DIFFICULTY
BREATHING
Pediatric
Variety of presentations including (but not
limited to):
- "common cold":
- red eyes
- fever
- swollen glands
- sore throat
- cough
- nasal congestion/discharge
- Wheezing:
- high pitched purring or whistling during expiration due
to bronchospasm
- most common cause
in children < 12 months of age is
bronchiolitis
- most common cause
in children > 3 years old is asthma
- Croup:
- hoarseness
- tight, low pitched cough resembling a barking seal
- wheezing may be heard during inspiration and expiration
- harsh raspy inspirations (stridor) seen with severe croup
A. Obtain and record telephone triage
assessment that includes:
|
|
- Rate and quality of respirations
- instruct
caller to put phone to child's nose & mouth and
listen carefully
|
- Associated symptoms and behavior
|
cough
|
exertional dyspnea
|
difficulty
feeding
|
fever
|
position
of comfort
|
ability
to speak in sentences
|
drooling
|
chest
pain
|
cough
(short, wet, bark, etc)
|
|
choking
|
vomiting
|
eye or
nasal discharge (color?)
|
earache
|
wheezing
|
sore
throat and/or hoarseness
|
headache
|
retractions
|
level of
consciousness
|
rash
|
stridor
|
difficulty
swallowing
|
cyanosis
|
hemoptysis
|
foreign body aspiration
|
pallor
|
grunting
|
inability
to bend neck forward
|
B. Risk Factors which increase the
acuity of the pediatric patient:
- Infants or small children
- Chronic or recent illnesses
- Immunosuppressed
- Recent trauma, surgery, or childbirth
- Cardiac disease
C. Activate Emergency Medical System
for Ambulance Transport (Call 911 now!)
- Severe difficulty breathing
- Decreased level of consciousness or syncope
- Grunting respirations
- Wheezing after ingestion of medication,
allergic food, or bee sting
- use prescribed anaphylactic kit as directed for known
allergies
- Blue lips, tongue, face, or ears
- Pale or gray face with clammy skin
- Drooling or inability to swallow
- Apnea (give instructions for mouth to mouth breathing)
- Apnea for >15 seconds
but has now returned
- Unable to speak or cry
- Requires sitting position or leaning forward position
D. See Immediately
- Triage nurse should advise the use
of an ambulance when the patient's current status is life
threatening, may deteriorate enroute to hospital, or
anxiety level is too high to safely drive to closest ED.
- Difficulty breathing not relieved by cleaning nose (under
12 months of age)
- Difficulty breathing when not coughing (over 12 months of
age)
- Facial cyanosis during coughing spasms
- Younger than 12 weeks of age with fever greater than 100.4
degrees F rectally or Fever greater than 105 degrees F
- Child choked on foreign body or small object
- Severe chest pain
- Retractions with moderate or minimal difficulty breathing
- Stridor not responsive to 20 minutes of steam mist
- Unable to bend neck forward
- Wheezing heard from across the room
- Tachypnea
- respirations > 60
in infants less than 12 month of age
- respirations > 40
in children older than 12 months of age
- Child looks like he did before when hospitalized for difficulty
breathing
- Peak flow less than 50% of the personal-best baseline
- Asthma/wheezing not improved after normal home management
- Child < 3 months
old
- Parent or caregiver is extremely anxious regarding this episode
- Child sounds very ill to triage nurse
- Has risk factor along with any of the above
E. See Within 4 Hours:
- Continuously or nonstop
coughing, non-responsive to:
- home care advice for general cough
- mist treatments for croup
- 2 asthma treatments with nebulizer or inhaler
- Stridor which responds to mist but has occurred 3 or more
time in past 24 hours
F. See Within 12 - 24 Hours:
- Younger than 4 weeks old with a cough or symptoms of croup
- Younger than 3 months
of age with a cough for >3 days
- Fever for more than 3 days
- Earache with or without discharge from the ear canal
- Mild or unexplained wheezing
- Yellow or green nasal drainage for more than 3 days
- Sinus pressure or headache
- Blood tinged sputum
- Coughing induced chest pain
- Coughing induced vomiting on more than 3 occasions
- Has missed more than 3 days of school
- Severe sore throat
G. Home Care Advice
- Increase fluid intake of clear fluids
- for coughing spasms, encourage warmed, clear fluids (apple
juice, tea, etc)
- Older child can suck on hard candy or cough drops
- Clean nose with warm water or saline nose drops or spray;
then use bulb syringe
- Use humidifier or cool mist vaporizer in bedroom
- Encourage small, frequent feedings
- Encourage proper use of asthma medications, allergy medications,
etc
- Avoid known triggers of asthma and allergies (tobacco smoke,
animals, etc)
- If coughing induces vomiting, reduce feeding amounts
- Avoid active or passive smoking
- Use cough suppressant for severe coughs as approved by MD
- For croup, sleep in same room as child for a few nights
- For stridor, croup, respiratory distress,
or severe coughing:
- breath warm mist from a steamy
bathroom for 15-20 minutes
- bundle child, and go out into the cold night air for
15-20 minutes
H. Call Back If:
- Signs of respiratory distress
- Breathing not improved 20 minutes after use of asthma nebulizer
or inhaler
- Fever lasts for >3
days
- Fever goes away for > 24
hours and then returns
- Nasal discharge lasts
for >10 days
- No improvement after warm mist treatment or cold air treatment
- Child looks or seems worse
- Increased parental concern, anxiety, or new questions
- Any of the above mentioned symptoms appear, if current symptoms
change, or new symptoms develop
(Briggs, 1997; Brown, 1994; Fleischer, Ludwig,
1993; Schmidt, 1994; Suddarth, 1991)
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RnCeus.com