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Emergency evaluation and immediate management of acute respiratory distress in children


Debra L Weiner, MD, PhD

Section Editor:

Gary R Fleisher, MD

Deputy Editor:

James F Wiley, II, MD, MPH

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Nov 2016. | This topic last updated: Nov 24, 2014.

INTRODUCTION — Respiratory distress is one of the most common chief complaints for which children seek medical care. It accounts for nearly 10 percent of pediatric emergency department visits and 20 percent of hospitalizations [1].

Respiratory distress in children, particularly neonates and infants, must be promptly recognized and aggressively treated because they may decompensate quickly. Factors that contribute to rapid respiratory compromise in children include smaller airways, increased metabolic demands, decreased respiratory reserves, and inadequate compensatory mechanisms as compared to adults. Respiratory arrest is the most common cause of cardiac arrest in children and outcomes are poor for patients who develop cardiopulmonary arrest as the result of respiratory deterioration [2-5].

The initial assessment and stabilization of children with respiratory and circulatory distress including airway management techniques, rapid sequence intubation (RSI), causes of respiratory compromise in children, and conditions causing respiratory distress in newborns are discussed separately:

●(See "Initial assessment and stabilization of children with respiratory or circulatory compromise".)

●(See "Basic airway management in children".)

●(See "Emergency endotracheal intubation in children".)

●(See "Rapid sequence intubation (RSI) in children".)

●(See "Causes of acute respiratory distress in children".)

●(See "Overview of neonatal respiratory distress: Disorders of transition".)

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of acute respiratory distress in children is discussed in detail separately (table 1). (See "Causes of acute respiratory distress in children".)

EVALUATION — The evaluation of a child with acute respiratory distress includes determining the severity, as well as the underlying cause. Tachypnea and in neonates, infants, and young children, retractions, are hallmarks of respiratory distress. Respiratory distress may manifest as inadequate respiratory effort, most often in those who have tired from attempts to compensate for respiratory compromise, those with underlying neuromuscular disease and those with disordered control of breathing (eg, bronchiolitis, opioid overdose). Tachypnea and decreased respiratory effort can lead to respiratory failure and/or arrest and the child with inadequate respiratory effort is often at more immediate risk.

The emergency evaluation of the child with respiratory distress must first determine the severity of respiratory distress and the need for emergent intervention. Features of the history and physical examination will ideally localize the source as well as suggest the etiology and direct initial treatment (table 2). Ancillary studies can then be performed as indicated to confirm the diagnosis and guide management (table 3). The clinical features and evaluation of specific conditions that cause acute respiratory distress in children are discussed separately. (See "Causes of acute respiratory distress in children".)

Regardless of etiology, the initial management of respiratory distress in children requires immediate evaluation and supportive care of airway, breathing, and circulation. For some conditions, specific interventions (ie, bronchodilator therapy for asthma or decompression of a pneumothorax) may rapidly relieve symptoms. With prompt aggressive treatment of respiratory distress and its underlying cause, most children with respiratory distress recover uneventfully.

Initial rapid assessment — The pediatric assessment triangle (PAT) focuses initial evaluation on appearance, breathing, and circulation for acutely ill or injured children to quickly identify conditions that require immediate intervention. The PAT is reviewed separately. (See "Initial assessment and stabilization of children with respiratory or circulatory compromise", section on 'Pediatric assessment triangle'.)

Features of the PAT that are specific to children with acute respiratory distress include (see 'General observation' below):

●Appearance – Restlessness, anxiety and combativeness are early manifestations or air hunger or hypoxia. Somnolence and lethargy are indicative of severe hypoxia, hypercarbia, and/or respiratory fatigue.

●Breathing – The initial response to respiratory compromise is usually tachypnea. Abnormal airway sounds (eg, stridor, wheezing), increased accessory muscle use, and positioning to maximize airway opening (eg, “sniffing” position, “tripod” position) are other indicators of respiratory compromise. As respiratory distress progresses, respiratory rate often decreases and the pattern of respirations becomes irregular. These are ominous signs. Without intervention, respiratory arrest quickly ensues.

