What is Respiratory Distress - Lower Airway?

In this lesson, we're going to cover lower airway respiratory distress, including causes, signs and symptoms, treatment options in general, and some information on the best courses of treatment for a few specific causes of respiratory distress in pediatric patients.

At the end of the lesson, we'll provide a Word about head bobbing or seesaw respirations, which often indicate that the child or infant has an increased risk for further deterioration.

Common Causes of Lower Airway Respiratory Distress

The two most common causes of lower airway respiratory distress in pediatric patients are:

• Asthma
• Bronchiolitis

These conditions cause obstructions to the lower airway specifically in the:

• Lower trachea
• Bronchi
• Bronchioles

In contrast to upper airway obstructions, lower airway obstructions are typically more apparent during the expiratory phase (rather than inspiratory) of the respiration cycle.

Signs and Symptoms

The signs of lower airway obstruction include:

• An increased respiratory rate
• An increased respiratory effort (such as retractions, nasal flaring, and prolonged expiration)
• Possible decreased air movement on auscultation
• A prolonged expiratory phase associated with increased expiratory effort (such as when expiration becomes an active rather than a passive process)
• Wheezing (most commonly expiratory but could also be inspiratory or biphasic)
• Cough

For instance, wheezing most commonly occurs during expiration – specifically a prolonged expiration that takes more effort – and can often be recognized as:

• Retractions
• Nasal flaring
• Active process, like attempting to blow air out of the lungs

Lung disease can also appear as a lower airway obstruction. Lung disease causes a child's lungs to become stiff, and increased effort during inspiration and expiration is often identified by:

• Retractions and accessory muscle use
• Accumulation of fluid
• Inflammation in the alveoli or interstitium

Because small airways in the lower lungs collapse, you might even see grunting respirations, as these are often present as a result of increased respiratory efforts.

Identifying and Treating Lower Airway Obstructions

Just as with upper airway obstructions, early recognition, identification, and treatment of respiratory distress in infants and children is extremely vital for a positive outcome and to increase their chances of survival. And remember, respiratory distress can quickly progress into respiratory failure and cardiac arrest.

Treatments for specific causes will often vary, however there are some general methods to treat a child in respiratory distress, and these include:

• Proper positioning – put the patient into a comfortable position that keeps the airway open to help support their breathing efforts, such as:
  
  • Sitting the child upright so their head is above their heart
  • Leaning the child forward if they're really distressed
  • Helping the child remain calm, perhaps by holding a toy or stuffed animal

• Check the patient's lung sounds and apply an oxygen saturation monitor while the child is still on room air, which will help establish a good baseline for their SpO2 levels
• Administer high flow oxygen immediately for respiratory arrest and remember the goal – keep the patient's oxygen saturation above 94 percent
• Assess the patient's blood pressure, pulse and respiratory rates, temperature, and ECG

It's also important to identify and treat specific types or causes of lower airway obstruction based on the patient's signs and symptoms.

Treating Asthma

If asthma is causing the child's lower airway obstruction, treat the patient via a nebulizer with 2.5mg of albuterol and the possible administration of corticosteroids.

Treating Bronchiolitis

If the child is suffering from bronchiolitis, suctioning the oral or nasal passages as needed will be your best course of treatment. However, assess the need for further treatment and consider laboratory and other tests such as:

• Viral studies
• Chest X-rays
• Arterial blood gas

Once the pediatric patient is stabilized, initiate medical consultation for effective and ongoing managed definitive care.

And remember to allow the infant or child to remain in the most comfortable position possible and always monitor them closely for deteriorating symptoms. And if they do deteriorate, treat them accordingly.

A Word About Head Bobbing or Seesaw Respirations

Head bobbing and seesaw respirations will often indicate that the child has an increased risk for deterioration.

Head Bobbing

Head bobbing is caused when the pediatric patient has to use their neck muscles to assist with breathing. The child will lift their chin and extend their neck during inspiration and allow their chin to fall forward during expiration. Head bobbing is most commonly seen in infants and can be a sign of respiratory failure.

Seesaw Respirations

Seesaw respirations are present when the patient's chest retracts, and their abdomen expands during inspiration. During expiration, the movement reverses, as the patient's chest expands, and the abdomen moves inward.

Seesaw respirations typically indicate an upper airway obstruction. However, they can also be indicated in severe lower airway obstructions, lung tissue disease, and states of disordered control of breathing.

Seesaw respirations are characteristic of infants and children with neuromuscular weakness. And it's important to note that this inefficient form of ventilation can quickly lead to fatigue.