Bedside detection of pulsus paradoxus (PP), an objective measure of airway obstruction and treatment response, may be helpful for predicting the need for adjunct medications, supplementary ventilation, and admission to a high-dependence unit (HDU)/intensive care unit (ICU) in children being managed for moderate to severe wheezing in the emergency department (ED), according to study results published in Archives of Disease in Childhood.

This single-center study conducted in the ED of a tertiary-care children’s hospital included a total of 285 children with moderate to severe respiratory distress aged ≤16 years. Patients were placed in the resuscitation bay and a triage nurse assessed the pulse oximeter plethysmographic waveform to detect PP.

Physicians in the ED then followed a standardized management protocol for each patient. The main outcome measures included the need for adjunct medications (ie, aminophylline or magnesium sulfate), supplementary ventilation, and admission to an HDU or ICU.

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Approximately 27.4% of children (n=78) in the study had PP upon presentation to the ED. Overall, 14% of patients (n=40) had PP after initial management. Children with PP after initial management had higher relative risks (RRs) of needing adjunct medications (RR, 12.5; 95% CI, 4-38.6; P <.001), supplementary ventilation (RR, 5.6; 95% CI, 1.2-26.5; P =.048), and admission to the HDU/ICU (RR, 5.6; 95% CI, 3-10.4; P <.001).

A potential study limitation included the lack of blinding of the practicing ED physicians, which could have introduced observer bias.

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According to the researchers, their findings suggest that “detection of [PP] on pulse oximetry can be used as a potential point-of-care tool to help in the assessment of response to initial treatment in pediatric patients with acute moderate to severe asthma exacerbations.”


Krishnan GS, Wong HC, Ganapathy S, Ong GY. Oximetry-detected pulsus paradoxus predicts for severity in paediatric asthma [published online February 24, 2020]. Arch Dis Child. doi:10.1136/archdischild-2019-318043