Approach to child with

Respiratory distress

Dr. Santosh T Soans

Karanataka

Definition
Dyspnoea is a clinical term for shortness of breath
or breathlessness, i.e., The discomfort associated
with effort in breathing or the urge to breathe

Definition Contd..
A recent consensus statement from the American
thoracic society offered the following definition of
dyspnoea:
Dyspnoea is a term used to characterize a subjective
experience of breathing discomfort that is comprised of
qualitatively distinct sensations that vary in intensity. The
experience derives from interactions among multiple
physiological, psychological, social and environmental
factors, and may induce secondary physiological and
behavioral responses."

Respiratory distress Clinical pearls

Supra-sternal indrawing
(Use of accessory muscles, Upper airway involvement)

Intercostal indrawing
(Decreased Parenchymal Compliance)

Subcostal indrawing
(Increased work of diaphragm)

Sounds during respiratory cycle

Stridor
(Extra thoracic airway structures)

Wheeze
(Intra thoracic airway structures)

Grunt
(Parenchymal lesions)

Types of Respiration

Prolonged Inspiration
Prolonged Expiration
Deep Breathing
Rapid shallow Breathing
Apneoic breathing

Respiratory signs
Extrathoracic

Intrathoracic

Pulmonary

Retractions

++++

++

++

Stridor

+++

Wheeze

++

+++

Tachypnoea

++

+++

Grunt

Respiratory Distress - History

Elucidate onset, duration, character, alleviating, and
exacerbating factors and treatment to date.
The impact that the symptoms have on everyday
activities, such as playing or exercise and the oral
intake of liquids and food are key.
Always consider the possibility of an acute
exacerbation of an indolent or more chronic
process.

Physical
The respiratory rate of the ill child is a key
parameter
The heart rate, temperature, and blood
pressure all give supporting evidence to the
physiologic state of the child
Oxygen saturation - via pulse oximetry

Respiratory Distress by Location

Location of Respiratory
Distress

Examples of Conditions

Upper airway

Croup, epiglottitis, foreign body, tracheitis

Lower airway

Asthma, bronchiolitis, foreign body

Pulmonary parenchyma

Pneumonia, interstitial lung disease, BPD,

cystic fibrosis,empyema,effusion

Mechanics

Trauma, spinal or chest wall deformity

Neuromuscular control

Seizure, acute paralysis, myopathy, anoxic

encephalopathy, head /spinal cord trauma,

Extra-pulmonary: Cardiac, Heart failure, hyperventilation, renal failure,

CNS, renal, Metabolic
drug overdose, Metabolic acidosis

Respiratory Distress Upper airway

Is there noisy breathing on inspiration?
Does the child's posture have an important impact
on the airway being opened maximally (e.g.,
leaning in the sniffing position) and does it improve
the condition?
Is the noise barky, sonorous or harsh, or highpitched?
Stridor is a particularly important sign of upper
airway obstruction

Lower airways
Clinical signs of lower airway pathology include
Hyperinflation of the lung and chest cavity.
Accentuation of the expiratory phase of respiration.
Accentuation of lung sounds on expiration.

Wheeze is a particularly important sign of lower airway

obstruction
All that wheezes is not asthma- consider entities such as an
aspirated foreign body, particularly with focal wheezing, or
something compressing the intra-thoracic airways such as
an enlarged lymph node

Parenchyma
Clinical signs of parenchymal pathologies include:

tachypnoea, grunting, and retractions

Focal findings may include splinting of the chest wall
changes in breath sound quality, and crackles
Grunting is a particularly important sign of
parenchymal involvement

Mechanics
The mechanics of respiration can be disrupted by the
presence of upper airway obstruction, lower airway
obstruction, chest wall or neuromuscular abnormality, and
extra pulmonary problems.
These may lead to less than effective ventilation and
respiratory failure.
Examples include a reduced lung volume secondary to an
intra-abdominal mass or large pleural fluid collection or the
air trapping.
Congenital or acquired skeletal abnormalities and trauma
(e.g., flail chest).

Neuromuscular
Ascertain breathing pattern:
Is the rate slow or absent?
Is the pattern of respiration insufficient to move the chest
wall?
Is there an unconscious state or active seizure that may
impair normal respiration?

Non pulmonary
Physical exam of the child with respiratory distress
should be complete.
Is there evidence of a primary brain problem
leading to alteration of respiration?
Is there primary heart failure with secondary
respiratory distress?
Any signs of other systemic disorders?

Non pulmonary Contd..

Is there evidence of acidosis (i.e. Hyperpnoea) or
other metabolic abnormality (i.e., Kussmaul
respiration with fruity breath) that may cause
respiratory distress?
Is there evidence of renal failure, liver disease, or a
congenital problem associated with respiratory
distress?
Is there a suggestion of drug overdose or drug
effect that is leading to respiratory distress?

Assessment
General condition:playful,toxic,drooling or
continuous cough,
Colour:pink,pale, or cyonosed
Mental status; agitated, anxious, lethargic ,comatose
Respiratory rate: tachypnea, episodes of apnea,
Vital signs
Facial deformity/ airway problem. Chest deformity,
scoliosis

Assessment Contd..
Hoarse voice, no voice or croupy cough.
Accessory muscle use
Stridor, wheeze, breath sounds, added sounds

Interventions
Oxygen therapy by mask, nasal cannula or head box.
Airway humidification.
Avoid forceful examination of throat or neck. And neck &
chest x-ray in suspected upper airway obstruction. Comfort
the child.
Maintain airway & breathing.
ET intubation under controlled situation.
Aerosol therapy-b2 agonist/ budesonide / adrenaline.
Needle aspiration in suspected pneumothorax.

Investigations

CBC, blood culture, electrolytes.

Portable x-ray chest & neck.
Broncoscopy- in suspected foreign body.
ABG.
Peak expiratory flow rate( PEFR).
Further investigate if non-pulmonary causes
suspected.

Management
Establish IV line for drugs like steroids & antibiotics.
Supportive care- correct dehydration, correct shock,
dyselectrolytemia, fever.
Continuous monitoring with pulse-oxymetry, TcO2
monitor, cardiac monitor.

Indications of mechanical ventilation

Indications are mainly clinical

Respiratory muscle fatigue, exhaustion,
Diminished air entry quite chest.
Pulses paradoxus > 20-40 mm Hg.
Deterioration of mental status.
PaO2 < 60 mm Hg or cyanosis not corrected by oxygen.
PaCo2 >50 mm H g and raising > 5 mm Hg/ Hr.

Thank you