Respiratory Distress

National Pediatric Nighttime Curriculum

Written by Liane Campbell, MD

Lucile Packard Children’s Hospital, Stanford University

Review the initial assessment of patient in respiratory distress

Review management of specific causes of respiratory distressUpper airway obstructionLower airway obstructionLung tissue diseaseDisordered control of breathing

Learning Objectives

During a busy night, you get the following page:

FYI: Sally, a 2 year old with PNA had a desat to 88% while on 2L NC.

What do you do next? What initial management steps would you take?

How do you initially assess a patient in respiratory distress?

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

Initial Assesment

History and Physical Exam

History Trauma Change in voice Onset of symptoms Associated symptoms Exposures Underlying medical

conditions

Physical Exam Mental status Position of comfort Nasal flaring Accessory muscle use Respiratory rate and

pattern Auscultation for abnormal

breath sounds

What initial studies would you get for a patient in respiratory distress?

Pulse oximetry May be difficult in agitated patient May be falsely decreased in very anemic patients

Imaging Chest X Ray

Consider in patients with focal lung findings or respiratory distress of a unknown etiology

Soft tissue radiograph of lateral neck May identify a retropharyngeal abscess or radiopaque

foreign body Labs

ABG/VBG Chemistry: calculate anion gap Urine toxicology and glucose if patient has altered

mental status

Initial studies

What are some examples of life threatening conditions?

Complete upper airway obstruction No effective air movement, speech or cough

Respiratory failure Pallor or cyanosis, altered mental status, tachypnea,

bradypnea, apnea Tension pneumothorax

Absent breath sounds on affected side, tracheal deviation and compromised perfusion

Pulmonary embolism Chest pain, tachycardia, tachypnea

Cardiac tamponade Apnea, tachycardia, hypotension, respiratory distress

Life threatening conditions

Specific Causes of Respiratory Distress Upper airway obstruction Lower airway obstruction Lung tissue disease Disordered control of breathing

Case 1

8 month old ex-FT girl with 2-3 days of nasal congestion, cough, and sneezing, was RSV+ on admission with mild work of breathing requiring 0.5L O2. As you’re watching the monitors on Short Stay with the nurse at 2am, she’s now 84-89%.

What is your diagnosis?

What are your next steps?

Case 2

4 year old boy admitted to GI service for monitoring and serial AXRs because he ingested a sharp object. He’s tucked in for the night with an AM AXR ordered. But after his dinner, he suddenly becomes stridulous, and starts crying and drooling. Parents just left the room to get dinner.

What is your initial evaluation/management?

Case 3

3 year old girl with 2 days of fever, noisy breathing and loud barking cough tonight. In the ED 3 hrs ago, got one racemic epi neb and a dose of oral steroids. Admitted for observation.

Nurse calls now because his breathing is getting noisy at rest and he’s coughing. No respiratory distress. How do you manage him overnight?

Jonathan is a 2 year old with Pompe’s disease who is BiPAP dependent overnight with settings of 18/5 and a backup rate of 18. Over the past few hours, he has had an increase in his oxygen requirement from an FiO2 of 21 to 40% and has spiked to 39.2.

What steps do you take to evaluate and manage him overnight?

Case 4

Causes: foreign body, tissue edema, trauma, viral infection, intubation, 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

Upper Airway Obstruction

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, magnesium sulfate), heliox

Lower Airway Obstruction

Etiologies of lung tissue disease Infectious pneumonia Aspiration pneumonitis Non-cardiogenic pulmonary edema (ARDS) Cardiogenic pulmonary edema (ARDS)

Consider positive expiratory pressure (CPAP, BiPAP or mechanical ventilation with PEEP) if hypoxemia is refractory to high concentrations of oxygen

Lung Tissue Disease

Abnormal respiratory pattern produces inadequate minute ventilation

Altered level of consciousness Elevated intracranial pressure

Cushing’s triad Poisoning or drug overdose

Administer specific antidote if available Hyperammonemia Metabolic acidosis

Neuromuscular disease Restrictive lung disease => atelectasis, chronic pulmonary

insufficiency, respiratory failure Support oxygenation and ventilation while treating the

underlying problem

Disordered Control of Breathing

The initial assessment of a patient in respiratory distress should be rapid and focused on quickly determining the severity of respiratory distress and need for emergent interventions

Specific causes of respiratory distress can be categorized as upper and lower airway obstruction, lung tissue disease and disordered control of breathing and require specific interventions

Take Home Points

Questions

1. Which of the following are NOT symptoms of an upper airway obstruction?

1. Gagging

2. Changes in voice quality

3. Noisy inspiration (stridor)

4. No audible speech, crying or cough

5. Crackles on auscultation

(answers are in speaker’s notes)

2. During a busy evening shift, you admit a 2 year old male who presents with a barking cough, stridor at rest, and moderate retractions. He is alert and oriented and calms with his mother. His vital signs on admission are temperature 38.5, heart rate 165, respiratory rate 65, blood pressure 90/45 and oxygen saturation of 92%. Which of the following should NOT be included in your initial management?

1. Oxygen

2. Keeping the patient NPO

3. Nebulized racemic epinephrine

4. Dexamethasone

5. Nebulized albuterol

3. What is the first medication that should be given to a patient with anaphylaxis and respiratory distress?1. Diphenhydramine

2. Ranitidine

3. Solumedrol

4. Epinephrine

5. Albuterol

4. While on call in January, you admit a 10 month old prev. healthy female who presents with cough, nasal congestion and fevers of 2 days and 1 day of tachypnea. She is fully immunized. On exam, her temp is 39.2, HR 130, RR 55 and O2 sat 93% on RA. Her lung exam reveals diffuse crackles and wheezes at the bases as well as moderate subcostal retractions, but no flaring, grunting or head bobbing. Which diagnostic test is most likely to demonstrate the cause of her respiratory distress?

1. Chest X Ray

2. Nasopharyngeal swab for viral panel

3. Blood culture

4. Urinalysis

5. CBC with differential

5. When performing an initial assessment of a patient in respiratory distress, the history should include all of the following elements EXCEPT: 1. Change in the quality of voice

2. Underlying medical conditions

3. Recent episodes of trauma

4. Previous episodes of respiratory distress

5. Detailed family history

Albisett, M. Pathogenesis and clinical manifestations of venous thrombosis and thromboembolism in infants and children. June 2010. UpToDate.

Bailey, P. Oxygen delivery systems for infants, children and adults. May 2010. UpToDate.

Ralston, M.et. al. Pediatric Advanced Life Support Provider Manual. 2006. American Heart Association.

Sherman, S.C. and Schindlbeck, M. When is venous blood gas analysis enough? Emerg Med 38(12):44-48, 2006

Simons, F. Anaphylaxis: Rapid recognition and treatment. September 2010. UpToDate.

Weiner, D. Emergent evaluation of acute respiratory distress in children. May 2010. UpToDate.

References