Respiratory Distress

December 23, 2022
Paediatrics
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Written by Dr Rebecca Evans, ST3 Paediatrics

One of the most common presentations to paediatric A&E is “SOB” “DIB” or “increased WOB”. There are many different causes of respiratory distress in infants and children, and it is important o be able to narrow down your list of differentials so you can tailor your management plan appropriately.

Knowing when to refer to paeds is pretty easy because any baby < 3 months with respiratory distress, any child needing oxygen or nebulisers and anyone with moderate to severe respiratory distress will need to be seen by your friendly paeds reg. But you need to be able to come up with a list of differentials and start some initial management.

I hope that this article will help you feel somewhat confident in how to assess a baby or a child with respiratory distress and give you some context of what you want to look for in your examination and important questions for the history and why.

Contents

Common causes of respiratory distress:
Initial Assessment in a baby < 1yo:
History for baby < 1yo:
Investigations:
Differentials:
Initial Assessment in a child > 1yo:
History if > 1yo:
Investigations:
Management:
Acronyms

Common causes of respiratory distress:

0-4 months: bronchiolitis, sepsis, congenital cardiac anomaly, inborn error of metabolism
0-1 year: Bronchiolitis, LRTI, croup, inhaled foreign body, aspiration pneumonia, sepsis
1-4 years: viral induced wheeze, LRTI, croup, inhaled foreign body, anaphylaxis, mediastinal mass,
> 4 years: Asthma, anaphylaxis, pneumothorax mediastinal mass, neuromuscular disorder

When you’re asked to go see a baby or child with respiratory distress in ED it can be daunting, particularly with worried parents present. However, you just need to take the same approach you would for any initial assessment: A-E approach and call for help if you’re worried or if the PED nurses are worried (their experience and gestaldt are invaluable for junior doctors).

If a child is in severe respiratory distress and you feel out of your depth, immediately call for senior help, put on 15L oxygen via non rebreathe mask, ask for a cap gas and prep a tray for a cannula – it’s that simple, you should not be expected to manage this on your own.

Initial Assessment in a baby < 1yo:

A – are they crying? This is a good sign! It means they have a patent airway. Listen for stridor, if not present at rest is it present when they start crying?

B – RR and oxygen saturations.

Assess work of breathing. Signs of increased WoB: IC and SC recession, tracheal tug, sternal recession, nasal flaring, head bobbing, grunting. Head bobbing and grunting are particularly concerning and if these signs are present it would be useful to get a capillary blood gas.

Auscultate for crackles, wheeze, reduced air entry.

C – Are they warm centrally and peripherally? CRT, HR, BP. Look for signs of dehydration such as dry mucous membranes and sunken eyes / fontanelle. Auscultate for heart murmurs (the absence of a heart murmur does not rule out a congenital cardiac anomaly). Feel femoral pulses.

DON’T EVER FORGET GLUCOSE – hypoglycaemia can present with respiratory distress and grunting in a baby. Assess AVPU. If alert are they irritable or miserable? This is important to distinguish. A miserable child will settle with cuddles and when you stop examining them, an irritable child will have a high-pitched cry and be inconsolable. Feel the fontanelle if patent, is it flat or bulging? Is their tone normal or are they floppy or stiff?

E – If fever is present fully expose to look for rashes.

Palpate the abdomen, different pathologies causing abdominal pain could present with respiratory distress. Feel for organomegaly: heart failure will present with hepatomegaly and inborn errors of metabolism may present with organomegaly

Examine the genitalia, it’s rare but a child with undiagnosed CAH (with ambiguous genitalia) can present with an adrenal crisis with respiratory distress

At each point of your assessment, if you find an anomaly then treat it before moving on, e.g. if oxygen sats are low then place in oxygen and wait for sats to improve before moving on to assess C. If they are haemodynamically compromised with prolonged CRT / tachycardia / hypotension prep for a cannula. If you feel confident in paediatric cannulas then go for it, if you’re not confident then don’t be the hero, ask for help and be useful in other ways such as prescribing antibiotics and fluids

