CLINICAL EVALUATION OF RESPIRATORY DISTRESS IN CHILDREN
Dr. H. Paramesh, (MD,FAAP,(USA),FIAP,FIAMS,FIAA,FICAAI ) *
Director, Pediatric Pulmonologist, Lakeside Institute of Child Health, Bangalore-42. *
Definition
Respiratory distress is defined as presence of tachypnea, grunting, chest retractions (subcoastal, intercostals, suprasternal), flaring of nostrils and reduced air exchange with or without cyanosis.

Magnitude of the Problem:
Acute respiratory problems constitute 45% of OPD, 30% of Inpatients, 50% care admissions. In neonatal period, the prevalence is 13%; Majority is from involvement of respiratory system.

Clinical Evaluation:
While evaluating a child with respiratory distress, the clinician should be aware of the considerable age-dependent changes in the susceptibility of the lungs to different types of diseases and the extent to which respiration is altered along with anatomic, pathologic and mechanics of $ breathing. Then he should pose few questions for quick evaluations.
  1. First and foremost identity the respiratory distress is from the involvement of pulmonary system or extra pulmonary like Cardiac, Metabolic, Hematologic, Musculoskeletal or Central nervous system. In Cardiac cases one can appreciate tachycardia, cardiac murmurs, cyanosis and H/O perspiration while feeding. In hematologic, signs of anemia, hyper dynamic circulation, signs of hemolysis. In Metabolic acidosis-like dehydration, diabetic ketoacidosis, salicylate poisoning, the rate and depth of respiration are both increased, kussmaul's breathing, feel and hear the expiratory breath sound more than 6 inches away from the nostrils. In Musculoskeletal diseases-restriction of expansion of chest wall causes restrictive lung disease, increase, in respiratory rate decrease in depth of respiration. In Central nervous system involvement, the clinical feature of encephalopathy or meningismus, initially increase in rate and depth of respiration later decrease in respiration and heart rate.
  2. After confirming the involvement of respiratory system, one has to look for the site of pathology. Is it the upper airway, lower airway or Parenchymal diseases based on clinical features of stridor, restrictive or diffusion problem?
  3. Is it obstructive, restrictive or diffusion problem? By clinical evaluation, pulmonary functions and blood gases
  4. How serious is the problem? By clinical evaluation very rarely blood gases are needed. Dyspnea, Dysphagia, Drooling of saliva, Odynophagia. See-saw chest movement, Head bobbing, Pulses paradoxus.
  5. What is the possible disease ? Is it a Congenital anomaly, Aspiration syndrome, Allergic Tumor growth or infections?
  6. Is it viral or bacterial infection? Clinical clues of multiple mucus membrane involvement, will delineate in most of the time .
  7. What is the possible organism? It is always an educative guess based on age of the child, site of pathology, environment and experience of the physician.
  8. Initiate treatment, based on physiologic derangement while awaiting for specific diagnosis.
  9. Know the merits and demerits of investigation.
  10. Never forget to appreciate the sounds the patient produces in clinical practice. Details will be discussed during the lecture.

Conclusion
Among the five basic clinical parameters, the cardinal signs of upper airway diseases are retraction, inspiratory stridor, the lower airway restriction wheeze, and parenchymal diseases - tachypnea and grunting. Finding the etiology is an educative guess. Selection of antibiotics is more of experience than experiment. Always listen to the sounds and cough the child produces.
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