Pediatric Advanced Life Support (PALS) Course

Recognize Respiratory Distress or Failure

Figure 11

In its simplest form, respiratory distress is a condition in which pulmonary activity is insufficient to bring oxygen to and to remove carbon dioxide from the blood. Challenge arises with the recognition of respiratory distress when the person appears to be breathing but is not actually breathing effectively. Proper rate and depth of breathing is important to assess when evaluating whether the person is effectively breathing. The two main actions involved in breathing are ventilation and oxygenation. Consider the signs and symptoms presented below.

VENTILATION
Is the airway clear?	Are the musclesof the chestfunctioning?	Is the rate ofbreathingsufficient?
Ex. An obstructedairway preventsgas flow	Ex. Chest musclefatigue can occur	Ex. CNSdepression canslow/stop breathing

OXYGENATION
Is oxygen available?	Is lung bloodflow adequate?	Can gases cross thepulmonaryvasculature?
Ex. High altitudeshave low O2	Ex. Vascular shunts may not send bloodto lungs	Ex. Pulmonaryedemaor pneumonia

Abnormal breath sounds

STRIDOR	• Upper airway obstruction (foreign body)
GRUNTING	Upper airway obstruction (Swollen airway) Pneumonia (grunting to recruit alveoli)
WHEEZING	• Lower airway obstruction (Asthma)
CRACKLES	• Fluid in lungs (Wet), Atelectasis (Dry)
ABSENT/DECREASEDBREATH SOUNDS	Collapsed lung (air, blood) Lung tissue disease (pneumonia)

Table 11

In some instances, breath sounds can provide information about the source of the breathing problem.

CAUSES OF RESPIRATORY DISTRESS/FAILURE

Respiratory distress or failure generally falls into one of four broad categories (Table 12): upper airway, lower airway, lung tissue disease, and central nervous system (CNS) issues. This list is not comprehensive, and specific conditions should be addressed with specific therapy; but these represent the most common causes of respiratory distress or failure in a pediatric population.

UPPER AIRWAY	LOWER AIRWAY	LUNG TISSUE DISEASE	CNS ISSUES
Croup (swelling)	Bronchiolitis	Pneumonia	Overdose
Foreign body	Asthma	Pneumonitis	Head trauma
Retropharyngeal abscess		Pulmonary edema
Anaphylaxis

Table 12

Respond to Respiratory Distress/Failure

INITIAL MANAGEMENT OF RESPIRATORY DISTRESS/FAILURE
AIRWAY	Open and support the airway	Suction	Consider advanced airway
BREATHING	Monitor O2 sats	Supplemental O2	Nebulizers
CIRCULATION	Monitor vitals	Establish vascular access

Table 13

As an example, croup management depends on the severity of the disease.
Dexamethasone, a corticosteroid, can cause hypertension and reduce activation of lymphocytes.

PALS management of respiratory distress/failure is adjusted based on the severity of the current condition. For example, mild asthma is treated with bronchodilator inhalers, but severe asthma (status asthmaticus) may require ET intubation. The provider must continually assess the person’s current needs and adjust care accordingly.

Croup Management

Figure 12

Upper Airway		Lower Airway
Cause	Treatment	Cause	Treatment
CROUP	Dexamethasone Oxygen (Heliox) Nebulizer (epinephrine) Intubate Tracheostomy	BRONCHIOLITIS	Suctioning Nebulizers
FOREIGN BODY	Dexamethasone Oxygen (Heliox) Nebulizer (epinephrine) Intubate Tracheostomy	ASTHMA	Oxygen (Heliox) Nebulizers (albuterol and ipratropium bromide) Corticosteroids Magnesium sulfate Epinephrine SQ Support breathing
ANAPHYLAXIS	Epinephrine IM Nebulizer Diphenhydramine

Lung Tissue Disease		CNS Issues
Cause	Treatment	Cause	Treatment
PNEUMONIA	Dexamethasone Oxygen (Heliox) Nebulizer (epinephrine) Intubate Tracheostomy	OVERDOSE	Naloxone (opioid reversal) Antidotes Support breathing
PNEUMONITIS	Antibiotics (bacterial) Nebulizers Support breathing	TRAUMA	Neurosurgery Reduce intracranial pressure Support breathing
PULMONARY EDEMA	Diuretics Inotrope Support breathing

Table 14

In general, providers commonly work from the least to the mostinvasive intervention (top to bottom).
If the person presents with severe distress, proceed directly to maneuvers that are more aggressive.
Albuterol is the most common medication used via nebulizer to cause bronchodilation.
Common causes of acute community-acquired pneumonia include Streptococcus pneumonia, Mycoplasma pneumonia, Haemophilus influenza, and Chlamydia pneumonia.
High fever is the most common cause of quiet tachypnea.