
uncommon, but both can present with fever and the features
of upper airway obstruction together with feeding difficulties.
• Treatment is by surgical drainage and intravenous antibiotics

30. Approach to the child with wheeze
• The two common causes of lower respiratory obstruction are:
• 1. Acute severe asthma .
• 2. Bronchiolitis.
• Bronchiolitis is mostly confined to the under 1‐year‐olds
• Asthma is much more commonly diagnosed in the over
1‐year‐olds.

31. Acute severe asthma
• It can be difficult to assess the severity of an
acute exacerbation of asthma.
• The following clinical signs should be recorded
regularly, e.g. every 30–60 minutes, or before
and after each dose of bronchodilator:
• Pulse rate
– >120 beats/min (>5 years)
– >130 beats/min (2–5 years)
• Respiratory rate
– >30/min (>5 years)
– >50/min (2–5 years
• Use of accessory muscles of respiration
• Degree of agitation and conscious level
• SpO2
• Peak flow (if possible in over 6–7‐year‐olds)
• Life‐threatening
asthma
• Exhaustion
• Poor respiratory effort
• Silent chest
• Hypotension
• Conscious level
depressed/agitated

32. Asthma emergency treatment
• Assess ABC.
• Give high‐flow oxygen via a face mask with a reservoir bag.
• Attach pulse oximeter and aim to keep SpO2 at 94–98%.
• Give a β2‐agonist, such as salbutamol
• Give oral prednisolone 1 mg/kg or, if vomiting, IV
hydrocortisone 4 mg/kg.
Continue ….

33. If not responding, or deteriorating condition• Consider IV aminophylline Loading dose 5 mg/kg IV over 20
minutes*Continuous infusion 1 mg/kg/h
• Give magnesium sulphate 40 mg/kg over 20 minutes.
• Give IV salbutamol infusion 15 micrograms/kg over 10 minutes in patients aged 2
years and older (<2 years: 5 micrograms/kg). The latter may be followed by IV infusion of 1–5
micrograms/kg/min, whilst monitoring ECG and serum potassium regularly to allow for the
detection and treatment of hypokalaemia.
• Contact the paediatric intensive care unit (PICU) or senior
anaesthetic support.
• Consider intubation for mechanical ventilation:

34. Indications for intubation:
● Increasing exhaustion
●Progressive deterioration in:
● clinical condition
● SpO2 – decreasing and/or oxygen requirement increasing
● PCO2 – increasing

35. Bronchiolitis emergency treatment
• Management is primarily supportive – fluid replacement, gentle
suctioning of nasal secretions, prone position (if in hospital), oxygen
therapy and respiratory support if necessary.
• Give a high concentration of oxygen via a mask with reservoir bag.
Monitor the SpO2 and keep at 94–98%.
• Milder and improving cases may use oxygen via nasal cannulae at <2
l/min.
• Consider using humidity, prone positioning and high‐flow, humidified
systems (flows of 1–2 l/kg/min).
• Maintain hydration and nutrition. In infants with significant respiratory
distress, maintain hydration by feeding via a nasogastric tube, or
intravenously at two‐thirds the usual maintenance. Remember,
nasogastric tubes may partially occlude the airway. Breastfeeding may
be too stressful, in which case breast milk should be expressed and
given via a gastric tube.
• Monitor for apnoea/SpO2, and PCO2 – transcutaneous, capillary or
end‐tidal.

36. • Heated, humidified, high‐flow nasal cannulae (HHHFNC) therapy and continuous
positive airway pressure (CPAP) are both believed to improve the work of
breathing by preventing dynamic airway collapse during the expiration thereby
reducing air trapping and improving gas exchange.
• CPAP results in decreased respiratory rate and PCO2, and clinical practice
suggests that CPAP decreases the need for mechanical ventilation with greatest
benefit if instituted early.
• Indications for CPAP include severe respiratory distress, a requirement for FiO2
>0.5 or infants with apnoeas.
• Mechanical ventilation is required in 2% of infants admitted to hospital. In severe
cases, infants with the following may need intubation and mechanical ventilation:
– recurrent apnoea,
– exhaustion, or
– severe hypercapnia and hypoxia.
– All intubated infants must have continuous SpO2 and CO2 monitoring.
• Both nebulised 3% saline and nebulised adrenaline with corticosteroids have been
subjected to trials, but without showing substantial benefit.
• Bronchodilators, steroids, antibiotics and physiotherapy are not useful.

