Approach to a child with breathing difficulty

Breathing difficulty and respiratory distress is the most common cause of admission to the Pediatric Emergency. Respiratory distress presents as altered breathing pattern, forced breathing efforts or obstructed breathing, and chest indrawing; respiratory failure is defined as paCO(2) >50 mmHg (inadequate ventilation) and/or a paO(2) < 60 mmHg (inadequate oxygenation). Rapid assessment is aimed to ascertain adequacy of airway patency, breathing, and circulation. Immediate care is directed at (a) restoration of airway patency- by positioning (head tilt -chin lift), cleaning the oropharynx, and/or insertion of oropharyngeal airway; (b) supporting breathing- with high flow oxygen and assisted ventilation (with bag and mask or endotracheal intubation and ventilation), and (c) restoration of circulation- using fluid boluses and inotropes, if necessary. Immediate specific management may require endotracheal intubation/tracheostomy for upper airway obstruction; needle thoracotomy and drainage of pneumothorax; and first dose of antibiotic for febrile children. Thereafter meticulous history, focused physical examination, and specific laboratory/radiological investigations are undertaken to identify the underlying cause. At the end of this, one should be able to categorize the child to one of the following: (a) upper airway obstruction, (b) pneumonia (syndrome of cough, fever and breathing difficulty), (c) lower airway obstruction, (d) slow or irregular breathing without pulmonary signs, and (e) respiratory distress with cardiac findings, to initiate specific treatment. Further respiratory support by Continuous Positive Airways Pressure (CPAP) and mechanical ventilation may be required in some cases. All children with respiratory distress must be monitored for early detection of worsening/complications, assessment of response to therapy and rapid documentation of clinical state.