Lucky for us that they build children as tough as Tonka Trucks. Even so, when they do crash and burn, they tend to do so quickly without much warning, and in the emergency department. Here then to help you out, is a brief guide in making a rapid paediatric respiratory assessment.
effort of breathing.
It takes only a moment to recognise an increase in a child’s effort of breathing
- Respiratory rate: an increase in respiratory rate indicates possible airway disease or metabolic acidosis. Conversely, a slow respiratory rate can be an ominous sign indicating breathing fatigue, cerebral depression or a pre-terminal state.
- Recession: as paediatric patients have a more compliant chest wall (that is, it is not as rigid as an adults) any increased negative pressures generated in the thorax will result in intercostal, sub-costal or sternal recession. Greater recession = greater respiratory distress.
But be careful, as children will tire from an increased effort of breathing much faster than adults, and as they do, these recessions will decrease.
- Stridor: is usually more pronounced in inspiration but may also occur during expiration. It indicates an upper airway obstruction. Always consider the possibility of an inhaled foreign body if you can hear stridor.
- Wheeze: Indicates lower airway narrowing and us usually more pronounced during expiration. Increased wheeze does not = increased respiratory distress. And once again, wheeze will subside as the patient becomes exhausted.
- Grunting: a grunting child is a bad thing. It is an attempt to keep the distal airways open by generating a grunted positive end-expiratory pressure. It is a sign of severe respiratory distress. Grunting may also be seen in children with raised intercrainial pressure.
- Use of accessory muscles: the child may begin using the sternomastoid muscle to assist with breathing. In infants this may lead to bobbing of the head. Looks cute, but isn’t.
- Gasping: a gasping child is really really bad. Get help.
efficacy of breathing.
Next we need to assess how effectual all this increased work of breathing is. Look for the degree of chest excursion (or in infants abdominal excursion) which will give you some idea of how much air is going in and out.
Auscultate for decreased or asymmetrical breath sounds. And while you’re there, listen for any adventitious (out of place) noises.
Pulse oximetry will give you a good indicator of the efficacy of breathing. We want it to be between 97-100% on room air. If it drops below 95%, begin oxygen therapy ASAP.
Pulse oximetry is not very accurate if the patient is shocked or below readings of 70%, but by the time the saturation is dropping this low you will be too busy kaking your uniform to worry about equipment accuracy.
The other thing to remember is children with elevated carboxyhaemaglobin levels (smoke inhalation from a house fire, for example) may have a falsely normal SaO2 and yet be significantly hypoxic.
Increased heart rate may indicate shock, or hypoxia. or fever, or anxiety.
Bradycardia is defined as a heart rate less than 60 or a rapidly falling heart rate with poor systemic perfusion. Bad, bad, bad.
Cardiac compressions will need to be commenced in infants with HR<60 and poor perfusion. You will probably be experiencing a holy crap moment at this time and be hesitant to begin CPR. If in doubt, just do it. *Unnecessary* chest compressions are almost never damaging.
Hypoxia will lead to peripheral vasoconstriction and eventually cyanosis. Once the cyanosis is evident centrally (think Smurf), the child is probably getting close to respiratory arrest.
A child with congenital heart abnormalities may remain cyanosed despite oxygen therapy.
As the child’s respiratory distress evolves, they will become distressed and anxious. This will be followed by increasing drowsiness as fatigue grows. And the best way to assess mentation is to ask the parents.
Which leads us seamlessly to the golden rule of paediatric assessment: always, always listen to the parents. If they are concerned about their child’s condition so should you be.
This information is mostly gleaned from the excellent book Advanced Paediatric Life Support. The practical approach.