approach to respiratory distress in children

“ Pediatric respiratory emergencies” (Nelson, O.P. Ghai,)

Presented By:Dr. Wasim Akram

ModeratorDr. R. S. Sethi (MD, DCH)

Professor & Ex. HOD

Dr. Om Shankar Chaurasiya (MD)Assistant Professor & Head

Dr. G. S. Chaudhary (MD)Lecturer

Dr. Aradhana Kankane (MD)Lecturer

DEPARTMENT OF PAEDIATRICSM. L. B. Medical College, Jhansi

Dr. Anuj Shamsher Sethi (MD)Lecturer

Dr. Sapna Gupta (MD)Lecturer

&

All Resident

Approach to a child with breathing

difficulty

– Synonymous with dyspnea,

– Respiratory distress

Definition

– Clinical state characterized by increased rate & increased

respiratory efforts

OR

– It refers to any type of subjective difficulty in breathing.

Features of respiratory distress

– Tachypnea

– Dyspnoea

– Nasal flaring

– Chest wall retraction

– Added sounds

– Head bobbing

– CVS &CNS manifestation

Grading of acute respiratory

distress

Mild

– Tachypnea

– Dyspnea or shortness of breath

Moderate

– Tachypnea

– Minimal chest wall retaractions

– Flaring of alae nasi

Severe

– Marked tachynea (> 70 breaths/min)

– Apneic episodes/bradypnea/irregular breathing

– Lower chest wall retractions

– Head bobbing (use of sternocleidomastoid muscles)

– Cyanosis

Features of Respiratory failure

– Defined as a paCO2 of >50 or paO2 of <60 while

breathing 40% oxygen

– Clinical definition : Severe respiratory distress with

cardiovascular manifestation and central nervous system

changes

– Cvs changes; marked tachycardia, or bradycardia,

hypotension

– Cns changes: lethargy, somnolence ,seizures and coma

Pathophysiology

Increased resistance due to edema

Pathophysiologic approach to clinical conditions

causing respiratory distress

Etiology Pathophysiology Clinical conditions

Interference with air flow (entry or exit)

Upper airway obstruction

Lower airway obstructionMechanical compressionThoracic wall injuries

Aucte laryngitis, laryngotracheitis, foreign bodyBronchiolitis, asthmaLarge pleural effusion, pneumothoraxFlail chest

Interference with alveolar gasexchange

Failure of alveolar ventilationFailure of diffusion

Pneumonia, pulmonary edemaPneumonia, pulmonary edema

Cardiovascular problems Mechanical or inadequate function Congestive cardiac failure, arrhythmias, myocarditis, pericarditis, Right-to-left shunts

CNS Depression of respiratory centerStimulation of respiratory centerNeuromuscular impairment of respiration

Raised ictAcidosis, salicylate intoxicationAcute paralytic poliomyelitis, Guillain-Barre syndrome, organophosphate poisonin, snake bite, diaphragmatic paralysis

Other Insufficient oxygen supply to tissues and/or increased oxygen demandsCompensation for metabolic acidosis

Sepsis, severe anemia, high altitude, carbon monoxide exposure, smoke inhalation, meth-hemoglobinemiaDiabetic ketoacisosis, acute renal failure

Approach

– Our primary / first approach should be directed to find out the extent of

respiratory and cardiovascular dysfunction and quantify its severity.

– The assessment determines the urgency with which interventions need to be

instituted

– Assessment is aimed to deciding weather airways

– Clear

– Maintable

– Not maintable

– Any audible sound during breathing is suggestive of respiratory airway

obstruction

Initial general assessment

– The goal is to rapidly assess for

– a)airway patency

– B)adequacy of gas exchange

– C)circulatory status

Assessment begins with using Pediatric Assessment

Triangle

Pediatric Assessment Triangle

– A)Appearance ; interaction ,muscle tone, consolability,

look speech, cry

– B)Work of breathing: use of accessory muscle,

bradypnoea

– C)Abnormal skin colour: pallor and cyanosis

Primary general assessment

– It is done by using the assessment pentagon which

includes

Airway

Breathing

Circulation

Disability

Exposure

Airway

Assessment is aimed to decide whether airway is:

CLEAR: open and unobstructed

MAINTAINABLE: maintained by simple measure like

position, suction etc

NOT MAINTAINABLE: needs advance measure like

intubation

ANY AUDIBLE SOUND

Noisy Breathing

– Snoring

– Grunting

– Stridor

– Wheeze

– Ronchi

Stridor

– Coarse high pitched sound typically heard on inspiration.

