Dyspnea or Respiratory Distress (Pediatric ED) (2024)

Associated Documentation

• Dyspnea/Respiratory Distress Management

Presentation

• difficulty breathing
• chest heaviness
• chest tightness
• feeling of air hunger
• feeling of inability to take a deep breath
• respiratory pattern irregular
• tachycardia
• tachypnea

Associated Signs/Symptoms

• accessory muscle use
• apnea
• breath sounds with wheezing or crackles
• cough
• cyanosis
• difficulty speaking or crying
• extreme fatigue
• fussiness
• grunting
• head-bobbing
• hoarseness
• jugular vein distension
• listless
• nasal flaring
• peripheral edema
• pursed lip breathing
• restlessness
• retractions
• shortness of breath
• sighing frequently
• sputum production
• stridor or noisy breathing

Potential Causes

• anxiety
• aspiration
• bronchopulmonary dysplasia
• congenital heart disease
• foreign body aspiration
• gastroesophageal reflux
• infection
• laryngomalacia or tracheomalacia
• panic attack

Initial Assessment

• airway patency
• breath sounds
• breathing pattern
• level of consciousness
• peripheral oxygen saturation
• weight
• work of breathing

History

• allergies
• comorbidities
• immunization status
• last menstrual period (females of childbearing age)
• medications
• alleviating factors
• birth and perinatal history, if infant
• coughing or choking
• effect on eating, sleeping and ability to speak/vocalize
• effort variation with position change or activity
• ongoing treatment side effects
• onset duration and precipitating events
• past episode treatment, such as hospitalization or intubation
• past episodes
• recent exposure, illness
• recent injury
• smoking history and status
• treatment prior to presentation

Laboratory Studies

• ABG (arterial blood gas)
• blood glucose level
• BNP (B-type natriuretic peptide)
• CBC (complete blood count) with differential
• CRP (C-reactive protein)
• D-dimer
• serum electrolytes
• serum lactate
• sputum culture
• toxicology levels
• viral culture

Diagnostics

• chest x-ray
• ECG (electrocardiogram)

Potential Additional Testing

• bronchoscopy
• CTPA (computed tomography pulmonary angiogram)
• echocardiogram
• laryngoscopy
• lateral soft tissue neck x-ray
• peak flow rate measurement
• pregnancy test (females of childbearing age)
• ultrasonography

Problem Intervention

Provide Respiratory Support

• Assess and monitor airway, breathing and circulation; maintain close surveillance for deterioration.
• Maintain open and patent airway with use of positioning, airway adjuncts and secretion clearance.
• Position to minimize the risk of aspiration, ventilation-perfusion mismatch and breathlessness.
• Minimize oxygen consumption and demand; limit activity, reduce fever and utilize breathing techniques.
• Provide oxygen therapy judiciously; titrate to prevent hyperoxemia.
• Consider inhaled beta-1 or beta-2 agonist, such as racemic epinephrine or albuterol, especially in the presence of stridor or wheezing.
• Implement noninvasive or invasive positive pressure ventilation to support oxygenation and ventilation, as well as relieve respiratory distress.

Problem Intervention

Provide Hemodynamic Support

• Monitor cardiovascular status.
• Observe for, and address, cardiac dysrhythmia.
• Position to support perfusion.
• Evaluate fluid status; provide fluid therapy to improve blood flow, perfusion and tissue oxygenation.
• Monitor and manage electrolyte levels; anticipate the need to correct imbalance; evaluate patient response.
• If cardiac origin identified, consider the need for pharmacologic measures, such as a diuretic or vasoactive agent.
• Anticipate urgent intervention in the presence of hemodynamic instability.

Problem Intervention

Promote Comfort and Manage Pain

• Use a consistent pain assessment tool; evaluate pain and treatment response at regular intervals.
• Involve patient and family in the management plan.
• Provide nonpharmacologic strategies, such as breathing techniques, positioning, distraction and diversion.
• Consider pharmacologic measures, such as an opioid or benzodiazepine agent, especially for palliation or breathlessness associated with anxiety or panic attack.
• Evaluate risk for opioid use and dependence.

Problem Intervention

Minimize and Manage Infection

• Assess for presence of infection and signs of early sepsis.
• Initiate precautions to prevent the spread of infection.
• Obtain cultures prior to initiation of antimicrobial therapy, when possible.
• Anticipate antimicrobial therapy administration; do not delay in the presence of high suspicion or clinical indicators.

Problem Intervention

Provide Psychosocial Support

• Proactively provide information; encourage questions and address concerns.
• Provide calm, reassuring presence.
• Recognize, identify and allow expression of emotions.
• Promote parent/caregiver presence at bedside.
• Offer choices to enhance a sense of control.
• Honor spiritual and cultural preferences.
• Recognize and utilize personal coping strategies.

Problem Intervention

Facilitate Procedures

• Initiate and maintain NPO (nothing by mouth) status.
• Prepare for, or assist with, procedure, such as chest tube placement, intubation and needle aspiration.
• Facilitate referral for follow-up with a specialist, clinic or disease-management program.

Teaching Focus

• symptom/problem overview

• risk factors/triggers

• self-management

• assistive device

• diagnostic test

• diet modification

• medical device/equipment use

• medication administration

• opioid medication management

• orthopaedic device

• safe medication disposal

• smoking cessation

• wound care

Forensics and Legal

• Utilize local, state/province, federal requirements and hospital policy and protocols to manage patient care involving forensics, protective services, workman’s compensation and mandatory reportable events and illness.

Human Trafficking

• Human trafficking victims most frequently seek healthcare services from Emergency Departments. Healthcare professionals, alert to signs of trafficking, can guide supportive care for victims.
• Trafficked individuals may be male or female and engaged in sex work or other forced labor. High-risk signs requiring more direct questioning about exploitation include, among others, current employment in a high-risk industry, prior sexually transmitted infections, recent immigration and other vulnerable and minority populations, as well as children who are homeless, runaways or in foster care.

Age-Related

• Infants under 6 months of age are obligate nose breathers.
• Infants and young children are at high risk for RSV (respiratory syncytial virus) infection.
• Asthma is the most common childhood chronic disease; however, most recurrent wheezing in children younger than 5 years of age is generally associated with respiratory tract infections.

Pregnancy

• Beyond 20 weeks gestation, supine position should be avoided. Maternal position should be lateral or lateral tilt to prevent compression of the inferior vena cava and aorta by the pregnant uterus.
• Presentation with a complaint of shortness of breath, absence of any known comorbidities and normal pulse oximetry readings may be “benign” dyspnea of pregnancy. This may occur as a normal response to increased partial oxygen tension in pregnancy that enables adequate fetal oxygenation.
• Potentially serious causes of dyspnea during pregnancy that should be considered include pulmonary embolism, dysrhythmia, pulmonary edema, pneumonia, asthma and cardiomyopathy.
• Incidence of pulmonary embolism is 5 to 10 times higher in pregnancy and the early postpartum phase.
• A pregnant abdomen may cause mechanical interference with breathing.