How to know which of the numerous children with respiratory symptoms will progress to respiratory failure?
Identifying patients with projected respiratory failure or impending respiratory failure is one of the most important skills for a pediatric clinician. A detailed history can give information about the vulnerability of the child to respiratory decompensation. Children who are very young, were born prematurely, have chronic pulmonary or cardiac diseases, or have immunodeficiencies are at particular risk. Recent medical advances, including the development of home nursing capabilities, have resulted in many “graduates” of intensive care nurseries living in our communities. EDs are confronted with these medically fragile children more than ever before.
Predicting the future is difficult, but most diseases have a typical natural history that should be considered. If a child is evaluated early in the course of respiratory infection, that child is very likely to worsen before improvement will be noted. Sometimes young children who look well require admission because they are vulnerable and are very early in the course of their respiratory illness. Children with significant respiratory effort who appear happy and playful and are maintaining their oxygen saturation and ventilation may worsen suddenly as they become fatigued, or as their disease process progresses.
Young children are more difficult to assess for respiratory problems. Histories are obtained secondhand, as the parent interprets behaviors and relays observations that have been made. A careful clinical assessment of risk factors, illness time course, and the current degree of respiratory distress is necessary to identify those patients most likely to develop respiratory failure.