ACUTE RESPIRATORY

DISTRESS IN CHILDREN-
DIAGNOSTIC EVALUATION
DR SAIRAM RALLABANDI,
SECOND YEAR POST GRADUATE,
SMC , VJA.
LEARNING OBJECTIVES

• 1. Approach to respiratory distress

using a stepwise structured history.
• 2. Classification of breathing patterns
to determine the physiological status.
PEDIATRIC AIRWAY VS ADULT AIRWAY
• The pediatric airway is narrower than the adult.
• Consequently, pathological processes that cause narrowing of the airway could result in an
exponential increase in airway resistance increasing the risk of hypoxia.
• In addition, respiratory efforts generated to counter airway resistance, increases turbulence of air
flow further worsening hypoxia.
• Crying or agitation can also aggravate hypoxia.

*To avoid precipitating hypoxia consequent to crying or agitation, children with respiratory distress or
impending respiratory failure should not be separated from their mother.
EVALUATION OF RESPIRATORY RATE & WORK
OF BREATHING

*Tidal volume or the volume of each breath per kilogram of body weight remains fairly
constant throughout life
*MV = TV × RR
CLASSIFICATION OF ABNORMAL RESPIRATION
• ●● Effortless tachypnea.
• ●● Respiratory distress.
• ●● Respiratory distress with features of
respiratory failure.
• ●● Relative bradypnea.
• ●● Apnea.
EFFORTLESS TACHYPNEA
• Increased respiratory rates without increased work of breathing.
• Hypoxia and shock due to various etiologies result in decreased availability of
oxygen at the cellular level.
• Anerobic metabolism supervenes, leading to lactic acidosis.
• The latter triggers the respiratory centers.
• Respiratory rates increase in an attempt to maintain a normal pH.

*Lung parenchyma is normal in children presenting with effortless tachypnea

RESPIRATORY DISTRESS
• Tachypnea and increased work of breathing.

*Abnormal lungs due to alveolar edema, pneumonia, bronchospasm,

bronchiolitis, etc. result in recruitment of the accessory muscles of
respiration.
*Retractions of the intercostal, subcostal, sternal and supraclavicular
muscles indicate that the underlying lung is diseased.
*In young infants, severe respiratory compromise can result in nasal flare
and head bobbing with each breath.
RESPIRATORY FAILURE
• Clinical state that requires intervention to prevent respiratory or cardiac arrest.
• Recognition of respiratory failure is based on the clinical features and not on blood gas analysis.
• ●● Inadequate respiratory rate or gasping respiration.
• ●● Inadequate effort or chest excursion with diminished peripheral breath sounds.
• ●● Grunting respirations.
• ●● Abdominal or see-saw respiration.
• ●● Decreased level of consciousness or response to pain; poor skeletal muscle tone or cyanosis.
*Due to high metabolic rates, the child has a higher oxygen demand than the adult. Oxygen consumption is 6–8 mL/kg in
children as compared to 3–4 mL/kg in the adults.
*Consequently, when a child develops alveolar hypoventilation or apnea, hypoxemia develops more rapidly.
RELATIVE BRADYPNEA
• Slowing of respiratory rates indicate respiratory muscle fatigue.
• Inability of young infants to sustain prolonged respiratory distress, result in early fatigue and
respiratory failure.
• Slowing of respiratory rates with reduced work of breathing is not as easy to identify as respiratory
distress.
• The profound fall in mental status, hypotonia and poor color suggest that the child is slipping into
respiratory failure.

*The normal respiratory rate for age', in association with profound alteration of mental status, grunt,
abdominal respirations, cyanosis, tachycardia, bradycardia and shock indicate that respiration is
failing.
*Unless recognized and managed in the ED, respiratory arrest may supervene.
STEP 1
TARGETED HISTORY TO IDENTIFY ETIOLOGY
*Duration of respiratory distress offers many clues to the possible etiology.
• Hours (hyperacute) suggests that aspiration could be the cause of respiratory distress.
• Days (acute) indicates that the presence of an infective lung disease, e.g. pneumonia, empyema,
bronchiolitis etc.
• Respiratory distress in months or since birth (chronic) implies that the possible etiology is cardiac
or less commonly chronic lung disease.
• Episodic breathlessness with symptom-free periods, points towards asthma. Rarely, recurrent
aspiration syndromes can present with episodic respiratory distress. Unlike asthmatic children, the
latter is often associated with failure to thrive or developmental delay.
• Acute first episode of respiratory distress, associated with history of fever and non-lung foci of
sepsis suggests the possibility of acute cardiogenic pulmonary edema.
STEP 2
TARGETED HISTORY TO IDENTIFY HYPOXIA OR
SHOCK.
• Ask mother, for history suggestive of altered mental status in
any child presenting with respiratory distress.
• If she denies fall in mental status, the child is unlikely to have
respiratory failure.
• History of talking or taking feeds could be misleading.
• Mother is the best judge. If she reports: ‘Not as usual’,
lethargic, ‘sleepier than usual’, recognize early hypoxia or
shock.
STEP 3
TARGETED HISTORY OF FEVER SUGGESTS
INFECTIVE CAUSES FOR RESPIRATORY
DISTRESS.

