BJA Education, 19(11): 350e356 (2019)

doi: 10.1016/j.bjae.2019.07.004

Matrix codes: 1C02,

2D01, 3D00

Paediatric respiratory distress

J. Challands1,* and K. Brooks2
1
Royal London Hospital, London, UK and 2Barts Health NHS Trust, London, UK
*Corresponding author: joanne.challands@nhs.net

Learning objectives Key points

By reading this article, you should be able to:

Recognise the paediatric patient in respiratory
distress and identify the signs of impending res-
piratory failure.

Describe the modifications that may be needed to
achieve safe induction of anaesthesia and
tracheal intubation in the paediatric patient in
respiratory distress.

Describe the emergency management of children
in respiratory distress with a tracheostomy.
Anaesthetists are part of the paediatric emergency response
team in hospitals throughout the UK. These teams respond to
all paediatric emergencies within the hospital. Respiratory
disease is the most common reason for acute hospital
admission in children, so it follows that a large number of
paediatric emergencies result from severe respiratory distress
or imminent respiratory failure. Often, by the time an emer-
gency call is put out or a referral to the anaesthetist is made,
the child has deteriorated significantly and usually requires
non-invasive or invasive ventilation and transfer to a paedi-
atric ICU (PICU). There are many causes of paediatric respi-
ratory distress with varying treatments and prognoses. A good
working knowledge of these diseases and their management
can inform and assist with anaesthetic intervention in this
stressful situation.
This article summarises the common causes of paediatric
respiratory distress and the anaesthetic management thereof.
The causes of stridor and respiratory compromise secondary
to this have been covered recently in this journal, and will not
be discussed here.1

Many paediatric emergencies result from severe
respiratory distress or imminent respiratory
failure.

Common causes of paediatric respiratory distress
include bronchiolitis, wheeze in the preschool
child, asthma and pneumonia.

Less common causes include interstitial lung
disease, pulmonary aspiration and problems
associated with tracheostomies.

Signs of impending respiratory failure warrant
involvement of an anaesthetist and, in most
cases, tracheal intubation and artificial
ventilation.

Management of paediatric respiratory distress
requires meticulous preparation to avoid com-
plications during induction of anaesthesia, intu-
bation and ventilation.
Bronchoconstriction and wheezing
Asthma affects one in 11 children. In 2016 asthma caused 6783
emergency admissions to hospital in patients aged 0e14 yrs.
Whilst hospital admissions are common, fatality is fortu-
nately rare with 12 deaths in the same age group in the UK in
2016.2 The pathogenesis is not fully understood. However,
variable airflow obstruction and airway hyper-reactivity are
involved. Exacerbations may be infective or non-infective; the
majority of infective exacerbations are caused by viral infec-
tion. The joint British Thoracic Society and Scottish Intercol-
legiate Guidelines Network guidelines outline the treatment
for children admitted to a hospital as follows:3

(i) Oxygen (method dependent on severity: low-flow nasal

cannulae, Hudson face mask, or high-flow nasal
Joanne Challands FRCA is a consultant paediatric anaesthetist at cannulae)
the Royal London Hospital. (ii) Nebulised b2-agonists with the addition of an inhaled
anticholinergic if response is poor
Katherine Brooks FRCA is a specialty registrar in anaesthesia at
Barts Health NHS Trust and the London School of Anaesthesia.

Accepted: 31 July 2019

© 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
For Permissions, please email: permissions@elsevier.com

