Pharmacological Treatment of Respiratory Failure in Pediatric Patients

Initial Assessment and Management

The American Thoracic Society recommends that pediatric patients with respiratory failure be assessed for signs of severe respiratory distress, including being too breathless to talk or feed, respiratory rate >50 breaths/min, pulse >140 beats/min, and Peak Expiratory Flow (PEF) <50% predicted 1, 3
Life-threatening features of respiratory failure in pediatric patients include PEF <33% predicted or poor respiratory effort, cyanosis, silent chest, fatigue, or exhaustion, and agitation or reduced level of consciousness 4

High-flow oxygen via face mask should be administered to maintain SaO₂ >92% in pediatric patients with respiratory failure 1, 3
Intravenous hydrocortisone should be administered immediately to pediatric patients with respiratory failure 1
Nebulized salbutamol 5 mg or terbutaline 10 mg should be administered via oxygen-driven nebulizer to pediatric patients with respiratory failure, with half doses used in very young children 1, 3
Intravenous aminophylline 5 mg/kg over 20 minutes followed by maintenance infusion of 1 mg/kg/hour should be administered to pediatric patients with life-threatening respiratory failure, omitting the loading dose if the child is already receiving oral theophyllines 1, 4

The American Thoracic Society recommends that pediatric patients with respiratory failure be monitored for treatment response, including repeat measurement of PEF 15-30 minutes after starting treatment, maintenance of oxygen saturation >92% using pulse oximetry, and charting of PEF before and after β-agonist administration 1, 3
In severe cases, repeat blood gas measurements should be performed within 2 hours of starting treatment if the initial PaO₂ <8 kPa (60 mm Hg), initial PaCO₂ was normal or raised, or the patient's condition deteriorates 1

Pediatric patients with respiratory failure should be transferred to the intensive care unit with a doctor prepared to intubate if they exhibit deteriorating PEF or worsening exhaustion, feeble respirations, persistent hypoxia or hypercapnia despite treatment, or coma, respiratory arrest, confusion, or drowsiness 1, 4