Respiratory/SOB

Adult · Respiratory / SOB

Undifferentiated dyspnea — assess, stabilize, treat in parallel

  • Immediate: SpO₂, continuous monitor, IV access, position upright, supplemental O₂ titrated to target sat.
  • Targets: SpO₂ ≥ 94% (88–92% if COPD / chronic CO₂ retainer).
  • Rapid differential: asthma · COPD · CHF/pulmonary edema · PE · pneumonia · pneumothorax · anaphylaxis · ACS · DKA · sepsis.
  • Look for life threats: stridor, tripoding, accessory-muscle use, single-word dyspnea, silent chest, paradoxical breathing, cyanosis, AMS.
  • Early bedside tools: POCUS (B-lines, effusion, RV strain, sliding), ECG, ABG/VBG, CXR, BNP, troponin, D-dimer if indicated.
No patient weight set. Open Pediatric Weight, Age, Height, or Length Tape to enable dose calculations.
A · Airway

Patency, protection, and anticipated failure

Assessment
  • Talking in full sentences? Pooled secretions? Stridor / hoarseness / drooling?
  • GCS ≤ 8, absent gag, or progressive angioedema → secure airway early.
  • Predict difficulty: LEMON (Look, Evaluate 3-3-2, Mallampati, Obstruction, Neck mobility).
Interventions
  • Suction, jaw-thrust / chin-lift, NPA / OPA as tolerated.
  • BVM with PEEP valve, two-person seal; nasal cannula at 15 L for apneic oxygenation.
  • Prepare for RSI if failure imminent — confirm with end-tidal CO₂.
  • Stridor / angioedema: nebulized epinephrine + IM epi; surgical airway kit at bedside.
Common adult RSI medications
  • 1.5–2 mg/kg IV — induction (preferred in bronchospasm, shock).
  • 0.3 mg/kg IV — induction (hemodynamically neutral).
  • 1.5–2.5 mg/kg IV — induction (avoid in hypotension).
  • 1.2 mg/kg IV — paralytic (lasts 45–60 min).
  • 1.5 mg/kg IV — paralytic (avoid in hyperkalemia, burns >24 h, neuromuscular dz).
  • 1–3 mcg/kg IV — pretreatment / post-intubation analgesia.
Quickcards · Adult RSI doses (70 kg)
IV
1.5–2 mg/kg → ~100–150 mg
Bronchodilator; preferred in shock
IV
0.3 mg/kg → ~20 mg
Hemodynamically neutral; transient adrenal suppression
IV
1.5–2.5 mg/kg → ~100–175 mg
Avoid in hypotension / hypovolemia
IV
1.2 mg/kg → ~85 mg
⚠ Max: Onset 45–60 s · DOA 45–60 min
IV
1.5 mg/kg → ~100 mg
⚠ Max: Avoid: ↑K, burns >24 h, NM dz
IV
1–3 mcg/kg → 50–200 mcg
Slow push to avoid chest wall rigidity
B · Breathing