350

Box 1
Signs of impending respiratory collapse

Exhaustion: evidenced by listlessness or decreased
respiratory effort

Cyanosis

Impairment of consciousness

SpO2 <92% despite supplemental oxygen FIO2 0.6

Recurrent apnoea

Worsening hypercarbia
(iii) Corticosteroids (i.v. route likely to be required in severe
respiratory distress)
(iv) Magnesium sulphate, salbutamol, and aminophylline
(i.v. infusions as required)
Of these treatments, there is some evidence that magne-
sium sulphate works the fastest, and it should, therefore, be
the first choice in patients requiring i.v. treatment. Where
there is poor response, artificial ventilation must be consid-
ered. In the child in whom medical management is failing,
mechanical ventilation must be considered, although it must
be noted that this alone does not correct the underlying
problem, and these children can be very difficult to manage
after tracheal intubation. Non-invasive ventilation is used in
some centres. At present, there is no clear evidence of its
effectiveness in avoiding intubation.3 However, a 2016
Cochrane review concluded that there was also no evidence of
harm.4 A large, single-centre, continuous quality improve-
ment programme in the USA suggests that using bilevel pos-
itive airway pressure ventilation in the emergency
department reduced the rates of admission to PICU.5 Medical
management must be optimised first, and on balance, it is
probably advisable to try non-invasive ventilation before
tracheal intubation.
Because of the high incidence of wheezing syndromes in
those children aged <6 yrs, asthma is not ordinarily diagnosed
before this, when more common causes of wheezing include
bronchiolitis and ‘preschool wheeze’. Bronchiolitis is the most
common disease of the lower respiratory tract in the first year
of life, affecting approximately one in three infants. Overall,
2e3% of cases require hospitalisation.6 It is most commonly
caused by respiratory syncytial virus, but other viruses are
also implicated. Infection of the epithelial cells of the small
airways causes inflammation, mucous production, and
sloughing of necrotic epithelial cells leading to obstruction of
the small airways with resulting hyperinflation, atelectasis,
and wheeze.7 Presentation is with coryzal symptoms followed
by tachypnoea, cough, crackles or wheeze; apnoea is more
common in babies less than 6 weeks old. The prognosis is
good and mortality is rare. Risk factors for severe illness are
prematurity (especially those babies born at <32 weeks
gestational age), bronchopulmonary dysplasia, congenital
heart disease, neuromuscular diseases, immunodeficiency,
and age <3 months. The initial treatment is suctioning the
nostrils, supplemental oxygen if SpO2 persistently is less than
92%, and nasogastric (NG) feeding (which will be stopped in
cases of severe respiratory distress). Chest physiotherapy,
nebulisers, antibiotics, and steroids are not included in the
current guidelines because of a lack of evidence. However, in
the context of progressive deterioration, these measures may
Paediatric respiratory distress
be considered to avoid invasive ventilation. CPAP should be
commenced if there are signs of impending respiratory failure
(see Box 1).6 Some units use high-flow oxygen therapy (HFOT)
via nasal cannulae instead of CPAP. A recent multicentre trial
comparing conventional nasal oxygen therapy with HFOT
showed that treatment failure requiring escalation of care
occurred less frequently in the HFOT group (12% vs 23%).8
The term ‘preschool wheeze’ is used to describe several
clinical syndromes, some of which are overlapping. Most
cases are transient with only 15% continuing to wheeze after 6
yrs of age. The vast majority of these episodes are managed at
home or in primary care, but children may present with this
history before surgery, so awareness of the condition is
important. If a child is unwell enough with preschool wheeze
to be admitted to a hospital, treatment includes supplemental
