approach to a child with respiratory distress

1. Approach to a child
with Respiratory
Distress
Resident: Madan Kumar Timalsena
Moderator: Dr. Shikhar Pradhan

2. Definition
– Indicate sign and symptoms of abnormal respiratory
pattern
– Clinical state characterized by increased rate & increased
respiratory efforts
OR
– It refers to any type of subjective difficulty in breathing.

3. Features of respiratory distress
– Tachypnea
– Dyspnoea
– Nasal flaring
– Chest wall retraction
– Added sounds
– Head bobbing
– CVS &CNS manifestation

4. Grading of acute respiratory
distress
Mild
– Tachypnea
– Dyspnea or shortness of breath
Moderate
– Tachypnea
– Minimal chest wall retaractions
– Flaring of alae nasi
Severe
– Marked tachynea (> 70 breaths/min)
– Apneic episodes/bradypnea/irregular breathing
– Lower chest wall retractions
– Head bobbing (use of sternocleidomastoid muscles)
– Cyanosis

5. Features of Respiratory failure
– Inadequacy of oxygenation or ventilation
– Defined as a paCO2 of >50 or paO2 of <60 while
breathing room air
– Clinical definition : Severe respiratory distress with
cardiovascular manifestation and central nervous system
changes
– Cvs changes: marked tachycardia, or bradycardia,
hypotension
– Cns changes: lethargy, somnolence ,seizures and coma

6. Pathophysiology

7. Increased resistance due to edema

8. Pathophysiologic approach to clinical conditions
causing respiratory distress
Etiology Pathophysiology Clinical conditions
Interference with air flow
(entry or exit)
Upper airway obstruction
Lower airway obstruction
Mechanical compression
Thoracic wall injuries
Aucte laryngitis, laryngotracheitis, foreign body
Bronchiolitis, asthma
Large pleural effusion, pneumothorax
Flail chest
Interference with alveolar gas
exchange
Failure of alveolar ventilation
Failure of diffusion
Pneumonia, pulmonary edema
Pneumonia, pulmonary edema
Cardiovascular problems Mechanical or inadequate function Congestive cardiac failure, arrhythmias, myocarditis,
pericarditis, Right-to-left shunts
CNS Depression of respiratory center
Stimulation of respiratory center
Neuromuscular impairment of
respiration
Raised ict
Acidosis, salicylate intoxication
Acute paralytic poliomyelitis, Guillain-Barre syndrome,
organophosphate poisoning, snake bite, diaphragmatic
paralysis
Other Insufficient oxygen supply to tissues
and/or increased oxygen demands
Compensation for metabolic acidosis
Sepsis, severe anemia, high altitude, carbon monoxide
exposure, smoke inhalation, meth-hemoglobinemia
Diabetic ketoacisosis, acute renal failure

9. Approach
– Our primary / first approach should be directed to find out the extent of
respiratory and cardiovascular dysfunction and quantify its severity.
– The assessment determines the urgency with which interventions need to
be instituted
– Assessment is aimed to deciding weather airways
– Clear
– Maintable
– Not maintable
– Any audible sound during breathing is suggestive of respiratory airway
obstruction

10. Initial general assessment
– The goal is to rapidly assess for
a)airway patency
b)adequacy of gas exchange
c)circulatory status
Assessment begins with using Pediatric Assessment
Triangle

11. Pediatric Assessment Triangle
A)Appearance : interaction ,muscle tone, consolability,
look speech, cry
B)Work of breathing: use of accessory muscle,
bradypnoea
C)Abnormal skin colour: pallor and cyanosis

12. Primary general assessment
– It is done by using the assessment pentagon which
includes
Airway
Breathing
Circulation
Disability
Exposure

13. Airway
Assessment is aimed to decide whether airway is:
CLEAR: open and unobstructed
MAINTAINABLE: maintained by simple measure like
position, suction etc
NOT MAINTAINABLE: needs advance measure like
intubation
ANY AUDIBLE SOUND

14. Noisy Breathing
– Snoring
– Grunting
– Stridor
– Wheeze
– Ronchi

15. Stridor
– Coarse high pitched sound typically heard on
inspiration.
– Inspiratory harsh sound continuously.
Can occur during expiration (intrathoracic) or both
phase of respiration.
– Asses the severity
– Drooling of saliva, respiratory distress,
unable to swallow, cyanosis

16. Stridor…
– Common causes:
– Infective: epiglottitis, laryngotracheobronchitis,
tracheitis, retropharyngeal abscess (rare)
– Malignancy: tumor compression, papilloma
– Allergic: angioneurotic oedema.
– Congenital: laryngomalacia, laryngeal web, vascular
ring,
– Aspiration: foreign body.
– Neuronal: paralysis of vocal cord.
– Investigation
– Blood count; Lateral neck X-ray; flexible
bronchoscopy.