Oxygenation, ventilation, work of breathing

Assessment
  • RR, SpO₂, ETCO₂ if available, breath sounds (wheeze, crackles, absent), symmetry, JVD, tracheal position.
  • Identify pattern: obstructive (wheeze) · alveolar (crackles) · pleural (absent + dull/hyperresonant) · neuromuscular (hypoventilation).
Interventions
  • O₂ ladder: NC 2–6 L → simple mask 6–10 L → NRB 10–15 L → HFNC 30–60 L (FiO₂ titrate) → NIV (BiPAP/CPAP) → intubation.
  • BiPAP: start IPAP 10 / EPAP 5; titrate IPAP for tidal volume, EPAP for oxygenation. First-line for COPD, CHF.
  • Tension PTX: needle decompression 4th–5th ICS midaxillary (or 2nd ICS MCL) → chest tube.
  • Address reversible causes — bronchodilators, diuresis, antibiotics, anticoagulation, steroids — see drug table.
Common adult bronchodilator / pulmonary meds
  • 2.5–5 mg nebulized q20 min × 3, then continuous 10–15 mg/hr if severe.
  • Ipratropium 0.5 mg nebulized q20 min × 3 (combine with ).
  • 125 mg IV — asthma/COPD exacerbation.
  • 40–60 mg PO daily × 5 days — no taper.
  • 2 g IV over 20 min — severe asthma.
  • 0.3–0.5 mg IM (1 mg/mL) — peri-arrest asthma / anaphylaxis.
  • Terbutaline 0.25 mg SQ q20 min × 3 — refractory bronchospasm.
  • Furosemide 40–80 mg IV (or 2× home dose) — acute pulmonary edema.
  • Nitroglycerin 0.4 mg SL q5 min × 3, then IV 5–200 mcg/min — CHF/SCAPE preload reduction.
  • 1–2 g IV + Azithromycin 500 mg IV — community-acquired pneumonia.
  • Heparin 80 U/kg IV bolus then 18 U/kg/hr — suspected/confirmed PE.
  • Alteplase () 100 mg IV over 2 hr — massive PE with shock.
Quickcards · Adult breathing/pulmonary doses
Neb
2.5–5 mg q20 min × 3, then 10–15 mg/hr
Continuous neb for severe asthma
Ipratropium
Neb
0.5 mg q20 min × 3
Combine with albuterol; first 3 doses only
IV
125 mg ×1, then 60 mg q6h
⚠ Max: Single dose ≤ 125 mg typical
PO
40–60 mg daily × 5 d
No taper for short course
IV
2 g over 20 min
⚠ Max: Severe asthma adjunct
IM
0.3–0.5 mg (1 mg/mL)
⚠ Max: Max 0.5 mg per dose; q5–15 min PRN
Terbutaline
SQ
0.25 mg q20 min × 3
⚠ Max: Max 3 doses · monitor for tachy
Furosemide
IV
40–80 mg (or 2× home dose)
Acute pulmonary edema
Nitroglycerin
SL/IV
0.4 mg SL q5 min × 3 → 5–200 mcg/min IV
Avoid SBP < 100 / RV infarct / PDE-5 use
IV
1–2 g + Azithromycin 500 mg IV
CAP coverage
Heparin
IV
80 U/kg bolus → 18 U/kg/hr
Suspected/confirmed PE; check aPTT q6h
Alteplase ()
IV
100 mg over 2 hr
⚠ Max: Massive PE w/ shock only
Pneumothorax · recognize → decompress → drain
Time-critical

Suspect in any acute dyspnea with unilateral findings, trauma, COPD/asthma exacerbation, post-procedure (central line, thoracentesis), or barotrauma on positive-pressure ventilation.

Recognition
  • Simple PTX: sudden pleuritic chest pain, dyspnea, ↓ breath sounds, hyperresonance on affected side; SpO₂ may be near-normal.
  • Tension PTX (clinical dx — do NOT wait for CXR): severe dyspnea, hypotension, JVD, tracheal deviation away from affected side, absent breath sounds, hypoxia, peri-arrest.
  • POCUS: absent lung sliding ± lung point (specific) — fastest bedside confirmation.
  • CXR/CT: visceral pleural line, no lung markings peripheral; quantify size (small < 2 cm apex-to-cupola, large ≥ 2 cm).
Management
  1. High-flow O₂ (NRB 15 L) — speeds reabsorption of pleural air; continuous SpO₂.
  2. Tension PTX → immediate needle decompression: 14–16 G angiocath, 4th–5th ICS midaxillary line (preferred in adults; thinner chest wall) or 2nd ICS MCL — listen for rush of air.
  3. Finger thoracostomy if needle fails or in arrested/intubated patient — same landmark, blunt dissection over rib.
  4. Tube thoracostomy: 28–32 Fr (trauma/hemo-PTX) or 14–22 Fr pigtail (spontaneous PTX) — 4th–5th ICS midaxillary, water seal ± low wall suction (−20 cmH₂O).
  5. Small primary spontaneous PTX (< 2 cm, asymptomatic): observe 4–6 h on O₂ + repeat CXR; outpatient follow-up if stable.
  6. On positive-pressure ventilation: any PTX needs a chest tube before/around intubation — small ones convert to tension rapidly.
Pearls / pitfalls
  • Do NOT delay needle decompression for imaging in suspected tension PTX.
  • Failed needle decompression is common (catheter too short for chest wall) — escalate to finger thoracostomy.
  • Bilateral PTX, hemo-PTX (> 1500 mL initial output or > 200 mL/hr × 2–4 h), or persistent air leak → thoracic surgery consult.
  • Re-expansion pulmonary edema risk if large PTX evacuated rapidly — drain to water seal first, avoid immediate high suction.
Bronchodilator escalation · Asthma / COPD

Reassess at each step: peak flow / FEV₁, work of breathing, SpO₂, ETCO₂, mental status. Advance one rung every 15–20 min if no improvement (or sooner if deteriorating).