oxygen, inhaled bronchodilators and oral corticosteroids. In
cases with poor response, the following can be considered, but
have equivocal or no evidence of efficacy: inhaled corticoste-
roids, leukotriene antagonists, antihistamines and i.v.
bronchodilators.9
Pneumonia and sepsis
The incidence of pneumonia in children is 14.4 per 10,000. It
affects all age groups, and can be bacterial, viral, or mixed. In
those children aged <2 yrs, the ratio of viral:bacterial causes is
50:50, whereas in older children bacterial pneumonia be-
comes more common, with pneumococcus being the most
common organism. Patients present with a history and signs
indicating respiratory distress and fever. Treatment is sup-
portive with supplemental oxygen and appropriate antimi-
crobials. Improvement is usually rapid, and a lack of
improvement within 48 h or persistent fever >38 C should
prompt a reassessment for complications, such as lung ab-
scesses, pleural effusion, or empyema, which occur in 1% of
cases overall, but in 40% of cases admitted to a hospital.
Infection with group A streptococcus and Staphylococcus
aureus is most likely to progress to these complications or
require admission to PICU. The prognosis is generally very
good in high-income countries, but it should be noted that
pneumonia is the leading infectious cause of paediatric mor-
tality worldwide; in high-income countries, pneumonia kills
3,000 children per year compared with meningitis, which kills
640 children per year.10
Chronic aspiration is a frequent underlying cause of
recurrent pneumonia and can be difficult to diagnose. There
are many potential causes, including undiagnosed tracheo-
oesophageal fistula, laryngeal cleft, craniofacial abnormal-
ities, gastro-oesophageal reflux disease, and neuromuscular
diseases (including bulbar palsy). If undiagnosed or untreated,
recurrent pneumonia will lead to chronic lung disease (CLD)
with the development of bronchiectasis and progressive res-
piratory failure. Chronic aspiration is the leading cause of
death in children with neuromuscular disease. Treatment is
supportive during acute episodes of infection with supple-
mental oxygen and appropriate, targeted antimicrobials.
Prevention of recurrent episodes relies on identifying the
underlying cause and correcting it where possible.11
It should be remembered that respiratory distress can be a
sign of non-respiratory sepsis. In addition, children present-
ing with decompensated congenital heart disease are likely to
be in respiratory distress. Therefore, a thorough assessment
of all systems in all children is vital.
BJA Education - Volume 19, Number 11, 2019 351
Paediatric respiratory distress
Chronic lung disease
Children’s interstitial lung disease (chILD) describes a widely
varied and poorly understood group of chronic respiratory
disorders in children, with an incidence in the region of 0.36
per 100,000. It represents a group of diseases with varying
pathophysiologies that are beyond the scope of this article.
The patterns of the disease can be either obstructive or
restrictive, or both, depending on the cause, and all may be
complicated by superimposed infection. Morbidity and mor-
tality are high with an overall mortality of 30% for which the
development of pulmonary hypertension is an independent
risk factor.12 Chronic lung disease of prematurity, previously
termed bronchopulmonary dysplasia, is the most common
chILD diagnosis, affecting 20% of neonates born at <30 weeks
gestational age with birth weight <1.5 kg. With improved
survival of babies born at the limits of viability with extremely
low birth weights, children with CLD present frequently to a
hospital with respiratory difficulty, which may result from
infection or chronic aspiration.13
Patients with a tracheostomy
Tracheostomy is being performed increasingly in children,
with an ever-increasing number of patients being cared for at
home. Indications for tracheostomy are wide ranging and
