Posted in Pediatrics

Respiratory distress in children is of special concern due to multiple factors, but if I had to sum it up into one…it’s this: children are not simply small adults. There are many differences between pediatric and adult respiratory anatomy and physiology which puts kids at higher risk for respiratory distress and respiratory failure. In fact, most causes of cardiac arrest in children are due to precipitating respiratory arrest. In this article we’ll look at some of the common causes of respiratory distress in the pediatric population. 

What is respiratory distress?

Respiratory distress is present when ventilation or oxygenation (or both) do not meet the body’s metabolic oxygen demands. It is typically characterized by signs of increased work of breathing such as accessory muscle use, nasal flaring, retractions, grunting, head bobbing, and tachypnea (though bradypnea may be present as the patient gets closer to respiratory arrest). Respiratory arrest, on the other hand, is present when the patient is no longer breathing, or when breathing is so dysfunctional that it cannot meet the body’s demands (such as with agonal breathing).

Differences between pediatric and adult airways

There are significant differences between pediatric and adult airways, including the size (it’s much smaller in diameter and length), its position (the larynx is located more toward the anterior than in adults) and its shape (the airway narrows at the cricoid ring whereas in adults its more narrow at the vocal cords). The other big difference is the size of the tongue which is relatively larger in the oropharynx than in an adult, making occlusion more likely and intubation more difficult.

The main issue that you’ll likely be dealing with is the short, narrow airway. Imagine a newborn having an average internal tracheal diameter of 2.5mm…there’s not much room there for edema or obstruction of any magnitude. Even a small obstruction will greatly increase airflow resistance, putting the patient at risk for respiratory distress. Of course, as the child ages, the tracheal diameter increases. By age 1 it’s about 4.5mm, by age 6 it’s closer to 6mm, and by 14 years it is at or approaching adult sizes of approximately 8mm diameter.

Pediatric patients also have physiological differences that make them more prone to respiratory distress and respiratory failure. For starters, infants have significantly higher oxygen consumption than do adults with one study showing an infant’s demands at 6mL/kg/min versus just 3ml/kg/min in an adult. Further, infants have lower functional residual capacity (the amount of air left in the lungs after exhalation), so even brief periods of apnea can cause desaturation to occur quickly. Also, from my observation of pediatric patients, they tend to decompensate quickly. They can compensate quite well but for shorter periods of time, and when they crump, they crump hard. So any pediatric respiratory distress should be viewed as an urgent situation and requires close monitoring along with expert intervention.

Common causes of respiratory distress in children

There are many causes of respiratory distress in children, ranging from acute conditions such as upper airway obstruction to chronic conditions such as cystic fibrosis and sickle cell disease. Today we’ll be looking at some acute conditions as these can escalate quickly and pose significant danger to our young patients. Note that traumatic injury can cause respiratory failure as well, but today we’ll be focusing on medical causes. Some acute and life-threatening respiratory conditions include: 

  • Upper airway obstruction: Airway obstruction can be from a foreign body (kids seem to put everything into their mouths), airway closure from anaphylaxis and epiglottitis, or even laryngospasm secondary to hypocalcemia. Again, any kind of airway edema or inflammation is going to be MUCH more serious in a child or infant because the airways are significantly more narrow than an adult airway. Even a small amount of swelling can greatly increase airflow resistance, so kids don’t have to have a lot of swelling to get into a lot of trouble very quickly. 
  • Asthma causes bronchospasm and accumulation of mucus, both which narrow the airways making it difficult for the patient to ventilate adequately. 
  • Respiratory tract infections can lead to respiratory distress such as with
    • epiglottitis and croup (both of which adversely affect the upper airway leading to obstruction)
    • pneumonia
    • bronchiolitis (which is often caused by RSV but can also be due to influenza)
    • COVID-19
    • infection of the trachea called tracheitis
  • Other times the cause of the respiratory compromise is related to a cardiovascular condition such as congenital heart disease. Pediatric patients with right-to-left shunting have decreased amounts of oxygen entering systemic circulation which leads to hypoxia. In a right-to-left shunt, deoxygenated blood bypasses the gas-exchange process in the lungs and is sent into systemic circulation, greatly reducing oxygen delivery to the tissues. Congenital conditions which result in right-to-left shunting include tetralogy of Fallot, transposition of the great arteries, pulmonary atresia and Eisenmenger syndrome. As a side note, shunting can also occur in pneumonia, atelectasis and with pulmonary arteriovenous malformations.
  • Physiologic conditions that can lead to respiratory distress include any abnormality of the chest wall and thoracic cavity that restricts lung expansion. This can include pectus excavatum which is a concave depression in the chest wall, asphyxiating thoracic dystrophy, and even in severe cases of kyphosis or scoliosis. So if you have a patient with one of these conditions, you want to be acutely aware of their respiratory status at all times, especially if they come in with something like an URI, asthma or pneumonia. 
  • Pediatric patients with chronic respiratory conditions such as bronchopulmonary dysplasia and cystic fibrosis are at increased risk for respiratory compromise.
  • In addition, any condition that affects the patient’s neuromuscular status can put them at risk for infection and occlusion due to weakened musculature. These include muscular dystrophy and spinal muscular atrophy among others.

