2026 Pediatric Airway / Respiratory Emergencies

This protocol addresses pediatric respiratory distress, including asthma, bronchospasm, bronchiolitis, reactive airway disease, anaphylaxis with respiratory involvement, and upper airway pathology such as croup, epiglottitis, foreign body obstruction, and congenital airway abnormalities (e.g., laryngomalacia, tracheomalacia).

GENERAL APPROACH

• Follow General Pediatric Protocol.

1. Initial assessment includes airway patency, work of breathing, lung sounds (wheezing, stridor, diminished, or silent chest), mental status, skin color/perfusion, and pulse oximetry.

2. Use continuous waveform capnography (EtCO2) for moderate to severe distress when available, and for any patient receiving BVM or noninvasive ventilation. 

3. Minimize agitation; allow position of comfort and caregiver presence when safe, especially in upper airway disease. 

4. Do not delay transport for repeated nebulizer treatments in severe distress; treat en route when feasible.

OXYGENATION / VENTILATORY SUPPORT

1. Provide the least distressing oxygen delivery method possible.

2. • Target SpO2 92-96% for most patients; avoid routine hyperoxia. 

3. If bronchiolitis is suspected and the patient is improving clinically, SpO2 >= 90% is acceptable.

4. If chronic lung disease is suspected, individualize goal (generally >= 90-92%) per clinical context and medical control as needed.

5. High-flow nasal cannula (HFNC), if available (ALS): initiate early in moderate to severe distress (e.g., bronchiolitis, asthma) before escalation to BVM/intubation. Suggested starting flow 1-2 L/kg/min (max per device), titrate to work of breathing and SpO2.  

   •  HFNC is  a Work in Progress

     1. Age 2-4 years apply 6-10lpm

     2. Age 4-10 apply 10-15lpm 

6. Noninvasive ventilation (CPAP/BiPAP), if available (ALS): consider for cooperative children with moderate to severe asthma or other causes of ventilatory failure without contraindications (e.g., vomiting, inability to protect airway, facial trauma). Typical starting CPAP 5 cm H2O; titrate 5-10 cm H2O as tolerated.

7. BVM with PEEP (if available) for impending respiratory failure; ensure proper mask seal and age-appropriate ventilation rate.

VASCULAR ACCESS

• Establish IV access only if it does not delay respiratory care; IO acceptable if respiratory failure is imminent.

SEVERITY ASSESSMENT

Use clinical appearance, work of breathing, air movement, mental status, and SpO2/EtCO2 trends. 

Silent chest is a pre-arrest finding requiring immediate escalation. 

Age-based normal respiratory rate (approximate): 

• Mild: age-appropriate RR; mild wheeze or coarse respirations; SpO2 generally >= 92% on room air; minimal or no retractions; normal mental status.

• Moderate: increased RR for age; wheezing with retractions or nasal flaring; SpO2 generally 90-92% on room air (or need for supplemental oxygen); anxious/irritable but alert.

• Severe: marked tachypnea or bradypnea; poor air movement or silent chest; SpO2 < 90% despite oxygen; severe retractions/head bobbing/grunting; altered mental status; rising EtCO2 or fatigue.

LOWER AIRWAY DISEASE

DYSPNEA / ASTHMA / BRONCHOSPASM

ALBUTEROL

< 2 years: 1.25 mg nebulized

>/= 2 years: 2.5 mg nebulized

May repeat every 15-20 minutes.

 CONTINUOUS ALBUTEROL (severe asthma)

0.5 mg/kg/hr nebulized (maximum 20 mg/hr) with close monitoring; consider inline delivery with NIV/BVM when applicable.

IPRATROPIUM BROMIDE (asthma - moderate to severe)

 < 20 kg: 0.25 mg nebulized mixed with albuterol

 >/= 20 kg: 0.5 mg nebulized mixed with albuterol

 Administer with first 2-3 albuterol treatments only

 SYSTEMIC CORTICOSTEROID

• dexamethasone 0.6 mg/kg PO/IM/IV (maximum 8 mg)

EPINEPHRINE

• Suspected anaphylaxis: epinephrine 1 mg/mL (1:1,000) IM 0.01 mg/kg (max 0.3 mg) immediately.

