Worsening Breathing in the Pediatric Emergency Department

You are leading the care team in the pediatric emergency department. A 4-year-old child weighing 16 kg has a history of asthma and has had worsening cough and difficulty breathing since the previous evening. The child is sitting upright, appears anxious, and speaks only one or two words at a time.

Respiratory rate is 44/min, heart rate is 156/min, blood pressure is 94/58 mm Hg, and oxygen saturation is 88% on room air. Marked intercostal and suprasternal retractions are visible.

A nurse and respiratory therapist are at the bedside. Oxygen, suction, airway adjuncts, bag-mask equipment, pediatric advanced-airway equipment, emergency medications, vascular-access supplies, and a monitor/defibrillator are immediately available. Additional team members are responding.