The purpose of this video to provide general
information and education about the care of
a critically ill child.
It is in no way a substitute for the independent
decision making and judgment by a qualified
health care professional.
The information contained in this video should
not be used to make a diagnosis or to overrule
the advice of a qualified health care provider,
nor should it be used to provide advice for
emergency medical treatment.
Recognizing Respiratory Distress by Dr. Monica
Kleinman Please note that in this video, we
will be following the guidelines used at Boston
Children's Hospital.
Some of this information may need to be modified
based on the equipment, guidelines, and practices
in place in your institution.
Hello, my name is Monica Kleinman.
I'm an attending physician in the medical
surgical intensive care unit at Children's
Hospital Boston, and today I'm going to be
talking to you about the recognition of respiratory
distress and failure in infants and children.
Introduction.
So we're going to be talking about recognition
of respiratory distress and failure in an
infant or child.
And respiratory distress is one of the most
common presenting signs of illness in a pediatric
patient.
It can represent a problem that doesn't necessarily
primarily involve the lungs.
A systemic problem like sepsis or heart failure
or compensation for a metabolic acidosis as
may occur in severe dehydration or in a toxic
ingestion.
But most of the time, respiratory distress
can be traced back to some primary problem
with the pulmonary system, and different types
of problems can present with different characteristic
signs and symptoms.
We're going to review those and use this mannequin
as well as some video to demonstrate the different
types of lung disease that can produce different
appearances of a child in respiratory distress.
Tachypnea.
When a child has a problem of any kind that
interferes with gas exchange or they need
to excrete more gases, in the case of a time
when they're producing more CO2 than normal,
their very first attempt at compensating for
that is to increase respiratory rate.
And so tachypnea is by far the most common
and universal sign of respiratory distress
in an infant.
Unlike an adult who does have a more expandable
chest cavity and stronger intercostal muscles,
the infant breathes already at a fairly high
lung capacity.
And so their ability to increase volume, tidal
volume, by compensatory mechanisms is limited.
It's much more efficient for them to breathe
fast.
And that's why tachypnea is the somewhat uniform
or universal sign of respiratory distress.
Now there's comfortable tachypnea, which typically
occurs when an infant is demonstrating compensation
for some primary lung problem like interstitial
edema, something that will reduce compliance
of the lungs.
And by being more tachypnic, they'll increase
minute ventilation, which is tidal volume
times respiratory rate.
And this quiet, comfortable tachypnea can
actually get to pretty significant rates.
It's not unusual for a young infant to be
able to breathe at 70, 80, 90, even 100 times
a minute and not look particularly uncomfortable
until one stops to really count that respiratory
rate.
Of course, breathing that fast uses a lot
of energy.
And so while the infant may be able to maintain
that for a period of time, it's one warning
sign that respiratory failure, or decompensation,
may develop.
Nasal Flaring.
The other signs of respiratory distress that
are important to look for are nasal flaring,
which is essentially a way of increasing the
size of the upper airway, which is a somewhat
high-resistance place for air to flow into.
And, by flaring the nostrils, one is making
that passage just a bit larger.
Retractions.
Another sign is retractions.
Retractions occur when there is collapse of
soft tissue because of muscular effort.
And one can see retractions in a number of
places when an infant is demonstrating increased
work of breathing.
And so their muscle activity is increased
in an effort to increase tidal volume of the
lung.
But this is a really limited compensatory
mechanism because of the shape and size of
their chest.
Retractions can be seen in a number of places.
Suprasternal retractions or the jugular notch
is a common place.
In between the ribs, called intercostal retractions.
A very common place is substernally or subcostally,
which you can see being demonstrated on this
baby, as an example of when the abdominal
muscle significantly contracts and reveals
the edges of the ribcage.
In a very young infant who has a very compliant
chest wall, one might even see the sternum
collapsing significantly because of their
effort of breathing.
And the muscular effort is strong enough to
make that soft cartilaginous sternum collapse.
And those are, of course, sternal retractions
as opposed to subcostal or substernal retractions.
Grunting.
Another sign of respiratory distress is grunting.
We're going to demonstrate grunting in just
a moment, but grunting is a mechanism by which
the baby tries to maintain lung volume, and
it's essentially closure of the glottis and
breathing against that closed glottis to provide
some peep to oneself, and therefore, hopefully
maintain alveolar volume.
And so our baby is now going to do a demonstration
of grunting.
[BABY GRUNTING] Thank you.
Grunting, as you can see, is an expiratory
noise.
It's sort of low pitched and coming from deep
in the throat, because that's where the closed
glottis is occurring.
See-saw breathing.
In terms of the patterns that one might see,
anything that results in obstruction to airflow
outward is likely going to show you excessive
use of abdominal muscles.
And excessive use of abdominal muscles can
oftentimes be seen in what's called see-saw
breathing.
We're going to try to demonstrate that to
you here.
