Respiratory Distress

RESPIRATORY
DISTRESS
SIGNS OF INCREASED WORK OF BREATHING
• Tachypnea
• Chest retractions (SC / IC / SS )
• Stridor / Wheeze / Grunt
• Flaring of Ala nasi
• Head bobbing
• Abdominal breathing
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RELATIONSHIP OF
COMPLIANCE – RESISTANCE – ELASTICITY ‐ RR

RESPIRATORY DISTRESS – PULMONARY CAUSES
Airway obstruction
• Ext. thoracic (Upper airway)
E.g.. ALTB / Epiglottitis / R.P. Abscess / L.Diphth
• Int. Thoracic (Lower airway)
Extra Pulm. (LAW) – E.g.. Vasc. ring / Med.Mass /
FBA
Intra Pulm. (SAW) – Broncholitis / Asthma
Parenchymal diseases
E.g.. Pneumonia
Pleural diseases
Empyema / Pneumothorax
STEP WISE APPROACH TO RESPIRATORY DISTRESS
1. Is it respiratory distress?
2. If so ‐ respiratory / Non respiratory
3. What is the anatomical level?
4. What are the useful investigations?
5. Are there features of respiratory failure?

R
Age Breaths per minute
< 2 months 60 or more
TACHYPNOEA IN DIFFERENT AGE GROUPS
2 months to 12 months 50 or more
12 months to 5 years 40 or more

NON RESPIRATORY CONDITIONS WHICH MIMIC
RESPIRATORY EMERGENCIES
• Cardiac failure
• Shock
• AGE with dehydration
• Metabolic acidosis (DKA, RTA)
• Salicylate poisoning
• Acute encephalitis

Acidotic Respiratory
Breathing VS Distress
RR  
ICR ‐ +
CVS Normal Abnormal
RS Normal Abnormal
CXR Hyperventilation Pneumonia
Empyema
Cardiomegaly

AN APPROACH TO A CHILD WITH INCREASED
RESPIRATORY RATE
Respiratory Cardiac Metabolic
Tachypnea ++ ++ ++
Chest Marked Minimal Nil
retraction

RESPIRATORY NOISES
Noises Phases Of Respiration Localization
Snoring Insp. / Exp. Oro‐pharynx
Stridor Inspiration Larynx
Wheeze Expiration Small AW
Grunt Expiration Alveoli

INTERPRETATION OF SIGNS
Airway
Parenchymal Dis. Pleural Dis.
obstruction
Upper Lower
Tachypnea ++ ++ +++ +++
Chest
+++ +++ ++ + ‐
Indrawing
Stridor +++ ‐ ‐ ‐
Wheeze ‐ +++ + ‐
Grunting ‐ ‐ +++ +++
DESCRIPTION OF RESPIRATION
• Rate
• Rhythm
• Depth
• Ease of breathing

RATE OF RESPIRATION
EVALUATION – RESPIRATORY DISTRESS
Respiratory pattern Diagnosis
Rapid, Shallow, Grunt Pleural,
Parenchymal Disease
Rapid, Prolonged Inspiration Croup Syndrome
with Stridor
Rapid, Prolonged Expiration Smaller Airway
with Wheeze Diseases – Asthma
Increased Respiratory Rate & Non‐respiratory ‐
Depth (Quiet Tachypnea) Metabolic Acidosis

EVALUATION – RESPIRATORY DISTRESS
Respiratory pattern Diseases
• Paradoxical Breathing •C.C.F
• Tachypnea with minimal •Diaphragmatic Paralysis
I.C.R. with tachycardia •Brain Stem Injury
• Irregular Rate, Depth &
Rhythm (Biots Breathing) •Barbiturate Poisoning
• Slow / Shallow / Drowsiness

CHOICE OF INVESTIGATIONS

• X‐ray chest – Respiratory / CVS
• CBC / CRP / Blood culture
• Culture of sputum / Nasopharyngeal secretions /
Tracheal aspiration
• Assessment of hypoxia – Pulse oximetry / ABG

•X‐ray neck lateral – Upper airway obstruction
•Barium swallow ‐ To R/O Tracheal compression ADDITIONAL INVESTIGATIONS
•CT Chest – Extra luminal causes
•FFBS – Intraluminal obstructions
•Echo – Cardiac evaluation
•US Chest ‐ To R/O pleural fluid

INCREASED RESPIRATORY WORK
Respiratory
Failure
Lung Failure Non-Respiratory Pump Failure

Interstitial Disease “Shock” Central &
Alveolar Disease Peripheral
Gas Exchange Respiratory Ventilatory

Failure Hypoxemia work Failure
Hypercapnia
Fatigue
ASSESSMENT OF RESPIRATORY DYSFUNCTION
Clinical
• Hypoxia (irritability, agitation, mental confusion,
drowsiness, hypotonia)
• Hypercarbia (generalised vasodilation, flushing)
• Muscle fatigue (sea‐saw respiration)
Biochemical
• PaO2 < 60 mm Hg
• PaCO2 > 50 mm Hg
• pH < 7.3

STAGE OF RESP. DISEASE ‐ ABG
pH PCO2 HCO3
PO2
i. Resp. Alkalosis   N N
ii. Transitional N   
iii. Resp. Acidosis  N/ N/ 
iv. Combined Acidosis    

RESPIRATORY DISTRESS ‐ ABG
PO2

PCO2 pH
• Resp. Distress without Resp. Diseases
(Hyper ventilation)
E.g.. ‐ CNS Stimulation N  
‐ Metabolic Diseases N  

• Severe RF Without
Obvious Resp. Signs
(Hypo ventilation)
E.g.. ‐ CNS Depr / Neuro Musc   

• Inability to drink
• Severe dyspnea
• Diminished air entry
• Stridor at rest
• Audible wheeze
• Expiratory grunt
•
•
•
Cyanosis
Apnea
Gasping
RESPIRATORY DISTRESS – WHEN TO REFER?

CONCLUSION
• Respiratory distress is not a disease – Symptom / sign
• A good history and thorough physical examination ‐
Clue To Diagnosis
• RR, ICR, Resp. Noises – Pin point the diagnosis
• X‐ray chest – conforms
• ABG – Specify / Quantify
• RR – Ominous sign
• Early identification and prompt treatment –
rewarding
• RR IS THE SIMPLEST PFT – DAY TO DAY PRACTICE

THANK YOU

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RESPIRATORY

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Respiratory Cardiac Metabolic

Tachypnea ++ ++ ++

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Snoring Insp. / Exp. Oro‐pharynx

Stridor Inspiration Larynx

Wheeze Expiration Small AW

Grunt Expiration Alveoli

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Lung Failure Non-Respiratory Pump Failure

Gas Exchange Respiratory Ventilatory

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ii. Transitional N   

iii. Resp. Acidosis  N/ N/ 

iv. Combined Acidosis    

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PO2

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