Respiratory Distress in

Children and its

Management
FACULTY OF MEDICINE - BRAWIJAYA UNIVERSITY
MALANG, 01 DECEMBER 2015
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Introduction

Respiratory distress and Respiratory Failure

significant morbidity and mortality in infants and children
Signs and Symptoms may be subtle, particularly in small infants

Decompensation:
May occur rapidly if ventilation/oxygenation is inadequate
May be prevented by prompt recognition and treatment
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Definition

Respiratory Distress:
increased work of breathing, usually precedes respiratory failure

Respiratory Failure:
Occurs when ventilation/oxygenation is not sufficient to meet the
metabolic demands of the tissues
Thus, Oxygenation of the blood is inadequate or carbon dioxide is not
eliminated
Then, lead to cardiopulmonary arrest if not corrected promptly
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Etiology

Common Cause of Respiratory Distress in Infants and Children

May be cause by:
Disease of the airways
Inadequate gas
exchange in the lungs
Poor respiratory efforts
Infection Submersion injury
Epiglottitis Pneumothorax or
Croup hemothorax
Bronchiolitis Pulmonary contusion
Pneumonia Smoke inhalation
Asthma Toxin exposure
Foreign body aspiration Cardiac disease
Allergic reaction Metabolic disease with
Congenital Anomalies acidosis
Neuromuscular disease
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Clinical Presentation

Most Common Signs: Increases in RR and Work of Breathing

Tachypnea/Bradypnea
Signs of increased work of breathing grunting, nasal flare, chest retraction
Signs of poor oxygenation: alteration of mental status, head bobbing,
change in skin colour (pallor, mottling and cyanosis)
Tachycardia/Bradycardia
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Respiratory Distress
Increase RR Production of sounds with respiration
Retraction: intercostal, substernal, (eg. gurgling, stridor, wheezing, ronchi, grunting)
diaphragmatic, or supraclavicular Diaphoresis
Nasal flaring Alteration in mental status
Decrease or absent breath sounds Poor feeding
Changes in TV or MV Inability to speak in sentences
Changes in I : E ratio Skin Changes: pallor, mottling, cyanosis,
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Pathophysiology

The adequacy of respiration depends on:

Effective gas exchange of CO2 and O2
Ability to move an adequate volume of gas in and out of the airways

Physiology of Respiration in infants and children:

Generally breath with minimal effort
Primarily used for ventilation: diaphragm and abdominal musculature
Tidal Volume (TV): 6-8 ml/kgBW
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Pathophysiology.
Physiology of Respiration in infants and children:
Tidal Volume (TV): 6-8 ml/kgBW
Minute Ventilation (MV) = Respiratory Rate (RR) x TV

Pathology
If TV is decrease (eg. airway obstruction) COMPENSATE by:
Increasing RR increasing Work of Breathing
If still INSUFFICIENT for adequate O2 exchange:
DECOMPENSATED RESPIRATORY FAILURE :
may Lead to: acidosis, myocardial dysfunction, shock
May progress to COMPLETE CARDIOPULMONARY ARREST
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Respiratory Distress: Children more prone
than adults ?

Comparison of Respiratory Systems in Children and Adults

The head in children is proportionally larger and has less muscular support
The tongue in children is larger in relation to the mouth, is poorly controlled
The airway diameter is smaller in children and collapse easily
The larynx is higher and more anterior in children and the epiglottis is floppy
The narrowest part of the airway in children: at the cricoid ring, adults: at vocal cords
The trachea in children is short
The major muscle of respiration in children is the diaphragm
Children have less pulmonary reserve and higher metabolic demands
Normal respiratory rates are higher in children and vary by age
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Differential Diagnosis

Pulmonary abnormalities
Cardiovascular abnormalities
Metabolic system abnormalities
CNS abnormalities

It is also important to make an initial differentiation between upper and lower airway disease
based on the presence or absence of stridor, ronchi, rales, or wheezes on examination
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Evaluation

