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Respiratory surge cripples pediatric hospitals

Maryland physician describes the current pediatric bed crisis as “far worse than the worst days of the adult critical care bed crunch during COVID”


Johns Hopkins Lifeline helicopter lifts off from Shady Grove Medical Center in Montgomery County, Maryland. The helicopter, based in Baltimore, transports critically ill adult and pediatric patients with specialty teams for each age population. PICU and NICU transport nurses, as well as physicians, may accompany the team during certain transfers.

Courtesy/Emily Roberts

Viruses that are common in the pediatric population have surged in the United States earlier than physicians expected, with news of this year’s surge making national headlines.

“This is like a perfect storm,” reported Dr. Jennifer Anders, a physician at Johns Hopkins Pediatric Emergency Department. “There are so many viruses circulating at once … rhino/enterovirus is still around, RSV is surging and now influenza has arrived.”

Healthcare officials in Maryland are calling for more attention to the situation because neonatal, pediatric intensive care and floor beds are at capacity, with many facilities boarding patients in their EDs and other areas within the facility.

“We are seeing very high numbers of very sick children here at Children’s National in the emergency department and in the inpatient wards,” said Dr. Sarah Combs, an emergency medicine physician and director of outreach at the hospital, in an interview with News4, an NBC Washington, D.C., affiliate.

Seeing a similar surge, Connecticut Children’s Hospital is exploring other options after being inundated with cases of the respiratory syncytial virus (RSV), including using temporary units on the hospital lawn to manage patients and discussing plans to use auxiliary resources through the state and National Guard.

“We saw a little bit of (RSV) last year, but this dramatic increase in cases of RSV in September and October is not something we have seen before historically,” Dr. Juan Salazar, executive vice president and physician-in-chief at Connecticut Children’s, told “The Today Show.” “I’ve been doing this for 25 years at Connecticut Children’s and in practice for over 30 years … at least in the hospitals I that I worked with, I’ve never seen this level of rapid transmission and the need for hospitalization in kids.”

Salazar added that “because they’re all coming at such high numbers, it’s creating a challenge for us to be able to have everyone hospitalized who needs to be hospitalized in the way we normally do it.”

Maryland C4 pediatrics monitoring the surge

I spoke with Dr. Anders, who told me the call volume at Maryland’s Critical Care Coordination Center for Pediatrics continues to rise precipitously, with double the number of calls per day in the past week.

“Calls are now coming in one on top of the other,” explained Anders, who also serves as the pediatric medical director for Maryland’s critical care coordination center. “This is the busiest volume since the inception of C4 … worse than the worst days of COVID in Maryland, and this pediatric bed crisis is far worse than the worst days of the adult critical care bed crunch during COVID.”

This month, nearly 40% of children are placed at a Maryland hospital, while 20% are sent to neighboring states. The remaining 40% of children have not found placement, instead being managed in place, Anders described. The C4 Pediatrics has been helping with ongoing management of these critically ill children, and has created clinical guidelines for the care of children on high-flow nasal cannula in community-based EDs and pediatric inpatient units.

With facilities at capacity, the coordinator and physician working in the critical care coordination center focus on identifying the sickest children and getting them prioritized for movement to a children’s center before they decompensate.

“This is a true crisis,” Anders said. “We have seen a handful of children who required intubation in community sites while boarding for PICU transfers … so far they have all done well, but this lack of critical care beds and prolonged ED boarding creates the daily risk of a tragic outcome. In the past week, we routinely have more than 20 children boarding in emergency departments as we seek PICU beds for them. This puts the emergency departments in a precarious place as they provide (pediatric) critical care for multiple days. The vast majority of these children are on high-flow nasal cannula oxygen.”


Johns Hopkins Lifeline helicopter sits on the helipad at Sinai Hospital in Baltimore, Maryland. The helicopter, based in Baltimore, transports critically ill adult and pediatric patients with specialty teams for each age population. PICU and NICU transport nurses, as well as physicians, may accompany the team during certain transfers.

Courtesy/Chad Bowman

Transport team considerations

As these critically ill patients sit in community EDs waiting for admission to specialty pediatric units, critical and specialty care transport teams are called upon to provide care during their transfers.

