NURSING CARE MANAGEMENT OF CHILD WITH RESPIRATORY DISTRESS; this topic will give information regarding respiratory distress and management for mild and moderately distressed child. Mainly mentioned about infection prevention and control triage measures.

1. Nursing Care Management Of
Child With Respiratory Distress
(Mild & Moderate)

2. PRESENTING BY

3. ✿ Introduction
✿ Definition
✿ When to suspect the child
✿ Causes
✿ Types
✿ Child with covid
✿ Diagnostic and investigation
✿ Process of identify positive cases
✿ Management of covid child
✿ Management of covid child along with other diseases
✿ Infection prevention and control triage measures

4. Every child is a different kind flower and altogether make
this world beautiful garden. But now this covid 3rd wave will be
trying to make this world as desert by showing its evil effect on
children health.

5. Clinical state characterized by increased rate or
respiratory effort or It refers to any type of subjective difficulty in
breathing is called Respiratory Distress.

6. 1. All symptomatic children who have undertaken
international travel in the last 14 d OR
2. All hospitalized children with severe acute respiratory
illness (fever and cough and/or shortness of breath) OR
3. Asymptomatic direct and high-risk contacts of a confirmed
case (should be tested once between day 5 and day 14 after
contact.

7. 1. Upper airway obstruction
2. Lower airway obstruction
3. Lung tissue disease
4. Disordered control of breathing

8. A. Acute respiratory distress
B. Chronic respiratory distress
Mild acute respiratory distress
Moderate acute respiratory distress
Severe acute respiratory distress
1. Mild illness - Asymptomatic
2. Moderate illness Pneumonia
3. Severe illness

9.  Fever,
 Cough,
 Breathlessness/ shortness of breath,
 Fatigue, myalgia, rhinorrhea,
 Sore throat,
 Diarrhea,
 loss of smell, loss of taste etc.
 Few children may present with gastrointestinal
symptoms and atypical symptoms.

10.  Initial assessment
 Initial studies & life threatening conditions
 Specimen collection
 Initial investigations

11. Rapid assessment
 Quickly determine severity of respiratory condition and
stabilize child
 Respiratory distress can quickly lead to cardiac
compromise
Airway
Support or open airway with jaw thrust
 Suction and position patient
Breathing
 Provide high concentration oxygen
 Bag mask ventilation
 Prepare for intubation
 Administer medication ie albuterol, epinephrine
Circulation
Establish vascular access: IV/IO

12. ( )
 It is a simple clinical test to assess cardio-pulmonary exercise
tolerance, and is used to unmask hypoxia
 Attach pulse oximeter to his/her finger and ask the child to
walk in the confines of their room for 6 minutes continuously
 Positive test: any drop in saturation < 94%, or absolute drop
of more than 3–5% or feeling unwell (lightheaded, short of
breath) while performing the test or at end of 6 minutes

13.  Children with positive 6-minute walk test may progress to
become hypoxic and early admission to hospital is
recommended (for observation and oxygen supplementation).
 The test can be repeated every 6 to 8 hours of monitoring in
home setting; avoid the test in patients with uncontrolled
asthma.

14.  Samples will be tested for SARS-CoV-2 at laboratories
(government or private) approved by the Government of
India .
 Trained health care professionals to wear appropriate
personal protective equipment (PPE) with latex free purple
nitrile gloves while collecting the sample from the patient.
Proper infection control precautions should be maintained
when collecting specimens.

15.  Entry of visitors or attendants during sample collection is to
be restricted.
 Requisition form for each specimen should be completed
and submitted.
 Proper disposal of all waste generated has to be ensured
(red container)
• Upper Respiratory Tract Nasopharyngeal and Oropharyngeal
(Throat) Swab
• Lower Respiratory Tract BAL and Endotracheal Aspiration

17. Lab tests on day 3-5 of illness (Repeat if done earlier):
1. CBC with peripheral smear
2. CRP, Serum ferritin, Serum LDH
3. PT, aPTT, INR, D-Dimer, Fibrinogen
4. LFT, RFT
5. Chest X Ray PA view if lower respiratory tract symptoms.

