FIGURE 71.1 A: Approach to the child with respiratory distress B: Approach to the child with respiratory distress Spo2 , percentage oxygen saturation; O2 , oxygen; EtCO2 , end-tidal carbon dioxide; CNS, central nervous system Vital sign abnormalities provide important clues about the severity of illness and adequacy of compensatory mechanisms Tachycardia is one of the early signs of respiratory compromise Bradycardia in a hypoxic child is a late and ominous sign that often signals impending cardiac arrest Cardiac arrhythmias that compromise cardiac output may result in respiratory distress Respiratory rate in children varies with age ( Table 71.7 ) Tachypnea is a compensatory mechanism for hypoxia, hypercapnia, and acidosis, and it also occurs with pain, anxiety, and increased activity Fever increases respiratory rate by up to 10 breaths per degree above normal, particularly in younger children Although not specific for respiratory distress, tachypnea is one of the findings most consistently present with respiratory distress and is particularly pronounced with lower airway processes Tachypnea may be the only manifestation of lower respiratory infection in children younger than months Bradypnea may reflect central respiratory depression, increased intracranial pressure, or fatigue of respiratory muscles It is often an ominous sign that heralds impending respiratory arrest Pulsus paradoxus, an exaggeration (more than 10 mm Hg) of the normal decrease in blood pressure during inspiration, correlates with degree of airway obstruction Hypotension in a child is a late and extremely worrisome finding It suggests profound shock, significantly decreased cardiac output, and impending cardiorespiratory arrest Oxygen saturation of ≥97% while awake is normal Central cyanosis usually reflects at least g/dL of unsaturated hemoglobin and an O2 saturation of less than 90% Peripheral cyanosis alone is not usually associated with a decrease in systemic O2 saturation On inspection, in addition to respiratory rate, one should appreciate depth, rhythm, and symmetry of respirations; the use of accessory muscles; and perfusion Rapid and shallow breathing may result from air trapping in obstructive lower airway disease It may also result from chest pain, chest wall musculoskeletal dysfunction, or abdominal pain and/or distention Kussmaul respirations (deep, regular, sighing breaths) are seen with metabolic acidosis, particularly diabetic ketoacidosis Cheyne–Stokes respirations (respirations with increasing then decreasing depth alternating with periods of apnea) are seen with CNS immaturity in otherwise normal neonates and infants, particularly during sleep In older children, this respiratory pattern is concerning for inadequate cerebral perfusion, brain injury, increased intracranial pressure, and central narcotic depression Biot, or ataxic, respirations (breaths of irregular depth interrupted irregularly by periods of apnea) suggest CNS infection, injury, or drug-induced depression Asymmetric chest wall movement and/or expansion suggest unilateral chest wall or thoracic cavity pathology Nasal flaring and supraclavicular, suprasternal, and subcostal retractions of accessory muscles of respiration usually reflect upper airway obstruction but may occur with lower processes ( Table 71.8 ) Intercostal retractions are usually a sign of inadequate tidal volume as a result of lower airway disease Head bobbing, more common in neonates and young infants, is another sign of accessory muscle use Thoracoabdominal dissociation, also called respiratory alternans or see-saw respirations, in which the chest collapses on inspiration and the abdomen protrudes, is a sign of respiratory muscle fatigue Peripheral cyanosis should be distinguished from central cyanosis TABLE 71.7 NORMAL RESPIRATORY RATES Age group Neonates Older infants/toddlers Elementary schoolaged children Older children/adolescents Respiratory rate (breaths/min) 35–50 30–40 20–30 12–20 Palpation of the chest commonly reveals vibratory rhonchi over the large airways, which suggests fluid in the airway Increased tactile fremitus suggests bronchopulmonary consolidation or abscess, when decreased or absent, it suggests bronchial obstruction or space-occupying processes of the pleural cavity Crepitus on palpation of the chest or neck may reveal subcutaneous emphysema caused by pneumothorax or pneumomediastinum Auscultation is useful for localizing the site of respiratory distress ( Table 71.8 ) Stertor, gurgle, dysphonia, aphonia, hoarseness, barky cough, and inspiratory stridor localize the respiratory distress to the upper airway A lower airway cause is suggested by decreased or asymmetric breath sounds, changes in pitch of breath sounds, expiratory stridor, grunting, and/or adventitious sounds, including crackles, rhonchi, wheeze, rub, bronchophony, egophony, and whispered pectoriloquy Transmission of breath sounds across the small pediatric chest may obscure focal findings, and upper airway sounds are often transmitted to lower airways The ratio of inspiratory to expiratory phase of respiration, normally 1:1, can be useful in distinguishing an upper from lower respiratory tract obstructive causes of respiratory distress Respiratory distress from upper airway disease usually results from difficulty of inward air movement The inspiratory phase is often increased relative to the expiratory phase Lower airway processes often impede outward air movement and may result in a prolonged expiratory phase Absence of wheeze in a child with continued or worsening respiratory distress may represent severe obstruction and should not be considered reassuring but rather may herald impending respiratory arrest TABLE 71.8 LOCALIZATION OF RESPIRATORY DISTRESS BY PHYSICAL EXAMINATION FINDINGS ... bronchophony, egophony, and whispered pectoriloquy Transmission of breath sounds across the small pediatric chest may obscure focal findings, and upper airway sounds are often transmitted to lower