ABC’s of Pediatric Respiratory Assessment, Part 2: Respiratory Distress
Children are so resilient. When they are sick, their young bodies compensate in amazing ways, often for quite a while- until they don’t anymore. For any nurse who assesses pediatric patients, being able to identify respiratory distress and intervene before it becomes respiratory failure is a critical skill which can help save lives.
This article, the second in a series, presents a brief review of pediatric respiratory distress and summarizes some of the nursing interventions which can help prevent respiratory failure. The Emergency Nurse Pediatric Course (ENPC) Provider Manual 1 serves as the primary reference for this article. ENPC is a required course for many emergency nurses who care for children, including those at my hospital.
Characterized by an increased work of breathing (tachypnea, nasal flaring, abnormal positioning, abnormal airway sounds, retractions, accessory muscle use).1 It is important to note that a child’s work of breathing is actually considered a more accurate indicator of oxygenation and ventilation than their respiratory rate or their breath sounds.1
In other words, if you can see or hear that a pediatric patient is working harder to breathe, they are already in some degree of respiratory distress.
Occurs when the patient is no longer able to compensate (they cannot maintain adequate oxygenation and/or ventilation).1 Respiratory failure is often preventable; recognizing the subtle signs of respiratory distress early in infants and children and intervening appropriately can prevent deterioration to respiratory failure or arrest. Simultaneous assessments and interventions can be key to preventing deterioration. As mentioned in article #1 of this series, a sustained respiratory rate over 60 indicates that the child is at higher risk for respiratory arrest 1,2 and should serve as a red flag.
Respiratory failure is the most common cause of pediatric cardiopulmonary arrest.1
Pediatric Respiratory Distress: Facts and Nursing Considerations
(1) Infants are “obligate nose breathers”, meaning they only breathe through their nose, until around four months of age when they learn to breathe through their mouths.1
Nursing considerations: A simple measure such as suctioning a congested infant’s nose can serve as a key step towards preventing or reducing respiratory distress. Saline drops can be instilled prior to suctioning to help thin the secretions. Nasal suctioning prior to feeding helps support adequate intake and prevent dehydration during a respiratory illness. Parents may fear that the suctioning will harm their infant and may benefit from reassurance and demonstration.
(2) The most common cause of airway obstruction in an unresponsive child is the tongue.1 The infant and young child’s head and tongue are larger in proportion to their body and oropharynx. The tongue can block the airway of a supine infant or young child.
Nursing Considerations: Repositioning and/or elevating the pediatric patient’s head can improve breathing effectiveness significantly. Infants and young children have relatively heavy heads in proportion to their bodies, which will sometimes drop forward and contribute to airway obstruction. A rolled towel or small blanket placed under the upper shoulders can help keep the airway open. This position is often referred to as “sniffing position”, because the infant or toddler’s head is extended slightly back to help keep the airway open and the nose is tilted up as if sniffing.
(3) Infants and young children have immature accessory muscles, cartilaginous ribs, and little supporting cartilage in their nares. Infants are “obligate nose breathers” (they only know how to breathe through their nose) until about the age of 4 months. 1
Nursing Considerations: Nasal flaring is an early sign of respiratory distress.1 The younger the child, the more likely that the chest wall will collapse, rather than expand, with distress. The more severe the degree of respiratory distress, the more likely they are to present with retractions.
(4) Infants and young children are “abdominal breathers”; the diaphragm is their major muscle of breathing.
Nursing Considerations: Anything that impedes diaphragmatic excursion from above or below (asthma, abdominal distention, constipation) can also impede breathing effectiveness and increase respiratory distress in the young child.
(5) The pediatric respiratory system grows continuously until around age 7 or 8, when it is similar to that of an adult. 1 The size of an infant’s trachea is approximately the diameter of the infant’s little finger.1
Nursing Considerations: Infants and young children have smaller airways which are more susceptible to obstruction from any insult: secretions, edema, inflammation, trauma and foreign bodies. Airway support such as suctioning secretions or vomitus can be critical in preserving an intact pediatric airway.
1. Emergency Nurses Association (2012). Emergency Nurse Pediatric Course Provider Manual 4th Edition. Des Plaines, IL; Emergency Nurses Association.References/Resources
2. Gilboy, N, Tanabe T, Travers D, Rosenau AM. Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care, Version 4. Implementation Handbook 2012 Edition. AHRQ Publication No. 12-0014. Rockville, MD. Agency for Healthcare Research and Quality. November, 2011.Last edit by Joe V on Oct 20, '17
Elizabeth Stone Griffin is a pediatric emergency nurse and a clinical instructor for a BSN program.
Joined: Sep '14; Posts: 41; Likes: 244
Pediatric Emergency Nurse and Clinical Instructor; from US
Specialty: 15+ year(s) of experience in Pediatric Emergency & Nurse EducationFeb 11, '15This was amazing! We just covered this in clinical and it's a fantastic review. Thank you!Feb 12, '15enpc is a great class. An absolute must if you work with peds. The more tools i have that allow me to avoid using pals the better. With kids, recognize the problem fast and fix 'em.