37. Features that help distinguish heart failure from
bronchiolitis
• Heart failure
• Feeding difficulty with growth
failure
• Restlessness, sweating
• Tachycardia and tachypnoea
• Pallor, sweating and cool peripheries
• Large heart with displaced apex beat
• Large liver
• Gallop rhythm
• Murmur
• Chest X‐ray shows pulmonary
congestion and large heart
• Bronchiolitis
• Coryzal and harsh cough
• Normal or apparently small
heart
• No murmur
• Liver lower than normal
• Hyperinflation on chest
X‐ray

38. Pneumonia emergency treatment
• oxygen via a face mask with reservoir bag. Attach a pulse oximeter; maintains
SpO2 at 94–98%, then nasal cannulae may be used with a flow <2 l/min.
• Antibiotics. :
– amoxicillin is effective against most bacteria.
– cefotaxime would be considered.
– flucloxacillin – if Staphylococcus aureus is suspected, or
– macrolide antibiotic – if atypical pneumonia or pertussis .
• Maintain hydration: extra fluid may be needed to compensate for loss from
fever, and restriction may be needed because of inappropriate antidiuretic
hormone (ADH) secretion. Fluid overload can contribute to worsening
breathlessness.
• Clinical examination and the chest radiograph may reveal a pleural effusion . This
should be confirmed with ultrasound and, if large, it should be drained to relieve
breathlessness, aid diagnosis and allow the instillation of intrapleural fibrinolytic
agents. Ultrasound may guide the positioning of an intrapleural drain.
• Airway and breathing support may especially be needed in children with
neurodisability or neuromuscular weakness, who may have poor airway control
and weak respiratory muscles even when well.

39. Approach to the child with heart failure
Left ventricular volume overload
or excessive pulmonary blood flow
Ventricular septal defect / Atrioventricular
septal defect
Common arterial trunk / Persistent arterial
duct
Left heart obstruction: Hypertrophic cardiomyopathy / Critical aortic
stenosis Aortic coarctation / Hypoplastic left
heart syndrome
Primary ‘pump’ failure: Myocarditis / Cardiomyopathy
Dysrhythmia: Supraventricular tachycardia /.Complete heart
block / VT
Causes of heart failure that may present as breathing difficulties

41. Left ventricular volume
overload or excessive
pulmonary blood flow
VSD ,PDA ASD
A chest X‐ray will usually provide supportive evidence in the
form of cardiomegaly and increased pulmonary
vascular markings. Give:
● high‐flow oxygen , and
● diuretics , oral diuretics are adequate and a combination of
loop diuretics (frusemide ) with a potassium‐sparing diuretic
(amiloride or spironolactone) in twice or thrice daily doses
should be commenced.
Electrolytes should be checked prior to commencing diuretics. In
severe cases, the first dose
Left heart obstruction:
eg Hypoplastic left heart
syndrome
inotropes for cardiogenic shock , and prostaglandin for duct
dependent lesions
Primary ‘pump’ failure:
e.g Myocarditis /
Cardiomyopathy
Children of all ages who present with breathlessness from heart
failure may have myocarditis. This is characterised by a
marked sinus tachycardia and the absence of signs of structural
abnormality. The patients should be treated with oxygen
and diuretics.
Dysrhythmia Drugs
Heart failure emergency treatment

42. • A full blood count and measurements of serum urea and
electrolytes, calcium, glucose and arterial blood gases should
be performed on all patients in heart failure.
• A routine infection screen including blood cultures is
recommended,especially in infants.
• A full 12‐lead ECG and a chest radiograph are essential.
• All patients suspected of having heart disease should be
discussed with a paediatric cardiologist, as transfer to a
tertiary centre will usually be required.
• Echocardiography will establish the diagnosis in most cases.
Heart failure emergency treatment

43. • See shock in the 4th part of PALS