pRRAPID

B

Breathing

RECOGNITION AND RESPONSE

Once you are happy that the Airway has been assessed and is patent or managed then you should assess breathing.

Looking at the child from the end of the bed can usually identify someone who is struggling to breathe and is hypoxic but these skills take experience and time to develop.  The assessment includes:

  1. Work of breathing:
  2. Efficacy of breathing:
  3. Effects of breathing on other organs:

Immediately life threatening respiratory conditions such as a severe asthma, tension pneumothorax or haemothorax should be recognised and treated without delay.

A

Recognition

Effort of breathing:

  • Respiratory rate
  • Recessions
  • Accessory muscle use
  • Flaring of nostrils
  • Inspiratory and expiratory noises: wheeze, stridor, and crepitations?
  • Grunting
  • Posture/position

Efficacy of breathing

  • Equal air entry?
  • Percussion note
  • Trachea central?
  • Gasping? • SpO2 in air
  • Chest movement

Effect on body:

  • Heart rate
  • Capillary refill
  • Conscious level

Response

  • If not breathing- ventilate with a bag-valve mask (BVM) device
  • Give O2 15 L/min via a non-rebreathe mask with reservoir bag
  • Aim O2 saturations 94-98%
  • Blood gas (ABG) – usually performed venously or capillary in infants and small children
  • Chest X-ray (CXR)
  • Site a nasogastric tube (especially if using a BVM)

Recognition

 

Effort of breathing

Respiratory rate (RR)

It is important to understand the physiological changes in respiratory rate in order to accurately determine if the RR is raised. Tachypnoea is often one of the first signs of respiratory inadequacy. Respiratory rate is a useful parameter for tracking patient improvement or deterioration (e.g. on a Paediatric Early Warning Score)

Recessions (also known as retractions)

Anatomically there are different recessions:

  • Sternal
  • Subcostal
  • Intercostal

The degree of recession will often given an indication of the severity or respiratory disease.  In children over five-years-of-age recessions are a sign of significant compromise.

Video: Child with grunt (secondary to viral wheeze).
This video is courtesy of Dr Damian Roland and is also available at:
https://www.youtube.com/watch?v=KQTEu1mpRY8

Accessory Muscle use

Increased work of breathing leads to use of the sternocleidomastoid muscles, found in the neck, causing “head bobbing”.

Flaring of nostrils

Flaring of the nostrils is a sign of respiratory distress

Added sounds

  • Stridor: high pitched inspiratory noise (upper airway obstruction)

  • Wheezing: expiratory noise (lower, intrathoracic, airway narrowing, usually at the level of the bronchioles).  Often audible without a stethoscope.

Video: Respiratory Distress in an infant - audible expiratory wheeze.
This video is courtesy of Dr Damian Roland and is also available at:
https://www.youtube.com/watch?v=QNrsjDzD0QM

  • Grunting: an expiratory noise created by exhaling against a partially closed glottis.  This is a physiological attempt to generate a positive end-expiratory pressure.  Regardless of its cause grunting is a sign of severe respiratory compromise.

Rewatch the Recessions video (above) and this time note the grunting.

Posture/position

Children will often find a posture that minimises their respiratory compromise.  The child should be supported in this position rather than moving them into what you feel to be the best position. 

There are three exceptions which demonstrate that the severity of respiratory distress (“increased work in breathing”) does not always correlate with the severity of the respiratory compromise
1. Exhaustion – Exhaustion is a pre-terminal sign. Children who have had increased work of breathing for a prolonged period of time may progress into decompensation.
2. Neuromuscular disease
3. Central respiratory depression

 

Efficacy of breathing

Air entry

Air entry should be equal and heard in all areas of the lungs.  The quality of air entry and expiration should be quantified.  A “very quiet” or “near silent” chest is a  sign of significant disease and is ominous.  Prolonged air expiration can indicate gas trapping in bronchoconstriction.

Chest movement

Chest movement should be observed and will demonstrate the extent and symmetry of chest expansion. 


Abdominal breathing:

Abdominal breathing is a sign of respiratory distress seen in children and is a sign of respiratory distress.  It results in the appearance of a see-saw.

Video: abdominal breathing (as well as the abdominal breathing, you will also note evidence of intercostal recessions in combination with a VSD cardiac surgery scar).

Percussion note

Different percussion notes will indicate the state of the underlying lung:

  • Resonant: normal air filled lung
  • Dullness: underlying collapse, consolidation or effusion
  • Hyper-resonance: pneumothorax

SpO2 in air

>94% is normal.  As arterial blood gases are often not used in children a SpO2 <90% in air or <95% in oxygen indicates respiratory failure.

If oxygen saturations are low it is important to ensure that the reading is “true”.  For example movement, poor peripheral circulation etc can lead to poor traces. 

Tracheal position

Should be central.  Deviation can be away from a pneumothorax or towards a collapse.

 

Effect on body

Heart rate

Hypoxia will usually cause tachycardia as the heart has to work harder to deliver oxygen to the body. Severe or prolonged hypoxia will ultimately lead to bradycardia. Bradycardia is therefore a pre-terminal sign.

Capillary refill time

Hypoxia causes vasoconstriction and therefore a prolonged capillary refill time (CRT).

Conscious level

Either hypoxia (oxygenation failure) or hypercapnoea (ventilation failure) can cause agitation or drowsiness. This can be associated with a general hypotonia.

 

Response

Response depends upon the clinical findings with the focus being on maintaining a patent airway and ensuring effective oxygen delivery and CO2 clearance:

  1. If the child is breathing normally:
  2. If the child is NOT breathing normally: