Respiratory distress and failure in children — formative SAQs

SAQ 1 (10)

A 5-month-old infant presents in winter with three days of coryza and worsening breathing. On arrival the infant is tachypnoeic with marked subcostal and intercostal recession, nasal flaring, and oxygen saturations of 87 per cent in air. The infant is alert and feeding poorly. [2] [1]

1. Describe how you assess the severity of this infant's respiratory distress at the bedside. (4) [1]
2. Outline your initial management and the stepwise escalation of respiratory support if the infant does not improve. (4) [2]
3. State two clinical signs that would tell you this infant is progressing from distress to failure. (2) [8]

Model answer

Bedside severity assessment. Assess the work of breathing (respiratory rate against age-normal ranges, recession, nasal flaring, grunting, accessory-muscle use), the efficacy of breathing (air entry, chest expansion, oxygen saturation), and the effect on the child (heart rate, colour, and conscious state). Interpret the respiratory rate using age-specific normal ranges, and note that a very high or, later, a falling rate both signal a struggling child. Poor feeding in an infant is an early marker of significant distress. [1]

Initial management and escalation. Give oxygen to a target saturation with minimal handling, and keep the infant with the parent to avoid distress. If hypoxaemia or high work of breathing persists, escalate to heated humidified high-flow nasal cannula, which reduces escalation of care in bronchiolitis, then to CPAP if high-flow fails, and to intubation and mechanical ventilation if non-invasive support fails or the infant tires. Treat any coexisting cause and involve senior and intensive-care help early. [2]

Signs of progression to failure. A falling respiratory rate with reducing recession but no clinical improvement (exhaustion), a silent chest with minimal air entry, deepening hypoxaemia despite oxygen, drowsiness or difficulty rousing, and apnoeas — any of these mark the shift from distress to failure and demand immediate escalation. [8]

SAQ 2 (10)

A 7-year-old with known asthma presents with a severe exacerbation. After initial bronchodilators the child is still working hard, speaking in single words, with reduced air entry. A blood gas now shows a normal-to-rising carbon dioxide. [8]

1. Interpret the blood gas finding and explain its significance in acute severe asthma. (3) [8]
2. Outline your ongoing management principles, including escalation of respiratory support (no invented drug doses). (4) [6]
3. State how caregiver concern and structured observations contribute to safe management on the ward. (3) [12]

Model answer

Blood-gas interpretation. In an acute severe asthma attack, hyperventilation should drive the carbon dioxide down, so a normal or rising carbon dioxide is a warning sign of a tiring child who can no longer maintain alveolar ventilation — a shift from type 1 towards type 2 respiratory failure. It signals impending exhaustion and mandates urgent senior review and escalation, not reassurance. [8]

Ongoing management and escalation. Continue oxygen to target, maximise inhaled bronchodilator therapy, and give systemic steroids, escalating to intravenous bronchodilator therapy and magnesium sulfate for severe or life-threatening disease per local guidelines. If the child continues to tire, escalate respiratory support and involve intensive care; non-invasive ventilation may be used in selected children, and intubation with lung-protective ventilation is reserved for failure of these measures. Name intent and sequence rather than inventing doses. [6]

Caregiver concern and structured observations. Caregiver concern that the child is deteriorating is independently associated with critical illness and should trigger reassessment rather than reassurance. Structured early-warning observations and clear escalation triggers help the ward team detect deterioration early and respond in time, provided the system is coupled to a responsive team. [12]