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.

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.

(Adapted from RCHM 2020)

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. a).

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. a).

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 foreign bodies
• Genetic conditions such as cystic fibrosis.

(HealthLink BC 2023)

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
• 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.

(Teachey 2018; RCHM 2019)

Paediatric Respiratory 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 (PCH 2022).

Generally, children in respiratory distress should have minimal handling - assessment can usually be made without touching the patient (RCHM 2019).

The ABCDE approach - Airway, Breathing, Circulation, Disability and Exposure - is a simple and effective method of assessment (PCH 2022).

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?

(PCH 2022)

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 saturation.
• Effects
  • Assess heart rate, skin colour and mental status.

(PCH 2022)

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 when assessing a patient.

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 (PCH 2022).

Following the initial assessment (and resuscitation if required), a secondary structured assessment should be undertaken to identify any other key signs or symptoms (PCH 2022).

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. b).