Nursing assessments for pediatric respiratory distress

Your assessment of the child will generally begin with an overall observation. If the child is alert, keenly responsive to the environment and playful, it’s not likely he is in respiratory distress. The child who is listless or even agitated deserves a closer look. With that said, a child who is crying is a child who is breathing! 

Next, observe the child’s work of breathing. Are they tachypneic? Tachypnea varies by age, as do most other pediatric vital signs. For example, a newborn can have a rate of 52, which is completely normal, but that would be considered tachypnea in an 18 month old. As the child gets older, the rate will more closely resemble that of an adult. Because reference ranges can vary widely, please defer to the resource your school or facility is utilizing. However, according to a 2011 study, Fleming, Thompson, Stevens et al, defined the normal range for various age groups as:

  • 0-3 months 34-57 bpm
  • 3 to < 6 months 33-55 bpm
  • 6 to < 9 months 31-52 bpm
  • 9 to < 12 months 30 -50 bpm
  • 12 to < 18 months 28-46 bpm
  • 18 to < 24 months 25-40 bpm
  • 2 to < 3 yrs 22-34 bpm
  • 3 to < 4 yrs 21-29 bpm
  • 4 to < 6 yrs 20-27 bpm
  • 6 to <8 yrs 1 -24 bpm
  • 8 to < 12 yrs 16-22 bpm
  • 12 to < 15 yrs 15-21 bpm
  • 15 to 18 yrs 13-19 bpm

You also want to assess if the child is using accessory muscles. Retractions, which are present when accessory muscles are helping the patient breathe, are a definitive sign of respiratory distress. Move the clothing and get your eyes on the patient’s chest and neck. You’re looking for the skin to visibly pull inward with each breath.

Move the clothing and get your eyes on the patient’s chest and neck.

Other signs to watch for include nasal flaring, grunting, head bobbing…all very clear clues the child is having significant difficulty, especially if grunting is present. Many times the child will assume what’s called a position of comfort or tripod position. This is typically sitting upright, leaning slightly forward with mouth open and jaw/neck thrust forward to open the airway (and often on a parent’s lap). If the child is drooling, this is likely due to a partial airway obstruction.

A child in respiratory failure will most likely have a decreased level of consciousness, be listless or somnolent. More significant work of breathing and grunting may be present. When you listen to the lungs you’re likely to hear diminished airflow and the child could be tachypneic but become bradypneic as they tire and head towards complete respiratory failure. Additionally, skin signs will show poor color such as pallor or even cyanosis at the nailbeds or around the mouth. These are very ominous signs requiring immediate intervention. Additionally, as the respiratory failure continues, it leads to cardiac failure. Bradycardia in a pediatric patient is a very, very concerning sign of potential imminent cardiac arrest. 

When you listen to the lungs you could hear:

  • wheezing, which is that sound airflow makes as it’s traveling through collapsed airways
  • crackles or rales which are associated with fluid accumulating in the alveoli
  • stridor, which is that high-pitched noise due to turbulent airflow through a narrow upper airway
  • diminished breath sounds, especially in cases of obstruction due to either a foreign body or airway narrowing

Nursing interventions for pediatric respiratory distress

The best chance the child has is with early intervention and we typically start with the least-invasive intervention first. 

