12: Respiratory Distress

IMMEDIATE MANAGEMENT OF LIFE-THREATENING PROBLEMS

ASSESS SEVERITY AND GIVE IMMEDIATE NECESSARY CARE

The pediatric patient presenting in respiratory distress can represent a challenge to the emergency department physician. Respiratory failure is a common cause of cardiac arrest of the pediatric patient and hence the patient in respiratory distress should be of the highest priority in the emergency department.

The patient should receive, in parallel, an evaluation and immediate therapy. Maintaining an adequate airway and breathing should be the initial primary consideration. Respiratory evaluation begins with the general appearance of the patient. The patient should have a visible abdomen, chest wall, neck, and abdomen. Infants and toddlers often compensate their respiratory efforts with signs such as nasal flaring, clavicular and/or sternal retractions. A decline in mental status is a critical component of advanced respiratory distress and pending respiratory failure.

Immediate oxygen supplementation should occur during initial assessment and continue in patients with severe respiratory distress. A rapidly performed and focused physical examination of the oropharynx, neck, lungs, heart, chest, and extremities should be done in parallel with getting the child on cardiovascular monitoring and obtaining a focused history. A chest x-ray should be obtained as soon as possible as it can provide immediate valuable diagnostic information. Caution should be used that the acquisition of a chest x-ray does not delay immediate life saving care or remove the child from an environment of close monitoring.

ASSESS ADEQUACY OF OXYGENATION

Mental Status

In a child, mental status can be of utmost important in the initial evaluation of oxygenation. Hypoxia can manifest as a variety of behavioral changes that include persistent sleepiness, fussiness, and irritability. More advanced and concerning behaviors associated with hypoxia are inconsolability, restlessness, overt agitation, confusion, lethargy, and reduced response to painful stimuli. The emergency department physician must be cautious not to attribute these signs and symptoms to normal infant or child behaviors in the setting of possible hypoxia.

Pulse Oximetry

Bedside pulse oximetry is a useful tool for rapid feedback that measures percent saturation of oxygen in capillary blood. It can be particularly useful during procedural sedation or endotracheal intubation because of the real-time delivery of physiological information. The information should be considered as part of the ventilation assessment because it does not measure PCO₂ and does not account for initial hypoventilation. It can be a challenge to obtain a consistent waveform in an uncooperative child or in a child who is in subsequent cardiopulmonary collapse with poor peripheral perfusion. Mental status paired with respiratory status of the child should therefore be used as oxygenation assessment until objective data may be obtained.

Arterial Blood Gas

Similar information regarding arterial oxygenation can be taken from an arterial blood gas (ABG) compared ...