Assessment of severity of respiratory conditions

  • See also

    Acute asthma
    Bronchiolitis
    Croup
    Pneumonia
    Minimising distress in healthcare settings
    Normal ranges for physiological variables

    Key points

    1. In general, children with respiratory distress should have minimal handling
    2. The assessment of severity can mostly be made without touching the child. Parents can be asked to uncover the child’s chest/abdomen
    3. Careful observation of the child is important. Oxygen saturations may be misleading

    Assessment

     

    Mild 

    Moderate

    Severe

    Life-threatening

     Behaviour

    Normal
    Able to vocalise normally

    Intermittent irritability  
    Reduced activity
    Some limitation of ability to vocalise

    Increasing irritability and/or lethargy
    Marked limitation of ability to vocalise, single words

    Drowsy or unconscious
    Unable to vocalise

    Colour

    Normal

    Pallor

    Pallor or cyanosis

    Cyanosis

    Respiratory rate
    (At rest and not crying)

    Normal or mildly increased

    Increased

    Increased

    Markedly increased or may have bradypnoea or apnoea

    Increased work of breathing*

    None or minimal 

    Moderate

    Marked

    Severe accessory muscle use or poor respiratory effort

    Oxygenation
    (Oxygenation is only of limited utility in judging severity in many paediatric respiratory conditions. Do not just focus on the SaO2 monitor. Look at the other signs.)

     

     

    SpO2 less than 90% (in room air)

    Any O2 requirement in croup is classed as severe

     

    Heart rate

    Normal or slightly increased

    Mildly increased

    Significantly increased or
    bradycardia

    Arrhythmia or bradycardia

    Blood pressure
    (Do not measure in croup)

    Normal

    Increased

    Increased

    Hypotension

    *Signs of increased work of breathing

    • Retractions (intercostal, suprasternal, costal margin)
    • Accessory muscle use eg nasal flaring, sternocleidomastoid contraction (head bobbing), forward posturing
    • Grunting

    Accessory muscle anatomy
    Other signs of respiratory distress

    Other considerations

    • Fever may be associated with an increase in respiratory rate and heart rate
    • Respiratory sounds and auscultatory findings can be useful in assessing children with respiratory presentations. For example, wheeze in Asthma and Bronchiolitis, and stridor in Croup and Acute upper airway obstruction. Reduced air entry is an important sign
    • In addition to assessing respiratory status, it is important to assess feeding and hydration as these may be affected early in respiratory illness
    • Effortless tachypnoea may be due to compensation for an underlying metabolic acidosis eg sepsis, DKA

    Management

    Management of individual conditions can be found under specific guidelines

    Consider consultation with local paediatric team when

    Any child with severe respiratory distress should be discussed with a senior clinician

    Consider transfer when

    Management is beyond the capability of the local health care facility

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Additional notes 

    Example videos of increased work of breathing 


     


    Last updated September 2024

  • Reference List

    1. Ausmed. Paediatric Respiratory Assessment. 29 March 2023 https://www.ausmed.com.au/learn/articles/paediatric-respiratory-assessment (viewed 10 July 2024)
    2. Baid, H et al. Respiratory assessment and monitoring. Oxford handbook of critical care nursing. February 2016 pg 101-132 https://doi.org/10.1093/med/9780198701071.003.0004
    3. Children’s Health Queensland, Queensland Paediatric Emergency Care, Respiratory Assessment: https://www.childrens.health.qld.gov.au/__data/assets/pdf_file/0032/179717/respiratory-assessment-in-children.pdf (viewed July 2024)
    4. Graham, H et al. Hypoxaemia in hospitalised children and neonates: A prospective cohort study in Nigerian secondary-level hospitals. EClinicalMedicine vol 16, Nov 2019, pg 51-63. https://www.sciencedirect.com/science/article/pii/S2589537019301919
    5. Perth Children’s Hospital, Serious illness emergency department guideline https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Serious-illness (viewed 10 July 2024) 
    6. Saikia, D and Mahanta, B 2019, Cardiovascular and respiratory physiology in children, Indian Journal of Anaesthesia vol 63 no 9 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6761775/ (viewed 10 July 2024)
    7. Sumit, R et al. Oxygen saturations less than 92% are associated with major adverse events in outpatients with pneumonia: a population-based cohort study. Clinical Infectious Diseases, vol 52 issue 2, 1 Feb 2011 pg 325-331 https://academic.oup.com/cid/article/52/3/325/305087