RESPIRATORY DISTRESS

IN CHILDREN

Department of Child Health

Faculty of Medicine Universitas Gadjah Mada
Yogyakarta

LEARNING OBJECTIVES
Upon completion of this lecture, you
will be better able to:
Define the most common types of
respiratory emergencies in children
List the steps in assessing a child who is
experiencing respiratory distress
Describe the proper interventions for
selected respiratory emergencies

BREATHING EMERGENCY
2 types of breathing emergencies
*Respiratory distress
*Respiratory arrest
Both conditions are life threatening
Resp. distress is a condition in which
breathing becomes difficult
Resp. arrest occurs when breathing stops
By recognizing resp.distress and taking
immediate action prevent resp.arrest

CAUSES OF RESPIRATORY
EMERGENCIES
Infection
Airway

obstruction

Trauma
Congenital

conditions
Allergic conditions
Neurologic : GBS

SIGNS AND SYMPTOMS OF

RESPIRATORY DISTRESS

Respiratory rate

Increased early, decreased late

NOTE: A slow respiratory rate is an ominous
sign in children

Respiratory observations
Nasal flaring
Retraction

Use of accessory muscles

Coughing

SIGNS & SYMPTOMS

Abnormal Breath Sounds

Wheezing - hallmark sign of lower airway
obstruction
Inspiratory Stridor - hallmark sign of upper
airway obstruction
Decreased, absent, unequal breath sounds
Expiratory Grunting - LATE sign
Color
Pale, flushed & bluish skin color
Cyanosis is a late sign
Level of consciousness
Somnolence/lethargy is a late sign
Increase heart rate

Signs of Respiratory
Distress

Cyanosis is a
late sign of
respiratory
distress

Seesaw
Respiration

CLINICAL MANIFESTATION OF
RESPIRATORY FAILURE
Hypoxia signs & symptoms of respiratory
failure
Diagnosis : Blood gas analysis sometime

not available ..?

Early detection clinical manifestation of
Potential Respiratory Failure

CLINICAL MANIFESTATION

Distress respiration
- Work of breathing
* Tachypneu
* Accessories muscle
* Chest wall retractin
* Nasal flare
- Consciousness & respons to pain
- Weakness of muscle tones
- Cyanotic

CLINICAL MANIFESTATION
Chest wall
Respiratory effort

Again, observe how

much energy the
patient is putting into
breathing

Skin

pallor and diaphoresis

indicate fight or flight
cyanosis indicates
hypoxia (peripheral,
then central)

Retractions &
accessory muscles
Symmetry
Signs of trauma
Dont forget to
look posterior!

Respiratory effort
Head bobbing
Grunting : pulmonary oedema, pneumonia,
HMD, atelectasis
Seesaw respiration inefficient
Stridor : upper airway obstruction
macroglossia, laryngomalacia, vocal cord
paralyse, mass, infection, oedema, foreign
bodies

Respiratory effort

Wheezy on expiration lower airway obstruction

- Bronchial asthma, bronchiolitis,
pulmonary
oedema, foreign bodies

Entry of air breathing

- Compliance of chest wall tidal volume <<
ventilation
Hypoventilation (inadequte) : obstruction,
atelectasis, pneumothorax, pleural effusion,
mucous plug, foreign bodies aspiration

PREDISPOSING
CONDITIONS
Allergies
Asthma
Cardiac

Anomalies
Cystic Fibrosis
Smoking
Immunodeficiencies

EQUIPMENT NEEDS
Basic

First-Aid
Body fluid isolation supplies
Stethoscope
Peak flow meters
Epinephrine 1:1000
Protocols with phone
numbers

TRIAGE AND TRANSPORT

EMERGENT

Signs and symptoms of severe

distress
and impending failure:
Cyanosis, lethargy, or agitation
Absent or severely decreased
breath sounds
Apnea, bradycardia, severe
retractions, or grunting

TRIAGE AND TRANSPORT

URGENT

Student with chronic

condition and/or
is in mild distress
Decreased air movement
(minimal)
Mild retractions