And that's where you visualize almost a rocking
motion of the chest and abdomen as a result
of increased muscle use during exhalation,
essentially a forced exhalation.
That's typically a sign of lower airway obstruction
and the need to essentially force air out
of the respiratory tract in diseases such
as bronchiolitis or reactive airway disease
or asthma.
When one has upper airway obstruction, the
most common finding is retractions in the
upper part of the chest, such as suprasternal
retractions, or in a young infant, sternal
retractions, as a result of the compliant
sternum.
In either of these, you may see grunting or
flaring as well.
Head Bobbing.
One specific sign that tends to occur along
this progression is something we call head
bobbing.
And head bobbing occurs in a baby who is becoming
lethargic but is still using significant amount
of accessory muscle use, i.e. has a significantly
increased work of breathing.
And what you'll typically see is that their
effort to expand the chest cavity actually
results in the head bobbing up and down with
each breath they try to take.
Again, this is often a fairly late sign, and
less likely to be seen in someone who is earlier
in the course of respiratory distress, but
head bobbing is somewhat unique to infants
who have severe respiratory distress and impending
respiratory failure.
Now the major reason it's important to distinguish
between where in the progression your patient
might be is that respiratory distress can
typically be treated with interventions, such
as supplemental oxygen, positioning, treatment
directed at underlying problems like broncospasm
or airway edema.
But typically, the infant is able to compensate
and maintain gas exchange without anything
invasive being done.
Whereas once one reaches respiratory failure,
assisted ventilation is going to be needed
in order to correct the significant problems
of hypoxia and hypercarbia, because if they
are left uncorrected the baby may progress
to cardiopulmonary arrest fairly rapidly.
Stress response.
The infant who has significant respiratory
distress is likely to be stressed in other
ways, and to demonstrate some aspects of the
stress response.
And the most common sign of stress response
of course would be tachycardia.
And so the degree of tachycardia may give
one some information about how significantly
stressed the baby is because it results from
endogenous catecholamine production in a sympathetic
response.
Likewise, they may be for age somewhat hypertensive
as a result of the stress.
The infant may actually have a worried or
anxious look on the face, and call that air
hunger.
Similar of a look of-- like they're trying
to say help me if they could talk.
They look, uncomfortable and like they are
really working to get air.
And some infants will be diaphoretic and show
that sign of a stress response as well.
Respiratory Failure.
The infant who can no longer exchange gas
using these compensatory mechanisms may develop
respiratory failure.
And the formal definition of respiratory failure
would be one where you have inadequate oxygenation
and inadequate ventilation.
And so in a pure sense, one would want to
look at an arterial blood gas to prove that
those abnormalities existed.
However, there are clinical correlates to
those changes that we can use to try to recognize
respiratory failure at the bedside.
With oxygenation, it's relatively straightforward.
The use of pulse oximetry to detect desaturation
will give you information about the adequacy
of oxygenation.
And this is easily corrected, of course, with
the administration of supplemental oxygen.
This can actually be deceiving because an
infant who has even fairly progressed in the
pathway to respiratory failure may still saturate
well because we're administering supplemental
oxygen and masking that particular sign of
respiratory failure.
Cyanosis, therefore, is a very late sign of
respiratory failure and usually heralds impending
arrest.
The infant who is not adequately ventilating
is one that will demonstrate some clinical
symptoms that can be used to recognize hypercarbia
rather than needing a blood gas to identify
hypercarbia.
Remember that the infant with respiratory
distress is stressed-- has a physiologic reaction,
which typically includes tachycardia, possibly
hypertension, diaphoresis, and an anxious
look.
That baby may be crying and irritable and
difficult to console.
Hypercarbia is a very, very stressful event.
It's essentially a feeling of suffocation.
And when hypercarbia occurs in someone who
is conscious, it produces expected reaction
of significant agitation, and a stress response
that will be exaggerated above what one might
see in just respiratory distress.
And so progressive tachycardia up to ranges
that would really concern you in an infant--
say it's a baby of this age with a heart rate
of 190 or 200 per minute, as well as agitation,
inability to settle, are typical signs in
an infant of hypercarbia.
In an older child who can communicate, they
may actually report they can't breathe.
They may become agitated and combative because
they're essentially feeling as though they
are suffocating, and acting as though they
are unable to catch their breath.
They may push away masks and be very uncooperative.
And these are very frightening signs that
respiratory failure is occurring.
We typically think of significant hypercarbia
as producing somnolence, and that is the case,
but remember that if you're watching an infant
progress, they'll typically go through first
this phase of agitation and distress before
they become somnolent from excessive hypercarbia.
And it takes a PCO2 that's fairly high to
produce CO2 narcosis.
And so it's not an early sign of respiratory
failure.
Once the O2 narcosis occurs, and the infant
is poorly responsive to exam, IV sticks, et
cetera, there are likely going to be other
signs of respiratory failure, including desaturation
that are going to help you identify that.
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That concludes our video on recognizing respiratory
distress.
Thank you.