18. PROCESS TO IDENTIFY
THE POSITIVE CASES

20. • Children with Covid 19 infection may be asymptomatic, mildly
symptomatic, moderately sick or severe illness.
• Asymptomatic children are usually identified while screening, if
family members are identified. Such children do not require any
treatment
• except monitoring for development of symptoms and subsequent
treatment according to assessed severity.
• Mild disease: Children with mild disease may present with sore
throat, rhinorrhea, cough with no breathing difficulty. Few
children may have
• gastrointestinal symptoms also.
• Such children do not need any investigations
MANAGEMENTOF CHILDRENWITHCOVID – 19 DISEASE:

22. Upper respiratory tract symptoms and/or fever without
shortness of breathing or hypoxia. Same criteria for children
and young adults. Admission category: Home isolation (advice
on OPD, day-care and / or tele-consultations)

23. MILD ACUTE RESPIRATORY DISSTRESS
Signs and symptoms
• Sore throat,
• Rhinorrhea,
• Cough
• No fast breathing
• Tachypnea
• Dyspnea or shortness of breath
Actions
• Continue providing home based care to
your child
• Do temperature charting
• Continue taking personal protective
measures
• In case of fever, you can do tepid
sponging and give syrup/tablet
paracetamol
• be watchful for danger signs

24.  Upper respiratory tract symptoms and/or fever without
shortness of breathing or hypoxia. Same criteria for
children and young adults. Admission category: Home
isolation (advice on OPD, day-care and / or tele-
consultations)

25. Advice:
1. Ensure adequate hydration and meal/nutrition intake.
2. 2. Continue to follow all personal protective measures. Children
above 2 years of age can use face mask.
3. 3. Temperature monitoring 6 hourly in all (more frequent if
having fever). Tepid sponging (tap water, not cold water) SOS.
4. 4. Baseline saturation (SPO2) followed by repeat record after 6
minute walking . Consult if baseline saturation below 94% or
fall in saturation of more than 5 % after 6 min walk. Monitor
and record 6 hourly (or more frequent if having lower
respiratory tract symptoms like fast breathing/indrawing of
chest)
5. 5. Gargles with chlorhexidine mouth wash 6 hourly and steam
inhalation as tolerates twice daily (under supervision of
parents).

26. 
1. Tab paracetamol 500 mg SOS if temperature >100F (can
take every 4-6 hourly, maximum 4 doses in 24 hours). 10-
15 mg/kg/dose for children
2. Tab Vitamin C 500 mg once daily x 2 weeks
3. Tab Zinc 50 mg once daily x 2 weeks (20 mg once a day
for children)
4. Tab levocetirizine 5 mg + montelukast 8 mg 1 tab once
daily at night before sleep for 5 days if throat congestion
(levocetirizine 2.5 mg + montelukast 4 mg or weight and
age appropriate for children)

27. c.Oral steroid (dexamethasone 6 mg per day or equivalent
dose of methylprednisolone) in cases with mild symptoms
but laboratory markers suggestive of inflammatory
changes. Prednisolone 1 mg/kg/day or equivalent doses of
methyl prednisolone or dexamethasone in children
5. Additional advise deemed appropriate for other associated
symptoms such as
a. Tab pantoprazole (40mg) 1 tab once daily empty
stomach for gastritis. (20 mg for children)
b. Probiotic sachet (1 twice a day for diarrhoeal
manifestation) (age appropriate for children)

28. Investigations:
Lab tests on day 3-5 of illness (Repeat if done earlier):
1. CBC with peripheral smear
2. CRP, Serum ferritin, Serum LDH
3. PT, aPTT, INR, D-Dimer, Fibrinogen
4. LFT, RFT 5. Chest X Ray PA view if lower respiratory tract
symptoms. Awake-proning: Following positions may be adapted
in series, each for 30 minute to 2 hours as tolerated
Awake-proning:
Following positions may be adapted in series, each for 30 minute to
2 hours as tolerated