History for baby < 1yo:

How many days have they been unwell for, has there been cough / coryza / fever. Is anyone else unwell at home? / was it a very sudden onset that would suggest they inhaled a foreign body?
If the baby is <3 months and there is a history of fever > 38 they need to be managed as presumed sepsis until proven otherwise.
An invaluable question in a paediatric history is What’s changed? If they’ve been unwell for a few days why have you bought them in to see me now at 4am? The answer might just be that they couldn’t get a GP appointment and the parents thought ED would be quiet, or it might be very useful such as they’ve not had a wet nappy for 18 hours or their work of breathing has deteriorated rapidly etc.
Feeding history is very important, how are they feeding compared to normal? Our general threshold at which we’d intervene with IV fluids or NG feeds is if they’re drinking < 50% of normal or look clinically dry. Are they still waking regularly for feeds or are you having to wake them? If they’re breastfed are they feeding for a similar length of time or are they getting tired and falling asleep? If bottle fed how much are they taking compared to normal? How many wet nappies are they having compared to normal? Are they sweaty or breathing faster when feeding? (would indicate a cardiac problem)
A birth and neonatal history is important in this age group. Ex-preterms are more prone to respiratory illnesses such as bronchiolitis and you should be wary of an ex-prem with chronic lung disease presenting with bronchiolitis even if they look well. If the baby is < 3mo and you’re considering sepsis are there any risk factors such as group B strep?
Are they fully immunised? An unimmunised child could present with whooping cough, meningococcal sepsis, epiglottitis
Is there a FH of any inheritable illnesses? Are parents consanguineous?
Obviously there are many other questions you can ask but these are the main things I would want to know if I was being referred a baby from PED.
Always listen to parents and acknowledge their concerns, they know their baby far better than you and whilst a worried parent with a well baby does not warrant a referral to paeds, it should make you think if there’s something you’re missing.

Investigations:

Paediatricians have a more minimalist approach than adult medics. X-rays expose babies and young children to harmful radiation and blood tests can be extremely distressing
If you are requesting investigations think how are these going to help you and how will they influence your management plan? If you don’t know the answer or you are doing them just out of habit then rethink your plan and talk it through with a colleague.
Viral NPA is probably the most common investigation we send from paeds and will be useful in confirming a viral illness.
Respiratory distress is not an indication for a CXR in a child. However, if they had severe respiratory distress needing a high concentration of oxygen or highflow / CPAP then you would want a CXR to rule out a lobar collapse or large area of consolidation.
A blood gas would be indicated in cases of moderate to severe respiratory distress to look for type 1 respiratory failure and to help you decide on escalating treatment. A gas can also give you an idea of hydration status using lactate, electrolytes and base excess.
Bloods are not of much use here as a general rule. If a child is stridulous please do not even attempt bloods or a cannula. Obviously the exception to this would be if sepsis is suspected then you need a blood culture, an FBC and a CRP, OR if a baby or child is acutely unwell with haemodynamic compromise, then you will be obtaining IV access anyway and can send a baseline set of bloods.
If you’re set on doing bloods but don’t need a cannula think if they can be done by heel or finger prick. These can be done by the nurses and are less invasive and less painful for the child.

Differentials:

