Chapter 4

• Tachypnea, hyperpnea, nasal flaring, and retractions are the key features of respiratory distress.
• Respiratory distress is the most common precipitating cause of cardiopulmonary arrest in pediatrics.
• Effective bag-mask ventilation is the single most important skill for managing a patient with respiratory failure.

Respiratory distress is one of the most common complaints in children who present to an emergency department (ED). Respiratory distress is characterized by increased respiratory effort, rate or work of breathing as manifested by tachypnea, hyperpnea, nasal flaring, and inspiratory retractions.

The primary function of respiration is to oxygenate tissues and to remove carbon dioxide produced from metabolism. Respiratory distress can progress to respiratory failure, which results in inadequate oxygenation or ventilation or both. In children, respiratory failure is the most common precipitating cause of in-hospital cardiopulmonary arrest necessitating cardiopulmonary resuscitation. Therefore, early recognition and management of respiratory distress is critical for the physician.

The respiratory system functions primarily to oxygenate the tissues and eliminate carbon dioxide and secondarily to provide immunologic defense and acid–base balance. Control of gas exchange is maintained through a well-coordinated interaction of the respiratory system, the central and peripheral nervous systems, the diaphragm, the chest wall, and the circulatory system.

The respiratory system can be divided into the upper airway which includes the nose, nasopharynx, oropharynx, larynx, trachea, and bronchi and the lower airway consisting of bronchioles, alveoli, and interstitium. Disruption anywhere along this anatomic pathway can produce respiratory distress. For instance, airway obstruction secondary to croup or a foreign body in the larynx will produce respiratory distress originating from the upper airway, while pulmonary edema, fibrosis, or pneumonia will produce respiratory distress originating from the lower airway.

CNS control of respiration lies in the respiratory centers of the medulla. Central chemoreceptors in the medulla respond to changes in the pH of CSF. Peripheral chemoreceptors, located in the aortic and carotid bodies, send afferent signals via the vagus nerve and the glossopharyngeal nerve respectively regarding changes in oxygen, carbon dioxide, and pH in the arterial blood. Disruption of the CNS control of respiration, such as in hydrocephalus or CNS immaturity in the case of premature infants, can produce respiratory distress. The peripheral nervous system provides innervation to the muscles of respiration and can be disrupted in diseases of the peripheral motor nerve, neuromuscular junction, or the muscle itself.

The diaphragm is the principal muscle of inspiration, while the intercostal muscles help to lower the ribs. The accessory muscles, such as the sternocleidomastoid, come into play when respiratory effort is increased. In infants, the chest wall is more compliant than in adults so that during inspiration the lower ribs descend rather than elevate. This provides for less efficient expansion of the lungs, meaning that the diaphragm needs to do more work to achieve good tidal volumes than in the adult.1 This predisposes infants to more rapidly progressing and severe respiratory distress.

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