History
Physical Examination
Investigations: Laboratory Tests, Imaging Studies
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Evaluation: History

A brief history should be taken while physical examination proceeds and initial treatment is begun

Respiratory Distress: Questions

1. For how long has this problem been occuring?
Has a similar problem ever occurred before?
1. Did the problem begin while the child was eating or playing?
2. Has the child had any recent infections?
3. Are any members of the household ill?
4. Is the child taking any medications?
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Evaluation: Physical Examination (1)

Before a complete assessment can proceed, CRITICAL INTERVENTIONS

that may change childrens clinical status SHOULD BE MADE.
1. Children should be placed in a position of comfort
2. Oxygen should be applied
3. Ventilation and oxygenation should be assessed
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Evaluation: Physical Examination (2)

Determine Respiratory State, CVS State and CNS State

Respiratory State: CVS State:

Respiratory Rate (RR) Pulse: rate, volume
Depth of respiration Perfussion: Capillary refill time
Effort of breathing/work of breathing Blood Pressure
Respiratory sounds: breath sound, Temperature
abnormal respiratory sounds
O2 saturation
O2 Saturation

CNS state: sensorium irritable, drowsy, letargis

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Respiratory State: Respiratory Rate

RR should be determined for a periode at least 60 seconds

Counts: abdominal excursions (in infant); chest excursions (in children)
Faster than normal (tachypnea)
Slower than normal (bradypnea)
Absent (apnea)
Neonates:
Periodic breathing (normal variant): regular respiration alternating with irregular breathing
True apnea: cessation of respiration > 20 second accompanied by bradycardia, change in
skin colour or tone or altered level of consciousness
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Vital Sign by Age
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Count of Breath
per minute
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Respiratory State: Depth of respiration

Should be noted Deep, gasping or shallow

Rapid, shallow respiration may not provide enough
inspiratory time for adequate gas exchange
HR may also reflect respiratory compromise
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Depth of respiration example: Rapid and Deep Breathing

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Respiratory State: Work of Breathing

Sign of increasing work of breathing:

The accessory respiratory muscles of respiration are used retraction present (intercostal,
subcostal, supraclavicular)
Breathing is abnormally noisy
Nasal flaring is seen
In young infant can also be manifested by feeding difficulties and diaphoresis

Work of breathing:
Normal State, consumes 2-3% of total oxygen consumption
Increase State: Severe respiratory distress, increase to 50% of total oxygen consumption
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Chest Indrawing/
Chest Retraction
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Nasal Flaring
and
Grunting
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Respiratory State: Respiratory Sound

Childrenbreath sounds usually well transmitted across the thorax (thin

chest wall)
It is common to hear upper airway noises when auscultating the lungs
Breath sounds: axillae bases apex
The absence of breath sounds may be an ominous sign
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Respiratory Sound: Abnormal Sounds

Abnormal Respiratory Sound caused by:

Turbulent air passing through a narrowed airway
Resistant to flow through a hollow tube

The
smaller the airway, the greater the resistant to flow generated by
small changes in the radius, as with, eg:
Edema
Secretions
Foreign bodies
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Abnormal respiratory sounds

The nature of the sounds depend on the narrowing airway location:

1. Upper airway: gurgling1, snoring2, stridor3
2. Lower airway: rales4, ronchi5 and wheezing6
Grunting7:
Turbulent air coming intact with a partially closed glottis
Generating their own partial obstruction of the upper airway and
positive end-expiratory pressure to increase oxygenation

If abnormal sounds (-) and Breath Sound (-) or decreased Upper or Lower Airways
may be totally obstructed
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Abnormal Sound of Respiratory

Stridor Adventitious Breath Sounds

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Head Bobbing
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Evaluation: Investigations

Laboratory tests
Complete blood count WBC increase in infection and inflammation,
eosinophils increase in allergy, asthma, and parasitic infection
Differential blood cell counts shift to the left: bacterial infection; shift to
the right: viral infection
Blood cultures help in the diagnosis of infections
Oxygen Saturation
Blood gas analysis impending respiratory failure
Imaging studies:
Chest X-ray
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Oxygen Saturation