include neuromuscular disease; respiratory disease; congen-
ital malformations of airway, lungs, or heart; craniofacial
syndromes; and acquired subglottic stenosis.14 It follows that
we can expect to see an increasing number of paediatric pa-
tients with a tracheostomy presenting in respiratory distress
to emergency departments. Perhaps more importantly in the
case of patients with a tracheostomy, it must be remembered
that this may be caused by airway obstruction or tracheos-
tomy problems, such as a large leak, as opposed to, or as well
as, primary lung pathology. It has been reported that 43% of
patients will have a serious complication with their trache-
ostomy, and mortality related to tracheostomy complications
is 0.7%.15
Emergency management of paediatric
respiratory distress: when, who, and how to
intubate
There are no evidence-based guidelines on the optimal
timing of tracheal intubation in cases of respiratory
distress.16 The general approach to the assessment and
management of a child in respiratory distress will be dis-
cussed in the following paragraphs and boxes, followed by
Box 2
Equations for size (internal diameter) and length of tracheal tube (TT)
Sizes for cuffed TT:
>3 kg up to 1 yr: start with size 3.0 mm
1e2 yrs: start with size 3.5 mm
>2 yrs: (age/4) þ3.5 mm
Depth:
(Age/2)þ12 cm OR internal diameter of ETT3
Tip of ETT should lie at mid-trachea
352 BJA Education - Volume 19, Number 11, 2019
disease-specific alterations to this approach that may be
considered.
Assessment
Assessment should be largely clinical, as the signs of
impending respiratory failure or severe respiratory distress
should be identifiable without the need for blood gas analysis,
and should prompt an interventiondeither non-invasive or
invasive ventilation. Beware of children with myopathy, as
they are unable to demonstrate signs of increased work of
breathing. Box 1 details the signs of impending respiratory
collapse.
General approach
Conduct of the intubation must be determined on a case-by-
case basis, looking at the cause of respiratory distress, pre-
dicted airway difficulty, equipment and available personnel,
and risk of aspiration. Monitoring, including end-tidal carbon
dioxide (CO2), should be prepared in advance. Thought must
be given to the most appropriate person to lead the induction
and intubation, and senior help is called where necessary.
Emergency drugs should be prepared in advance in the correct
dose for the patient, and these drugs include atropine and
suxamethonium with the addition of adrenaline (epineph-
rine) if the patient is haemodynamically compromised. Pre-
pare a 10e20 ml kg1 i.v. fluid bolus in advance. Induction of
anaesthesia in an unstable child almost always mandates
having secured i.v. access, but intraosseous access should not
be overlooked if i.v. access fails.
Consideration should be given to the correct drug for in-
duction of anaesthesia. Ketamine confers the benefits of
bronchodilatation and relative cardiovascular stability over
propofol, the dose of which must be reduced in the haemo-
dynamically compromised or septic child. Thiopental can
cause bronchoconstriction and so is a poor choice in a child
with obstructive respiratory disease. Inhalation induction
with sevoflurane is an option if scavenging is available; sev-
oflurane also results in bronchodilatation. Neuromuscular
block will provide optimal intubating conditions in most
cases: rocuronium, suxamethonium, or atracurium is used.
The choice of agent can be based on familiarity of the oper-
ator. However, it should be noted that atracurium can pre-
cipitate histamine release and may therefore worsen
bronchoconstriction. Similarly, the addition of fentanyl will
help provide optimal intubating conditions.
Straight laryngoscope blades are generally used in babies
up to 6 months and curved blades thereafter. Tracheal tube
Size for uncuffed TT:
<1 yr: 1 kg: size 2.5 mm
2 kg: size 3.0 mm
>3 kg: size 3.5 mm
>1 yr (age/4) þ4 mm

