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  • Tachypnea is a universal finding in infants with respiratory distress; the increased muscle exertion can result in fatigue and respiratory failure.
  • Children have twice the oxygen consumption rate compared to adults and smaller functional residual capacity. During intubation they may desaturate rapidly.
  • A well-positioned and proper-sized endotracheal tube will have an air leak when ventilation is applied at 15 to 20 cm water level.
  • For older infants and children requiring ventilator assistance, a volume-controlled ventilator is usually preferred with a tidal volume of 8 to 10 mL/kg.
  • Use of modest positive end-expiratory pressure (PEEP) (3–5 cm H2O) will help maintain lung volume and reduce the risk of barotrauma associated with high tidal volumes.
  • When managing ventilator care, pH and Pco2 can be adjusted by manipulating minute ventilation; Po2 can be adjusted by manipulating Fio2 and PEEP.
  • Noninvasive mechanical ventilation techniques such as continuous positive airway pressure (CPAP), bimodal positive airway pressure (BiPAP), and Vapotherm are finding their way into the emergency department (ED) as alternatives to avoid intubation.


Respiratory failure is the most common cause of cardiac arrest in pediatric patients. It is important to recognize respiratory distress early so that actions can be taken to avoid respiratory failure whenever possible. If respiratory failure does occur, prompt intervention will give the patient the best chance for survival with the least neurologic sequelae. Young children have less physiologic reserve and can deteriorate very rapidly. In a critical situation, the emergency physician has the task of not only making quick resuscitation management decisions but must also consider age-related anatomic differences, appropriate equipment (Table 24–1), and drug-dosage differences when caring for infants and children.

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Table 24-1. Endotracheal Tube Size and Length and Size of Laryngoscope Blades by Age*,†

Children have anatomic and physiologic differences that should be considered when evaluating a pediatric patient presenting in respiratory distress. Young infants may be obligate nose breathers, and any degree of obstruction ...

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