Stridor

– Inspiratory harsh sound continuously.

Can occur during expiration (intrathoracic) or both phase of respiration.

– Asses the severity

– Drooling of saliva, respiratory distress, unable to swallow, cyanosis

– Common causes:

– Infective: epiglottitis, laryngotracheobronchitis, tracheitis, retropharyngeal abscess (rare)

– Malignancy: tumor compression, papilloma

– Allergic: angioneurotic oedema.

– Congenital: laryngomalacia, laryngeal web, vascular ring,

– Aspiration: foreign body.

– Neuronal: paralysis of vocal cord.

– Investigation

– Blood count; Lateral neck X-ray; flexible bronchoscopy.

Wheeze

– It is a whistling sound heard most often during expiration

indicating lower airway obstruction.

WHEEZE Vs RHONCHI

WHEEZE

– Continuous ,high pitched musical

sound

Heard during expiration, however can

be heard on inspiration

Produced when air flows through

narrowed airways.

RHONCHI

– Subtype of wheeze

– Low pitched, snoring quality,

continuous musical sound

– Implies obstruction of larger

airways by secretions.

Grunting

– Short, low pitched sound heard during expiration produced by

forced expiration against a partially closed epiglottis

it keeps small airway and alveoli open to maintain oxygen

– typically a sign of severe respiratory distress

– Sometimes grunting can be heard in fever and abdominal pain

2)breathing

< 2 months > 60/min

2 months – 1 year > 50/min

1 year – 5 years > 40/min

5 years > 30/min

a) Tachypnea

Breathing contd…..

– 2)BRADYPNOEA: apparently normal respiratory rate

which is inappropriate for the clinical situation

– 3)RETRACTIONS:

– Suprasternal retraction-upper airway obstruction

– Intercostal Retraction – Parenchymal

– Subcostal Retraction-LOWER AIRWAY OBSTRUCTION

Breathing contd…..

– 4)See saw respiration it is seen in neuromuscular

weakness, but can also occur in late stage of severe

respiratory pathology

– 5)pulse oximetry measure % saturation of hb with

oxygen

–

3)Circulation

– PR

– Pulse volume: feeble pulse is the first sign of

compromised perfusion

– CRT

– BP

4)Disability

– Reduced O2 supply to brain affects consciousness muscle

tone and pupillary response

– Early manifestations are anxious look and irritability and

agitation followed by lethargy

5)Exposure

– If indicated it is done to look for evidence of trauma,

petechae and purpura and warming

Categorization of severity of the

clinical condition

– Life threatening conditions

– If at any point during the assessment, a life threatening

condition is identified, appropriate interventions are

instituted, before proceeding with the rest of the

assessment.

Signs of life-threatening illness in a child

with respiratory distress

Airway BreathingCirculationDisabilityExposure

Complete or severe airway obstructionApnea/bradypnea, markedly Increased work of breathingAbsence of detectable pulse, poor perfusion, hypotension, bradycardiaUnresponsivenessSignificant hypothermia or bleeding, petechae/purpura consistent with septic shock

Immediate care

– The goal is to relieve hypoxemia and support respiratory functions until specifictherapy becomes effective.

– This is done by (a) Ensuring an open airway and breathing, (b) Delivering oxygenwithout causing agitation, and (c) Ensuring adequacy of circulation, normaltemperature and hydration.

– Airway patency can be achieved with

a) Proper positioning (extend the neck, pull the mandible forward, to lift thetongue),

b) Cleaning the oropharynx of any secretions (manually if necessary), and

c) Insertion of an oropharyngeal airway.