A PICU or NICU transport team is familiar with the equipment type and size, medication dosing and vital signs for their specialty. These teams can use ground ambulances or aircraft for transport modality.

While many of these children are on high-flow nasal cannula, others require critical airway support, like RAM cannula, BiPAP or intubation. Let’s consider the implications of each.

High-flow nasal cannula

This type of oxygen therapy is commonly prescribed when caring for acutely hypoxic patients.

A journal article published by the National Library of Medicine detailed HFNC basic components: a flow generator providing gas flow rates up to 60 liters per minute, an air-oxygen blender that achieves escalation of FiO2 from 21% to 100% irrespective of flow rates, and a humidifier that saturates the gas mixture at a temperature of 31-37°C. To minimize condensation, the heated, humidified gas is delivered via heated tubing through a wide-bore nasal prong.

Five physiologic mechanisms are believed to be responsible for the efficacy of high-flow nasal cannula:

  1. Physiological dead space washout of waste gases, including carbon dioxide
  2. Decreased respiratory rate
  3. Positive end-expiratory pressure
  4. Increased tidal volume
  5. Increased end-expiratory volume

RAM cannula

The RAM cannula is a form of non-invasive ventilatory support providing positive pressure to patients via a nasal interface. Continuous positive pressure can be delivered using several treatment modalities, most commonly by continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP). This type of support has been shown to be effective in treating patients in the acute setting to prevent endotracheal intubation.

RAM cannulas were first introduced in 2011 for infants in the NICUs, according to the NIH. This device has the potential to improve patient tidal volume, decrease work of breathing, and improve ventilation and oxygenation.

Comparing the RAM cannula to traditional nasal cannulas, this device is made of more flexible, softer material with thinner walled nasal prongs.


CPAP is a type of ventilatory support set at a pressure that stays the same when a child breathes in and breathes out. BiPAP gives a child extra support by pushing in a higher level of air when a child breaths in. BiPAP may also be set to give a child a breath if there is a pause in breathing.

CPAP is indicated for patients with various lung infections, including pneumonia. The patient should be alert and able to follow commands, show signs of respiratory distress, with rapid breathing and a SpO2 of less than 90%.

BiPAP is indicated for children whose respiratory system is compromised by airway obstruction, weakened respiratory muscles, decreased respiratory drive or lung disease.


The intent of the abovementioned ventilatory support is to prevent intubation; however, some pediatric patients will decompensate and require intubation, either by the physician or a member of the transport team. After the patient is intubated, ventilations using an ambu-bag will be required until the patient is transitioned to a ventilator to provide continuous and controlled support for their ideal body weight during the transport.

Pediatric patients should be placed in the sniffing position during tracheal intubation. This provides a standard position of glottis exposure with alignment of the external auditory meatus and sternal notch.

Clinicians intubating children should remember pediatric anatomy and associated risks, including a large tongue relative to the mouth, filling the oropharynx. The tongue will easily obstruct the larynx if the baby loses consciousness.

As a general rule, the correct size endotracheal tube can be calculated by dividing the child’s age by 4 and then adding 4 for uncuffed tubes [(Age/4)+4]. For cuffed tubes, use the child’s age divided by 2 and add 3.5 [(Age/2)+3.5].

Uncuffed tubes are mainly indicated for neonates, infants and children under the age of 8.

As with any intubation, the ET tube should be confirmed by:

  1. Visualization of the cords
  2. Chest rise and fall
  3. Quite epigastric sounds
  4. Using end-tidal CO2 device for monitoring

Each time the pediatric patient is moved, a clinician should re-verify the ET tube placement by confirming bilateral lung sounds and quiet epigastric sounds. Using your ETCO2 monitors will also offer guidance.


Read more:

Enterovirus, rhinovirus and RSV on the rise

A surge of viral infections is increasing pediatric hospitalizations and transports

Todd Bowman is a nationally registered and flight paramedic with more than 18 years of prehospital experience in Maryland. He attended Hagerstown Community College for his paramedic education and later obtained his bachelor’s degree in journalism from Shepherd University in Shepherdstown, West Virginia. His experience ranges from rural, metro and aviation-based EMS. He is an experienced EMS manager, public information officer and instructor. Follow him on social media at @_toddbowman.