Pediatric emergency medicine trisk 353

Flaring: reflexive opening of nares during inspiration with airway obstruction
Retractions: accessory muscle use manifest as inward collapse of chest wall as
a result of high negative intrathoracic pressure from increased respiratory
effort; supraclavicular, suprasternal, and subcostal retractions usually reflect
upper airway obstruction, intercostal retractions reflect lower airway
obstruction or disease but may be seen with severe upper airway obstruction
Head bobbing: extension of head and neck during inhalation and flexion during
exhalation, seen in neonates, young infants, reflects accessory muscle use
Stertor: snoring with nasal congestion, adenotonsillar hypertrophy,
neuromuscular weakness
Gurgle: inspiratory and expiratory bubbling sounds caused by secretions in the
oropharynx, trachea, or large bronchi
Aphonia/dysphonia: vocal cord obstruction, dysfunction
Muffled voice: oropharyngeal obstruction
Hoarseness: laryngeal obstruction, dysfunction
Barky cough: subglottic, tracheal obstruction
Stridor: abnormal turbulence over airway obstruction; (i) inspiratory: quiet,
high pitched from glottic, subglottic region; (ii) expiratory: loud, harsh from
carina or below; and (iii) biphasic: loud, harsh from trachea
Grunt: expiration against a closed glottis to maintain expiratory lung volume
with lower airway, gastrointestinal process
Tracheal deviation: shifting of trachea to nonaffected side of chest due to air,
fluid space-occupying process on contralateral side
Wheeze: continuous, musical; (i) obstructed bronchi, bronchioles—polyphonic
(variable pitched, regional differences) expiratory as in asthma; (ii)
obstructed central airway—monophonic (low pitched, same in all lung fields)
expiratory ± inspiratory as with tracheal foreign body, tracheomalacia
Crackles (rales): discontinuous, usually high pitched, inspiratory; moist, from
thin secretions in (i) bronchi, bronchioles (medium rales), or (ii) alveoli (fine
rales)
Rhonchi (coarse rales): discontinuous, usually low pitched, inspiratory; moist

or dry, from exudate, edema, inflammation of larger bronchi
Pericardial friction rub: saw-like sound, inspiratory, expiratory between
sternum and apex of heart due to pericardial inflammation, fluid
Hamman crunch/sign: pericardial crackles synchronous with heart beat due to
heart beating against pneumomediastinum, left-sided pneumothorax


Bronchophony, egophony, whispered pectoriloquy: alterations in voice sounds
as a result of lobar pneumonia, pleural effusion
Tactile fremitus: vibration on percussion increased with consolidation,
abscess, decreased/absent with bronchial obstruction, pleural cavity spaceoccupying lesion
Percussion of the chest may reveal either hyperresonance, suggesting air
trapping, or dullness, suggesting an area of consolidation, atelectasis, a mass in
the lung or pleural space, or pleural fluid ( Table 71.8 ). Air trapping is suggested
by depressed position of the diaphragm. Diaphragmatic excursion can be
accessed by measuring the difference between the level of dullness on percussion
during full inspiration and full expiration. Poor diaphragmatic excursion may
reflect diaphragmatic dysfunction.
The remainder of the physical examination should concentrate on the
neurologic, cardiac, gastrointestinal, renal, skin, metabolic/endocrine, and
hematologic systems as potential source of respiratory distress.

Approach
The approach to the child with respiratory distress ( Fig. 71.1A,B ) begins with
the assessment of airway patency, oxygenation and ventilation. For patients in
extremis, appropriate resuscitation as per Basic and Advanced Life Support
guidelines, should be initiated immediately. Patients in extremis ( Fig. 71.1A )
also require rapid identification and emergent treatment of underlying conditions.
Etiologies of extremis due to trauma most commonly include airway obstruction,
tension pneumothorax, flail chest, CNS depression and cardiac tamponade. The

