Initial Assessment

Respiratory Emergency In
Children And Its Management

Tatty Ermin Setiati

Diponegoro University
Dr. Kariadi Hospital – Semarang
 Introduction (1)
• Respiratory disease  Most frequent medical
emergency, need early intervention to decrease
mortality
• Initial assessment is a very important to
differentiate upper or lower respiratory
emergency
• Pediatric Assessment Triangle (PAT)  an easy
and fast initial assessment to measure the
severity of the disease, and begin inflammatory
treatment
 Introduction (2)

• Specific treatment for airway obstruction after

PAT and ABCDE assessment should be given
• Positioning, suctioning, non-invasive and invasive
airway management, and pharmacologic
treatment (Nebulizer, Antibiotics)
• Oxygen therapy according to the need
 Initial Assessment
• PAT  Differentiate Respiratory Distress,
Respiratory Failure, and Respiratory Arrest

APPEARANCE Conciousness

Core-Skin Temp. Different

Resp. Rate Capillary refill
WORK OF CIRCULATION
BREATHING
Retraction Warm or cool skin
Initial Assessment
Pediatric Assessment Triangle :

Circulation to Skin
Appearance (“Tickles” = TICLS)

• Tonus
• Interactive ness
• Consol ability
• Look/Gaze
• Speech/Cry
Work of Breathings

• Abnormal airway sounds

• Abnormal positioning
• Retractions
• Nasal flaring
 Circulation to Skin

Characteristic of Circulation to Skin

• Pallor
• Mottling
• Cyanosis
• Capillary Refill Time >
Normal capillary refill is < 2 seconds in a warm environment
PAT : Potential Respiratory Failure

Normal Increased

Circulation to Skin

Normal
PAT : Respiratory Failure

Increased
Abnormal or
decreased

Circulation to Skin

Normal or abnormal
Rapid Cardiopulmonary Assessment
Physical Examination – Breathing
• Rate
• Effort / mechanics
• Air entry
• Skin color and temperature
 Respiratory Rate

• In non-critical : RR determine by sitting the child

in his caregiver’s lap and exposing his chest
• RR may be affected by level of activity, fever,
anxiety, and metabolic state
• RR > 60x / minute  abnormal in any age
• RR < 20x / minute in a sick child < 6 years and <
15x / minute in a sick child 7-14 years  RF
 Air Movement and
Abnormal Lung Sound
• Stethoscope at the mid axillary line  clinical
estimation of tidal volume (a volume of air
exchanged with each breath)
• Abnormal breath sound (stridor, wheezing,
expiratory grunting, inspiratory crackles, absent
breath sounds despite  WOB)
 Causes of Poor Air
Movement in Children
• Obstruction of airways : Asthma, Bronchiolitis,
Croups
• Restriction of chest wall movement : Chest wall
injury, severe scoliosis
• Chest wall muscle fatigue :  WOB, Muscular
dystrophy
• Decreased central respiratory drive : Head injury
• Chest injury : Rib fractures, pneumothorax
 Oxygen Saturation (SaO2)
• Pulse oxymetry  excellent tool for assessing a
child’s breathing
• SaO2 > 94%  oxygenation probably good
• SaO2 < 90% in a child on 100% oxygen NR mask
 need assisted ventilation
• Interpret SaO2 together with WOB
 Circulation Heart Rate
• Tachycardia  Early sign of hypoxia or low
perfusion, but may also caused by : fever, anxiety,
pain, excitement
• A trend of increasing or decreasing HR 
worsening hypoxia or shock or improvement after
treatment
• Bradycardia  critical hypoxia and or ischemia
 Circulation Pulse quality
• Normally the brachial pulse is palpable inside or
medial to the biceps (weak / strong)  if strong
probably not hypotensive
• If peripheral pulse not palpated, check the central
pulse (femoral / carotid)
• Absent of a central pulse  CPR
 Skin Temperature
Capillary Refill Time
• The child skin warm near the wrists and ankles -
 good perfusion
• Decreasing perfusion  the line of separation
from cool to warm advances up the limb
• Capillary refill time (N 2-3 seconds), affected by
environmental factors  cool room temp
• Circulation to the skin (skin temp., capillary refill
time, pulse quality)  assessment circulatory
status
 Rapid Cardiopulmonary Assessment
• Physical Examination : Breathing
 Respiratory Arrest

• Absence of effective breathing

• If ventilation and oxygenation are not adequately
support  Cardio respiratory Arrest  a low
probability of survival
 General Non-invasive
Treatment Positioning
 Patient position of comfort  Severe upper
airway obstruction may get into sniffing position
• Severe lower airway obstruction  Tripod posture
• Infants and Toddlers  caregiver’s arms or lap
The sniffing position
The abnormal tripod position

Retractions
 Oxygen

• Treatment with High flow O2  safe

• Give oxygen to any child with clinical signs of
cardiopulmonary distress, or with a history
suggesting possible abnormalities in gas exchange
• When treating children, it is better to overuse
oxygen than to underused it
 Management of Respiratory Failure
• Initially treat with general noninvasive measures
• Upper or lower airway obstruction  specific
treatment
• Altered level of consciousness and signs of  or 
WOB (flaring, grunting, gasping, apnea, cyanosis)
and or SaO2 < 90% on 100% NR O2 mask 
Assisted Ventilation or PPV with BVM ventilation
or ET intubation
• Placement of OG or NG tube (relieve gastric
distension and improve ventilation)
 BVM Ventilation

