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Pediatric respiratory distress: California out-of-hospital protocols and evidence-based recommendations
Tabitha Cheng1, Jennifer Farah1, Nicholas Aldridge1
1Department of Emergency Medicine University of California San Diego (UCSD) San Diego California USA.
Insights
Prehospital pediatric respiratory distress protocols vary significantly across California emergency medical services (EMS). This study provides evidence-based recommendations to standardize out-of-hospital care for conditions like croup and bronchiolitis.
Area of Science:
- Emergency Medicine
- Pediatrics
- Public Health
Background:
- Prehospital emergency medical service (EMS) protocols for pediatric respiratory distress are not standardized across California.
- Significant variations exist in the evaluation and treatment of pediatric respiratory conditions by local EMS agencies.
Purpose of the Study:
- To develop evidence-based recommendations for the out-of-hospital management of pediatric respiratory distress.
- To evaluate existing pediatric respiratory distress protocols from 33 California local EMS agencies.
Main Methods:
- Conducted an extensive literature review on current evidence for out-of-hospital treatment of pediatric respiratory distress.
- Compared protocols from 33 California EMS agencies against evidence-based recommendations.
- Focused on stridor (croup), wheezing < 24 months (bronchiolitis), and wheezing > 24 months (asthma).
Main Results:
- Wide variability in protocols was observed across the 33 California EMS agencies.
- Stridor (croup) protocols showed the highest variability, with no single treatment universally adopted.
- Only 9.1% of agencies differentiated treatment for wheezing in infants < 24 months (bronchiolitis).
- All agencies included albuterol and epinephrine for pediatric wheezing (asthma), but nebulized epinephrine and magnesium were uncommon. Steroids were not included in any protocols.
Conclusions:
- Protocols for pediatric respiratory distress, particularly for stridor (croup) and infant wheezing (bronchiolitis), vary considerably across California.
- The developed evidence-based recommendations can assist EMS medical directors in creating and updating pediatric respiratory distress protocols.
Objectives:
Prehospital protocols vary across local emergency medical service (EMS) agencies in California. We sought to develop evidence-based recommendations for the out-of-hospital evaluation and treatment of pediatric respiratory distress, and we evaluated the protocols for pediatric respiratory distress used by the 33 California local EMS agencies.
Methods:
Evidence-based recommendations were developed through an extensive literature review of the current evidence regarding out-of-hospital treatment of pediatric patients with respiratory distress. The authors compared the pediatric respiratory distress protocols of each of the 33 California local EMS agencies with the evidence-based recommendations. Our focus was on the treatment of 3 main pediatric respiratory complaints by presentation: stridor (croup), wheezing < 24 months (bronchiolitis), and wheezing > 24 months (asthma).
Results:
Protocols across the 33 California local EMS agencies varied widely. Stridor (croup) had the highest protocol variability of the 3 presentations we evaluated, with no treatment having uniform use among all agencies. Only 3 (9.1%) of the local EMS agencies differentiated wheezing in children < 24 months of age, referencing this as possible bronchiolitis. All local EMS agencies included albuterol and epinephrine (intravenous/intramuscular) in their pediatric wheezing (asthma) treatment protocols. The least common treatments for wheezing (asthma) included nebulized epinephrine (3/33) and magnesium (2/33). No agencies included steroids in their treatment protocols (0/33).
Conclusion:
Protocols for pediatric respiratory distress vary widely across the state of California, especially among those for stridor (croup) and wheezing in < 24 months (bronchiolitis). The evidence-based recommendations that we present for the prehospital treatment of these conditions may be useful for EMS medical directors tasked with creating and revising these protocols.
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