(TT) size and length should be calculated using the standard
formulae in Box 2. A cuffed TT is preferable to an uncuffed TT
particularly in disease states with high resistance, such as
asthma, where high ventilatory pressures will need to be
delivered over a prolonged period. Cuff pressure must be
monitored. The practice of cutting the TT runs the risk of the
tube being too short, requiring reintubation in a critically ill
child.
With regard to rapid sequence induction (RSI) in this setting,
it must be remembered that the priority is supporting
oxygenation and haemodynamic stability whilst securing the
airway. The incidence of aspiration in paediatric practice is
extremely low.17 Some would argue an RSI increases the risks
of haemodynamic instability, hypoxia and awareness. Risk
assessment must be performed on a case-by-case basis, but
some would argue that RSI has no place in paediatric practice.18
Preoxygenation of the lungs is invaluable if it can be ach-
ieved. It may be most appropriate to continue the mode of
delivery of oxygen currently in place in settled children, as
disturbing them with a tight-fitting face mask may cause
distress and increased work of breathing and oxygen demand.
In view of the potential inability to preoxygenate, increased
oxygen consumption, and closing capacity in small children,
the length of apnoea time tolerated before desaturation is low.
Oxygenation must remain the priority, and most would
advocate continued gentle mask ventilation whilst waiting for
adequate neuromuscular block regardless of fasting status.18
In adult practice, the introduction of transnasal humidified
rapid-insufflation ventilatory exchange (THRIVE) using high-
flow nasal cannulae during apnoea has allowed a significant
increase in apnoea times before oxygen desaturation. THRIVE
is beginning to be used in paediatric practice with promising
results in case reports, and so is an option to prolong apnoea
time in carefully selected paediatric patients if equipment is
available.19
Post-intubation care
The specific details of care after intubation are determined on
a case-by-case basis, but the following points must be
considered:
(i) Sedation and neuromuscular block: midazolam and
morphine are commonly used in combination with
either vecuronium or atracurium. Fentanyl and keta-
mine are suitable alternatives. Propofol is avoided in
some centres, except in short-term sedation, because of
the risk of propofol-related infusion syndrome. The ev-
idence for this is inconclusive20; local guidelines should
be followed.
(ii) NG tube insertion to relieve gastric insufflation and
consequently reduce airway pressures
(iii) Chest X-ray: to check the position of the TT; exclude
endobronchial intubation or an inadequately advanced
TT that may migrate out during transfers; to rule out
pneumothorax, which is a particular risk in broncho-
constriction requiring invasive ventilation
(iv) Ventilation strategy: there is a much smaller evidence
base for specific ventilation strategies compared with
adults, but the trend is towards a ‘lung-protective’
strategy with the aim of achieving adequate gas ex-
change at the lowest possible pressures and volumes to
avoid alveolar trauma secondary to stretching. There-
fore, the following general principles are advised:21
Paediatric respiratory distress
(a) Tidal volumes of 5e7 ml kg1
(b) Plateau pressure of <30 cmH2O
(c) Peak inspiratory pressures of <35 cmH2O
(d) PEEP 5e7 cmH2O
(e) I:E ratio of 1:2 in most cases (see section ‘Bronchocon-
striction’ for further information on this)
(f) SpO2 >91e92% (with the exception of patients with pul-
monary hypertension and brain injury in whom SpO2
should be kept >94%)
(g) Ventilatory frequency dependent on age of patient and
balance between avoiding barotrauma, yet achieving an
adequate minute ventilation
(h) Regular chest physiotherapy and suctioning
(v) Transfer of patient to PICU: if this involves interhospital
transfer, this would be done by a local specialist retrieval
service who should be contacted early to facilitate
planning.
Disease-specific considerations
Bronchoconstriction
The aforementioned general approach may need to be modi-
fied in patients with asthma or other pathologies, in which
bronchoconstriction can occur, including bronchiolitis, pre-
school wheeze and chILD. Ketamine should be considered as
an i.v. induction agent because of its direct effects causing
bronchodilation. However, it should be remembered that ke-
tamine may also increase respiratory secretion load, and
therefore, treatment with an anticholinergic may be useful
(e.g. atropine 20 mg kg1, maximum 600 mg, or glycopyrrolate
4e8 m kg1, maximum 200 mg in <12 yrs and 400 mg in >12 yrs).
A cuffed TT is essential in these diseases because of the
need for high airway pressures to achieve oxygenation and
ventilation.16 High airway resistance and therefore slow
expiratory flow can lead to incomplete exhalation, which in-
creases the end-expiratory volume and leads to the develop-
ment of intrinsic PEEP. Intrinsic PEEP can be identified using
an end-expiratory breath-hold manoeuvre on the ventilator.
The value at which the pressure settles is the intrinsic PEEP.
The addition of further extrinsic PEEP set on the ventilator to
this, with an expiratory time that is too short, can lead to
breath stacking and further expansion of the alveoli leading to
volutrauma, CO2 retention and pneumothorax. The recom-
mended principles for ventilation of a patient with broncho-
constriction are a low ventilatory frequency, extended
expiratory time to allow for complete expiration (observe for
cessation of flow on the flowevolume loop before inspiration
and set I:E ratio accordingly), and a low extrinsic PEEP that
does not exceed intrinsic PEEP.22 In the authors’ local PICU, a
value of 60% of the intrinsic PEEP is commonly used as a
starting point. Neuromuscular blocking agents are almost
invariably required to achieve adequate oxygenation and
ventilation.
The aforementioned ventilator settings may not allow for
the removal of enough CO2 to maintain normocapnia.
Permissive hypercapnia allows oxygenation whilst reducing
the risk of ventilator-associated lung injury caused by exces-
sive pressure or volumes needed to maintain normocapnia.
There is no firm consensus on how low to allow the pH to go,
but a range of pH 7.15e7.3 was recently recommended by a
panel of experts. However, it should be noted that patients
with intracerebral pathology, severe pulmonary
BJA Education - Volume 19, Number 11, 2019 353
Paediatric respiratory distress

