What is the management of respiratory retraction?

Management of Respiratory Retraction

Respiratory retractions should be recognized as a sign of increased work of breathing and respiratory distress that requires prompt assessment and intervention based on severity and underlying cause. 1

Assessment of Respiratory Retractions

Types and Significance of Retractions

• Intercostal retractions: Visible pulling between the ribs during inspiration
• Subcostal retractions: Inward movement below the rib cage
• Suprasternal retractions: Pulling above the sternum/clavicles
• Sternal retractions: Inward movement of the sternum, especially in infants 2

Associated Clinical Signs to Evaluate

• Vital signs: Tachypnea (respiratory rate >50 breaths/min in children <2 years, >40 breaths/min in children >2 years) 1
• Oxygen saturation: <90% indicates severe disease requiring hospitalization 1
• Other signs of respiratory distress:
  • Nasal flaring
  • Grunting (indicates severe disease and impending respiratory failure) 1
  • Head bobbing
  • Tracheal tugging
  • Diaphoresis (associated with more severe disease) 3
  • Altered mental status (sign of impending respiratory failure) 1

Risk Stratification

High-Risk Factors

• Age: <12 weeks 1
• History of prematurity 1
• Underlying conditions:
  • Cardiopulmonary disease 1
  • Immunodeficiency 1
  • Hemodynamically significant congenital heart disease 1
  • Moderate malnutrition 1

Severity Assessment

1. Mild: Minimal retractions, normal oxygen saturation (>93%), no signs of respiratory fatigue
2. Moderate: Obvious retractions, tachypnea, oxygen saturation 90-93%
3. Severe: Marked retractions with:
   • Grunting, nasal flaring, head nodding 1
   • Oxygen saturation <90% 1
   • Altered mental status 1
   • Inability to speak or feed 1
   • Cyanosis 1
   • Increasing fatigue 1

Management Algorithm

Immediate Interventions for All Patients

1. Position: Place in upright position to optimize respiratory mechanics 3
2. Oxygen: Administer if SpO2 <90% (or <93% in some settings) 1
3. Monitoring: Continuous pulse oximetry, respiratory rate, heart rate 4

Mild Respiratory Retractions

• Outpatient management with close follow-up
• Hydration: Ensure adequate fluid intake
• Education: Teach caregivers warning signs requiring return
• Follow-up: Within 24-48 hours

Moderate Respiratory Retractions

• Consider hospitalization if:
  • SpO2 <93% 1
  • Presence of high-risk factors 1
  • Inability to maintain adequate oral intake 1
  • Poor social support for home monitoring 1
• Interventions:
  • Supplemental oxygen to maintain SpO2 >92%
  • Frequent reassessment (every 1-2 hours)
  • Consider trial of bronchodilators if wheezing present 1

Severe Respiratory Retractions

• Immediate hospitalization 1
• Consider ICU admission if:
  • Requiring FiO2 ≥0.50 1
  • Altered mental status 1
  • Worsening fatigue or apnea 1
  • Inability to maintain SpO2 >90% despite supplemental oxygen 1
• Interventions:
  • High-flow oxygen or ventilatory support
  • Continuous cardiorespiratory monitoring 1
  • Consider IV fluids if unable to maintain oral intake
  • Specific therapy based on underlying cause

Disease-Specific Management

Bronchiolitis

• Primary management: Supportive care with oxygen and hydration 1
• Not recommended: Routine chest radiographs or laboratory studies 1
• Avoid: Routine use of antibiotics unless bacterial infection is suspected 1

Asthma Exacerbation

• First-line: Inhaled short-acting beta-agonists (albuterol)
  • 0.15 mg/kg (minimum 2.5 mg) every 20 minutes for 3 doses, then as needed 1
• Add: Systemic corticosteroids for moderate-severe exacerbations 1
• Consider: Continuous nebulization for severe cases 1

Pneumonia

• Outpatient management possible for mild cases without hypoxemia 1
• Hospitalization criteria:
  • Hypoxemia (SpO2 <90%)
  • Moderate-severe respiratory distress
  • Inability to maintain oral intake
  • Failed outpatient therapy
• Antibiotics: Based on age and likely pathogens 1

Monitoring and Follow-up

Inpatient Monitoring

• Vital signs: Every 1-4 hours based on severity
• Continuous pulse oximetry for moderate-severe cases
• Reassessment: After initial interventions and with any change in status

Outpatient Follow-up

• 24-48 hour follow-up for all patients managed as outpatients
• Return precautions: Worsening retractions, difficulty breathing, poor feeding, lethargy

Pitfalls and Caveats

1. Don't rely solely on oxygen saturation - retractions can indicate significant respiratory distress even with normal SpO2 4
2. Beware of clinical deterioration in young infants (<12 weeks) who can decompensate rapidly 1
3. Don't assume all retractions indicate lower respiratory tract infection - upper airway obstruction can also cause retractions 1
4. Avoid excessive oxygen administration without appropriate ventilatory support in patients with chronic CO2 retention 4
5. Never ignore a patient complaining of breathing difficulty even if objective signs are minimal 4
6. Don't delay definitive airway management if signs of respiratory failure develop 4

Remember that respiratory retractions represent increased work of breathing and should always prompt thorough assessment and appropriate intervention based on severity to prevent progression to respiratory failure.