Ensure breathing if spontaneus normal breathing isabsent/inadequate by:

(a) Assisted ventilation by bag and mask ventilation,

(b) Endotracheal intubation as soon as adequate expertiseand equipment are available,

(c) Providing oxygen. Never delay resuscitation tor lack ofequipment or trained personnel.

Ventilation

– Nasal prongs are the recommended way of providing oxygen to most of the

children

– Infant 5 to 1l/min

– Child 1 to 2 litre

However there is no significant difference in oxygen administration by nasal prongs

or nasopharyngeal catheters

For older children oxygen is best given by face mask

Common oxygen delivery devices and

delivered oxygen concentration (FiO2) at given

flow rates

FiO2 Device (Flow rate/min)

25 – 50 % Nasal cannula (1 – 6 L) Nasal prons

35 – 65 % Simple Face Mask (6 – 12 L)

24 – 60 % Graded ventury mask (graded 4 – 12 L)

60 – 80 % Oxyhood (10 – 15 L)

> 90 % Non rebreathing masks ( 10 – 12 L)

Ensure circulation

– If the patient is in shock, or has signs of severe sepsis, initiate

septic shock protocol. Establish intravenous access and initiate

infusion of a saline bolus (20mg/kg).

– If venous access is not feasible, consider intrasseous infusion in

young children.

– The first dose of an appropriate antibiotic for severe infections,

including severe respiratory infection, must be administered

without delay.

Subsequent management

– If pneumothorax is suspected/detected, proceed with

needle thoracotomy in the second intercostal space

under water seal (using a syringe with saline), followed

by intercostal drainage.

Child with respiratory distress

Approach to a child with breathing difficulty

Pediatric assessment triangle

Pediatric assessment pentagone

Secure airway, start oxygen, ensure breathing, restore circulation

Is there stridor or drooling!Intubation or TracheostomyYes

Is pneumothorax suspected ?Needle thoracotomy intercostal drainageYes

Is there fever ?First dose of antibioticYes

No

No

No

Detailed clinical examination for specific cause

Pneumonia Wheezing UAO

Specific investigationsSpecific management

CNS MetabolicCardiac

Diagnostic evaluation of

respiratory distress

A- History

– Acute, recurrent or chronic and nature of progression

– Associated symptoms: cough, fever, rash, chest pain

– Preceding events : choking, foreign body inhalation

trauma/accident, and exposure of chemical or environmental

irritants.

– Family history exposure to infections, tuberculosis, atopy.

Contd...

B - Physical Examination

– Assess stability of the airways, and ventilatory status.

Respitatory (counted for a full minute), rhythm, depth and work of breathing

Color, level of activity and playfulness.

Chest movements, indrawing of chest wall

Stridor (suggests upper airway obstruction)

Wheezing (suggests lower airway obstruction)

Grunttng (suggests alveolar disease causing loss of functional residua) capacity)

– Tracheal position

– Segmental percussion

– Auscultation: Air entry, type of breath sounds, wheeze, rhonchi, crepitations

– Clubbing, lymphadenopathy

– Assessment of CVS and CNS C Diagnostic Work-up

Contd...

C – Diagnostic work - up

– Direct laryngoscopy, if upper airway obstruction is detected/suspected

– X-ray: cheat, lateral neck, and decubitus views

– Arterial blood gas analysis for hypoxemia (pa02 <60 mm Hg), hypercarbia

(paCO2 >40 mm Hg), (acidosis pH < 7.3), alkalosis (pH > 7.5, and Sa02

monitoring

– Sepsis work-up; Blood counts and culture studies

Neurological illnesses

– Though neurological illnesses can lead to ‘breacthlessness’, it is

unlikely to be the only or chief complaint.

– Whether the neurological illness is acute (head injury, encephalitis,

meningitis), subacute or chronic (Guillian Barre syndrome, spinal

muscular atrophy) there is usually a prominent history or the

initiating/primary events which suggest the possible cause.

