3 Respiratory Distress
Etiology and Pathogenesis
Clinical Presentation
Initial Assessment
The evaluation of a child with acute respiratory distress includes determining the severity as well as the underlying cause. Given that respiratory distress may range in severity from mild to severe, the clinical presentation can be quite varied. In all cases, the first key to the assessment is to ensure the patency of the airway, adequate breathing, and intact circulation (see Chapter 1). After these basic life support principles have been addressed, the physical examination may proceed.
History
A thorough history, including existing medical problems and recent events leading to the current presentation, provides important clues to the underlying cause (Table 3-1). For example, a patient with a foreign body obstruction or anaphylaxis may have an acute presentation of severe respiratory distress compared with a child with an infectious cause in whom the presentation may be more gradual.
Component | Comments and Examples |
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Onset, duration, and chronicity |
Physical Examination
Vital Signs
Vital signs, including temperature, heart rate, blood pressure, respiratory rate, and pain score, should be promptly obtained in all patients with respiratory distress. Pulse oximetry, although not classically part of the vital signs, should also be noted to detect hypoxia. Tachypnea (rapid breathing) is one of the most consistent findings among children with respiratory distress and may be caused by fever, hypoxemia, hypercarbia, metabolic acidosis, pain, or anxiety (Table 3-2). However, many children with significant respiratory disease may have normal respiratory rates. Bradypnea may also occur in response to hypoxia in younger infants or from respiratory fatigue, CNS depression, or increased intracranial pressure. Pulsus paradoxus, an exaggeration of the normal decrease in blood pressure during inspiration, of greater than 10 mm Hg correlates well with the degree of airway obstruction but is very difficult to assess in children and therefore not routinely measured.