Approach to child with Respiratory distress.pptx

Clinical state characterised by increased rate and increased respiratory efforts

Or

It refers to any type of subjective difficulty in breathing

1. Approach to child with Respiratory distress Dr. Rita Panyang Kataki

2. Definition – Contd.. A recent consensus statement from the American thoracic society offered the following definition of dyspnoea : “ Dyspnoea is a term used to characterize a subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity . The experience derives from interactions among multiple physiological, psychological, social and environmental factors, and may induce secondary physiological and behavioral responses."

3. Definition Clinical state characterised by increased rate and increased respiratory efforts Or It refers to any type of subjective difficulty in breathing

4. Respiratory Rate

5. Features of respiratory distress Tachypnea Dyspnoea Nasal flaring Chest wall retraction Added sound Head nodding CVS and CNS manifestation

6. Grading of respiratory distress Mild Tachypnea Dyspnoea or shortness of breath Moderate Tachypnea Minimal chest wall retaction Nasal flaring Severe

7. Cont. Severe Marked tachypnea > 70 breath /min Apnea / bradycardia /irregular breathing Lower chest wall retraction Head nodding (use of sternocleidomastoid ) Cyanosis

8. Feature of Respiratory failure Pa Co2 of >50 or paO2 of <60 while breathing 40% O2 Clinical def: severe respiratory wit cvs manifestation and cns changes Cvs changes : marked tachycardia or bradycardia,hypotension Cns changes : lethergy , somnolence,seizures and coma

9. Respiratory distress – Clinical pearls Supra-sternal indrawing (Use of accessory muscles, Upper airway involvement) Intercostal indrawing (Decreased Parenchymal Compliance) Subcostal indrawing (Increased work of diaphragm)

10. Sounds during respiratory cycle Stridor (Extra thoracic airway structures) Wheeze (Intra thoracic airway structures) Grunt (Parenchymal lesions)

11. Types of Respiration Prolonged Inspiration Prolonged Expiration Deep Breathing Rapid shallow Breathing Apneoic breathing

12. Respiratory signs Extrathoracic Intrathoracic Pulmonary Retractions + + + + + + + + Stridor + + + + - Wheeze - + + + + + Tachypnoea + + + + + + Grunt - - +

13. History Mode of onset Severity Progress – increasing, stastic , decreasing Any PND Associated with other respiratory symptoms History of allergy Any known cardiac disease Treatment history

14. Mode of onset Acute /sudden Pneumothorax FB inhalation PND Bronchial Asthma

15. Insidious Pneumonia Bronchiolitis Pleural effusion/ empyema Bronchial asthma Pulmonary tuberculosis bronchiectasis

16. Assessment of severity G 1- dyspnoea on climbing upstairs/walking some distance/after crying G2 –After minor household work eg : dressing / undressing G3 – dyspnoea on rest

17. Progression R apidly increasing dyspnoea Tension pneumothorax Bronchial asthma Slowly increasing dyspnoea Pneumonia Bronchiolitis Empyema thoracic Asthma

18. Respiratory Distress - History Elucidate onset, duration, character, alleviating, and exacerbating factors and treatment to date. The impact that the symptoms have on everyday activities, such as playing or exercise and the oral intake of liquids and food are key. Always consider the possibility of an acute exacerbation of an indolent or more chronic process.

19. Physical The respiratory rate of the ill child is a key parameter The heart rate, temperature, and blood pressure all give supporting evidence to the physiologic state of the child Oxygen saturation - via pulse oximetry

20. Respiratory Distress by Location Location of Respiratory Distress Examples of Conditions Upper airway Croup, epiglottitis, foreign body, tracheitis Lower airway Asthma, bronchiolitis, foreign body Pulmonary parenchyma Pneumonia, interstitial lung disease, BPD, cystic fibrosis,empyema,effusion Mechanics Trauma, spinal or chest wall deformity Neuromuscular control Seizure, acute paralysis, myopathy, anoxic encephalopathy, head /spinal cord trauma, Extra-pulmonary: Cardiac, CNS, renal, Metabolic Heart failure, hyperventilation, renal failure, drug overdose, Metabolic acidosis