Bronchiolitis will present with a few days of cough and coryza with reduced feeding. Often a parent or older sibling will have a cold at the same time. There will be mild- severe increased work of breathing and on auscultation you will often hear widespread crackles and wheeze.
A LRTI presents in a similar way but sometimes with a more productive cough or and creps or reduced air entry on one side of the chest. A child who has had bronchiolitis can present with a secondary opportunistic bacterial infection with a prolonged history of illness but new fevers.
An inhaled foreign body often presents with a very sudden onset of respiratory distress, often after playing unsupervised and then the parent will hear them choking and coughing. They may also have stridor or added airway noises + tracheal deviation and reduced AE on the affected side.
Croup presents with a short history of a loud barking, seal like cough (once you’ve heard it you won’t forget it), which is worse at night time +/- stridor which can be present at rest if severe or just when crying if milder.
A septic baby will present with fevers, tachycardia, tachypnoea, hypotension, poor feeding, irritability. There may be a history of GBS in the pregnancy or other risk factors for sepsis such as prolonged rupture of membranes or maternal sepsis.
Inborn errors or metabolism can present with tachypnoea, irritability, haemodynamic instability, feed intolerance and a FH of consanguinity or metabolic problems. These babies will likely have electrolyte imbalance on a gas with high lactate and a low blood sugar.
Undiagnosed congenital cardiac disease can present immediately postnatally (day 0-7) if duct dependent with: cyanosis, haemodynamic instability and poor feeding. They will have low sats not responding well to oxygen, hepatomegaly and weak or impalpable femoral pulses. There may or may not be an audible murmur on auscultation. A baby with a cardiac condition can also present after 7 days of age with a longer history of failure to thrive with poor feeding, sweating, SOB +/- cough and will examine similarly.

Initial Assessment in a child > 1yo:

A – are they crying or talking? Is there stridor or do they have stertuous breathing? (snoring)

B – RR, oxygen sats. Assess work of breathing. Auscultate for creps, wheeze, reduced air entry. If you cannot hear wheeze THINK: is it because they are tight and have little air entry? Wheezers can often present with a tight chest and it can be difficult to appreciate wheeze but after 1 or 2 salbutamol nebs it will open them up and they will suddenly sound wheezy.

C – Are they warm centrally and peripherally? CRT, HR, BP. Any signs of dehydration? (sunken eyes, dry mucous membranes, cool peripheries) Feel peripheral pulses, brachial or radial

D – BM, AVPU

E – Exposure for rashes. Palpate the abdomen for tenderness and organomegaly. LRTI can present with abdominal pain and an empyema can present as an acute abdomen.

History if > 1yo:

How many days have they been unwell for? History of cough / coryza / fever? Have they presented in a similar way before? E.g. recurrent LRTI in CF or recurrent ViW
If there is a history of cough, SOB and swinging fevers for 5 or more days consider an empyema in your differentials.
If there a history of atopy or FH of atopy? Is there a history of interval symptoms (this means symptoms of poorly controlled asthma such as nocturnal cough, SOB on exertion, regularly using salbutamol at home)
If the child has a history of wheeze, have they previously needed HDU / ICU care? Have they needed intubation? These are predictors of more severe exacerbations of wheeze / asthma that may require repeated intensive care admissions
Ask about oral intake. We’re not too bothered about food, if you’re poorly you won’t want to eat but drinking is really important. How much are they drinking and how many wet nappies are they having?
Do they go to nursery / school? Have parents been notified of any illnesses going around at the moment?
Are they fully immunised? Against flu / COVID / whooping cough / HiB (causes epiglottis) (asking if imms are up to date is enough to gauge this information, but these are the illnesses you’re thinking about if they’re unimmunised and presenting with respiratory distress.)

Investigations:

The same rule applies for older children with chest x-rays, be sparing with your radiation. If a child has severe refractory wheeze then a chest x-ray would be useful to rule out a foreign body or mediastinal mass, especially if it is a first episode of wheeze in a child with no history of atopy. (A mediastinal mass presenting with wheeze is not as rare as it sounds, I’ve seen 2 in 5 years)
Bloods and a CXR should be done in a child with a history of prolonged fever for 5 days or more to look for an empyema +/- raised inflammatory markers and help guide your management.
If a child is on very regular salbutamol or a salbutamol infusion then regular gases will be needed to monitor potassium and lactates rather than U&Es. (salbutamol drives potassium into your cells so the serum potassium can plummet, and lactate can increase secondary to salbutamol toxicity.)

Management:

Obviously your management plan will differ based on your differentials but in a very unwell child your first management should always be call for help and give the child oxygen. In a child with stridor the best approach is a hands-off approach with the aim to not upset them to the point of occluding their own airway.

For management of individual conditions please see other articles linked below:

Bronchiolitis

Croup

Viral Induced Wheeze