17. WHEEZE Vs RHONCHI
WHEEZE
– Continuous ,high pitched musical
sound
Heard during expiration, however can
be heard on inspiration
Produced when air flows through
narrowed airways.
RHONCHI
– Subtype of wheeze
– Low pitched, snoring quality,
continuous musical sound
– Implies obstruction of larger
airways by secretions.

18. Grunting
– Short, low pitched sound heard during expiration produced by
forced expiration against a partially closed epiglottis
– typically a sign of severe respiratory distress
– Sometimes grunting can be heard in fever and abdominal pain

19. Breathing
< 2 months > 60/min
2 months – 1 year > 50/min
1 year – 5 years > 40/min
5 years > 30/min
a) Tachypnea

20. Breathing
contd…..
2)BRADYPNOEA: apparently normal respiratory rate
which is inappropriate for the clinical situation
3)RETRACTIONS:
– Suprasternal retraction-upper airway obstruction
– Intercostal Retraction – Parenchymal
– Subcostal Retraction-LOWER AIRWAY OBSTRUCTION

21. Breathing
contd…..
4)See saw respiration it is seen in neuromuscular
weakness, but can also occur in late stage of severe
respiratory pathology
5)pulse oximetry measure % saturation of hb with
oxygen

22. 3)Circulation
– Pulse Rate/Heart Rate
– Pulse volume: feeble peripheral pulse is the
first sign of compromised perfusion
– Capillary refill time
– Blood pressure

23. 4)Disability
– Reduced O2 supply to brain affects consciousness muscle
tone and pupillary response
– Early manifestations are anxious look and irritability and
agitation followed by lethargy

24. 5)Exposure
– If indicated it is done to look for evidence of trauma,
petechae and purpura and warming

25. Categorization of severity of the
clinical condition
– Life threatening conditions
– If at any point during the assessment, a life threatening
condition is identified, appropriate interventions are
instituted, before proceeding with the rest of the
assessment.

26. Signs of life-threatening illness in a
child with respiratory distress
Airway Complete or severe airway obstruction
Breathing Apnea/bradypnea, markedly Increased work of breathing
Circulation Absence of detectable pulse, poor perfusion, hypotension, bradycardia
Disability Unresponsiveness
Exposure Significant hypothermia or bleeding, petechae/purpura consistent with
septic shock

27. Immediate care
– The goal is to relieve hypoxemia and support respiratory functions
until specific
therapy becomes effective.
– This is done by (a) Ensuring an open airway and breathing, (b)
Delivering oxygen without causing agitation, and (c) Ensuring
adequacy of circulation, normal temperature and hydration.
– Airway patency can be achieved with
a) Proper positioning (extend the neck, pull the mandible
forward, to lift the tongue),
b) Cleaning the oropharynx of any secretions (manually if
necessary), and
c) Insertion of an oropharyngeal airway.

28. Ensure breathing if spontaneus normal breathing is
absent/inadequate by:
(a) Assisted ventilation by bag and mask ventilation,
(b) Endotracheal intubation as soon as adequate expertise
and equipment are available,
(c) Providing oxygen. Never delay resuscitation for lack of
equipment or trained personnel.

29. Ventilation
– Nasal prongs are the recommended way of providing
oxygen to most of the children
– 1 to 5 litre per min
For older children oxygen is best given by face mask

30.  Low Flow Systems
 Provides relatively stable FiO2 levels as long as
respiratory rate and pattern are stable
Can deliver high FiO2, but actual amount will vary
from breath to breath
Examples include nasal cannula, simple face

31.  High Flow Systems
• Indicated in patients with variable respiratory rate
and pattern to provide appropriate FiO2 to meet a
patients respiratory demand
• Examples include Venturi mask, high flow nasal
cannula, and mechanical ventilation

33. Ensure circulation
– If the patient is in shock, or has signs of severe sepsis, initiate
septic shock protocol. Establish intravenous access and initiate
infusion of a saline bolus (20mg/kg).
– If venous access is not feasible, consider intrasseous infusion in
young children.
– The first dose of an appropriate antibiotic for severe infections,
including severe respiratory infection, must be administered
without delay.

