Variation in Prehospital Protocols for Pediatric Respiratory Distress Management in the United States

Abstract

Objective: This study aimed to compare statewide emergency medical services protocols for the management of pediatric respiratory distress. Methods:We performed a descriptive study of emergency medical services protocols for the management of pediatric respiratory distress in the United States, excluding those without model or mandatory protocols. We compared medication recommendations for specific disease processes, including asthma, croup, epiglottitis, anaphylaxis, generalized respiratory distress, intubation, and drug assisted intubation.Results: Thirty-four state protocols were included. All had protocols to address the management of pediatric respiratory distress. There was high agreement in albuterol use for bronchospasm and epinephrine use in anaphylaxis. Epinephrine was recommended in all anaphylaxis protocols, 27 croup protocols (79%), and 3 epiglottitis protocols (9%). Six states (18%) called for albuterol in patients with generalized respiratory distress. Steroid recommendations and indications had variance among states; 26 states (76%) allowed steroid use in patients with asthma, 19 states (56%) recommended steroid use in anaphylaxis, and 11 (32%) recommended steroid use in croup protocols. The route for steroid administration also varied among protocols. Five states (15%) allowed continuous positive airway pressure application in pediatric patients, whereas endotracheal intubation and rapid sequence intubations had varying requirements as well as recommendations for use. Twelve (35%) listed impending or current respiratory failure as an indication, whereas other states had specific markers, such as Glasgow Coma Scale or oxygen saturation, as indications.Conclusions: All included states had specific recommendations for the management of pediatric respiratory distress. There was consistency in recommendations for albuterol use for wheezing and epinephrine use for anaphylaxis. However, there was wide variability in other uses for epinephrine, steroid administration, continuous positive airway pressure use, and specific treatments for croup and epiglottitis. The findings of this study provide a base for important future evidence-based protocol developments and changes in prehospital pediatric respiratory distress treatment.

The association of prehospital systemic corticosteroids with emergency department and in‐hospital outcomes for patients with asthma exacerbations

“…Administration by the oral route may overcome this burden, though many EMS protocols do not allow for the use of oral corticosteroids. 26 In a pilot study, a change in prehospital protocols to include oral corticosteroid administration was associated with a decrease in hospital admission rate and LOS. 13 When systemic corticosteroids can only be administered intravenously, it may be prudent to avoid the time spent securing IV access to administer systemic corticosteroids in EMS encounters that are anticipated to be shorter.…”

“…Considering that systemic corticosteroids are most commonly available and administered by the IV route, difficulty in obtaining IV access represents a unique challenge in the administration of systemic corticosteroids to children. Administration by the oral route may overcome this burden, though many EMS protocols do not allow for the use of oral corticosteroids 26 . In a pilot study, a change in prehospital protocols to include oral corticosteroid administration was associated with a decrease in hospital admission rate and LOS 13 .…”

Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial (EASI‐AS‐ODT)

“…Those low rates are further supported by a Florida statewide study 11 and a national study, 12 which reported systemic corticosteroid administration rates to children of 11% and 8%, respectively. One potential reason for those low rates is that IV methylprednisolone is the most commonly used systemic corticosteroid in EMS protocols, 13,14 yet there are numerous barriers to prehospital pediatric IV placement resulting in a minority of pediatric EMS patients receiving prehospital IVs from EMS clinicians. 15,16 Therefore, there is a need to study both oral and IV systemic corticosteroid options for EMS administration to pediatric asthma patients.…”