  1. Step 1 · SABA monotherapy
    Trigger

    Mild — speaking full sentences, SpO₂ ≥ 95%, PEF > 70% predicted

    • Albuterol 2.5–5 mg neb (or MDI 4–8 puffs with spacer) ×1
    • Reassess in 15–20 min
    ↓ Advance when: Persistent wheeze, SpO₂ < 94%, PEF 50–70%, or ↑ work of breathing
  2. Step 2 · Add ipratropium + start systemic steroid
    Trigger

    Moderate — partial sentences, accessory-muscle use, PEF 50–70%

    • Albuterol 2.5–5 mg + Ipratropium 0.5 mg neb together, q20 min × 3
    • Methylprednisolone 125 mg IV (or Prednisone 40–60 mg PO) NOW — peak effect 4–6 h
    • Continuous SpO₂; consider ABG/VBG
    ↓ Advance when: No improvement after 3 stacked nebs, or deteriorating work of breathing
  3. Step 3 · Continuous SABA + magnesium
    Trigger

    Severe — single-word dyspnea, PEF < 50%, SpO₂ < 92% on O₂

    • Albuterol continuous neb 10–15 mg/hr (drop ipratropium after 3rd dose)
    • Magnesium sulfate 2 g IV over 20 min (single dose)
    • Maintain steroid; add IV access ×2; cardiac monitor
    • Consider heliox 70:30 if available
    ↓ Advance when: Rising CO₂, fatigue, silent chest, AMS, SpO₂ < 90% despite max therapy
  4. Step 4 · Adjuncts + NIV
    Trigger

    Refractory severe — fatigue, normal/rising ETCO₂ in asthmatic

    • Epinephrine 0.3–0.5 mg IM (1 mg/mL) — peri-arrest asthma
    • Terbutaline 0.25 mg SQ q20 min × 3 (alternative to IM epi)
    • BiPAP trial: IPAP 10 / EPAP 5, titrate IPAP for tidal volume
    • Ketamine 0.1–0.5 mg/kg IV — bronchodilation + anxiolysis pre-intubation
    ↓ Advance when: Cannot maintain SpO₂ ≥ 90%, GCS dropping, or apnea
  5. Step 5 · Intubate (lung-protective)
    Trigger

    Impending arrest — silent chest, cyanosis, AMS, bradycardia

    • RSI: Ketamine 1.5–2 mg/kg IV + Rocuronium 1.2 mg/kg IV (induction of choice)
    • Largest ETT possible (8.0+) to reduce resistance
    • Vent: VC, RR 8–10, Vt 6 mL/kg IBW, I:E 1:4–1:5, PEEP 0–5, plateau < 30
    • Permissive hypercapnia; deep sedation ± paralysis if breath-stacking
    • Continue albuterol via inline neb; bronchoscopy if mucus plugging
    ↓ Advance when: Persistent hypoxia / barotrauma → ECMO consult

De-escalation: once PEF > 70% predicted and SpO₂ ≥ 95% on RA × 1 h, space nebs to q1–4 h PRN, complete 5-day steroid course, ensure inhaler technique + follow-up before discharge.