30. • Duration of home isolation: 10 days from symptom
onset and no fever for 3 days (20 days in diagnosed
immunocompromised states). RTPCR negative report is
not needed either to finish home isolation or for
discharge from hospital

31. MODERATE ACUTE RESPIRATORY DISSTRESS
• Fast breathing (age based):
≥60/min for 5years
• No signs of severe
pneumonia/illness
• Tachypnea
• Chest wall retractions
• Flaring of alae nasi
Actions
• Visit your nearby doctor as soon
as possible
• Continue to follow other
suggestions as advised above 9
Signs and symptoms

32. Any of following
 Respiratory rate more than 24 in adults; (In pediatric age
group: Pneumonia defined by respiratory rate >60/min in
infants 50/min in infants 2-12 months; >40/min in 1-5
year age; >30 in older than 5 years)
SpO2< 94% in room air
Admission category: COVID Ward; Dedicated pediatric
COVID ward for children
Management of childrenwith ModerateCovid – 19 disease:

33. Management plan
Oxygen support to target SpO2 > 92%
 Anti-inflammatory agent: Steroid (oral or IV dexamethasone 6 mg
od or equivalent dose of methylprednisolone). Prednisolone 1
mg/kg/day or equivalent doses of methyl prednisolone or
dexamethasone in children.
Anticoagulation: Low molecular weight heparin 1 mg/kg per day
subcutaneous in two divided doses. In children use LMWH only if
established thrombosis.

34. Serial laboratory and radiological investigations (HRCT may
be considered if worsening, subject to feasibility)
Investigations as suggested for mild disease plus additional
specific tests such as blood gas, electrolytes (serial
monitoring if persisting or worsening)
Additional antibiotics in cases of suspected secondary
bacterial infection
 Restrictive fluid therapy.

35. Awake-proning: Following positions may be adapted in series, each
for 30 minute to 2 hours as tolerated.

36. SEVERE ACUTE RESPIRATORY DISSTRESS
• Severe pneumonia,
• ARDS Sepsis
• Indrawing of chest
• Sunken eyeballs and dry mouth
• Not passed urine for more than 3- 4 hours
• Refusing to feed
• Looks drowsy or lethargic
• Septic Shock,
• MODS Pneumonia with cyanosis,
• SPO2
• Marked Tachypnea(>70 breaths/min
• Apneic episodes/bradypnea
• Lower chest retractions
• Head bobbing
ACTION
YOUR CHILD NEEDS URGENT
HELP, RUSH TO THE NEAREST
HOSPITAL
• Keep the child warm.
• If the child is drowsy or is having
abnormal body movements, keep them
turned to their left side.

37. MANAGEMENT OF CHILD WITH
COVIDALONG WITH LIFE
THREATENING CONDITIONS

38.  Initial management is to categorize the child according to their sign and
symptoms.
 Assess the feautures of respiratory failure in children
 Tachypnea
 Dyspnea
 Nasal Flaring
 Chest wall retraction
 Added sounds
 Head bobbing
 CVS & CNS manifestation
 Over view the child condition by
oInitial assessment of patient in respiratory distress
o Review management of specific causes of
respiratory distress
o Upper airway obstruction
o Lower airway obstruction
o Lung tissue disease
o Disordered control of breathing.
IF CHILDWITHCOVIDALONGWITHLIFETHREATENINGCONDITIONSTHE
MANAGEMENTANDTREATMENTOF CHILDRENARE DIFFERENTWAYS.

