Respiratory Assessment and the Pediatric Special Needs Patient: Some Considerations

Responding to pediatric special needs patients can be challenging. Depending on the disability, the person may be unable to relate pertinent information as to their complaint, level of discomfort, or emotional state. And when the emergency involves the respiratory tract, it only increases the stress of the situation. So let’s discuss some considerations when performing a respiratory assessment on pediatric patients with special needs.

 

Many special needs patients suffer from pre existing respiratory conditions. A recent study identified several respiratory issues related to children with disabilities and some risk factors you may encounter in the field:¹

  • Children with neurocognitive impairment often present with chronic or recurrent respiratory problems.
  • Respiratory problems have an important impact on quality of life and life expectancy.
  • The underlying causes are multiple: risk of aspiration, insufficient cough, upper airway obstruction and progressive kyphoscoliosis.
  • There is often a complex interplay between these known risk factors. Some risk factors include:
    • Respiratory insufficiency
    • Recurrent and chronic lung infections
    • Respiratory muscle wasting
    • Hypoxemia
    • Malnutrition
    • Aspiration
    • Decreased cough efficacy with secretions
    • Obstructive sleep apnea syndrome

Responding to special needs children not only presents respiratory challenges; you must also consider the type of disability or impairment and how it might affect your assessment and treatment.

Disabilities come in a wide range and can affect:

  • Vision
  • Movement
  • Thinking
  • Remembering
  • Learning
  • Communicating
  • Hearing
  • Mental health
  • Social relationships

Any of these can present significant challenges to performing a thorough assessment. And when the patient is a child, there are additional anatomical and physiological differences you must consider when treating a child’s respiratory emergency.

 

The Unique Attributes of Children

Here are several essential facts concerning pediatric respiratory systems identified by Vanderpool (2008):²

  • At birth, the respiratory system isn’t fully developed. Consequently, respiratory decompensation occurs more rapidly in children and recovery takes longer.
  • Alveoli keep expanding and replicating until about age 4. The lungs develop completely between ages 5 and 6, and alveolar maturation reaches adult capacity during adolescence.
  • Age and respiratory rate have an inverse relationship: the younger the child, the faster the respiratory rate.
  • Preterm infants have weak respiratory muscles. They also experience periodic breathing, marked by episodes of rapid breathing and apnea, which may lead to hypoxia.
  • Children breathe mainly through the nose until about age 4 weeks (or in some cases, up to several months).
  • A child’s diaphragm is flatter than an adult’s.
  • Infants and children have smaller airways than adults, leading to increased airway resistance, which manifests as a rapid respiratory rate.
  • Because of increased airway resistance and nasal breathing, children are at high risk for airway obstruction, even with minimal amounts of mucus or edema.
  • Infants and children have abnormally large tongues, which can cause airway obstruction.
  • Children have thinner chest walls than adults and therefore louder breath sounds.
  • A child’s chest has cartilaginous structures that increase lung compliance (and also promote cooperation during auscultation).

With all the complexities of special needs patients, their situation is only compounded when the patient is a child.


 

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Respiratory Assessment Fundamentals

As you approach your patient, your assessment begins. Depending on the special needs, your approach should be tailored to put the patient at ease. Engage family and caregivers; have them assist you if the patient is apprehensive or combative. If the patient has a preexisting respiratory condition, they may have a stoma or be on supplemental oxygen or even a ventilator. Get as much information as you can from caregivers.

 

Begin with the patient's general appearance. Check to see if they are exhibiting signs of distress, such as:

  • Positioning (tripod or unable to recline)
  • Anxiety
  • Tachycardia
  • Tachypnea

Assess vital signs, including:

  • Respiratory rate
  • Pulse
  • Oxygen saturation
  • Capnography
  • Blood pressure
  • Cardiac rhythm

What is their level of consciousness, keeping in mind that it may be permanently altered? Is their skin warm and dry, or are they pale, diaphoretic, or cyanotic? Be alert for signs of imminent respiratory arrest, which include:

  • Decreasing level of consciousness
  • Patient tiring/exhaustion
  • Cyanosis—a late sign and unreliable
  • Use of accessory muscles, obvious retractions
  • Inability to speak smoothly
  • Inability to lie flat
  • Diaphoresis
  • Agitation and restlessness that will decline to loss of consciousness

Auscultate the chest. If possible, have the patient sit upright when listening to breath sounds and be sure to place your stethoscope directly on the skin, not through clothing. Assess for rate, depth, and rhythm of respirations, and be sure to palpate the chest. Place your hands directly on the chest wall during respiration to assess lung status, chest expansion, and skin (subcutaneous emphysema).

 

Children with special needs pose certain challenges that must be overcome when performing a respiratory assessment. But by gauging their level of comfort, enlisting the help of family and caregivers, and performing a thorough assessment, you can treat the child effectively, despite their preexisting challenges.

 

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¹ Proesmans, Marijke, (2016), Respiratory Illness in Children with Disability: A Serious Problem? Breathe, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5297954/

² Vanderpool, Patricia, (2008), Pointers for Pediatric Respiratory Assessment, American Nurse Today, https://www.americannursetoday.com/pointers-for-pediatric-respiratory-assessment/