Respiratory assessment

Positioning

• Most children will adopt the best position to support their breathing
• Do not change the child's position unless they have an altered level of consciousness or severe respiratory distress.
• Handling or repositioning the infant or child should be kept to a minimum. It can:
• increase HR, BP and RR
• increase the work of breathing
• cause desaturation in young infants.
• Minimal handling and interventions are essential in croup and airway obstruction, e.g. inhaled foreign body.
• Upper airway obstruction can rapidly deteriorate and may require emergency airway management.
• Keep the child near the parent or carer.

Look

• Most of the assessment can be done through observation and minimal interventions.
• Look for signs of upper airway obstruction, including drooling and stridor.
• Expose the chest and abdomen. To reduce anxiety, ask the carer to remove the clothing or blankets.
• Look at the overall appearance of the patient, including their level of activity and positioning.
• Look at the colour, peripherally and centrally.
• Count the respiratory rate and assess the pattern of respirations as:
• regular
• irregular
• shallow
• tachypnoeic
• bradypnoeic.
• Assess the patient's respiratory rate and work of breathing as either:
• mild
• moderate
• severe.
• Check if the patient can speak in sentences or words only.
• Look for use of accessory muscles:
• tracheal tug
• intercostal
• subcostal
• suprasternal
• substernal
• supraclavicular
• abdominal
• head bob
• nasal flaring.
• Check if the trachea is midline.
• Measure the oxygen saturations where appropriate. Oxygen saturations do not need to be measured in mild–moderate croup as it can cause unnecessary stress to the infant.
• Hypoxia in croup or any upper airway obstruction is a late sign.

Listen

• Auscultate the lung fields with a stethoscope assessing for:
• quality of breath sounds
• adventitious breath sounds, e.g. wheeze, crackles, crepes or stridor
• describe the location of the sounds.
• Listen for audible sounds, e.g. stridor, hoarse voice/cry, wheeze, grunting or cough.
• Listen for a productive or dry cough or sputum.

Feel

• Feel for even chest expansion. Consider flail chest in asymmetrical movements
• Feel for skin temperature, turgor and moisture.
• Measure the capillary return, centrally and peripherally.
• Feel for fremitus. Increased fremitus may indicate inflammation or dense lung tissue.
• Feel for subcutaneous emphysema.

Other

• Fever alone can cause tachypnoea.
• Always assess the patient's hydration status if they have respiratory distress. See dehydration focused assessment.