Respiratory Reassessment Guide for Pediatric Residents on Call

Overview

Respiratory reassessment is critical in pediatric patients, especially those with respiratory compromise. Effective reassessment involves detailed physical examination, vital signs evaluation, and monitoring respiratory support settings to assess improvement or deterioration.

Key Steps in Respiratory Reassessment

1. Evaluate Vital Signs
   • Respiratory Rate (RR): Check for tachypnea or bradypnea based on age-specific norms. Persistent tachypnea may indicate worsening condition.
   • Heart Rate (HR): Assess for tachycardia, which can be a compensatory response to respiratory distress.
   • Oxygen Saturation (SpO₂): Aim for a target SpO₂ (typically ≥92–94% in most pediatric patients unless otherwise specified, e.g., chronic lung disease).
   • Blood Pressure: Hypotension may indicate severe respiratory distress or underlying shock.
2. Physical Examination
   • General Appearance: Assess for signs of increased work of breathing (e.g., agitation, lethargy, cyanosis).
   • Chest Observations:
     • Retractions: Note any intercostal, subcostal, or suprasternal retractions, which signal increased respiratory effort.
     • Accessory Muscle Use: Observe neck and shoulder muscles; this is more common in severe respiratory distress.
     • Nasal Flaring and Head Bobbing (infants): Indicate increased work of breathing.
   • Auscultation:
     • Breath Sounds: Listen for crackles, wheezes, or diminished breath sounds.
     • Symmetry: Note differences in air entry between sides (could suggest atelectasis or pneumothorax).
     • Inspiratory/Expiratory Ratios: Prolonged expiration can indicate obstructive processes like asthma.
3. Respiratory Support Review
   • Oxygen Therapy: Review the current flow rate and oxygen delivery method (nasal cannula, mask, high-flow nasal cannula, etc.). Adjust as needed to maintain target oxygen saturation.
   • Non-Invasive Support (if applicable): Confirm the settings on devices like CPAP or BiPAP, noting the FiO₂, pressure support levels, and compliance with treatment.
   • Mechanical Ventilation (if applicable): Check ventilator settings (e.g., tidal volume, PEEP, FiO₂, respiratory rate) and adjust based on blood gases and patient response.
4. Laboratory and Imaging Review (if Indicated)
   • Arterial Blood Gas (ABG): Assess pH, pCO₂, pO₂, and HCO₃ levels to determine respiratory status, especially if there is increased work of breathing or altered mental status.
   • Chest X-Ray (CXR): Obtain CXR if there is suspicion of pneumothorax, atelectasis, or other pathology that could impact respiratory function.
5. Document Reassessment and Plan
   • Record all findings, adjustments in support, and planned follow-up.

Example Template for Event Note

• Date/Time: [e.g., Nov 5, 2024, 20:00]
• Patient ID and Location: [Name, MRN, Room]
• Respiratory Assessment:
  • Vital Signs: HR: ___, RR: ___, SpO₂: ___ on [oxygen source/type, e.g., nasal cannula at 2 L/min]
  • Physical Exam Findings:
    • General: [e.g., no cyanosis, alert]
    • Respiratory Effort: [e.g., moderate subcostal retractions, nasal flaring present]
    • Breath Sounds: [e.g., decreased on right base, wheezing bilaterally]
  • Respiratory Support:
    • Oxygen Therapy: [e.g., 3 L/min nasal cannula, FiO₂ adjusted to maintain SpO₂ ≥94%]
    • Mechanical Ventilation (if applicable): [e.g., ventilator rate set at 20 breaths/min, FiO₂ 40%]
  • Lab and Imaging: [e.g., ABG: pH 7.32, pCO₂ 50 mmHg; CXR showed right lower lobe atelectasis]
• Interventions/Plan: [e.g., increase oxygen to 4 L/min; re-evaluate RR and retractions in 30 minutes]
• Resident Signature: [Your Name and Title]

Suggested Video Resources

1. Pediatric Respiratory Assessment Tutorial - Covers physical signs and common abnormalities.
2. Understanding Pediatric Chest X-Ray Interpretation - Guides on reading common respiratory findings in children.

Respiratory System Examination | Pediatrics

Respiratory Assessment by B. Leary, L. DelSignore | OPENPediatrics