Paediatric Respiratory Assessment

In order to recognise, manage and treat respiratory conditions in children effectively, we need to be able to confidently assess a child’s respiratory rate, effort and efficacy.

In other words, we need to know what’s normal before we can assess what is abnormal.

Unlike adults, children breathe at different respirations per minute (rpm) according to age. It’s not uncommon for a newborn to have a respiratory rate of 60, whereas a 12-year-old can comfortably have a respiratory rate of 18 rpm (RCHM 2017).

The following table details the normal respiratory rate and heart rate for unwell children of different ages.

Paediatric Respiration and Heart Rate

Note: These are acceptable ranges for unwell children. They are not what would be expected normal ranges for healthy children.

Age	Approximate Weight (Kg)	Respiration: Breaths/Min	Heart Rate: Beats/Min
Term	3.5kg	25-60	110-170
3 Month	6kg	25-55	105-165
6 Month	8kg	25-55	105-165
1 yr	10kg	20-40	85-150
2 yr	13kg	20-40	85-150
4 yr	15kg	20-40	85-150
6 yr	20kg	16-34	70-135
8 yr	25kg	16-34	70-135
10 yr	30kg	16-34	70-135
12 yr	40kg	14-26	60-120
14 yr	50kg	14-26	60-120
17+yrs	70kg	14-26	60-120

(RCHM 2017)

Why are Children Different to 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 an adult’s 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.).

Overall, children’s smaller airways in addition to their other physiological differences mean they are more susceptible to airway obstruction, and their ability to breathe may be compromised by even minor injury or swelling (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.

(HealthLink BC 2019)

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 or
• leaning 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)

Assessment

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).

When assessing the breathing, you should consider the following:

• 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.

(Perth Children’s Hospital 2018)

Always Remember

You need to be aware of what is normal before you can recognise what is abnormal. It’s helpful to establish a baseline to compare progress or deterioration. Use a systematic approach, such as ABCDE.

The goal of assessment is not to make a diagnosis but to identify a deteriorating child and respond to the symptoms in order to prevent arrest. Consider oxygen, suction and medication depending on the assessment (Perth Children’s Hospital 2018).

Following the initial assessment (and resuscitation if required), a secondary structured assessment should be undertaken to identify any other key signs or symptoms (Perth Children’s Hospital 2018).

When assessing the airway, the life threat to identify is airway obstruction. This is a medical emergency and requires prompt management so that the patient can be oxygenated (RCHM n.d.)

• Perth Children’s Hospital, Serious Illness Assessment, https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Serious-illness
• Royal Children’s Hospital Melbourne, How are Children Different, https://www.rch.org.au/trauma-service/manual/how-are-children-different/
• Royal Children’s Hospital Melbourne, Normal Ranges for Physiological Variables, https://www.rch.org.au/clinicalguide/guideline_index/Normal_Ranges_for_Physiological_Variables/
• How To Assess a Deteriorating / Critically Ill Patient (ABCDE Assessment), https://www.ausmed.com.au/cpd/articles/abcde-assessment
• Rhonchi or Rales? Important Lung Sounds Made Easy, https://www.ausmed.com.au/cpd/articles/rhonchi-vs-rales-wheezing-crackles

References

• HealthLink BC 2019, Respiratory Problems, Age 11 and Younger, HealthLink BC, viewed 27 March 2020, https://www.healthlinkbc.ca/health-topics/rsp10
• 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
• 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/
• Royal Children’s Hospital Melbourne 2017, Normal Ranges for Physiological Variables, Royal Children’s Hospital Melbourne, viewed 26 March 2020, https://www.rch.org.au/clinicalguide/guideline_index/Normal_Ranges_for_Physiological_Variables/
• Royal Children’s Hospital Melbourne n.d., How are Children Different, Royal Children’s Hospital Melbourne, viewed 26 March 2020, https://www.rch.org.au/trauma-service/manual/how-are-children-different/
• Royal Children’s Hospital Melbourne n.d., Trauma Service: Primary and Secondary Survey, Royal Children’s Hospital Melbourne, viewed 27 March 2020, https://www.rch.org.au/trauma-service/manual/primary-and-secondary-survey/
• 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

(Answers: b, d, a)