C · Circulation

Perfusion, preload, afterload, rate/rhythm

Assessment
  • HR, BP (cycle q5 min if unstable), cap refill, mottling, mental status, urine output.
  • JVD + crackles → cardiogenic. Flat neck veins + clear lungs → hypovolemic / distributive.
  • RV strain on POCUS / ECG (S1Q3T3, RBBB) → consider PE.
Interventions
  • 2× large-bore IV; lactate, ABG, troponin, BNP, CBC/BMP, type & screen.
  • Targeted fluids — small (250–500 mL) crystalloid challenges; reassess lungs after each.
  • Treat rhythm: synchronized cardioversion if unstable tachydysrhythmia; pacing if unstable bradycardia.
  • Start vasoactives early in shock — avoid over-resuscitation in cardiogenic / pulmonary edema.
Common adult circulatory adjuncts
  • 0.05–0.5 mcg/kg/min IV — first-line vasopressor (septic, distributive).
  • 0.05–0.5 mcg/kg/min IV — anaphylactic / cardiogenic shock.
  • Vasopressin 0.03 U/min IV — adjunct in septic shock.
  • 2–20 mcg/kg/min IV — cardiogenic shock with adequate BP.
  • 6 mg → 12 mg IV rapid push — stable SVT.
  • 150 mg IV over 10 min — stable wide-complex tachycardia.
  • 1 mg IV q3–5 min (max 3 mg) — symptomatic bradycardia.
Quickcards · Adult circulatory doses
IV gtt
0.05–0.5 mcg/kg/min (start 5 mcg/min)
First-line septic/distributive shock
IV gtt
0.05–0.5 mcg/kg/min
Anaphylactic / cardiogenic shock
Push-dose
IV
10–20 mcg q2–5 min
⚠ Max: Bridge to drip only
Vasopressin
IV gtt
0.03 U/min (fixed)
⚠ Max: Do not titrate; adjunct to NE
IV gtt
2–20 mcg/kg/min
Cardiogenic shock w/ adequate BP
IV
Bolus 50–200 mcg · gtt 0.5–5 mcg/kg/min
Pure α; avoid in low CO
IV
6 mg → 12 mg → 12 mg rapid push
⚠ Max: Max 12 mg per repeat dose
IV
150 mg over 10 min → 1 mg/min × 6 h → 0.5 mg/min
⚠ Max: Cumulative ≤ 2.2 g/24 h
IV
1 mg q3–5 min
⚠ Max: Max 3 mg total
IV
1–2 g over 10 min
Hyperkalemia / CCB toxicity / membrane stabilization
IV
1–2 mEq/kg bolus (50–100 mEq)
Wide-QRS TCA / severe acidosis
Crystalloid bolus
IV
250–500 mL LR/NS, reassess after each
⚠ Max: Stop if rising B-lines / JVD
Croup → Circulation escalation ladder

Stridor + worsening perfusion = upper-airway obstruction crossing into shock. Escalate one step every 5–10 min if vitals deteriorate (SpO₂ ↓, HR ↑↓, BP ↓, AMS, mottling).

  1. Step 1 · Stable stridor (mild)
    Vitals

    SpO₂ ≥ 94%, normal HR/BP, no AMS

    • Keep child calm on caregiver lap — no painful procedures
    • Single dose dexamethasone 0.6 mg/kg PO/IM/IV (max 16 mg)
    • Cool humidified air; observe 2–4 h
  2. Step 2 · Stridor at rest (moderate)
    Vitals

    Tachypnea, mild retractions, SpO₂ 90–94%

    • Nebulized racemic epi 0.5 mL of 2.25% in 3 mL NS (or L-epi 5 mL of 1 mg/mL)
    • Repeat dexamethasone if not given; monitor ≥ 3 h post-neb for rebound
    • Continuous SpO₂ + cardiac monitor; IV access
  3. Step 3 · Severe distress + early shock signs
    Vitals

    Severe retractions, fatigue, RR ↓, HR ↑↑, cap refill ≥ 3 s, cool extremities

    • Repeat racemic epi q15–20 min; prep airway team and difficult-airway cart
    • Heliox (70:30) if available to reduce work of breathing
    • 20 mL/kg isotonic bolus (max 1 L) — reassess lungs/perfusion after each
    • Notify PICU / anesthesia / ENT for OR-ready intubation plan
  4. Step 4 · Impending arrest (airway + circulatory failure)
    Vitals

    Silent chest, cyanosis, AMS, SBP < 5th %ile, bradycardia

    • Bag-mask with 100% O₂; gentle PEEP — avoid agitation
    • Awake / ketamine-only intubation by most experienced operator; ETT 0.5–1 mm smaller than predicted
    • Start epinephrine infusion 0.05–0.3 mcg/kg/min for refractory hypotension
    • Push-dose epi 1 mcg/kg IV q2–5 min as bridge to drip
    • Surgical airway (needle cric → jet ventilation) if cannot intubate / cannot oxygenate

Transition trigger to next step: any worsening vital (HR, RR, SpO₂, BP, mental status) within 5–10 min of intervention. Document time-stamped reassessments.