Prehospital Assessment and Treatment of Infants and Toddlers in Respiratory Distress: A Retrospective Analysis

Prehospital recognition of upper versus lower airway disease in infants or young children is critical as management strategies differ. A minimal amount is known regarding how well these distinctions are made in the field and whether they are associated with changes in care. We describe patient characteristics, emergency medical services (EMS) clinician impressions, assessments, and prehospital treatments for patients under 3 years old who were diagnosed in the emergency department (ED) with upper airway disease (croup) or lower airway disease (acute bronchitis, bronchiolitis, or asthma).

This retrospective analysis of prehospital electronic patient care records used linked hospital outcome data from the 2019-2020 ESO Data Collaborative, a national database of de-identified records from more than 1,200 agencies. We included 9-1-1 responses for patients older than 24 h and younger than 3 years of age who were diagnosed in the ED with croup, acute bronchitis, bronchiolitis, or asthma using ICD-10 codes. We describe patient and encounter characteristics, EMS clinician impressions, vital sign assessment, and prehospital treatments stratified by upper versus lower airway conditions.

Of 1,352 records analyzed, 346 (25.6%) patients were diagnosed with an upper airway condition. Patients with upper airway diagnoses tended to be older, male, and more likely to be discharged home from the ED. "Acute respiratory distress" was the most common emergency medical services (EMS) primary impression in both upper (60.4%) and lower airway groups (50.0%). End-tidal CO₂ (EtCO₂) was recorded for 8% of patients, while SpO₂ was recorded for 92%. The most common treatments for patients diagnosed with upper airway disease were oxygen (33.2%), albuterol (28.3%), and nebulized epinephrine (23.1%). For patients with lower airway diagnoses, the most common treatments were oxygen (39.6%), albuterol (32.6%), and ipratropium (11.9%).

EMS clinicians documented similar primary impressions and administered many of the same treatments across both upper and lower airway groups, demonstrating minimal differentiation in prehospital management of young children. Therefore, EMS impressions and treatments did not consistently align with the underlying etiology diagnosed at the ED. Addressing these gaps through protocol revisions, system-wide improvements, and targeted education may help strengthen the quality and safety of prehospital pediatric respiratory care.