Pediatric respiratory complaints are some of the most common presentations we see in the emergency department. After recognizing respiratory distress, which is sometimes challenging in a young child who might be scared or upset, the next challenge is in deciding what disease process we’re dealing with and how aggressively we need to treat it.
During shifts, I often think about three overlapping groups of patients:
- Children with asthma
- Infants with bronchiolitis
- The confusing middle ground sometimes called “asthmalitis.”
These patients can look very similar, but their management can be quite different. Here are 10 practical pearls I think about when managing pediatric respiratory emergencies.
1. My first question is always: how sick is this child?
When a child presents with respiratory distress, I’m not initially asking: “Is this asthma?”
My first question is: How sick is this patient?
Severity should drive management.
Many of us use elements similar to the Pediatric Asthma Severity Score (PASS) when making this assessment, including:
- Work of breathing
- Aeration
- Wheezing
- Ability to speak
- Mental status
- Oxygen saturation
Even if you don’t formally calculate the score, you’re likely already incorporating these factors into your clinical judgment.
2. If it looks like asthma, I treat it like asthma
A child does not need a prior asthma diagnosis for me to initiate asthma therapy.
If a patient has:
- Significant work of breathing
- Wheezing
- Poor aeration
I start treatment.
Waiting for diagnostic certainty often delays care, and these kids can deteriorate quickly.
3. I give steroids early
Corticosteroids remain one of the most important treatments for asthma exacerbations.
They:
- Reduce airway inflammation
- Enhance the effect of beta-agonists
- Prevent progression of airway obstruction
Because of this, I try to administer steroids early whenever asthma is suspected.
In some pediatric EDs, steroids are even given in triage.
4. I usually choose dexamethasone
In many cases, I prefer dexamethasone over prednisone or prednisolone.
Dexamethasone has several advantages for kids:
- Better taste
- Less vomiting
- Fewer doses
- Better adherence
Because dexamethasone lasts 36–48 hours, many patients only need one or two doses total.
Note: Dosing varies by institution, but since the tabs come as 2mg and are so easy to give, it makes sense to use the 0.6mg/kg dose in the literature, round to the nearest 2mg, and consider your max. I have used a max of 8mg with good effect.
5. Albuterol dosing matters more than we think
One thing I frequently see is underdosing of albuterol.
A standard duoneb (albuterol + ipratropium) contains 2.5 mg of albuterol.
For severe exacerbations, larger children may require continuous albuterol approaching 15 mg/hour, depending on weight and severity.
So when I hear that a patient received “an hour of albuterol,” I always ask:
How much albuterol did they actually receive?
6. Magnesium is a great drug that we often give too late
Magnesium sulfate works as a bronchodilator by relaxing airway smooth muscle and decreasing inflammatory mediator release.
Historically it was often delayed because of concerns about hypotension, but pediatric studies suggest the risk is quite low.
Because of this, I often consider magnesium earlier in moderate to severe exacerbations.
7. I try hard to avoid intubating severe asthma patients
Children with severe asthma are frequently hyperinflated, which makes mechanical ventilation difficult.
Whenever possible, I prefer non-invasive ventilation such as BiPAP.
These patients often require higher pressures than expected because of the degree of hyperinflation.
Avoiding intubation whenever possible is an important goal in severe asthma management.
8. Bronchiolitis is a completely different disease
Bronchiolitis is not primarily bronchospasm.
Instead, the underlying problem is:
- Viral inflammation
- Mucus plugging
- Airway obstruction
- V/Q mismatch
Because bronchospasm is not the main issue, bronchodilators usually do not help.
9. Most medications don’t help bronchiolitis
Evidence consistently shows that medications do not change the course of classic bronchiolitis.
For typical infant bronchiolitis, I generally avoid:
- Bronchodilators
- Racemic epinephrine
- Steroids
- Hypertonic saline
Management should focus on supportive care:
- Suctioning
- Hydration
- Respiratory support when needed
10. Toddlers are where things get messy
Children between 12 and 36 months often fall into a gray zone.
They may have:
- Bronchiolitis
- Early asthma
- Or a combination of both
In these cases, I think a trial of albuterol — and sometimes steroids — can be reasonable, especially if it may prevent hospitalization or transfer.
Clinical judgment is especially important in this age group.
Bottom Line
When I approach pediatric respiratory emergencies, I try to remember a few key principles:
- Start by assessing severity
- Treat suspected asthma early
- Don’t underdose albuterol
- Consider magnesium sooner
- Recognize that bronchiolitis is mostly supportive care
And in infants with bronchiolitis, one of the most effective treatments is still something simple: good suctioning.
Editor’s note: This post was developed in collaboration with Dr. Delgado, based on her talk at the recent PCOM Advancing Emergency Care in Critical Moments Conference. ~JB
Dr. Eva Delgado is a Pediatric Emergency Medicine physician and Director of Emergency Medicine Resident Education at the Children’s Hospital of Philadelphia. She can be reached at DelgadoE2@chop.edu.