most common causes of extremis in patients with no history of trauma are foreign
body, infection, and anaphylaxis.
For patients with mild to moderate respiratory distress, the initial focus of the
examination should be on the respiratory and cardiac systems. Assessment begins
with the observation of patient position, general appearance, work of breathing,
and respiratory sounds that can be appreciated without a stethoscope. This is
followed by evaluation of oxygenation and ventilation, and auscultation to assess
abnormal cardiopulmonary sounds. The remainder of the examination is
performed when the child is sufficiently stable to tolerate the examination.
All patients with respiratory distress should have their oxygenation tested
immediately by pulse oximetry. Capnography measures end-tidal carbon dioxide
(EtCO2 ) and CO2 waveform as a rapid means of assessing ventilation and can
help identify upper or lower airway obstruction. Stridor, altered phonation, and/or


dysphagia suggest partial airway obstruction. Children with abnormal
auscultatory findings (i.e., wheeze, rales, rhonchi, and/or asymmetric breath
sounds) and fever are likely to have infectious etiologies (e.g., pneumonia or
bronchiolitis).
Patients can be further categorized on the basis of tachypnea ( Fig. 71.1B ).
Children with rapid respirations and fever may have pneumonia, even in the
absence of rales; empyema, pulmonary embolism, and encephalitis are also
important considerations. Tachypnea without fever points to trauma, cardiac
disease, metabolic disturbances, toxic ingestions, or exposures. Febrile children
without tachypnea may have apnea or bradypnea as late manifestations of CNS
infection. In afebrile patients, considerations include CNS depression, spinal cord
injury, neuromuscular disease, and neonatal apnea.
Diagnostic tests should be performed selectively to evaluate for diagnoses
suggested by history and physical examination ( Table 71.9 ). Laboratory tests
can inform respiratory status and diagnosis.

Airway and chest radiographs can be helpful in determining the site and often
the etiology of respiratory distress, and may provide insights into the likely
clinical course. Flexible nasopharyngoscopy can help identify some etiologies of
upper airway obstruction, as indicated. Ultrasound may also provide information
on diagnosis, as well as guide the management ( Table 71.10 ). Pulmonary
ultrasound can be used to evaluate for pneumonia, pleural effusion,
pneumothorax, and hemothorax. Cardiac ultrasound can be used to detect
presence of a pericardial effusion and assess overall cardiac function. As
appropriate, ultrasound findings can then be confirmed with chest x-ray or formal
echocardiogram. For complete details on pulmonary and cardiac ultrasound
technique and findings, please refer to Chapter 131 Ultrasound .

Treatment
Regardless of the cause of respiratory distress, aggressive treatment must be
initiated immediately to rapidly address airway patency, oxygenation and
ventilation ( Table 71.6 ). In the alert patient, establish and maintain the position
that maximizes respiratory function. Every effort should be made to avoid
agitating the child. Supplemental oxygen can be administered using nasal
cannula, high-flow nasal canula, and simple or nonrebreather mask. Noninvasive
positive pressure ventilation, in the form of CPAP or BPAP may be trialed to
decrease work of breathing and improve respiratory status. In the patient with
decreased sensorium, positioning the airway by chin lift (contraindicated if neck
injury is suspected) or jaw thrust may relieve soft tissue obstruction of the airway.
The oral cavity should be cleared of secretions, vomitus, blood, and visible


foreign matter. In the alert patient with suspected soft tissue obstruction of the
airway, a nasopharyngeal airway may improve airway patency. In an unconscious
patient, an oropharyngeal airway can be placed to relieve obstruction. Bag-valvemask ventilation should be initiated in apneic patients or those with ineffective
respiratory efforts. The child in whom airway patency and/or adequate ventilation

and oxygenation cannot be established or maintained using noninvasive
approaches, requires endotracheal intubation. Indications for endotracheal
intubation directly related to respiratory distress include airway obstruction,
inability to handle secretions, and risk of aspiration, and respiratory failure.
Tension pneumo- or hemothorax and/or pericardial fluid causing tamponade must
be decompressed immediately. Ultrasound is increasingly being used in
management of patients in respiratory distress, including to establish lung
pathology, to confirm tracheal intubation, and to guide relevant procedures (e.g.,
thoracentesis, thoracostomy, pericardiocentesis). Adjunctive therapies that can
help with respiratory distress include placement of a nasogastric tube to
decompress a distended abdomen and full expansion of the lungs, addressing
fever, and correcting metabolic derangements and/or drug or toxin intoxication.