PALS | Management of Respiratory Failure/ Distress

1️⃣ MANAGEMENT OF RESPIRATORY DISTRESS (Compensation Phase)Goal → Support oxygenation & ventilation BEFORE fatigue sets in.A. Airway Opening ManeuversPositioning is everythingInfants: sniffing positionOlder kids: tripod or chin lift / jaw thrustAvoid hyperextension in infants (soft trachea collapses)B. Oxygen Administration 🫧Start low → escalate:Blow-by (infants, mild)Nasal cannulaSimple mask / NRBHumidified O₂ for croupTarget SpO₂ ≥ 94% unless chronic lung disease.C. Treat the Underlying ProblemUpper airway (stridor):Racemic epi nebDexamethasoneAvoid upsetting the child ❗Lower airway (wheezing):Albuterol ± ipratropiumMagnesium sulfate (severe)SteroidsParenchymal (pneumonia):AntibioticsHigh-flow nasal cannula if hypoxemicFluid overload: diureticsForeign body: encourage cough; prepare for removalD. MonitoringContinuous pulse oxReassess work of breathing q5–10 minCap refill, mental status, perfusionPrepare airway equipment earlyE. Red Flags That Require EscalationIncreased fatigueDeclining retractions (NOT improvement)Rising CO₂ signs: headache, confusion, lethargySpO₂ not improving with O₂2️⃣ 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 availableWatch chest rise and SpO₂Avoid over-ventilation (↓ venous return → ↓ BP)C. Consider Airway AdjunctsOPA if no gagNPA if gag intactSuction PRND. Prepare for IntubationIndications:FatigueWorsening hypoxemiaHypercarbiaApnea / bradypneaDiminished or silent chestSetup:Appropriate ETT sizeStyletSuctionBVM with PEEPConfirm with waveform capnographyE. Ventilation Strategy Post-IntubationUse lowest pressures neededAvoid breath stackingAdjust rate for CO₂ goalsReassess every few minutesF. Treat the Cause (Critical)Anaphylaxis → IM epi, fluidsAsthma → continuous albuterol, steroids, mag, possible ketamineCroup → racemic epi, steroidsBronchiolitis → suction, high-flow