• Severe/life-threatening asthma with impending respiratory failure: epinephrine 1 mg/mL IM 0.01 mg/kg (max 0.3 mg) may be used

• as rescue therapy; do not substitute for bronchodilators/steroids. 

MAGNESIUM SULFATE (ALS; refractory severe asthma)

• 25-50 mg/kg IV over 20 minutes (maximum 2 grams). Place on cardiac monitor; use caution with hypotension. 

• Use EtCO2 trending when available to monitor ventilation and fatigue; rising EtCO2 or decreasing respiratory effort indicates deterioration. 

Avoid intubation if possible; it carries high risk of peri-intubation decompensation/cardiac arrest in pediatric asthma. If unavoidable, optimize oxygenation/ventilation and coordinate closely with medical control.

BRONCHIOLITIS (INFANTS)

Supportive care is primary (position of comfort, nasal suctioning, oxygen/HFNC as needed).

Do not use bronchodilators routinely. A single bronchodilator trial may be considered in select patients (e.g., recurrent wheeze or strong atopic history); continue only if clear, documented improvement in work of breathing/air movement.

FOREIGN BODY AIRWAY OBSTRUCTION

Red flags: sudden onset cough/choking episode, asymmetric breath sounds, localized wheeze, or wheeze not responding to bronchodilators. 

Conscious patient: infants - back blows and chest thrusts; children - abdominal thrusts.

Unconscious patient: begin CPR; remove object only if visible; do NOT perform blind finger sweeps.

Advanced airway: laryngoscopy and removal with forceps if trained; do NOT intentionally push obstruction distally.

UPPER AIRWAY DISEASE

STRIDOR / CROUP / SUSPECTED EPIGLOTTITIS

• Minimize agitation and handling; allow position of comfort; caregiver may hold child if safe.  

• Provide oxygen only if hypoxemic or in significant distress; titrate to SpO2 92-96%. 

NEBULIZED EPINEPHRINE:

• Racemic epinephrine 2.25%: 0.05 mL/kg in 3 mL NS (max 0.5 mL)

• If unavailable: L-epinephrine 1 mg/mL (1:1,000) 0.5 mL in 3 mL NS (clinically equivalent to racemic dosing in most EMS practice). 

• May repeat every 20 minutes as needed.

After nebulized epinephrine, symptoms may recur as medication effect wanes (rebound). Transport is recommended even if improved. 

• DEXAMETHASONE: 0.6 mg/kg PO/IM/IV (maximum 8 mg).

Suspected Epiglottitis: drooling, toxic appearance, high fever, tripod positioning. Do NOT instrument airway unless respiratory failure is imminent. Early medical control notification and rapid transport.

IMPENDING RESPIRATORY FAILURE

• Exhaustion or decreasing respiratory effort; worsening mental status; rising EtCO2; silent chest; bradypnea.

• Escalate oxygenation/ventilation: HFNC or NIV if available and appropriate; otherwise BVM with PEEP.

• Airway adjuncts as tolerated; prepare backup airway plan.

• Intubation is a last resort; coordinate with medical control and prioritize pre-oxygenation and hemodynamic stability.

MEDICAL CONTROL

• Failure to respond to initial therapy.

• Suspected epiglottitis.

• Need for magnesium or advanced airway.

• Severe asthma requiring continuous albuterol, NIV/HFNC escalation, or IM epinephrine outside suspected anaphylaxis.

• Three or more bronchodilator treatments, persistent SpO2 < 90%, or rising EtCO2/clinical fatigue.

TRANSPORT

• Rapid transport for all moderate to severe distress.

• Early destination notification for anticipated airway compromise.

• Prefer pediatric-capable destination (or consult medical control) for refractory asthma, upper airway pathology, need for HFNC/NIV, magnesium administration, or anticipated advanced airway.

• Treat en route when feasible; avoid prolonged scene times in severe distress.