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PALS Primary Assessment – Breathing

Still in primary assessment, now we’re talking about breathing, which is paramount on a child, the ability to assess their breathing.

If you show up at the scene, it’s best to try to get a respiratory rate or look at their breathing before you start poking at this kid, which means if you show up to a scene and Mom’s still holding the child, don’t poke the child yet. Stand back and try to get a respiratory rate before you lay hands on this kid. You’re more likely to get a more accurate rate. They’re not going to be agitated and start breathing faster, crying. When you’re assessing the rate, try to get a count for at least 30 seconds. Know that a child’s respiratory pattern will speed up and slow down naturally, so you really need to assess the rate over about 30 seconds, and that’ll give you a more accurate reading. You have to know the normals, just like in anything else. You have to kind of look at this chart here and know what’s a normal respiratory rate for the particular age of the child. Any respiratory rate less than 10 or greater than 60 is a huge red flag.

First, let’s talk about fast respiratory rates. When we’re talking about fast respiratory rate, it can be one of two things. It can either be a lung problem or it can be non-lung in origin. Let me give you an example. Let’s say they’re having an asthma attack. In an attempt to better oxygenate, they’re going to breathe faster. If they have pneumonia, fluid in the lungs, they’re going to breathe faster in an attempt to better oxygenate. Fast respiratory rates are usual compensatory in nature, but they may not always be from a lung problem. For example, let’s say they’re in DKA (diabetic ketoacidosis). They may have a fast respiratory rate because they’re trying to blow off the acid. The lungs are fine. We have to assess for and find the cause of this fast respiratory rate, which is usually compensatory in nature. Other causes? Pain can cause a child to have a fast respiratory rate. The lungs are fine. The body’s fine. They’re just in pain. We need to treat that. They could just be anxious. I show up in my flight suit and I look like a cosmonaut, I’m scary to a kid. I’m probably scary to most people. They could just be anxious and breathing faster. We’re going to help calm them down. We need to assess for and find the cause of this fast respiratory rate and treat that, but know that a fast respiratory rate is usually compensatory in nature.

Slow respiratory rates. A slow respiratory rate in a child is an ominous sign. Anything slow in a kid is bad. Slow respiratory rate and slow heart rate are ominous signs a child is pre-arrest. Usually when things are fast, they’re compensating, until they can no longer compensate. Then things start to slow down. We need to find the cause of this low respiratory rate and treat it quickly. For example, an overdose. Did the kid get into a drug that is a respiratory depressant? In older children, we may see this. Heroin is running rampant in America. We need to assess for an overdose. Number one, start breathing for the child. If they have a slow respiratory rate, we need to open that airway. We need to begin to bag, oxygenate, and ventilate that child. That’s our priority. First, get their respiratory rate up while we’re assessing for the underlying cause so we can treat that.

In assessing their breathing, after we’ve gone through their rate, we’re going to look at the quality of their breathing, which means we’re going to listen to lung sounds. We have our stethoscope out. We’re listening to this kid’s chest. What are we listening for? Wheezing is one thing. Asthma in children has grown exponentially in America. We’re going to hear this high-pitched wheezing sound, and this is caused by constriction of the airways. Usually we’ll hear it during exhalation. As the child breathes in, those airways open up. The airway pressure increases and the airways open up. As soon as the child starts to exhale, the pressure in the lungs drops dramatically and those constricted airways squeeze down. They’re trying to squeeze air out of these constricted airways, and that’s what creates the whistling sound. If we have an asthmatic child and we’re listening, we may hear expiratory wheezing. It’s worse if we hear both inspiratory and expiratory wheezing. That means there’s constriction of the airways during the inspiratory cycle when the airways should be opening up. Grunting—we can hear this from across the room in a child. Children grunt by closing their glottic opening, usually during exhalation, in an attempt to keep the airways open. Think of it as auto-PEEP. They’re trying to auto-PEEP, maintain this open airway, and reverse the effects of atelectasis so they can better oxygenate. The result of that is the child is grunting. We know if we hear grunting, they’re self-PEEPing. They’re trying to keep their airway open. They have respiratory distress.

More assessment tools to see if this kid’s in respiratory distress: We have to expose and look at the chest. We’re looking for retractions. What causes retractions? Remember, when the child breathes in, the diaphragm drops down, creates a negative pressure, and they’re trying to suck air in. If they have an obstruction in their airway from edema, constriction, whatever, the air can’t get in, but they’re still creating negative pressure. They start sucking in, literally, parts of the chest. We may see retractions underneath the collarbone, intercostal (between the ribs), above or below the sternum. We’re looking for these signs of retraction. What that tells us is the child is trying to take air in, but the air is not coming into them. They’re generating so much negative pressure that they’re literally sucking the chest inside the body. Huge sign for respiratory distress. Another assessment tool in how well this child’s oxygenating is the use of pulse oximetry. A pulse oximeter really doesn’t measure oxygenation. It measures found hemoglobin—how much of that hemoglobin circulating through the body is bound up. The machine will give us a percentage of that. Usually it’s oxygen. However, know that with carbon monoxide, carbon monoxide has a greater affinity than oxygen to the hemoglobin. We can have, essentially, a dead person from carbon monoxide poisoning, but their pulse oximetry reads 100% because the hemoglobin is 100% bound with CO instead of oxygen. Having said that, in most cases it’s oxygen and that’s what we’re looking for. Concerning the pulse oximeter, it’s not enough just to put the pulse oximeter on the child and get a reading. We have to put the pulse oximeter on the child, then verify that it’s an accurate reading. How do we do that? One, the pulse oximeter itself. The two probes have to be opposite each other. There’s an infrared wave that goes through the tissue that looks at the bound hemoglobin. The two parts—the two physical parts—of the pulse oximeter itself have to be opposing each other. We can run into a problem with this if we’re using the kind of pulse oximeter that tapes onto the child. Let’s say the child’s finger is too small, and we have one probe here but another probe over here. They’re not opposite each other. We may not get an accurate reading. Another thing, remember, this is a pulse oximeter—remember, pulse oximeter. On the pulse oximeter itself, it’s going to give us a pulse reading. That pulse reading should match the pulse we’re taking from the patient or what we’re seeing on our cardiac monitor. If our cardiac monitor says 100 beats per minute and our pulse oximeter says 60 and we have a low saturation reading, it’s probably not accurate. It’s not verified. They don’t match. Those numbers have to match. Also, if our machine has waveform pulse oximetry, we should be looking at a good arterial waveform. If it’s flattened or disrupted or anything but a normal wave pattern, that reading may be inaccurate. So, the probes have to be opposite each other, the pulses have to match, and we should have a good waveform or bar reading on our pulse oximeter to verify that we have an accurate pulse oximeter reading. If we’re using our pulse oximeter, we’ve verified it, the pulses match, and we have a good waveform and if we’re giving this child 100% oxygen—we’re administering 100% FiO2 to this child—and their pulse oximetry is still coming under 90%, this child needs a more advanced airway. That’s one great use for a pulse oximeter. Again, 100% FiO2 with a pulse oximetry less than 90%, whatever we’re doing is not working and we need to up the game. Move to a more advanced airway so we can better oxygenate that child. Remember, the number one cause of cardiac arrest in a pediatric patient is respiratory in nature, so it is a constant reassessment of this pediatric patient’s respiratory status: evaluate, identify, and intervene. Constant reassessment of the pediatric airway can help keep that kid from arresting in the first place.

This has been just a quick review of the breathing assessment for the primary assessment of pediatric patients. I’ll see you in circulation, coming up next.

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