Respiratory distress: management
Assess the patient for the following:
· Colour: pallor or cyanosis.
· Respiratory drive: pattern and timing of breathing may reflect a central or brainstem cause.
· Inspiration and expiration of air at the mouth and nose: upper airway obstruction produces stridor; lower airway obstruction leads to cough, wheeze, and a prolonged expiratory phase.
· Chest wall movement: chest and abdominal wall dynamics may indicate flail-chest, diaphragmatic palsy, pneumothorax, or foreign body inhalation.
· Position and level of agitation.
· Mental state.
· Heart rate and perfusion: these may reflect impending arrest.
· Non-invasive: pulse oximetry measurement of oxyhaemoglobin saturation, pulse oximetry measurement of oxyhaemoglobin saturation (SpO2).
· Arterial blood gas: assessment of acid–base, PaO2, PaCO2. A capillary blood sample is a good alternative (for pH, PCO2) if the extremity is warm and the blood flows freely.
· Blood tests: full blood count (FBC), electrolytes, glucose, and cultures.
· CXR: for diagnosis (e.g. severe pneumonia); for assessment of complications (e.g. pulmonary oedema, pneumothorax).
· Pulse oximetry.
· Continuous ECG.
· Fluid balance.
· Conscious level.
There are specific therapies for each condition listed in the ‘Differential diagnoses’. With regard to fluid ther-apy, we generally restrict total volume to 80% maintenance for the fol-lowing reasons.
· Distress with retraction: high –ve intrathoracic pressure will pull fluid out of capillaries into the interstitial space and will aggravate breathing with pulmonary oedema.
· Syndrome of inappropriate antidiuretic hormone (SIADH): this is a common problem in moderate to severe respiratory distress.
· Diuresis is limited: in the hydrated patient consider using furosemide (0.5–1mg/kg, IV). It may help the patient with extra-interstitial water without overt oedema.