Well-Child Respiratory Assessment Tips

Children are diferent from adults Infants have larger heads and occiputs relative to their body size; therefore the head is naturally flexed in the supine position. They also have large tongues in a small mouth and the trachea is shorter and more compliant. Due to these differences, a child’s airway is much easier to occlude than an adult’s (Saikia & Mahanta 2019).

A child’s upper and lower airways are also smaller than adults, and their lungs are not fully developed. They have soft, horizontally sloped ribs and poorly developed intercostals. Their chest walls are more compliant and children rely heavily on their diaphragm (Saikia & Mahanta 2019; RCHM n.d.). Causes of Respiratory Distress in Children The following are some common causes of respiratory distress in children.

Upper respiratory infections such as croup and influenza; Lower respiratory infections such as pneumonia and bronchiolitis; Bacterial infections such as bacterial pneumonia or tuberculosis; Allergies; Asthma;
Tobacco smoke (second-hand smoke);
Inhalation of a foreign body; and
Genetic conditions such as cystic fibrosis.

Assessing respiratory function in young children can be challenging. The nurse must adapt techniques to match the child's age and developmental level while systematically assessing the child's compete physical condition. Providing a quite, warm and comfortable environment will likely improve the quality of the assessment. The very young are at risk for hypothermia, they may require additional warmth.

Greeting observations:

• Parent-child bonding
• Preliminary inspection of the child
  • Airway
    • abnormal breathing sounds?
    • ability to vocalize
    • condition of lips, mouth & nose, excessive drooling, difficulty swallowing
  • Breathing
    • labored?
    • chest or abdomen excursion
  • Circulation
    • color of skin and lips
    • jugular distention
  • Disability or neurologic status
    • awake, alert, responsive to sound & verbal command
  • Euthermic to touch

History

• Onset and duration of signs and symptoms,
• Allergies
• Medications
• Hobbies and pets
• Respiratory diseases with a genetic component - eg, cystic fibrosis, emphysema (alpha-1-antitrypsin deficiency).
• Infectious diseases such as tuberculosis (remember high-risk groups).
• Atopic diseases such as asthma, hay fever and eczema
• Adventitious Breath Sounds: Stridor, Wheezes / Rhonchi, Crackles / Rales and Pleural Rub | (Ausmed Jan 20, 2020)
• YOUTUBE
• https://www.ausmed.com/cpd/articles/paediatric-respiratory-assessment 

Inspection

• Respiratory rate, rhythm and depth (shallow, normal or deep)
• Respiratory effort: mild, moderate, severe, inspiratory/expiratory ratio, shortness of breath
• Respiratory retraction: supraclavicular, intercostal, subcostal
• Use of accessory muscles: intercostal/subcostal/suprasternal/supraclavicular/substernal retractions, head bob, nasal flaring
• Symmetry and shape of chest
• Tracheal position
• Audible sounds: vocalisation, wheeze, stridor, grunt, cough - productive/paroxysmal
• Monitor for oxygen saturation

Auscultation

Use a pediatric stethoscope (diaphram) when listening to the chest of infants and young children. Listen to the full inspiration & expiration of a cycle before moving the stethoscope; abnormal sounds can be generated in one portion of the cycle. Breath sounds of toddlers are generally more intense and bronchial sounding than adults, with expiration more pronounced than inspiration.

• Systematically compare anterior lung fields side to side for the equality of breath sounds and presence of adventitious sounds
• Systematically compare posterior lung fields side to side for the equality of breath sounds and presence of adventitious sounds
• Effort
  • What is the respiratory rate?
  • Is there nasal flaring, grunt, tracheal tug or subcostal/intercostal recession?
• Efficacy
  • Assess air entry, chest expansion and oxygen saturations.
• Effects
  • Assess heart rate, skin colour and mental status.
  • 

Palpation

Wash and warm the hands to gently examine the tracheal mobility & alignment, head & neck lymph nodes, anterior & posterior chest. Observe for:

• Enlarged lymph nodes
• Tracheal immobility or deviation
• Subcutaneous crepitus
• Asymmetry of chest expansion
• Discomfort
• Capillary refill time >2 seconds (central/peripheral)
• Asymmetric tactile fremitus

When doing the assessment, keep in mind that respiratory rate of a child is more rapid than an adult.

View this UBC Learn Pediatrics "Learn Peds Respiratory - Palpation".

Symptoms of Respiratory Distress in Children

• Increased respiratory rate;
• Increased heart rate;
  
• Colour changes (e.g. bluish colour around the mouth or fingernails, pale or grey skin);
  
• Noises such as stridor, wheezing or grunting;
  
• Nose flaring;
  
• Retractions of the chest where it appears to sink in below the neck or breastbone with each breath;
  
• Sweating;
  
• Accessory muscle use;
  
• Sternocleidomastoid contraction;
  
• Changes in conscious state; and
• Body positions including thrusting the head backwards with the nose up orleaning forward while sitting. These positions are a final attempt for the child to improve their breathing.
  (University of Rochester Medical Center n.d.; RCHM 2019)

Early recognition of respiratory distress and deficit is vital to the successful management of sick children and the prevention of further deterioration or arrest. In order to manage respiratory distress, it is important to have a systematic approach to assessment (Perth Children’s Hospital 2018).

Generally, children in respiratory distress should have minimal handling - assessment can usually be made without touching the patient (RCHM 2019).

The ABCDEs approach - Airway, Breathing, Circulation, Disability and Exposure - is a simple and effective method of assessment (Perth Children’s Hospital 2018).

When assessing the airway, you should consider the following:

• Is there airway patency?
• Are there any signs of airway obstruction?
• Is the patient making noises (e.g. stridor, snoring)?
• Does the patient have a hoarse voice?
• Is there any neck swelling or bruising?
• Is there a foreign body present?
  (Perth Children’s Hospital 2018)

Drooling can be indicative of an obstruction. Patients with swelling such as epiglottitis will drool due to being unable/unwilling to swallow, and will often sit immobile with the tongue protruding (Gray & Chigaru 2017).

References

Elflein,J. Feb 3, 2021 COPD in the U.S. - Statistics & Fact.s Statistica https://www.statista.com/topics/4339/chronic-obstructive-pulmonary-disease-copd-in-the-us/

Gray, M & Chigaru, L 2017, Acute Upper Airway Obstruction in Children, World Federation of Societies of Anaesthesiologists, viewed 26 March 2020, https://www.wfsahq.org/components/com_virtual_library/media/9eccfd4c9f60b27ddeb3c6c72b433b57-ATOTW-368.pdf

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary lung disease [Internet] (Updated 2015). [cited 2016 Aug 12.] Available from: http://goldcopd.org/gold-reports/

PEDIATRIC ASSESSMENT 2016, New York State Department of Health. Emergency Medical Services for Children. https://www.health.ny.gov/publications/4157.pdf

Perth Children’s Hospital 2018, Serious Illness Assessment, Perth Children’s Hospital, viewed 26 March 2020, https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Serious-illness

Royal Children’s Hospital Melbourne 2019, Assessment of Severity of Respiratory Condition, Royal Children’s Hospital Melbourne, viewed 26 March 2020, https://www.rch.org.au/clinicalguide/guideline_index/Assessment_of_severity_of_respiratory_conditions/

Saikia, D & Mahanta, B 2019, ‘Cardiovascular and respiratory physiology in children’, Indian Journal of Anaesthesia, vol. 63 no. 9, viewed 26 March 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6761775/

University of Rochester Medical Center n.d., Signs of Respiratory Distress in Children, University of Rochester Medical Center, viewed 27 March 2020, https://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=90&ContentID=P02960

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