Initial treatment may be required for stabilization before a complete history and physical examination can be performed.
Ask for a description of respiratory problems, including onset, duration, and progression of symptoms. Keep in mind that respiratory distress can present as difficulty with feedings in infants and decreased activity or feeding in toddlers. Inquire about precipitating or exacerbating factors. Ask if there was any recent history of choking, as this may be the only clue for a foreign body aspiration. Inquire if they have ever had a similar presentation in the past. Review all prior medications (chronic and acute) and note time of administration. For example, how many times albuterol was given per day in the past several days and the last time given before coming to the ED. Ask if immunizations are up to date, as failure to do so could put the child at risk for rare diseases (ie, epiglottitis, pertussis). Review in detail all past medical history. Infants born prematurely may have bronchopulmonary dysplasia (BPD), making reactive airway disease, respiratory infections, hypoxia, and hypercarbia more likely. When treating children with asthma, ask about frequency of exacerbations, if they ever required intubation or positive pressure ventilation, previous admissions (ED, general floor, intensive care unit) and the last time they were on steroids. A history of chronic cough or multiple previous episodes of pneumonias may be suggestive of a congenital condition, undiagnosed reactive airway disease, or foreign body aspiration.
The assessment should be conducted in a calm, efficient manner, with assistance from parents. Agitating a child can worsen symptoms and even precipitate acute decompensation, especially in suspected upper airway obstruction. Allow the child to assume a position of comfort. Take extra caution if the patient is presenting in the sniffing position (head and chin are positioned slightly forward), as this may indicate severe upper airway obstruction. Likewise, if the patient is presenting in the tripod position (leaning forward and supporting the upper body with their hands), this indicates severe lower airway obstruction, and this position will optimize their accessory muscle use. Respiratory rate varies in relation to age: newborn (30–60); 1–6 months (30–40); 6–12 months (25–30); 1–6 years (20–30); > 6 years (15–20). Heart rate also varies with age: newborn (140–160), 6 months (120–160), 1 year (100–140), 2 years (90–140), 4 years (80–110), 6–14 years (75–100), >14 years (60–90). Keep in mind that tachycardia is typical with albuterol treatment.
Skin exam can show diaphoresis, cyanosis (peripheral or central), rash (eg, hives), bruising, or trauma and can be a clue to the cause of respiratory distress. Make sure to fully unclothe the patient, taking care not to worsen distress.
Stridor indicates upper airway obstruction, and the phase of the respiratory cycle in which it occurs is a clue to the location of obstruction. Inspiratory stridor is seen with subglottic/glottis obstruction above the larynx (eg, epiglottitis). Nasal flaring, dysphonia, and hoarseness also suggest upper airway obstruction. Expiratory stridor is consistent with obstruction below the larynx, in the bronchi or lower trachea. Croup is the most common cause, but also consider foreign body, epiglottitis, anaphylaxis, angioedema, peritonsillar abscess, retropharyngeal abscess, tracheomalacia, laryngomalacia, or obstructing mass.
Inspect the chest for depth, rhythm, and symmetry of respirations. Retractions indicate accessory muscle use. As the involved muscle groups move more superiorly (subcostal, intercostal, suprasternal, supraclavicular), airway obstruction is more severe. Also examine the chest and neck for any crepitus.
Lung exam is particularly important. Pneumothorax is suggested by unilateral decreased or absent breath sounds, but this finding is not always present. Wheezing and a prolonged expiratory phase indicate lower airway obstruction. It is important to note that in patients with very severe lower airway obstruction, wheezing may be absent as a result of poor aeration. Crackles, rhonchi, and decreased or asymmetric breath sounds are found with alveolar disease. Grunting prevents alveolar collapse and preserves functional residual capacity (FRC). Its presence implies severe respiratory compromise.
The remainder of the physical exam should focus on localizing the underlying source of distress, especially if there is no evidence of airway disease. Poor respiratory effort or apnea with depressed airway reflexes suggests central nervous system disease. Congestive heart failure can present with diminished heart sounds, a murmur or gallop, venous distension, or hepatosplenomegaly. Pallor or cyanosis suggests anemia. Consider sepsis or metabolic acidosis with isolated tachypnea. Look for any signs of ingestion or inhalation injury, such as burns or soot in the oropharynx or nares.