●Circulatory status – Pallor, ashen color, and cyanosis are concerning findings that may indicate hypoxemia, but may also be observed in patients with shock.

Conditions that require immediate, life-saving interventions include (table 4):

●Complete or rapidly progressing partial upper airway obstruction

●Tension pneumothorax

●Cardiac tamponade

●Respiratory failure

Throughout this evaluation, every reasonable effort must be made to keep the child calm and comfortable, since anxiety and crying can substantially increase the work of breathing in young children by decreasing upper airway diameter and increasing metabolic demand for oxygen [6]. The child should be positioned or allowed to maintain the position that best supports their respiratory effort.

History — A detailed history should be obtained once the child's condition is stabilized. (See "Initial assessment and stabilization of children with respiratory or circulatory compromise", section on 'Initial stabilization'.)

Helpful historical information includes:

●Trauma – A history of recent trauma suggests specific diagnoses, such as pneumothorax, pulmonary contusion, flail chest, cardiac tamponade, intraabdominal and/or central nervous system injury.

●Change in voice – Many children with acute upper airway pathology will have a change in voice (either muffled or hoarse). In comparison, those with lower airway processes have a normal voice.

●Onset and duration of symptoms – The abrupt onset of gagging or choking suggests upper airway conditions, such as an aspirated foreign body, allergy, or irritant exposure. A child who suddenly complains of chest pain may have a pneumothorax.

An infant who gradually develops tachypnea and retractions may have asthma, bronchopulmonary infection, or heart failure.

●Associated symptoms – Fever suggests an infectious etiology. Fever itself can result in an increase in respiratory rate of three to seven breaths per minute per degree centigrade above normal [7,8]. A child with tachypnea without fever, URI symptoms, or cough may be compensating for a metabolic acidosis. A complaint of abdominal pain may indicate a gastrointestinal process (ie, appendicitis or bowel obstruction), diaphragmatic irritation from a pneumonic condition (as can occur with basilar pneumonia and/or pleural effusion), or a metabolic abnormally (ie, ketoacidosis from diabetes).

●Exposures – Exposure to specific infections, toxins (including medications, substances of abuse, biologic, chemical or nuclear agents), or allergens may suggest an etiology for respiratory distress.

●Previous episodes – Information regarding previous episodes of respiratory distress, including treatments that have been used and their effect, may guide interventions. As an example, an infant or young child who is wheezing, and has not been diagnosed with asthma, may have had previous episodes of wheezing that responded to bronchodilators

●Underlying medical conditions – Respiratory distress may be an acute manifestation of a process associated with a specific chronic medical condition (ie, acute chest syndrome in a child with sickle cell disease) or a complication of a chronic condition (ie, pneumothorax in a patient with asthma). (See"Causes of acute respiratory distress in children", section on 'Acute on chronic diseases'.)

●Family history – Family history of inheritable conditions (including asthma, cardiac disease, diabetes mellitus) may give clues to possible undiagnosed etiologies of respiratory distress.

Physical examination — The initial physical examination of the child with severe respiratory distress should be completed rapidly, focusing on the respiratory and cardiovascular systems, but recognizing that other organ system processes may be the etiology of respiratory distress [9].

After rapid assessment of airway, breathing and circulation, vital signs, including pulse oximetry, and actual or estimated weight, should be obtained. Side port capnography, is helpful in detecting hypercarbia. Once the child is stabilized, the clinician should perform a complete physical examination.

General observation — The following observations suggest severe respiratory distress:

●Mental status – Agitation and combativeness suggest early air hunger or hypoxia, while somnolence and lethargy are manifestations of severe hypoxemia or hypercarbia.

●Position of comfort – To maximize airway patency, a child with upper airway obstruction may sit upright and assume the "sniffing position" (neck flexed, head mildly extended) to align the airway axes and improve airflow (picture 1). With lower airway disease, the child may assume a “tripod position”, ie, sitting up and leaning forward on outstretched hands.

●Cyanosis – Cyanosis is generally a late finding in children with hypoxemia. It is seen most often in those who have low cardiac output in addition to low arterial oxygen saturation. Severely anemic patients (hemoglobin ................

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