TRIAGE AND TRANSPORT NONURGENT

No

signs or symptoms of
distress
Breath sounds normal
Color normal

Etiology

EPIGLOTTITIS

Life-threatening bacterial infection of

the epiglottis

Most often caused by Haemophilus

influenzae type B

Most commonly seen in children age

2-6 years, however with immunization
compliance, older children and young
adults are more commonly affected

SOFT TISSUE
SWELLING

FOREIGN BODIES
Food
Small

toys
Other objects

LOWER AIRWAY EMERGENCIES

Asthma

Bronchiolitis
Pneumonia

Pneumothorax

ASTHMA
Recurrent and reversible airway
obstruction
Status asthmaticus - Severe airway
obstruction that is life-threatening
Caused by allergens and other factors
Risk factors include prior intubation,
multiple hospital stays, and use of steroids

ASTHMA ASSESSMENT
Respiratory

distress
Severe anxiety
Decreasing level of
consciousness
Tachypnea, tachycardia or
bradypnea, bradycardia with
impending respiratory failure

ASTHMA

EXPECTED OUTCOMES WITH

ASTHMA
Decreased

respiratory

distress
Decreased work of
breathing
Improved air exchange
Decreased anxiety

BRONCHIOLITIS
Viral

disease, affects children

under the age of one year
Respiratory Synctial Virus
(RSV) most common cause
History of runny nose and
cough, poor fluid intake

PNEUMONIA
Pneumonia is an infection of the lower
respiratory tract
CAUSES
Infants and preschool children: viruses
likely
School-aged children: Mycoplasma more
common than viruses
NOTE: TB pneumonia is reappearing

PNEUMONIA

PNEUMOTHORAX
CAUSES
Trauma to chest
Asthma
Pneumonia
Cystic fibrosis

SIGNS AND SYMPTOMS

Dyspnea
Chest

pain
Decreasing breath sounds on
affected side
Agitation

Priorities in Initial Management

of Respiratory Dysfunction
Potential
Probable
Respiratory Failure Respiratory Failure
Keep with caregiver
Separate from
caregiver
Position of comfort
Control airway
Oxygen as tolerated
100 % FiO2
Nothing by mouth
Assist ventilation
Monitor pulse
oximetry
Nothing by mouth
Consider cardiac
Monitor pulse
monitor
oxymetry
Cardiac monitor

FAILURE TO
RECOGNIZE
AND TREAT
RESPIRATORY
DISTRESS CAN
LEAD TO
CARDIAC
FAILURE
AND DEATH!!!

OXYGENATION

Goals and Indications

Goal and Indication

to provide tissue oxygenation at the lowest

inspired FiO2
Indications :
1.

Documented Hypoxemia

2.

Infants & Children : PaO2 < 60 mmHg or SaO2 < 90%

(breathing room air)
Neonates : PaO2 < 50 mmHg or SaO2 < 88%

Acute care situation in which hypoxemia is

suspected :

Shock
Severe trauma
Short term therapy (during certain medical procedures)

Contraindication

No specific contraindications
Nasal cannulas : Nasal Obstruction
Nasopharyngeal catheters : Basal skull
fracture, Maxillofacial trauma & Nasal
obstruction

Hazzard, Precaution,
Complication

Physiologic:
Preterm infants (ROP)
Pulmonary fibrosis
High FiO2 : Absorption atelectasis,
BPD, free radicals

Equipment related
Hypoxemia, Hyperoxemia

Oxygen Therapy Devices

Low
flow
Nasal
cannula
Nasal
catheter

Reservoir

High flow Enclosu

re

Simple mask
Partial
rebreathing
mask
Non
rebreathing
mask

Air
Oxyhood
entraintmen Incubator
t mask
O2 Tent
(Venturi
mask)

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Nasal Canula

Advantages

Easy to use
Disposable
Useful for moderate
O2 need

Disadvantages

Irritating nose and

throat (> 6 L/min)
Low FiO2
Variability in actual
FiO2

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Thank You