the purpose of this video is to provide
general information and education about
the care of a critically ill child
it is in no way a substitute for the
independent decision-making and judgment
by a qualified health care professional
the information contained in this video
should not be used to make a diagnosis
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used to provide advice for emergency
medical treatment
recognising respiratory distress by dr.
Monica Kleinman please note that in this
video we will be following the
guidelines used at Boston Children's
Hospital some of this information may
need to be modified based on the
equipment guidelines and practices in
place in your institution hello my name
is Monica Kleinman I'm an attending
physician in the medical surgical
intensive care unit at Children's
Hospital Boston and today I'm going to
be talking to you about the recognition
of respiratory distress and failure in
infants and children introduction
so we're going to be talking about
recognition of respiratory distress and
failure in an infant or child and
respiratory distress is one of the most
common presenting signs of illness in a
pediatric patient it can represent a
problem that doesn't necessarily
primarily involve the lungs systemic
problem like sepsis or heart failure or
compensation for a metabolic acidosis as
may occur in severe dehydration or in a
toxic ingestion but most of the time
respiratory distress can be traced back
to some primary problem with the
pulmonary system and different types of
problems can present with different
characteristic signs and symptoms we're
going to review those and use this
mannequin as well as some video to
demonstrate the different types of lung
disease that can produce different
appearances of a child in respiratory
distress
- Kip Nia
when a child has a problem of any kind
that interferes with gas exchange or
they need to excrete more gas as in the
case of a time when they're producing
more co2 than normal
their very first attempt at compensating
for that is to increase respiratory rate
and so to Kipp Nia is by far the most
common and universal sign of respiratory
distress in an infant unlike an adult
who does have a more expandable chest
cavity and stronger intercostal muscles
the infant breathes already at a fairly
high lung capacity and so that their
ability to increase volume tidal volume
by compensatory mechanisms is limited
it's much more efficient for them to
breathe fast and that's why to Kip knee
is the somewhat uniform or universal
sign of respiratory distress
now there's comfortable to Kipp Nia
which typically occurs when an infant is
demonstrating a compensation for some
primary lung problem like interstitial
edema something that will reduce
compliance of the lungs and by the more
to kipnuk they'll increased minute
ventilation which is tidal volume times
respiratory rate and this quiet
comfortable to Kipp Nia can actually get
to pretty significant rates it's not
unusual for a young infant to be able to
breathe at 70 80 90 even a hundred times
a minute and not look particularly
uncomfortable until one stops to really
count that respiratory rate of course
breathing that fast uses a lot of energy
and so while the infant may be able to
maintain that for a period of time it's
one warning sign that respiratory
failure or decompensation
may develop
nasal flaring
the other signs of respiratory distress
that are important to look for our nasal
flaring which is essentially a way of
increasing the size of the upper airway
which is somewhat high resistance place
for air to flow into and by flaring the
nostrils one is making that passage just
a bit larger retractions
another sign is retractions retractions
occur when there is collapse of soft
tissue because of muscular effort and
one can see retractions in a number of
places when an infant is demonstrated
increased work of breathing and so their
muscle activity is increased in an
effort to increase tidal volume of the
lung but this is a really limited
compensatory mechanism because of the
shape and size of their chest
retractions can be seen in a number of
places suprasternal retractions or the
jugular notch it's a common place in
between the ribs called intercostal
retractions a very common place is
substernal ii or sub costal ii which you
can see being demonstrated on this baby
as an example of when the abdominal
muscle significantly contracts and
reveals the edges of the ribcage in a
very young infant who has a very
compliant chest wall one might even see
the sternum collapsing significantly
because of their effort of breathing and
the muscular effort is strong enough to
make that soft cartilaginous sternum
collapse and those are of course sternal
retractions as opposed to subcostal or
substernal retractions
grunting
another sign of respiratory distress is
grunting we're going to demonstrate
grunting in just a moment but grunting
is a mechanism by which the baby tries
to maintain lung volume it's essentially
closure of the glottis and breathing
against that closed glottis to provide
some peep to oneself and therefore
hopefully maintain alveolar volume and
so our baby is now going to do a
demonstration of grunting thank you
grunting as you can see is an expert Ori
noise it's sort of low-pitched and
coming from deep in the throat because
that's where the closed glottis is
occurring seesaw breathing
in terms of the patterns that one might
see anything that results in obstruction
to airflow outward is likely going to
show you excessive use of abdominal
muscles and excessive use of abdominal
muscles can oftentimes be seen in what's
called seesaw breathing we're going to
try to demonstrate that to you here and
that's where you visualize almost a
rocking motion of the chest and abdomen
as a result of increased muscle use
during exhalation essentially a forced
exhalation that's typically a sign of
