Paediatrics: Respiratory distress: management

Respiratory distress: management

Clinical assessment

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.

Investigations

·  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).

Monitoring

·  Pulse oximetry.

·  Continuous ECG.

·  BP.

·  Temperature.

·  Fluid balance.

·  Conscious level.

Therapy

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.