September 7, 2026

Good morning, 

This month, we will discuss Pediatric Respiratory Emergencies. Since children are more likely to develop acute respiratory problems from winter through spring, it is essential to recognize, evaluate, and manage symptoms promptly.

Respiratory emergencies account for many childhood emergency department visits and hospital admissions and are a leading cause of cardiopulmonary arrest in children. Children are not simply “little adults.” They have smaller airways, higher metabolic demands, lower respiratory reserves, and limited compensatory mechanisms. The pediatric airway is also cone-shaped, with the cricoid cartilage as the narrowest point, which can make visualization more difficult than in adults. Neonates are obligate nose breathers, and their smaller airways mean that even mild edema or secretions can significantly affect breathing. For this reason, it is important to keep children calm. Even minor colds can cause noisy breathing, including congestion, stridor, and wheezing.

Early recognition of impending respiratory failure is critical when evaluating children, and prompt intervention can improve outcomes. Use a step-by-step assessment: 

• Ask yourself, “Is this child in respiratory distress?”

• “What interventions are needed now to prevent respiratory failure?”  

Resuscitation courses emphasize airway, breathing, and circulation. In pediatrics, add another “A” for Appearance. A child’s appearance is essential to guiding evaluation and management. A quick “sick or not sick” assessment provides valuable information. Observe the child’s level of alertness and activity. Are they active and curious, looking around the room? Do they appear pale, mottled, or cyanotic? Do they have normal tone, appear floppy, or refuse to move from a certain position?

Next, pay close attention to respiratory mechanics. Watch for significantly increased work of breathing, such as grunting, nasal flaring, and subcostal, intercostal, or suprasternal retractions. Decreased respiratory effort can indicate fatigue and may signal impending respiratory failure. Listen to the child’s voice or cry. Is it hoarse or muffled? Do you hear stridor or wheezing? In a verbal child, assess whether they can speak in full sentences or only one-word responses. For example, children with severe asthma exacerbations may be unable to speak in full sentences. 

In summary, remember A-ABC when assessing children: Appearance – Airway, Breathing, and Circulation.

Be safe, stay warm, and keep up the amazing work!

Regina A. Yaskey, MD

September 14, 2026

Good Morning, 

Last week, we discussed the overall step-by-step approach to evaluating a child in respiratory distress. This week focuses on the evaluation and management of the child presenting in respiratory distress secondary to an upper airway involvement. When faced with a child in respiratory distress, ask yourself: is it an upper or lower airway obstruction? Think about it! What sound do you hear from kids with an upper airway obstruction? It is STRIDOR. It is a high-pitched, crowing noise typically heard on inspiration. It indicates the presence of a large airway obstruction above the thoracic inlet.

CROUP is a common upper airway respiratory illness. It is an acute viral infection that inflames the subglottic airway, causing upper airway obstruction. Its hallmarks are stridor, barky cough (baby seal sound), and hoarseness. Some children present with fevers and others do not. When evaluating and treating these patients, keep them calm and do not agitate them (remember, they have edema of their upper airway). Keep them in their position of comfort. Do not lay them down and DO NOT perform a digital airway exam. Check a pulse oximetry and place them on the cardiac monitor. If they are in mild distress, without stridor, give them nebulized normal saline during transport. If they have stridor at rest with a barky cough, give them nebulized racemic epinephrine. If they are in moderate/severe distress with stridor and a barky cough, give racemic epinephrine plus IV solumedrol (2 mg/kg; Max Dose = 60 mg in children). Of note, if racemic epinephrine is unavailable, you can administer aerosolized epinephrine 1 mg/ml. Of note, I want you to also know that: (1). If your patient is wheezing, then it is not croup. Wheezing in the breathing patient with respiratory distress indicates lower airway disease, not upper. With croup, you should be able to note some improvement after a dose or two of racemic epinephrine (whether it is improvement in stridor or work of breathing). If you do not note any improvement, then consider an Upper Airway Foreign Body Obstruction at the top of your differential.

Upper Airway Foreign Body Obstruction is the leading cause of accidental death in toddlers. The history is that of a crawling infant or toddler presenting with an abrupt onset of choking or gagging. The parents will usually tell you that the patient has not been ill with any respiratory symptoms before this event. During auscultation, there is usually minimal or no air exchange despite effort from the child. Cyanosis can be present in a complete obstruction. Crawling infants and toddlers love to put things in their mouth; hence the saying “everything is edible” to them. Therefore, please keep your index of suspicion HIGH in a toddler-aged child. In coughing and conscious infants (0-12 months), administer oxygen (10-15L) via infant mask as tolerated. If the infant is conscious but there is concern for a complete obstruction (no breath sounds on auscultation, cyanosis), give five back blows followed by five chest thrusts. If the child is of toddler age or is older, perform abdominal thrusts instead. In the case of an unconscious patient with a complete obstruction, immediately begin chest compressions/CPR. Have your partner open the airway to see if they can visualize the foreign body. If they can and it is attainable, they can remove it with their fingers or consider using the laryngoscope and Magill forceps to retrieve and remove it. If unable to remove the foreign body, ventilate the patient via bag-valve mask and transport to an appropriate facility. DO NOT PERFORM A BLIND FINGER SWEEP. This could lodge the foreign body even further down the airway. Remember to contact Medical Control when indicated and provide appropriate transfer of care. 

Acute Epiglottitis is a life-threatening bacterial infection of the epiglottis and surrounding structures. Nowadays, it is very rare because of the administration of the Haemophilus Influenzae type B vaccine (also known as Hib vaccine). These patients are toxic-appearing and present with a very abrupt onset of fever, stridor, sore throat, and drooling. Do not agitate them; allow the child to maintain their position of comfort. Ensure adequate ventilation via BVM as soon as possible. DO NOT ATTEMPT invasive airway procedures on the conscious patient who is suspected of having epiglottitis, unless they are in respiratory arrest. Call Medical Control early and transport to an appropriate facility.

We will discuss lower airway obstruction next week. 

Thank you and stay safe!

Regina A. Yaskey, MD