Non invasive measure of difference in light absorption between

oxygenated and de-oxygenated blood
Allow pulse oxymeter to settle before reading
Compare reading with the colour/clinical state of child
If poor signal, do not believe result try warmer, better perfused digit
or ear lobe
Inaccurate at extremes of range
 Chest X-ray 31

Only order CXR when you suspect it will provide information that will change your management,
eg. Where diagnosis unclear or child very ill
Stridor Asthma
CXR or lateral neck X-ray not required routinely Only when:
and never if suspect epiglottitis Unilateral signs that persist after initial
treatment
Acute severe asthma, to exclude
pneumothorax or lobar collapse
Pneumonia Foreign body
If the diagnosis is clinically apparent, children Mandatory. Ideally inspiratory and expiratory
do not routinely need CXR films. Otherwise, lying on affected side to
Only required if child tachypneic and/or demonstrate that lobe does not deflate
febrile and diagnosis uncertain

Bronchiolitis Hemoptysis
Rarely need CXR. Necessary if sudden If significant blood loss
deterioration to exclude pneumothorax or lobar
collapse
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Management
STEP MANAGEMENT
1. Targeted history to identify etiology
2. Targeted history to identify hypoxia or shock
3. Targeted history of fever suggests infective cause for respiratory distress
4. Perform the rapid cardiopulmonary cerebral assessment
5. Management

General Management Etiology Management

1. Position - Aspiration - Asthma
2. Oxygen administration - Pneumonia - Septic/cardiogenic shock
3. Monitoring - Bronchiolitis - Etc.
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Management: (1) Position

Children in Respiratory Distress, who:

Alert and breathing spontaneously position of comfort
Small infant (incapable of positioning themselves) upright (not to flex/extend the neck)
Children and their caregiver kept together to reduce anxiety
Unconscious:
Sniffing Position neck slightly and head extended (placing towel under occiput of the
head or shoulder)
Manouver head tilt/chin lift/jaw thrust
Airway adjuncts nasopharyngeal/oropharyngeal airways
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Proper Positioning

Unconscious Child
Alert and Breathing spontaneously Child
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Management: (2) Oxygen Administration

Oxygen should be delivered by any method tolerated by children

Methods:
Nasal prongs
Oxygen mask
Face tent
Assissted ventilalation with bag-valve-mask devices or
endotracheal intubation
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Methods of Oxygen Administration

Nasal Prong/Canule
Oxygen Tent
Oxygen Mask
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Management: (3) Monitoring

All should be carefully monitored by:

Clinical assessment
Assissted devices: pulse oxymetry, cardiac and respiratory monitor

Frequent assessment are critical to ensure a good outcome

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Etiology Management
Management Based on Etiology

Aspiration Pneumonia Brochiolitis

General management General Management General Management
Treat shock Treat shock Treat Shock
Antibiotics Nebulization (Epinephrine,
Hypertonic Saline)

Asthma Septic/Cardiogenic Shock

General Management General Management
Treat shock Treat shock
Nebulization (2 agonist, costicosteroid) Inotrope infusion
Aminophylin, etc. antibiotics
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Prognosis

Respiratory Failure and resulting cardiopulmonary arrest are preventable

Need to:
carefully assessed
make appropriate critical intervention
Careful attention to ventilation and oxygenation of patients usually
results in a good outcome
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Lets make short review again
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References

1. Burbulys DB, 2014 Respiratory Distress. In Berkowitz a Pediatrics Primary

Care Approach, 5th Ed. American Academy of Pediatrics. Saunders
Company: USA.
2. Crisp S., Rainbow J. 2013. Emergencies in Paediatrics and Neonatology.
Oxford University Press:UK
3. Shantanam I, 2013. Pediatric Emergency Course. Jaypee Brother
Publisher: India.
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