Pediatric emergency medicine trisk 2767 2767

Primary hypoxemia 1. High-flow supplemental oxygen (e.g., nonrebreather
mask nonrebreather mask or high flow nasal cannula),
titrate for cyanosis, or by pulse oximetry or PaO 2
2. Use PEEP through CPAP or BiPAP to further improve
oxygenation
3. Consider endotracheal intubation when persistent
hypoxemia on FIO 2 >0.6 or when decreased lung
compliance and FIO 2 >0.4
4. Use assisted ventilation to improve gas exchange
(increased inspiratory time, normal respiratory rates,
tidal volume: 10–15 mL/kg; pressure cycle ventilation if
wt. <10 kg, volume cycle ventilation if wt. >10 kg). If
inspiratory pressure exceeds 40 cm H2 O, consider use
of permissive hypercapnia to reduce barotrauma.
5. Treat underlying cause
Primary
1. Supplemental oxygen (as above)
hypoventilation 2. Support ventilation
a. Oral/nasal pharyngeal airway or endotracheal
intubation to open the airway
b. Bag-mask ventilation with high-flow oxygen
c. Use assisted ventilation (normal to increased
respiratory rates, increased expired time and
increased flow rates with obstructive airway disease),
BiPAP is favored over CPAP for noninvasive
ventilation with primary hypoventilation
d. Use increased tidal volume (pressure) with atelectasis
e. Monitor carefully for side effects of ventilation
Adjunctive therapy 1. Intravenous fluid to achieve normal vascular volume
(less fluid for child with interstitial lung disease)
2. Diuretics such as furosemide (1 mg/kg) for acute

pulmonary edema or fluid overload
3. Sedatives/analgesics—morphine sulfate (0.1–0.2
mg/kg) every 1–2 hrs intravenously; midazolam (0.1–
0.2 mg/kg every 2–4 hrs intravenously);
dexmedetomidine (dosing per institutional protocol)