  • If the airway is obstructed by a foreign body, clear the airway if at all possible using your BLS appropriate for that age child. Recall that in infants, it’s alternating back blows and chest thrusts while children over 12 months of age get abdominal thrusts or the Heimlich maneuver. 
  • If safe and indicated, suction the oropharynx to remove secretions, blood, vomitus and mucus. Be very careful with epiglottis, however. Stimulating the airway can cause it to close further.
  • Allow the child to assume a position of comfort..most often this is sitting upright, leaning slightly forward with mouth open and sitting on a parent’s lap.
  • Maintain airway patency with NPA or OPA, jaw thrust or chin lift maneuver. Typically an NPA is used in awake patients, while an OPA is only used if the patient is unconscious without a gag reflex.
  • For children that aren’t critical and requiring emergent intervention, sometimes the MD will simply order some O2, possibly humidified. 
  • Avoid agitating the patient or doing anything that will increase oxygen demands.
  • Give medications as ordered. The patient may need nebulized medication such as albuterol to open restricted airways or racemic epinephrine for croup. Other patients may need a combination of epinephrine, benadryl and solumedrol for anaphylaxis or angioedema, antibiotics for infection, etc…
  • If the child is in critical distress, he will likely need assisted ventilation with the BVM and could also require an oropharyngeal airway to maintain airway patency. 
  • Very critical patients may require intubation or even a needle cricothyroidotomy if intubation would prove impossible or too difficult such as in facial trauma and severe epiglottitis. Keep in mind that intubating a child is a very difficult procedure, so must be done with great care and with the most experienced individual available.

Want to learn more about respiratory disorders? Learn when your adult patient is heading toward intubation here, or concepts related to oxygenation here.

 

Drill this topic in and listen to episode 140 of the Straight A Nursing podcast. You can stream it from here or download and subscribe wherever you get your podcasts.

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References:

Agbim, C., Wang, N. E., & Lee, M. (n.d.). Respiratory distress in pediatric patients. https://www.reliasmedia.com/articles/142390-respiratory-distress-in-pediatric-patients

Challands, J., & Brooks, K. (2019). Paedeatric respiratory distress. BJA Education, 19(11), 350–356.

Cheifetz, I. M. (2011). Pediatric acute respiratory distress syndrome. Respiratory Care, 56(10), 1589–1599. https://doi.org/10.4187/respcare.01515

Fleming, S., Thompson, M., Stevens, R., Heneghan, C., Plüddemann, A., Maconochie, I., Tarassenko, L., & Mant, D. (2011). Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: A systematic review of observational studies. The Lancet, 377(9770), 1011–1018. https://doi.org/10.1016/S0140-6736(10)62226-X

Harless, J., Ramaiah, R., & Bhananker, S. M. (2014a). Pediatric airway management. International Journal of Critical Illness and Injury Science, 4(1), 65–70. https://doi.org/10.4103/2229-5151.128015

Harless, J., Ramaiah, R., & Bhananker, S. M. (2014b). Pediatric airway management. International Journal of Critical Illness and Injury Science, 4(1), 65–70. https://doi.org/10.4103/2229-5151.128015

Liu, L. (2020). Pediatric respiratory emergencies algorithm. ACLS Training Center. https://www.acls.net/pals-algo-respiratory-emergencies.htm

EMS World. (2018). Recognizing pediatric respiratory distress. EMS World. https://www.emsworld.com/article/219976/recognizing-pediatric-respiratory-distress

Shah, U. K., & Jacobs, I. N. (1999). Pediatric angioedema: Ten years’ experience. Archives of Otolaryngology–Head & Neck Surgery, 125(7), 791. https://doi.org/10.1001/archotol.125.7.791

Teachey, R. C. (2014, August 23). Signs of respiratory distress in children. Children’s Hospital of Philadelphia. https://www.chop.edu/conditions-diseases/signs-respiratory-distress-children

Weiner, D. L., Fleisher, G. R., & Wiley, J. F. (2020a). Acute respiratory distress in children: Emergency evaluation and initial stabilization. https://www.uptodate.com/contents/acute-respiratory-distress-in-children-emergency-evaluation-and-initial-stabilization

Weiner, D. L., Fleisher, G. R., & Wiley, J. F. (2020b). Causes of acute respiratory distress in children. https://www.uptodate.com/contents/causes-of-acute-respiratory-distress-in-children