lower airway obstruction and the need to
essentially force air out of the
respiratory tract in diseases such as
bronchiolitis or reactive airway disease
or asthma when one has upper airway
obstruction the most common finding is
retractions in the upper part of the
chest such as suprasternal retractions
or in a young infant sternal retractions
as a result of the compliant sternum in
either of these you may see grunting or
flaring as well head-bobbing
one specific sign that tends to occur
along this progression is something we
call head bobbing and head bobbing
occurs in a baby who is becoming
lethargic but is still using significant
amount of accessory muscle use ie has a
significantly increased work of
breathing and what you'll typically see
is that their effort to expand the chest
cavity actually results in the head
bobbing up and down which with each
breath they try to take again this is
often a fairly late sign and less likely
to be seen in someone who is earlier in
the course of respiratory distress but
head bobbing is somewhat unique to
infants who have severe respiratory
distress and impending respiratory
failure now the major reason it's
important to distinguish between where
in the progression your patient might be
is that respiratory distress can
typically be treated with interventions
such as supplemental oxygen positioning
treatment of directed at underlying
problems like bronchospasm or airway
edema but typically the infant is able
to compensate and maintain gas exchange
without anything invasive being done
whereas once one reaches respiratory
failure assisted ventilation is going to
be needed in order to correct the
significant problems of hypoxia and
hypercarbia because if they are left
uncorrupted the baby may progress to
cardiopulmonary arrest fairly rapidly
stress response
the infant who has significant
respiratory distress is likely to be
stressed in other ways and to
demonstrate some aspects of a stress
response and the most common sign of
stress response of course would be
tachycardia and so the degree of
tachycardia may give one some
information about how significantly
stressed the baby is because it results
from endogenous catecholamine production
and a sympathetic response likewise they
may be for age somewhat hypertensive as
a result of the stress you may actually
have a worried or anxious look on the
face you call that air hunger somewhat
of a look of like they're trying to say
help me if they could talk they look
they look uncomfortable and like they
are really working to get air and some
infants will be diaphoretic and show
that sign of a stress response as well
respiratory failure
the infant who can no longer exchange
gas using these compensatory mechanisms
may develop respiratory failure and the
formal definition of respiratory failure
would be one where you have inadequate
oxygenation and inadequate ventilation
and so in a pure sense one would want to
look at an arterial blood gas to prove
that those abnormalities existed however
there are clinical correlates to those
changes that we can use to try to
recognize respiratory failure at the
bedside with oxygenation it's relatively
straightforward the use of pulse
oximetry to detect desaturation will
give you information about the adequacy
of oxygenation and this is easily
corrected of course with the
administration of supplemental oxygen
this can actually be deceiving because
an infant who has even fairly progressed
in the pathway to respiratory failure
may still saturate well because we're
administering supplemental oxygen and
masking that particular sign of
respiratory failure cyanosis therefore
is a very late sign of respiratory
failure and usually herald-sun
impending arrest the infant who is not
adequately ventilating is one that will
demonstrate some clinical symptoms that
can be used to recognize hypercarbia
rather than needing a blood gas to
identify hypercarbia remember that the
infant with respiratory distress is
stressed has a physiologic reaction
which typically includes tachycardia
possibly hypertension diaphoresis and an
anxious look that baby may be crying and
irritable and difficult to console
hypercarbia is a very very stressful
event it's a essentially a feeling of
suffocation
and when hypercarbia occurs in someone
who is conscious it produces a expected
reaction of significant agitation and a
stress response that will be exaggerated
above what one might see in in just
respiratory distress and so progressive
tachycardia up to ranges that would
really concern you in an infant seis a
baby of this age with a heart rate of
190 or 200 per minute as well as
agitation inability to settle our
typical signs in an infant of
hypercarbia in an older child who can
communicate they may actually report
they can't breathe
they maybe get become agitated and
combative because they're essentially
feeling as though they are suffocating
and acting as though they're they're
unable to catch their breath they may
push away masks and be very
uncooperative and these are very
frightening signs that respiratory
failure is occurring we typically think
of significant hypercarbia as producing
somnolence and that is the case but
remember that if you're watching an
infant progress they'll typically go
through first this phase of agitation
and distress before they become
somnolent from excessive hypercarbia and
it takes a PCO to that's fairly high to
produce co2 narcosis and so it's not an
early sign of respiratory failure one
co2 narcosis occurs and the infant is
poorly responsive to exam IV stat sticks
etc there are likely going to be other
signs of respiratory failure including
desaturation that are going to help you
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complete this activity in the guided
learning pathway that concludes our
video on recognizing respiratory
distress thank you
you