39. • Causes: foreign body, tissue edema, tongue movement to posterior
pharynx with decreased consciousness
• Symptoms
◦ Partial obstruction: noisy inspiration (stridor), choking, gagging
or vocal changes
◦ Complete obstruction: no audible speech, cry or cough
• Management
 Rapidly decide if advanced airway is needed
 Avoid agitation
 Suction only if blood or debris are present
 Reduce airway swelling
• Inhaled epinephrine
• Corticosteroids
• Croup and anaphylaxis require additional management

40. • Bronchiolitis
• Symptoms: copious nasal secretions, wheezes and crackles in child
less than 2 years
• Management:
• Oral or nasal suctioning
• Viral studies, CXR, ABG/VBG
• Trial of nebulized albuterol
• Asthma
◦ Symptoms: wheezing, tachypnea, hypoxia
◦ Management:
• Mild-moderate: oxygen, albuterol, oral corticosteroids
• Moderate to severe: oxygen, albuterol-ipratropium (Duo- Neb),
corticosteroids (IV), magnesium sulfate
• Impending respiratory failure: oxygen, albuterol- ipratropium,
corticosteroids, assisted ventilation (bag-mask ventilation,
BiPAP, intubation), adjunctive agents (terbutaline)

41. • Consider positive expiratory pressure (CPAP, BiPAP or mechanical
ventilation with PEEP) if hypoxemia is refractory to high
concentrations of oxygen
• Etiologies of lung tissue disease
Infectious pneumonia
Chemical pneumonitis
Aspiration pneumonitis
Non-cardiogenic pulmonary edema (ARDS)
Cardiogenic pulmonary edema (ARDS)

42. • Infectious pneumonia:
Symptoms: fever, tachypnea, hypoxemia, increased work of breathing,
crackles or decreased breath sounds
Management:
• Ancillary testing: ABG/VBG, CXR, viral studies, CBC, BCx
• Antibiotics to treat gram + organisms, consider macrolide coverage
• Albuterol if wheezing
• Reduce temperature if febrile
• Chemical pneumonitis :
Symptoms: Tachypnea, dyspnea, cyanosis, wheezing
Management :
o Nebulized bronchodilator if wheezing
o If patient rapidly decompensates, consider advanced ventilatory
techniques
• Aspiration pneumonia ◦
 Symptoms: coughing or gagging associated with feeding, more common in
children with abnormal neurologic status
 Management Respiratory support and antibiotics if infiltrate is present on
CXR

43.  Non-cardiogenic pulmonary edema (ARDS)
• Pulmonary or systemic insult to the alveolar-capillary unit
with release of inflammatory mediators
• Intubate if hypoxemia is refractory to high inspired oxygen
concentrations
 Cardiogenic pulmonary edema
◦ Elevated pulmonary capillary pressure results in fluid
accumulation in lung interstitium
◦ Ventilatory support
◦ Support cardiovascular function
• Preload reduction
• Afterload reduction
• Decrease myocardial metabolic demand

44. Abnormal respiratory pattern produces inadequate minute
ventilation
Altered level of consciousness
o Elevated intracranial pressure
• Cushing’s triad
o Poisoning or drug overdose
• Administer specific antidote if available
oHyperammonemia
oMetabolic acidosis
Neuromuscular disease
◦ Restrictive lung disease => atelectasis, chronic pulmonary
insufficiency, respiratory failure

45. Management
• Immediate implementation of IPC measures
• Early supportive therapy & monitoring
• Collection of specimens for Laboratory Diagnosis
• Management of septic shock
• Management of Respiratory Failure & ARDS
• Prevention of complications

46. • Methyl prednisolone 1-2 mg/kg/day
• IVIG 2 gm/kg over 24-48 hours
• Anti-microbials and evaluate for tropical infections
• Consider anakinra/ tocilizumab If not life-threatening disease
• Evaluate for tropical infections and consider anti-microbials
• Methyl prednisolone 1-2 mg/kg/day
• IVIG 1-2 gm/kg over 24-48 hours Antiplatelet therapy is indicated
if there is thrombocytosis or CAA (Z score>2.5)
• Aspirin 3-5 mg/kg/day (max 81 mg/day Anticoagulation is
indicated if there is CAA (Z score>10), thrombosis or LVEF