• Example: Pneumonia, bronchiolitis

STEP 4
PERFORM THE RAPID CARDIOPULMONARY
CEREBRAL ASSESSMENT.
a. Does this child have respiratory distress or respiratory failure?
*Classifying whether respiratory distress or respiratory failure whilst taking history on arrival helps
initiate bag valve-mask ventilation if needed.
b. Does this child have shock or not?
*It is not uncommon for shock to coexist in hypoxic children.
*Early and aggressive fluid resuscitation ofshock is mandatory for early resolution of hypoxia.
*Respiratory distress and shock viz cardiogenic shock may mimic asthma or bronchiolitis!
*When respiratory distress and shock are noted in children presenting with ‘non-lung etiologies’ such
as scorpion sting, septic foci, acute diarrhea, submersion injury, hypoxic ischemic encephalopathies,
etc. suspect the presence of pulmonary edema due to cardiac dysfunction or acute lung injury.
C. Does this child have cardiogenic shock or not?
*Muffled heart sounds, gallop, relative bradycardia, low BP, low MAP are
signs of myocardial dysfunction.
*Examination of the liver span in a child with respiratory distress often
provides valuable information on cardiac function.
*Since a pushed down liver could erroneously suggest hepatomegaly,
emphasis is laid in assessment of the span.
*Assessment of the liver span during the cardiopulmonary assessment helps
to find out whether respiratory distress is due to respiratory or cardiac
causes.
*Chronic respiratory distress associated with increased liver span, points
towards a structural heart disease with cardiac failure.
*Acute respiratory distress with increased liver span could occur due to
cardiac failure or cardiogenic shock secondary to myocarditis or severe sepsis.
D. Does this child have severe hypoxia or
shock as evidenced by features of non-
convulsive status epilepticus?
*Nystagmus, conjugate deviation or eyelid
twitch or a combination of signs, which signal
severe hypoxia in young children and infants
with respiratory distress indicate NCSE (avoid
treating with anticonvulsants)
MANAGEMENT BASED ON ETIOLOGY

• Aspiration
• Hyperacute respiratory distress:
Treatment is focused on correction of
hypoxia and shock
• Pneumonia
• Acute first episode of breathlessness
with high grade fever.
• Whilst correcting hypoxia and shock,
administer the first dose of antibiotic.
• Bronchiolitis
• Acute first episode breathlessness with wheeze in young healthy
infants, presenting with low-grade fever and prodrome is suggestive
of bronchiolitis.
• ●● Provide O2 using the JR circuit.
• ●● Correct shock if identified (usually 20–30 mL/kg may be needed
unless the infant shows signs of SIRS with septic shock).
• ●● Nebulize with hypertonic saline.
• ●● Epinephrine nebulization 0.1 mL/kg (1:1,000) in 4 mL of normal
saline has also been recommended.
*Monitor ECG for cardiac arrhythmias.
Septic Cardiogenic Shock
First episode respiratory distress with or without
hepatomegaly due to acute pulmonary edema.
• Provide oxygen through flow inflating ventilation
device.
• ●● Administer smaller aliquots of fluids.
• ●● Initiate early inotrope infusion and perform early
intubation if needed.
• ●● Administer 1st dose of antibiotic
• Asthma
• Episodic breathlessness in healthy children more
than 2 years of age is probably asthma.
• Grade severity and implement treatment as per
asthma management guidelines.

*Caution: Avoid treating all children with respiratory

distress and wheeze as asthma with salbutamol
nebulisation. Acute cardiogenic or noncardiogenic
pulmonary edema could mimic asthma