The inadequate gas exchange in the lungs resulting from any condition that compromises oxygenation and ventilation.
Goal of Care
Support airway and ventilation; improve oxygenation and rapid transport to the nearest facility.
Respiratory distress in a child is a very anxious situation for the child, the parents and the paramedics. The child presents with abnormal respirations (laboured, irregular, elevated or decreased) or cyanosis and pallor.
One of the key symptoms to guide management is the presence of stridor which can worsen if you try and intervene. Stridor signifies upper airway obstruction to the point of critical narrowing. Negative pressure during inhalation causes the tissues to get even closer and vibrate, causing stridor.
Stridor may be due to a foreign body or swelling due to infection or allergy. Patients with stridor should not be given Salbutamol as it can worsen the upper airway obstruction.
Wheezing, however, will respond well to Salbutamol. Therefore, it is very important to distinguish stridor, which is a problem inhaling, from wheeze, which is a problem exhaling.
In all cases prepare airway equipment and keep it handy.
Patients with stridor should be kept calm in the position that they prefer.
Oxygen can be administered, however, the patient must be closely observed. Complete obstruction can occur without a prior decrease in oxygen saturation in the pre-oxygenated patient.
Be prepared to intubate only in the event of complete obstruction.
In children with severe respiratory distress ”blow-by” oxygenation can provide enough extra oxygenation without distressing the child. Be calm and reassuring and hold the O2 or nebulizer at 90 degrees beside the mouth and nose so the child feels that his face is clear. He/she will be breathing a significant amount of the O2 and medication.
EPINEPHrine by nebulization can be used for patients with stridor if croup is the likely cause and the mask is tolerated. Croup scores can be calculated here, and for reference the BC Children's Hospital croup algorithm can be accessed here.
Salbutamol should be given to children with a history of asthma who are presenting with wheeze. If there is no history of asthma, transport urgently but do not expect Salbutamol to work as well as in asthma.
Severe life threatening asthma with failing respirations can be treated with EPINEPHrine by IM injection.
Administer EPINEPHrine IM if the likely cause is anaphylaxis.
If the patient with stridor completely obstructs, bag-valve-mask ventilation is often successful since it expands the upper airway under positive pressure. Intubation will be difficult so do not rush to intubate but do try to ventilate with the BVM.
If there is a history of foreign body aspiration, BLS maneuvers should be attempted to relieve the obstruction.
Respiratory distress in children is most commonly caused by viral infections. Other causes include bacterial pneumonia, aspiration pneumonia, and foreign body aspiration.
Signs of respiratory distress can be subtle in small children - important cues are accessory muscle use and overall appearance and activity level.