47. These children can be managed at home with home isolation and symptomatic
treatment.
For home isolation it is important to assess whether home isolation is feasible by
following steps:
i. There is requisite facility for isolation at his/her residence and also for quarantining
the family contacts
ii. Parents or other care taker who can monitor and take care of child
iii. If available, Arogya Setu App should be downloaded
iv. The parents/care giver has agreed to monitor health of the child and regularly
inform his/her health status to the Surveillance Officer/ doctor
v. The parents/ care giver has filled an undertaking on self-isolation and shall follow
home isolation/quarantine guidelines

48.  Children with underlying comorbid condition including:
congenital heart disease, chronic lung diseases, chronic organ
dysfunction, Obesity (BMI> 2SD) may also be managed at home, if
they have features of mild disease and there is easy access to health
facility in case of any deterioration. In case there is lack of proper
arrangement to manage these children at home/ access to health
facility is difficult, such children may be admitted.

49. General Measures
1. Oxygen supplementation to maintain SpO2 > 92%.
2. Conservative fluid management is followed in mechanically
ventilated patients (restrict fluid to 70–80% maintenance, if there is
no evidence of hypovolemia).

50. 3. Symptomatic treatment: Paracetamol for fever ((10– 15 mg/kg/ dose
SOS/ q 4–6 hourly if required); avoid ibuprofen and other NSAIDs
4. Blood culture sample should be sent at time of admission before starting
anti-microbials.
5. Empirical antimicrobials (e.g., Ceftriaxone) within 1 h of admission in
case of suspected sepsis and septic shock.
6. Oseltamivir may be considered after sending appropriate investigation if
influenza is suspected.
7. Systemic corticosteroids are not recommended, unless indicated for any
other reason.
8. MDI with spacer is preferred for administration of inhaled medication
over nebulization, as nebulization is associated with increased risk of
aerosolization
9. Close monitoring for worsening clinical status is of paramount
importance. Children who have significant distress may be managed in a
HDU setting; those needing intubation and mechanical ventilation or
other organ support should be managed in an ICU. Respiratory Support

51. PREVENTIVE
MEASURES

52. Infection Control Infection prevention and control are important
aspects of the care. Patients suspected of having SARS-CoV-2
infection should be shifted to the isolation facility/ designated COVID-
19 areas from the triage area as soon as possible. The HCP should be
handling the patients after donning appropriate PPE according to their
level of exposure as described .
Appropriate guidelines should be followed by
•Medical mask and direct patient to separate area
•At least 1meter distance between suspected patients and other patients
•Cover nose and mouth during coughing or sneezing with tissue or
flexed elbow for others
•Hand hygiene after contact with respiratory secretions

53. •Medical mask if working within 1-2 metres of the patient
•Place patients in single rooms, or group together those with the same
etiological diagnosis
•Group patients with similar clinical diagnosis and based on
epidemiological risk factors, with a spatial separation
•Use eye protection (face-mask or goggles)
•Limit patient movement within the institution
•Ensure that patients wear medical masks when outside their room
•Cover your mouth and nose with a tissue when coughing or sneezing.
•It may prevent those around you from getting sick

54. • Use PPE (medical mask, eye protection, gloves and gown) when
entering room and remove PPE when leaving
• Use either disposable or dedicated equipment (e.g. stethoscopes,
blood pressure cuffs and thermometers). Instruments should be
disinfected using 70% alcohol swabs or hypochlorite solutions
before and after each use , if these instruments need to be shared.
• Avoid contaminating environmental surfaces that are not directly
related to patient care (e.g. door handles and light switches).
Ensure adequate room ventilation. Avoid movement of patients
or transport. Perform hand hygiene

55. Ensure that healthcare workers performing aerosol-generating
procedures (i.e. open suctioning of respiratory tract, intubation,
bronchoscopy, cardiopulmonary resuscitation) use PPE,
including gloves, long-sleeved gowns, eye protection, and fit-
tested particulate respirators (N95 or equivalent, or higher level
of protection).

56. THANK YOU