Emergency Paediatric Tracheostomy Management

SAFETY - STIMULATE - SHOUT FOR HELP - OXYGEN
SAFE: Check Safe area, S mulate, and Shout for help, CALL 2222 (hospital) or 999 (home)
AIRWAY: Open child’s airway: head lt / chin li / pillow or towel under shoulders may help
OXYGEN: Ensure high flow oxygen to the tracheostomy AND the face as soon as oxygen available
Capnograph: Exhaled carbon dioxide waveform may indicate a patent airway (secondary responders)

SUCTION TO ASSESS TRACHEOSTOMY PATENCY

The tracheostomy tube is patent
Basic Response

Remove any a achments: humidifier (HME), speaking

valve and change inner tube (if present) Perform tracheal suc on
Inner tubes need re-inser ng to connect to bagging circuits Consider par al obstruc on
Consider tracheostomy tube change
Can you pass a SUCTION catheter? Yes
CONTINUE ASSESSMENT (ABCDE)
No
EMERGENCY TRACHEOSTOMY TUBE CHANGE
Deflate cuff (if present). Reassess patency a er any tube change
1st – same size tube, 2nd – smaller size tube
* 3rd – smaller size tube sited over suc on catheter to guide
IF UNSUCCESSFUL – REMOVE THE TUBE

IS THE PATIENT BREATHING? - Look, listen and feel at the mouth and tracheostomy/stoma

No
5 RESCUE BREATHS – USE TRACHEOSTOMY IF PATENT Yes
Patent Upper Airway – deliver breath to the mouth RESPONDS:
continue oxygen,
Obstructed Upper Airway – deliver breath to tracheostomy/stoma
reassessment
and stabilisation
CHECK FOR SIGNS OF LIFE ? – START CPR
Plan for definitive
15 compressions : 2 rescue breaths airway if tube
Ensure help or resuscita on team called change failure

Primary emergency oxygena on Secondary emergency oxygena on

Advanced Response

Standard ORAL airway manoeuvres ORAL intuba on may be appropriate with

may be appropriate. a downsized ET tube
If so cover the stoma (swabs / hand). Uncut tube, advanced beyond stoma
Use: Prepare for difficult intuba on
Bag-valve-face mask ‘Difficult Airway’ Expert and Equipment**
Oral or nasal airway adjuncts
Supraglo c airway device e.g.
Laryngeal Mask Airway (LMA)
A empt intuba on of STOMA
3.0 ID tracheostomy tube / ETT
‘Difficult Airway’ Expert and Equipment**
Tracheostomy STOMA ven la on
Paediatric face mask applied to stoma **EQUIPMENT: Fibreop c scope, bougie,
LMA applied to stoma airway exchange catheter, Airway trolley

*3-smaller size tube sited over suc on catheter to guide: to be used if out of hospital
NTSP (Paediatric Working Group) Sep 2014

Fig 1 Algorithm for the emergency management of paediatric tracheostomies. Reproduced with permission from the National Tracheostomy Safety Project.