Cardiac causes

– Detection of cardiac failure, shock, or cyansosis may

suggest a cardiac cause of breathlesness and should be

managed accordingly

Metabolic causes

– When children manifest with kussmaul breathing a metabolic

cause should be suspected

– In such child patient would have marked tachypnoea with

minimum retraction and chest would be clear

– common causes:

– DKA

– ARF

– Severe dehydration

– Septic shock

Indication for urgent X-ray

– Most of the reparatory distress conditions do not require

urgent x-ray

– Its only indicated if following conditions is suspected

– Pneumothorax

– pleural effusion

– Pneumomediastinum

– Flail chest

Status ofABG

Arterial Blood Gas analysis: single most important lab test for evaluation of respiratory failure.

Respiratory failure: Evaluation

The following parameters are important in evaluation of respiratory failure:

PaO2

PaCO2

Alveolar-Arterial PO2 Gradient

P(A-a)O2 Gradient = PIO2 – PaCO2 / R 713 X

FiO2 - PaCO2X0.8 - PaO2

Laboratory investigations

Arterial BG─ Info on oxygenation and ventilation status─ Difficult to get in some patients

Venous BG─ Ventilation info but not oxygenation─ Venous – good only if obtained from free flowing site – no

tourniquet─ PaCO2 slightly higher in VBG

Capillary – Easiest to obtain

Remember metabolic side (base deficit, [HCO3-])

Alveolar-Arterial O gradient

Normal 5-10 mm of Hg

A sensitive indicator gas exchange.

Useful in differentiating extrapulmonary and pulmonary causes of resp. failure.

Hypoxemia

1. Low PiO2 ~ at high altitude

2. Hypoventilation ~ Normal A-a gradient

3. Low V/Q mismatch ~ A-a gradient

4. R/L shunt ~ A-a gradient

Hypercapnia

Better to be defined by pH rather than pCO2 Metabolic

alkalosis can raise pCO2 without acidosis

Hypoventilation

Severe low V/Q mismatch: major mechanism of hypercapnia in intrinsic lung disease

Can occur with many respiratory diseases, usually as patients get tired

12 yr girl with ascending weakness

Anxious

PR-120, RR-34, SpO2-95, BP-130/90,

Chest: Shallow Respiration, B/L airentry

Flaccid paralysis

pH - 7.30

pCO2 - 60

pO2 - 70

A-a Gradient = 4.73

12 yr girl with ascending weakness

Anxious

PR-120, RR-34, SpO2-88, BP-130/90,

Chest: Shallow Respiration, B/L air entry

Flaccid paralysis pH - 7.30

pCO2 - 60

pO2 - 54

A-a Gradient = 20.98

12 yr girl with ascending weakness

Anxious on 50% oxygen

PR-120, RR-34, SpO2-99, BP-130/90,

Chest: Shallow Respiration, B/L air entry

Flaccid paralysis pH - 7.30

pCO2 - 60

pO2 - 261

A-a Gradient = 20.98

12 year boy

High fever, cough and fast breathing for 5 day

PR-120, RR-42, SpO2-85 %, BP-110/68

Chest: B/L Extensive crept with bronchial breathing, air entry

O2 by NRM (FiO2-90%)- SpO2- 98%

pH - 7.45

pCO2 - 45

pO2 - 90

A-a Gradient = 495.45

12 year boy

High fever, cough and fast breathing for 5 day

PR-120, RR-42, SpO2-85 %, BP-110/68

Chest: B/L Extensive crept with bronchial breathing, air entry

O2 by NRM (FiO2-90%)- SpO2- 98%

pH - 7.45

pCO2 - 32

pO2 - 90

A-a Gradient = 511

V/Q mismatch- Diagnosis

PaO2

A-a gradient is

PaCO2 may or may not be elevated

Hyperoxia Test : Response

2 year boy with TOF

Fever for 2 days

P-120, RR-30, SpO2 on RA-78%,

Chest clear, CVS- Short systolic murmur at base

pH - 7.41

pCO2 - 34

pO2 - 40A-a Gradient = 556.95

R-L shunt: diagnosis

PaO2 is

PaCO2 is usually normal

A-a gradient is