• The best technique for providing oxygenation and

ventilation during resuscitation and transport
• 60-95% O2 can be given effectively and safely by
choosing a well-fitted mask, connecting with O2
reservoir to an oxygen source at 15L/ minute
 How To Use
Resuscitation Mask
 Possible Complications
BVM Ventilation
• Hypoxia
• Barotraumas
• Gastric Distension
• Emesis and Aspiration
 Endotracheal Intubation (ETT)
• Potential Advantages : Definitive Airway Control,
Decrease Risk of Aspiration, Ease of assisted
ventilation
• Potential Complications : Transient hypoxia,
hypercarbia (due to prolonged intubation
attempts), elevation if intracranial pressure,
mechanical trauma of the airway, misplacement
of the tube (intrabronchial / esophageal
intubation)
 DOPE

• Intubated patient fail to respond (improve color,

SaO2, HR, and appearance)
• Dislodgment  Extubate, BVM, Reintubate
• Obstruction  Suction, Extubate, BVM,
Reintubate
• Pneumothorax  Needle thoracocentesis
• Equipment  Check equipment “ patient-to-tank
 Specific Treatment
For Respiratory Distress
• Determine upper or lower airway obstruction
• Snoring or stridor  upper airway obstruction
• Wheezing  lower airway obstruction
• Upper airway obstruction due the tounge and
mandible falling back/ partially blocking the
pharynx  head tilt / chin-lift or jaw trust
• Maintenance of adequate airway: Placement of
an oropharyngeal airway, nasopharyngeal or ETT
 Croup

• A viral disease with inflammation, edema,

narrowing of the larynx, trachea, and bronchioles
• Affects infants and toddlers
• Cold symptoms several days followed by the
development of a barking cough, stridor, various
level of respiratory distress
• Fever and symptoms are worse at night
 Croup Treatment
• Cool mist (humidified oxygen or nebulized saline)
• Cool water vapor reduced the inflammation and
obstruction
• Pharmacologic treatment: Nebulized epinephrine
(stridor,  WOB, poor air movement, SaO2 < 94%,
altered appearance (need observation in ED for
4 – 6 hours)
 Croup Assisted Ventilation
• Rare case
• Invasive airway management : ETT in a case that
does not respond to BVM ventilation
• Choosing ETT one or two sizes smaller than
normal for age or length (inflammation of the
trachea at the subglottic level)
 Bacterial Upper Airway Infections
• Usually > 12 months
• Appears ill, Toxic, Pain on swallowing, Stridor may
be present, no barking cough
• Examples: Epiglotitis ( H. Influenzae), Tracheitis,
Diphtheria, Peritonsillar Abcess, Retropharyngeal
Abcess
• Treatment : General noninvasive dgn high flow
oxygen and position of comfort. In RF give BVM
consider ETT
 Lower Airway Obstruction
(Bronchiolitis)
• Bronchiolitis  viral lower respiratory infection,
usually in children < 3 years caused by RSV
• Destruction lining of the bronchioles, profuse
secretions, bronchoconstriction
• Assessment shows variable degrees of  WOB,
tachypnea, diffuse wheezing, insp. Crackles,
tachycardia
 Predictors of RF in
Suspected Bronchiolitis
• RR > 60x / minute with  WOB
• RR < 20x / minute with  WOB
• HR > 200x / minute or < 100x / minute
• Poor appearance
• SaO2 < 90% on supplemental O2
 Asthma

• Asthma is a disease of small airway inflammation

leads to bronchoconstriction, mucosal edema,
and profuse secretions
• Severe airway obstruction and V/Q mismatch
• Clinically  Different degrees of tachypnea,
tachycardia, WOB, wheezing on exhalation,
SaO2 normal or low
 Asthma with RF

• Altered appearance
• Exhaustion
• Inability to recline
• Interrupted speech
• Severe retraction
• Decreased Air Movement
 Management
Lower Respiratory Obstruction
• General noninvasive treatment with high flow O2
therapy
• Nebulized Bronchodilators
• In asthma : Assisted Ventilation  PPV required
very high insp. Pressure may caused
pneumothorax / pneumomediastinum
• BVM ventilation or ETT  If RF and failed to
respond to high flow O2 and maximal
bronchodilator therapy
 Summary (1)
• The PAT is a good tool for determining the
effectiveness of gas exchange
• The PAT also identify the critical child in RF who
requires immediate assisted ventilation
• Obtaining RR, listening for air movement, and
SaO2 in concert with PAT
• An initial assessment allow an evaluation of
severity and urgency for treatment, establish
specific treatment for upper / lower airway
obstruction
 Summary (2)
• Specific treatment for croup cool mist and
nebulized epinephrine
• If RF occurred begin with assisted ventilation with
BVM at an age-appropriate rate
• Add spesific treatment for airway obstructed if
indicated
• Performed ETT, and be alert for DOPE in the
intubated child who suddenly worsens / fails to
respond