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

September 21, 2026

Good morning, 

Over the past two weeks, we have discussed: (1) the step-by-step approach to evaluating a child in respiratory distress and (2) the signs, symptoms, and clinical presentations of children with respiratory distress secondary to upper airway involvement. This week, we will be discussing lower airway involvement. Respiratory illnesses of the lower airway are obstructive, parenchymal, or alveolar diseases. The clinical hallmarks include dyspnea, tachypnea, and cough. Common causes include bronchiolitis, asthma, congenital abnormalities (tracheal webs, cysts, vascular rings, and lobar emphysema), pneumonia, pulmonary edema, inhalation injury, and Cystic Fibrosis. 

Bronchiolitis, a viral infection, is a lower respiratory tract infection of the bronchioles (small airways). It usually presents in the winter – spring months. It is usually seen in children under 24 months old. Respiratory Syncytial Virus (RSV) is the most common cause. Clinical signs are like those of a viral respiratory infection. These children usually start with a prodrome of nasal congestion, rhinorrhea, fever, cough, wheezing, and mild respiratory distress. Additional signs and symptoms include apnea, decreased oral intake, and moderate to severe respiratory distress (tachypnea, nasal flaring, and retractions, grunting), cyanosis, restlessness, and lethargy. Risk factors for severe disease include children less than 12 weeks old, history of prematurity (less than 37 weeks), history of congenital heart disease, history of chronic lung disease, and history of immunodeficiency. The course of bronchiolitis is variable and dynamic. It ranges from transient events such as apnea or mucous plugging to progressive respiratory distress from lower airway obstruction. Symptoms are usually worse on days 3 – 5 of illness. Determining the degree of airway obstruction is the most important consideration when assessing children with bronchiolitis. Examine their general appearance, their degree of respiratory distress, cyanosis or pallor, and their level of oxygen saturation. En route, give supplemental oxygen if oxygen saturation is consistently below 92%. Insert an IV and administer fluids if they appear to be dehydrated. If wheezing is present, a trial of a bronchodilator (Albuterol) is an option. Please auscultate before and after the albuterol administration to determine if it made a difference in the patient’s air exchange or work of breathing.

Asthma accounts for 15% of all emergency department visits. It is a chronic inflammatory lung disease. Symptoms include paroxysmal cough, wheezing, dyspnea, and chest tightness. It is caused by airway inflammation and narrowing that is partially or completely reversible. Precipitating factors include infection, allergens, irritant exposure (tobacco smoke, air pollution), exercise, cold exposure, beta blockers, and emotional stress. When presented with a patient with asthma, your goal is to rapidly determine the severity of the acute exacerbation and examine their overall appearance (color and level of consciousness). Their respiratory mechanics are important. Look for tachypnea, retractions, nasal flaring, grunting, abdominal breathing, and prolonged expiratory phase. When auscultating, listen for their degree of air exchange (Are they wheezing, are they moving no air at all, do they have symmetry of their breath sounds?). Please monitor their hydration status. In severe exacerbations, the child may be breathless, have difficulty speaking in complete sentences, and may have a change in mental status (remember that hypoxia can cause agitation and hypercapnia causes drowsiness or coma). Treatment for acute asthma exacerbations includes oxygen, duo nebulizer treatments (albuterol and ipratropium). These treatments can be repeated in route if the work of breathing persists. In cases of severe exacerbations, insert an IV or IO, administer fluids for hydration, and add Solu-Medrol (2 mg/kg; Max Dose: 60 mg for children). Transport the patient to an appropriate facility. Remember to consult Medical Control when indicated. 

Thanks for all your hard work. Have a great week. Stay Safe!

Regina A. Yaskey, MD

September 28, 2026

Measles is a highly contagious viral illness that can cause serious complications, particularly in young children. The disease is spread through the air when an infected person coughs or sneezes, and the virus can remain suspended in the air for up to two hours. Although measles can lead to severe illness, it is largely preventable through vaccination. Two doses of the measles, mumps, and rubella (MMR) vaccine are ~97% effective at preventing measles infection.  

Common symptoms include fever, cough, runny nose, and red or irritated eyes. As the illness progresses, a characteristic rash usually develops two to four days after the initial symptoms begin. The rash typically starts along the hairline and spreads downward across the face, neck, trunk, and the rest of the body. Some individuals also develop small white spots inside the mouth, known as Koplik spots, which may appear two to three days before the rash develops. The virus spreads through the air when an infected person breathes, coughs, or sneezes and may survive in the environment for up to two hours. Individuals who have not been vaccinated and have not previously had measles have more than a 90% chance of becoming ill after exposure. A person with measles is contagious four days before the rash appears until four days after the rash develops.

Complications of measles can range from having ear infections, pneumonia, diarrhea with dehydration, to life-threatening seizures, encephalitis, and death. Because of these potentially severe outcomes, prevention through vaccination and infection control measures is essential.

All first responders should have documented evidence of immunity against measles and should follow their EMS agency’s policies regarding proof of immunity. Evidence of immunity may include documentation of two valid doses of live measles or MMR vaccine administered at least 28 days apart, laboratory evidence of immunity, or laboratory confirmation of prior measles infection. Individuals born before 1957 who don't have laboratory evidence of immunity or previous disease should receive two doses of the MMR vaccine at the recommended interval.

Appropriate Personal Protective Equipment (PPE) is important when caring for patients with suspected or confirmed measles. First responders should wear an N-95 respirator, while patients should wear a surgical mask whenever possible. Only personnel known to be immune to measles should have direct contact with patients who may be infected. Healthcare facilities should be notified before the arrival of any patient with known or suspected measles. Advance notification allows facilities to prepare appropriate infection prevention measures, including placement of patients in negative-pressure rooms or rooms equipped with HEPA filtration systems. During ambulance transport, the patient compartment exhaust vent should be operated on a high setting, and the driver compartment should be isolated from the patient area whenever possible. The driver compartment ventilation system should also be set to high airflow without recirculation to reduce the risk of airborne transmission.

That is all for September. Keep up the great work and stay safe!

Regina A. Yaskey, MD