21. Respiratory Distress – Upper airway Is there noisy breathing on inspiration? Does the child's posture have an important impact on the airway being opened maximally (e.g., leaning in the sniffing position) and does it improve the condition? Is the noise barky, sonorous or harsh, or high-pitched? Stridor is a particularly important sign of upper airway obstruction

22. Lower airways Clinical signs of lower airway pathology include Hyperinflation of the lung and chest cavity. Accentuation of the expiratory phase of respiration. Accentuation of lung sounds on expiration. Wheeze is a particularly important sign of lower airway obstruction All that wheezes is not asthma - consider entities such as an aspirated foreign body, particularly with focal wheezing, or something compressing the intra-thoracic airways such as an enlarged lymph node

23. Parenchyma Clinical signs of parenchymal pathologies include: tachypnoea , grunting, and retractions Focal findings may include, decrease movement, intracostal suction, splinting of the chest wall changes in breath sound quality, and crackles Grunting is a particularly important sign of parenchymal involvement

24. Mechanics The mechanics of respiration can be disrupted by the presence of upper airway obstruction, lower airway obstruction, chest wall or neuromuscular abnormality, and extra pulmonary problems. These may lead to less than effective ventilation and respiratory failure. Examples include a reduced lung volume secondary to an intra-abdominal mass or large pleural fluid collection or the air trapping. Congenital or acquired skeletal abnormalities and trauma (e.g., flail chest).

25. Neuromuscular Ascertain breathing pattern: Is the rate slow or absent? Is the pattern of respiration insufficient to move the chest wall? Is there an unconscious state or active seizure that may impair normal respiration?

26. Non pulmonary Physical exam of the child with respiratory distress should be complete. Is there evidence of a primary brain problem leading to alteration of respiration? Is there primary heart failure with secondary respiratory distress? Any signs of other systemic disorders?

27. Non pulmonary – Contd.. Is there evidence of acidosis (i.e. Hyperpnoea) or other metabolic abnormality (i.e., Kussmaul respiration with fruity breath) that may cause respiratory distress? Is there evidence of renal failure, liver disease, or a congenital problem associated with respiratory distress? Is there a suggestion of drug overdose or drug effect that is leading to respiratory distress?

28. Assessment General condition:playful,toxic,drooling or continuous cough, Colour:pink,pale, or cyonosed Mental status; agitated, anxious, lethargic ,comatose Respiratory rate: tachypnea, episodes of apnea, Vital signs Facial deformity/ airway problem. Chest deformity, scoliosis

29. Assessment – Contd.. Hoarse voice, no voice or croupy cough. Accessory muscle use Stridor, wheeze, breath sounds, added sounds

30. Interventions Oxygen therapy by mask, nasal cannula or head box. Airway humidification. Avoid forceful examination of throat or neck. And neck & chest x-ray in suspected upper airway obstruction. Comfort the child. Maintain airway & breathing. ET intubation under controlled situation. Aerosol therapy-b2 agonist/ budesonide / adrenaline. Needle aspiration in suspected pneumothorax.

31. Investigations CBC, blood culture, electrolytes. Portable x-ray chest & neck. Broncoscopy- in suspected foreign body. ABG. Peak expiratory flow rate( PEFR). Further investigate if non-pulmonary causes suspected.

32. Management Establish IV line for drugs like steroids & antibiotics. Supportive care- correct dehydration, correct shock, dyselectrolytemia, fever. Continuous monitoring with pulse-oxymetry, TcO2 monitor, cardiac monitor.

33. Indications of mechanical ventilation Indications are mainly clinical Respiratory muscle fatigue, exhaustion, Diminished air entry –quite chest. Pulses paradoxus > 20-40 mm Hg. Deterioration of mental status. PaO2 < 60 mm Hg or cyanosis not corrected by oxygen. PaCo2 >50 mm H g and raising > 5 mm Hg/ Hr.

34. Thank you