1. Respiratory Assessment of the Pediatric patient
And Mycoplasma…The GREAT Masquerader

2. Pediatrics…They are not small Adults
Accelerated growth and cell division in children
Children and infants cannot accumulate stores of nutrients/energy the way that adults can
Children and infants have a smaller airway diameter
Children and infants are often unable to indicate the site, severity or quality of their illness
There are physiological, metabolic and psychological differences that differentiate children and adults.
Which Results in a higher demand for energy and oxygen than in adults
As a Result will tire and fall towards respiratory failure much more rapidly than adults
Placing them at greater risk from conditions which further reduce airway size
Making it important to be well attuned in recognizing and interpreting the posture, body language and behavior of a respiratory compromised child.

3. Basic etiology of respiratory illness
Inadequate airway patency
Inadequate gas exchange
Inhalation of foreign object
Asthma
Croup
Bronchiolitis
Epiglottitis
Quinsy/Peritonsillar Abscess
Anaphylactic reactions
Middle or lower lobe chest infection
Viral Pneumonia
Bacterial Pneumonia
Pneumothorax
Hemothorax
Pulmonary edema
Severe Asthma
Severe Bronchiolitis
Respiratory compromise in children and infants is generally the result of either
Inadequate airway patency---resulting in inadequate ventilation of lungs and alveoli
Inadequate gas exchange within the lungs and alveoli
It should be especially noted that acute asthma and bronchiolitis may result in BOTH inadequate airway patency as well as inadequate gas exchange and these children should be closely observed and monitored for rapid deterioration of condition.

4. Measurable observations:
Respiratory Rate
Oxygen Saturation
Heart Rate
Blood Pressure
Temperature
Respiratory rate will rise in an effort to compensate for the effects of decreased air entry and/or decreased gas exchange and will often reflect work of breathing.
RR is an important indicator of respiratory function and a key indicator for respiratory distress. Infants and children who display tachypnea will tire and fall toward respiratory arrest if interventions are not initiated to increased gas exchange and ease work of breathing to lower the respiratory rate.
Oxygen Saturation measurement is a percentage of the hemoglobin’s maximum oxygen carrying potential. It provides us information about the efficiency of gas exchange within the lungs and is most useful in indicating the severity of congestive respiratory conditions seen in primary care such s pneumonia, asthma, bronchiolitis, and Flu-like illness.
Heart Rate will increase in response to increasing work of breathing and decreasing air entry/gas exchange. Remember that some treatment interventions may elicit tachycardia as a known side-effect. The most common among these are beta-agonists such as Salbutamol (Ventolin).
Blood pressure finding is most significant in respiratory compromise related to trauma (hemothorax/pneumothorax), however in the hemodynamically stable child BP rarely provides significant findings when applied to the respiratory assessment in the primary care setting.
Temperature: Febrile conditions in the respiratory compromised child are typical in cases of URI/FLU, Pneumonia and quinsy. Elevated temps may also elevate RR and HR but also not significant in determining respiratory status.

5. Initial Impression:
Does the child look well/unwell
Active, playful, interacting with toys/parents
Miserable, Distressed, unable to be distracted
Floppy

6. Behavior: Comfortable Restless/Irritable Lethargic/Flat Drooling
Comfortable: No obvious sign of distress. Interactive with parents and provider. Comfortable in the environment.
Restless/Irritable: Distressed, not easily distracted or comforted. Could result from sleep deprivation, hunger, sudden change of environment/routine, invasive/noninvasive procedures. In most cases these children can be comforted/entertained and consoled.
Lethargic/Flat: NEVER Confuse with “merely sleeping”. This child is difficult to rouse, may not be stimulated by assessment or even unpleasant/invasive procedures.
Drooling: Most commonly associated with Quinsy, severe croup and epiglottis. Results from the child’s unwillingness to swallow due to pain or fear of invoking a full airway obstruction.
Assessment of the Comfortable child should be balanced by all findings made during visual and auscultation assessments along with VS.
The restless/irritable child should be watched closely for increasing hypoxia
Severe Lethargy in the respiratory compromised child is indicative of advanced hypoxia, exhaustion and potential respiratory arrest
Drooling noted in upon physical exam should trigger the evaluation of deterioration of patent airway and increasing inflammation may also result in respiratory arrest.

