Recognizing Respiratory Distress and Failure by Dr. Monica Kleinman.
When we say respiratory distress, we're really referring to the use of compensatory mechanisms
to maintain adequate oxygenation and ventilation when something, one of many things, is causing
respiratory compromise.
Typically, the compensation consists of an increase in the rate and work of breathing.
That increase will increase minute ventilation, allowing the child to exhale more carbon dioxide
when gas exchange is impaired.
Signs of respiratory distress include retractions, sternal retractions, for instance, because
of the flexible, compliant breastbone, as well as intercostal retractions.
And this is an example of increased effort resulting in muscles exaggerating the spaces
between the ribs or in the sternum.
Use of accessory muscles, such as the strap muscles in the neck, nasal flaring, and grunting,
an expository noise that's designed to apply some PEEP.
[GRUNTING SOUND] Children in respiratory distress typically are anxious.
It's an uncomfortable feeling, and with that stress, they oftentimes have tachycardia.
These are some examples, as well, of signs of respiratory distress.
The child who wants to sit upright and is unable to lie flat comfortably.
The child on the left looks anxious, and the child on the right is demonstrating increased
work of breathing.
Respiratory failure, on the other hand, is at the other end of the spectrum and is defined
by inadequate oxygenation and ventilation.
Essentially occurs when compensatory mechanisms fail to maintain gas exchange.
Interestingly, respiratory failure can occur without preceding respiratory distress, meaning
it can happen when there is depression of respiratory effort, typically by something
like a poisoning, which depresses mental status, or seizures, or severe weakness leading to
inadequate respiratory effort.
Signs of respiratory failure, when the compensatory mechanisms are no longer able to sustain gas
exchange, include desaturation or cyanosis despite supplemental oxygen.
The appearance of increased effort leading to poor air entry, in other words, lots of
work for very little gain.
This may be characterized by a sound of gasping when the child inspires.
[GASPING SOUND] Head bobbing, which is an exaggerated form of accessory muscle use in
which the head literally will bob as the muscles of the neck and shoulders are trying to participate
in gas exchange.
Seesaw or paradoxical respirations, where the abdomen and chest move in the opposite
ways than they usually do.
And sounds of severe obstruction, such as stridor.
[STRIDOR SOUND] The hallmark of respiratory failure, to distinguish it from respiratory
distress, is a change in mental status.
When oxygen levels fall and carbon dioxide rises, this is a very stressful feeling and
results in sympathetic stimulation and agitation.
As carbon dioxide continues to rise, it has a sedating effect on the central nervous system,
leading to a child who is lethargic, sleepy, or obtunded.
The child who appears to have increased work of breathing, desaturation, and sleepiness
or obtundation is one whom you need to be very concerned has transitioned from respiratory
distress to respiratory failure and may progress to respiratory arrest and cardiac arrest.