Clinical Practice Guidelines : Assessment of severity of respiratory conditions

Assessment of severity of respiratory conditions

PIC Endorsed

Key points

In general, children with respiratory distress should have��minimal handling
The assessment of severity can mostly be made without touching the child. Parents can be asked to uncover the child’s chest/abdomen
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��

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Last updated September 2024

Reference List

Ausmed. Paediatric Respiratory Assessment. 29 March 2023 (viewed 10 July 2024)

Baid, H et al. Respiratory assessment and monitoring. Oxford handbook of critical care nursing. February 2016 pg 101-132

Children’s Health Queensland, Queensland Paediatric Emergency Care, Respiratory Assessment: (viewed July 2024)

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.

Perth Children’s Hospital, Serious illness emergency department guideline (viewed 10 July 2024)��

Saikia, D and Mahanta, B 2019, Cardiovascular and respiratory physiology in children, Indian Journal of Anaesthesia vol 63 no 9 (viewed 10 July 2024)

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

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