Paediatric Respiratory Assessment

CPD
4m

Published: 31 March 2020

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)

assessment choking
Inhalation of a foreign body is a common cause of respiratory distress in children.

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)

assessment baby
In order to manage respiratory distress, it is important to have a systematic approach to assessment.

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.)

Multiple Choice Questions

Q1. True or false? The purpose of an initial assessment is to diagnose the patient.

  1. True
  2. False

Q2. What might drooling indicate?

  1. Allergies
  2. Viral infection.
  3. Asthma
  4. Obstruction

Q3. True or false? Children in respiratory distress should generally have minimal handling.

  1. True
  2. False
References

(Answers: b, d, a)

Authors

Portrait of Ausmed Editorial Team
Ausmed Editorial Team

Ausmed’s Editorial team is committed to providing high-quality and thoroughly researched content to our readers, free of any commercial bias or conflict of interest. All articles are developed in consultation with healthcare professionals and peer reviewed where necessary, undergoing a yearly review to ensure all healthcare information is kept up to date. See Educator Profile

Portrait of Abbie Blog
Abbie Blog

Abbie is a Nurse Practitioner currently working in a Specialist Allergy Clinic in Brisbane. She has been a paediatric nurse for over 20 years originally working in the UK before moving to Australia with her young family 8 years ago. Abbie has a diverse career working with some of the most vulnerable patients. She has worked in paediatric oncology , emergency and general paediatrics. She has worked for NGO's in the fields of child protection and parental support as well as currently working with re- settled refugees. Abbie is a passionate nursing advocate and has just started the new challenge of blogging. See Educator Profile