34. Child with respiratory distress
Approach to a child with breathing difficulty
Pediatric assessment triangle
Pediatric assessment pentagone
Secure airway, start oxygen, ensure breathing, restore circulation
Is there sever stridor or
drooling!
? Intubation or Tracheostomy
Yes
Is pneumothorax suspected ?
Needle thoracotomy intercostal drainage
Yes
Is there fever ?
First dose of antibiotic
Yes
No
No
No
Detailed clinical examination for specific cause
Pneumonia Wheezing
UAO
Specific investigations
Specificmanagement
CNS Metabolic
Cardiac

35. Diagnostic evaluation of
respiratory distress
A- History
– Acute, recurrent or chronic and nature of progression
– Associated symptoms: cough, fever, rash, chest pain
– Preceding events : choking, foreign body inhalation
trauma/accident, and exposure of chemical or environmental
irritants.
– Family history exposure to infections, tuberculosis, atopy.

36. Contd...
B - Physical Examination
– Assess stability of the airways, and ventilatory status.
 Color, level of activity and playfulness
 Respiratory rate (counted for a full minute),
rhythm, depth and work of breathing
 Chest movements, indrawing of chest wall
 Stridor (suggests upper airway obstruction)
 Wheezing (suggests lower airway obstruction)
 Grunting (suggests alveolar disease causing loss of
functional residual capacity)

37. Contd...
– Tracheal position
– Segmental percussion
– Auscultation: Air entry, type of breath
sounds (wheeze, rhonchi, crepitations)
– Clubbing, lymphadenopathy, pallor,
icterus
– Assessment of CVS and CNS

38. Contd...
C – Diagnostic work - up
– Direct laryngoscopy, if upper airway obstruction is
detected/suspected
– X-ray: chest, lateral neck, and decubitus views
– Arterial blood gas analysis for hypoxemia (pa02 <60 mm Hg),
hypercarbia (paCO2 >40 mm Hg), (acidosis pH < 7.3),
alkalosis (pH > 7.5, and Sa02 monitoring
– Sepsis work-up; Blood counts and culture studies

40. Neurological illnesses
– Though neurological illnesses can lead to ‘breacthlessness’, it is
unlikely to be the only or chief complaint.
– Whether the neurological illness is acute (head injury, encephalitis,
meningitis), subacute or chronic (Guillian Barre syndrome, spinal
muscular atrophy) there is usually a prominent history or the
initiating/primary events which suggest the possible cause.

41. Cardiac causes
– Detection of cardiac failure, shock, or cyansosis may
suggest a cardiac cause of breathlesness and should be
managed accordingly

42. Metabolic causes
– When children manifest with kussmaul breathing a metabolic
cause should be suspected
– In such child patient would have marked tachypnoea with
minimum retraction and chest would be clear
– common causes:
– DKA
– ARF
– Severe dehydration
– Septic shock

43. Indication for urgent X-ray
– Most of the reparatory distress conditions do not require
urgent x-ray
– Its only indicated if following conditions is suspected
– Pneumothorax
– pleural effusion
– Pneumomediastinum
– Flail chest

44. Status ofABG
 Arterial Blood Gas analysis: single most important lab
test for evaluation of respiratory failure.

45. Respiratory failure: Evaluation
The following parameters are important in
evaluation of respiratory failure:
 PaO2
 PaCO2
 Alveolar-Arterial PO2 Gradient

46. Laboratory investigations
 Arterial BG
— Info on oxygenation and ventilation status
— Difficult to get in some patients
 Venous BG
— Ventilation info but not oxygenation
— Venous – good only if obtained from free flowing site – no
tourniquet
— PaCO2 slightly higher in VBG
 Remember metabolic side (base deficit, [HCO3-])

47. Alveolar-Arterial O gradient
 Normal 5-10 mm of Hg
 A sensitive indicator gas exchange.
 Useful in differentiating
extrapulmonary and pulmonary causes
of resp. failure.

48. Hypoxemia
1. Low PiO2 ~ at high altitude
2. Hypoventilation ~ Normal A-a gradient
3. Low V/Q mismatch ~ increased A-a
gradient
4. R/L shunt ~increased A-a gradient

49. Hypercapnia
 Better to be defined by pH rather than pCO2 Metabolic
alkalosis can raise pCO2 without acidosis
 Hypoventilation
 Severe V/Q mismatch: major mechanism of
hypercapnia in intrinsic lung disease
 Can occur with many respiratory diseases, usually as
patients get tired

50. Refrences:
 Nelson text book of pediatrics 21st edition
 Johnhopkinssolutions.com
 Uptodate.com