7. Appearance: Loosen/Remove clothing to visualize the chest Color
Work of breathing
Nasal Flaring
Tracheal Tug
Sternal recession
Rib retraction/Accessory muscle use
To perform a visual exam you must be able to see the chest…loosen/remove clothing to view the torso/chest.
Pink!!
Cyanosed or dusky color changed in lips, oral mucosa and peripheries are often a LATE sign of severe respiratory distress resulting in hypoxia and indicate immediate intervention is necessary…Oxygen and higher level of care!
Work of Breathing or Respiratory effort refers to the effort/energy required in order for the child to move air in and out of the lungs.
Criteria described as absent, mild, moderate, severe: Nasal Flaring: noted during periods of inspiration. This IS a sign of respiratory distress and seen most significantly in an infant.
Criteria described as absent, mild, moderate, severe: Tracheal Tug: noted during period of inspiration. This is a “depression” or “sinking in” of the skin a t the site covering the trachea immediately above the sternum. Observable Tracheal Tug is indicative of respiratory distress and is consistent with conditions resulting in severe airway obstruction. Seen in severe croup, but could also be seen with inhalation of a foreign object and in infants with bronchiolitis.
Criteria described as absent, mild, moderate, severe: Sternal recession seen most commonly in infants occurs on inspiration and similar to the appearance of tracheal tug except it occurs at the site of the sternum. Seen in infants suffering severe bronchiolitis
Criteria described as absent, mild, moderate, severe: Rib retraction and accessory muscle use. This is an effort to overcome excessive resistance to the movement of air in and out of the lungs the body will enlist the aid of intercostal and accessory muscles. These muscles are not NORMALLY needed or required for the act of breathing. Commonly seen in children suffering acute asthma a retraction of the skin and muscle around the ribs can be seen on inspiration.

8. Upper, Middle, Lower Lung fields Good, Decreased, Tight, Nil
Auscultation:
Air Entry
Upper, Middle, Lower Lung fields
Good, Decreased, Tight, Nil
What cannot be heard, is often more significant that what can!
Upon Auscultation we are using our stethoscope to determine the patency of the airway/lungs and evaluate the quantity, quality and efficacy of air moving through the air way structure
Air Entry: Listening for the volume and extent of air movement throughout the respiratory system. Commonly described as Good-Normal, Decreased-Discernably less than, Tight-Minimal with wheeze, Nil-No audible movement of air
We are documenting this assessment in the upper, middle, and lower lung fields systematically
Normal sounds are the typical “whoosh” of freely moving air on deep inspiration and expiration
The Respiratory compromised child will exhibit an audible decrease in air entry, coarse breath sounds and or wheezes. In Tight and Nil assessment serious respiratory compromise and immediate intervention including immediate transfer to higher level of care.

9. Abnormal Respiratory Assessment
Cough
Wheeze
Crackles
Stridor
Grunting
Apnea
Cough: Voluntary or Involuntary response to irritation o the airway: URI, Partial upper airway obstruction, Pneumonia, Asthma, Croup, Bronchiolitis, Pertussis
*Frequency- infrequent, frequent, persistent
*Quality- Productive, Dry, Hacking, Non-Productive, Strong/Effective or Weak/Ineffective
*Characteristic- Barking, Whoop, Paroxysmal coughing (rapid repetitive and prolonged bout of coughing)
Wheeze: High pitched sound on inspiration or expiration caused by high-velocity flow of air through a narrowed airway. May be isolated to a particular airway structure or lung field, scattered or wide spread throughout the lung fields “Asthma”
Crackles: Usually associated with viral and bacterial URIs, pneumonias, asthma. Crackling/Popping sound created when air moves rapidly through respiratory structures constricted by ex essive collections of mucus. May also be isolated, scattered or wide spread throughout the lung fields. Could coincide with the development of a productive cough
Stridor: High pitched constricted/hoarse sound heard mostly on inspiration due to decreased volumes of air moving rapidly through a partial obstruction of the trachea or larynx. “Croup”. Consider this: a “soft inspiratory stridor” without “good air entry” is a child heading toward potential respiratory arrest.
Grunting: audible slow, even, release of air upon expiration. This act serves to increase end respiratory pressure and so prolong the period available for gas exchange within the lungs and alveoli. The residual pressure maintained within the lungs when expiration of air is restricted and controlled assists in keeping alveoli open and effective…a natural form of CPAP. Severe resp distress, particularly in the infant. Consider pneumonias, pneumothorax, hemothorax, pleural involvement, pulmonary edema and acute/severe asthma.
Apnea: Absence of spontaneous respiration lasting a few seconds to an excess of 20 seconds. Most often seen in infants…bronchiolitis is most common, but consider other respiratory, cardiac and congenital related conditions.

10. CASE Study

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12. Correct use of MDIs and Asthma Action Plan

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17. Resources