how to pick the sick….really quick.

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.

heart rate.

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.

skin colour.

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.

5 Responses to “paediatric respiratory assessment.”

  1. Hi just found this page with Google and loved it, v helpful. Am a NICU nurse and can do vented 23wkrs with my eyes shut but when it comes to my 14month son, I have no clue! Ta for the paeds reminders.

  2. Terrific website, thanks. I’m the Manager of Education for St. Mary’s Healthcare System for Children in New York City. St. Mary’s specializes in children with chronic illness and/or disability. I was looking for a no-nonsense approach to a pediatric respiratory assessment for nurses, and I have now found it. Thank you again :-) Kathleen

  3. great website, thanks. was googling looking for answers about my son’s breathing. He’s 8 and said that his chest hurt when he exhaled, hmmmm. Only mild asthma and usually only when he has a cold. Had 2 slices of hawaiin pizza but has never bothered him previously. Gave him ventolin, checked his pulse and breathing rate which is very slow, only about 16 per minute. He is usually holding his breath in for a while before exhaling as he says it doesnt hurt as much. Will see a gp tomorrow. Thanks again for your no crap info. Cheers robyn :)

  4. i am a registered nurse (adults) but have got 2 small children, today i took my son to the out of hours emergency G.P. My son has had a previous wheeze (viral) so luckily i have some ventolin at home (my daughter has asthma, so i have had experience) He has recieved 3 doses of ventolin in 10 hours so i asked for himt to be seen i was sent away with antibiotics and told to use the inhaler as i felt necessary!!! how often should that be i asked?as you feel you should. so now i’m here looking at these guidelines thinking at least i have some ammo should he not improve. Thank you for this site i feel more confident in my abilities now.

  5. Just discovered your website – Brilliant! I am an Enrolled Nurse volunteering in Viet Nam & at times I am so out of my depth (let alone Scope of Practice!). Unfortunately, i am the only one in this new charity with any medical background, so, until someone else comes along I am it!!! have been desperately looking for some resources & I think I may have found one! Cheers, Mai.

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