Version May 2024
| Test | Indications | Comments |
| Bedside testing | ||
| Pulse oximetry | All patients with respiratory distress. | Erroneous readings may occur with improper probe application, poor waveform readings, or certain medical conditions. Refer to UpToDate content on causes of erroneous pulse oximetry readings. |
| EtCO2 measurement | Confirmation of successful endotracheal intubation. Noninvasive monitoring of ventilation in intubated and non-intubated patients. Noninvasive monitoring for sedation in children. | Measurable in non-intubated and intubated patients. |
| Electrocardiogram | Clinical suspicion of cardiac disease (eg, cardiac murmur, gallop, differential pulses or blood pressure between upper and lower extremities). | Typically combined with chest radiograph to assess heart size and pulmonary vasculature in order to determine need for echocardiography. |
| Point-of-care ultrasound | Clinical suspicion of pulmonary pathology (eg, pneumonia, pleural effusion, pneumothorax, or hemothorax), heart failure (can assess myocardial function and presence of pulmonary edema), or pericardial tamponade. | To be performed by an appropriately trained and experienced provider. Other uses include confirmation of endotracheal tube placement, blood volume status, and presence of intra-abdominal or pelvic fluid. |
| Laboratory testing | ||
| Arterial or venous blood gas | For arterial sample only, determine PaO2 for calculation of physiologic measures of oxygenation (eg, A-a gradient, PaO2/FiO2 ratio). Correlate pCO2 with EtCO2 measurements Measure pH and correlate with venous pH. | EtCO2, pulse oximetry, and venous blood gases may be used as less invasive methods for ongoing monitoring of oxygenation, ventilation, and acid-base status if they correlate with arterial blood gas measurements. |
| Electrolytes, blood urea nitrogen, and creatinine | Patients with metabolic acidosis. | Assesses for the presence of an anion gap and renal dysfunction. |
| Glucose | Altered mental status, diabetic ketoacidosis. | |
| Ammonia | Altered mental status and other findings suggestive of urea cycle defects. | |
| Carboxyhemoglobin cooximetry | Smoke inhalation. Altered mental status, headache, vomiting, and possible exposure to carbon monoxide (eg, blocked furnace flue). | Pulse oximetry is falsely elevated in the presence of carboxyhemoglobin. |
| Methemoglobin cooximetry | Cyanosis in the presence of a normal PaO2 on arterial blood gas. Exposure to agents known to cause methemoglobinemia (eg, nitrites, benzocaine, aniline dyes) or young infants with severe dehydration. | Oxygen saturation by cooximetry identifies the presence of an abnormal hemoglobin if specific measure of methemoglobin is not available. Methemoglobinemia causes falsely normal or elevated pulse oximetry readings. |
| D-dimer | Clinical findings suggestive of pulmonary embolus (eg, low oxygenation, pleuritic chest pain, wedge-shaped infiltrate on chest radiograph, and predisposing condition [eg, sickle cell disease, thrombotic condition]). | Pulmonary embolus is a rare cause of respiratory distress in children. Imaging is indicated for patients with moderate to high clinical probability. For recommended studies, refer to UpToDate topics on imaging for venous thromboembolism in children. |
| Troponin, BNP | Clinical findings suggestive of possible myocarditis or pericarditis; history of recent COVID-19 infection or COVID-19 vaccination raises concern. | Normal electrocardiogram, chest radiograph, do not exclude diagnosis. |
| Imaging | ||
| Lateral neck radiograph | Clinical findings suggestive of epiglottitis, retropharyngeal abscess, or ingested foreign body. | Croup can usually be diagnosed clinically without a radiograph. |
| Chest radiograph | All children with significant respiratory distress and those with focal lung findings. | To assess for pulmonary and or cardiac pathology. |
| Forced expiratory or bilateral decubitus chest radiograph | Suspected foreign body aspiration. | Hyperaeration noted on the side with the bronchial foreign body. |
| Unilateral decubitus chest radiograph | Assess whether lung opacity is due to parenchymal disease or effusion. | Loculated effusions and very large effusions may not show evidence of layering. |
| Echocardiography (including bedside ultrasonography) | Identify cardiac tamponade; assess cardiac function and presence of structural heart disease. | History of recent COVID-19 infection or vaccination raises concern for myocarditis, pericarditis. |
| Abdominal radiographs (supine and upright or cross-table lateral) | Significant abdominal tenderness and/or distension with concern for intestinal obstruction or perforation. | Other testing (eg, ultrasound, upper gastrointestinal contrast study, abdominal CT or MRI) may also be indicated depending upon clinical findings and likely etiologies. |
| CT or MRI of the head | Clinical findings suggestive of increased intracranial pressure or intracranial mass lesion. | |
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