354 BJA Education - Volume 19, Number 11, 2019


hypertension, and significant ventricular dysfunction are not
appropriate candidates for this technique.23
Pneumothorax must be considered if there is any deterio-
ration in gas exchange or cardiovascular function. The inci-
dence of pneumothorax in patients with asthma requiring
mechanical ventilation is approximately 1e3%.16 Pharmaco-
logical therapy with i.v. bronchodilators (salbutamol or
aminophylline) to treat bronchoconstriction must continue,
as without it ventilation will deteriorate. In patients whose
lungs are difficult to ventilate adequately, sevoflurane can be
considered if scavenging is available.3
Pneumonia and sepsis
The conduct of induction of anaesthesia, tracheal intubation,
and mechanical ventilation should be largely the same in
patients with pneumonia. However, it should be noted that, if
there are signs of sepsis, the dose of induction agent will need
to be reduced to prevent a precipitant decrease in arterial
blood pressure. Moreover, if there are already signs of circu-
latory compromise, ensure adequate volume resuscitation,
calculate and prepare inotropic agents and vasopressors, and
consider starting these before induction of anaesthesia. Post-
intubation care in cases of pneumonia will need to include
regular suctioning and chest physiotherapy.
Patients with a tracheostomy in respiratory distress
The initial assessment of a patient with a tracheostomy in
respiratory distress must include a thorough assessment of
the patency of the tracheostomy. The UK National Tracheos-
tomy Safety Project has outlined an emergency algorithm for
this purpose (Fig. 1). After confirmation of the tracheostomy’s
patency, if the patient requires positive pressure ventilation,
then it may be necessary to upsize or change the tracheos-
tomy tube to a cuffed tube to facilitate this. The management
of patients with respiratory distress is otherwise largely
similar to those patients without tracheostomy. It should be
remembered that they often have a complex medical back-
ground, and therefore, the threshold for ventilatory support
may be different to the child who is previously fit. Further
discussion of this is outside the scope of this article.
Additional strategies to improve gas
exchange
In the event of failure of oxygenation despite best-practice
ventilation, several other strategies may be considered. The
evidence base for all is small, although research is ongoing. A
survey conducted in 2013 showed that, despite a lack of strong
evidence, the following techniques are considered and used in
many centres across North America and Europe, and they are
therefore relevant to current PICU practice.24
High-frequency oscillatory ventilation (HFOV) was recently
recommended as an alternative strategy in a consensus paper
from the Pediatric Acute Lung Injury Consensus Conference in
patients with plateau pressures greater than 28 cmH2O. It
should be noted that, although there is some evidence that
supports a reduction in time on ventilator in paediatric pa-
tients, there is none to support a mortality benefit.23
Inhaled nitric oxide has been used in neonatal practice for
many years, but there is as yet no evidence to support a
mortality benefit in paediatric practice. The mechanism of
action is thought to be an improvement of oxygenation via
Paediatric respiratory distress
pulmonary vasodilation and improved ventilation/perfusion
mismatch. A recent study showed a quicker time to cessation
of mechanical ventilation and avoidance of other in-
terventions, such as HFOV and extracorporeal membrane
oxygenation (ECMO), when hypoxia had responded to inhaled
nitric oxide.25
Prone positioning is one option that can be considered. It
has been shown to decrease mortality in adult patients with
acute respiratory distress syndrome, but this is yet to be
shown in paediatrics. The mechanism of action is thought to
be recruitment of previously collapsed dorsal (dependent)
areas of lung and subsequent improvement in ventilation/
perfusion matching.26 Before using this technique, the po-
tential haemodynamic effects of the prone position, poten-
tially catastrophic loss of a secured airway, and any predicted
difficulty in securing the airway whilst maintaining oxygen-
ation must all be considered.
Extracorporeal membrane oxygenation is considered in
cases where there is borderline or inadequate gas exchange
with high risk of ventilator-induced lung injury (mean airway
pressure >20e25 cmH20) and continued severe respiratory
failure (PaO2:FIO2 ratio <60e80 or oxygen index >40) despite
less invasive therapies, such as those therapies mentioned
previously.27 It has been shown to confer a survival advantage
in neonates with respiratory failure, and remains an option in
paediatric respiratory failure. Presently, there is no evidence
of a survival benefit, and a recent small paired cohort study
confirmed this and highlighted the need for further research
into the benefits of ECMO, which remains an expensive and
invasive treatment option.28
Conclusions
Respiratory distress is a common reason to alert the paedi-
atric emergency response team or request input from
anaesthetists in the hospital setting. This article has exam-
ined some of the more common causes of respiratory
distress (bronchiolitis, preschool wheeze and asthma) along
with rare, but commonly limiting illnesses, such as chILD. It
should be remembered that respiratory distress can also
have extrapulmonary causes, such as sepsis (with a source
other than pulmonary) and heart disease. Management by
the anaesthetist requires meticulous and methodical plan-
ning of induction, intubation and ventilation to avoid com-
plications thereof. Senior help is always advised when
dealing with these patients. Patients with tracheostomies in
respiratory distress represent a special group in whom a
careful assessment of tracheostomy patency is the key, in
addition to the standard general approach, to paediatric
respiratory distress.
Declaration of interest
The authors declare that they have no conflicts of interest.
Acknowledgements
The authors thank Dr Simona Lampariello, consultant in
paediatric intensive care, and Dr Chin Nwokoro, consultant
respiratory paediatrician and honorary clinical senior lecturer
at the Royal London Hospital for their helpful suggestions and
comments.
BJA Education - Volume 19, Number 11, 2019 355
Paediatric respiratory distress
MCQs
The associated MCQs (to support CME/CPD activity) will be
accessible at www.bjaed.org/cme/home by subscribers to BJA
Education.
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