The respiratory rate is about 60 for the first two days after birth, then decreases to about 40. Adult values of 12 are reached by about age 14. In infants, periodic breathing is sometimes seen where respiratory pauses exist because of a lack of complete development of respiratory control.
||Average Systolic BP
| 1-6 months
| 6-12 months
| 1-4 years
| 4-6 years
| 8-12 years
| >12 years
Rarely, an infant may have an episode of prolonged apnea (>20 sec) sometimes
accompanied by choking and gagging. This “apparent life-threatening event”—ALTE (also known as “near-miss SIDS”) is a respiratory problem that appears to be related to sudden infant death syndrome (SIDS). It is seen between the ages of 1 month and 1 year (with peaks at 2 and 4 months). Over 70 theories have been proposed for ALTE and SIDS. Among the more substantive are prematurity, sleeping prone, siblings with SIDS, substanceabusing mothers, respiratory syncytial virus, child abuse, gastroesophageal
reflux and infantile botulism.
hospitalization for an apnea workup. The infant is then sent home with an apnea monitor.
Upper Respiratory Emergencies
by a foreign body in the child may pose a problem because the circumstance is often unwitnessed and signs may be confusing. Choking, coughing and gagging may occur, then subside as the object passes into a smaller airway, usually the right mainstem bronchus (the anatomical continuation of the trachea). This may later produce coughing, wheezing or stridor in any combination (a foreign body in the upper esophagus causes stridor, drooling and dysphagia). The diagnosis is made by a high index of suspicion and various x-ray techniques, among them bilateral decubitus chest x-rays. The normal chest shows decreased relative volume on the downside compared to the upside. With obstruction on the downside, the downside remains fully inflated.
laryngoscopy or bronchoscopy with removal of the object in the operating room under anesthesia. Esophageal foreign bodies are removed by endoscopic forceps.
Croup, or laryngotracheobronchitis, is a viral infection (parainfluenza virus) of the upper airway in the 6-month to 3-year-old population (most under 1 year). Fever and a barking cough are present, mostly at night, often accompanied by mild stridor, tachypnea and retractions.
humidified oxygen (“mist wand”), racemic epinephrine 0.5 cc in 3 cc NS, prednisolone (Prelone syrup) 1 mg/kg PO or dexamethazone (Decadron) 0.3 mg/kg PO or IM and PO fluids.
Epiglottitis is an infection of supraglottic tissue causing edema and partial obstruction of the glottis (airway). The incidence has decreased because of Hemophilus influenza vaccine. Other organisms are Strep and Staph. The median age is 7. Symptoms are a sudden onset of fever, sore throat and difficulty swallowing and talking (dysphonia). Stridor and drooling are often present, and the child sits with the chin forward. Treatment:
because obstruction of the upper airway may occur at any time, a portable neck x-ray is taken in the emergency department, intubation equipment is assembled, and the doctor remains with the patient at all times. If the x-ray confirms the diagnosis, arrangements are made for immediate intubation by anesthesiology in the operating room. The child remains seated, and no blood is drawn or other treatments begun. If the child is seen in a doctor’s office, a physician able to intubate should accompany the child to the hospital. After the airway is secured, cultures are taken and antibiotics are administered (i.e., ceftriaxone 50 mg/kg every 24 hours).
Lower Respiratory Emergencies
Asthma, is an allergic reaction precipitated by irritants, stress and infection. Mast cells release histamine and other mediators which cause bronchoconstriction, followed by airway edema. Signs and symptoms include shortness of breath, cough, wheezing and tachypnea. Evaluation is by means of pulse oximetry, peak flow, and blood gases.
oxygen is placed if the O2 saturation is <94%, a beta-agonist such as albuterol 2.5 mg in 2 cc NS is administered by nebulizer over an hour, and prednisolone (Prelone syrup) 1 mg/kg is given orally. The need for close observation is indicated with a history of frequent hospitalizations, a previous intubation, use of steroids, an oxygen saturation <94% and a peak flow less than 10% improvement after several nebulizer treatments. An oxygen saturation less than 90% mandates ABGs. A CO2 of >50 mmHg indicates impending respiratory failure. Signs of respiratory distress are nasal flaring, retractions, agitation, lethargy, confusion, sweating, altered consciousness and grunting.
Bronchiolitis is similar to asthma except that the cause is a virus (usually respiratory syncytial virus—RSV) causing an inflammation of the bronchioles. It is seen in a younger age group (under 2 years of age) than the asthmatic. Fever, wheezing and tachypnea are present. Evaluation is by oxygen saturation and ABGs. Nasal washings may identify RSV.
nebulized racemic epinephrine (as for croup) is administered. Steroids are not used. PO or IV hydration is helpful. Pulse oximetry showing an oxygen saturation
of 91% or below and/or sustained tachypnea (respiratory rate of 60 or greater) indicates the need for admission.