Respirations, grunting
Respirations, grunting: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)
Characterized by a deep, low-pitched grunting sound at the end of each breath, grunting respirations are a chief sign of respiratory distress in infants and children. They may be soft and heard only on auscultation, or loud and clearly audible without a stethoscope. Typically, the intensity of grunting respirations reflects the severity of respiratory distress. The grunting sound coincides with closure of the glottis, an effort to increase end-expiratory pressure in the lungs and prolong alveolar gas exchange, thereby enhancing ventilation and perfusion.
Grunting respirations indicate intrathoracic disease with lower respiratory involvement. Though most common in children, they sometimes occur in adults who are in severe respiratory distress. Whether they occur in children or adults, grunting respirations demand immediate medical attention. (See Positioning an infant for chest physical therapy, pages 678 and 679.)
Emergency interventions
If the patient exhibits grunting respirations, quickly place him in a comfortable position and check for signs of respiratory distress: wheezing; tachypnea (a minimum respiratory rate of 60 breaths/minute in infants, 40 breaths/minute in children ages 1 to 5, 30 breaths/minute in children older than age 5, or 20 breaths/minute in adults); accessory muscle use; substernal, subcostal, or intercostal retractions; nasal flaring; tachycardia (a minimum of 160 beats/minute in infants, 120 to 140 beats/minute in children ages 1 to 5, 120 beats/minute in children older age 5, or 100 beats/minute in adults); cyanotic lips or nail beds; hypotension (less than 80/40 mm Hg in infants, less than 80/50 mm Hg in children ages 1 to 5, less than 90/55 mm Hg in children older than age 5, or less than 90/60 mm Hg in adults); and decreased level of consciousness.
If you detect any of these signs, monitor oxygen saturation, and administer oxygen and prescribed medications such as a bronchodilator. Have emergency equipment available and prepare to intubate the patient if necessary. Obtain arterial blood gas analysis to determine oxygenation status.
History and physical examination
After addressing the child’s respiratory status, ask his parents when the grunting respirations began. If the patient is a premature infant, find out his gestational age. Ask the parents if anyone in the home has recently had an upper respiratory tract infection. Has the child had signs and symptoms of such an infection, such as a runny nose, cough, low-grade fever, or anorexia? Does he have a history of frequent colds or upper respiratory tract infections? Does he have a history of respiratory syncytial virus? Ask the parents to describe changes in the child’s activity level or feeding pattern to determine if the child is lethargic or less alert than usual.
Begin the physical examination by auscultating the lungs, especially the lower lobes. Note diminished or abnormal sounds, such as crackles or sibilant rhonchi, which may indicate mucus or fluid buildup. Characterize the color, amount, and consistency of any discharge or sputum. Note the characteristics of the cough, if any.
Medical causes
Asthma
Grunting respirations may be apparent during a severe asthma attack, usually triggered by a upper respiratory tract infection or an allergic response. As the attack progresses, dyspnea, audible wheezing, chest tightness, and coughing occur. Patients may have a silent chest if air movement is poor. Immediate bronchodilator therapy is needed.
Heart failure
A late sign of left-sided heart failure, grunting respirations accompany increasing pulmonary edema. Associated features include a productive cough, crackles, jugular vein distention, and chest wall retractions. Cyanosis may also be evident, depending on the underlying congenital cardiac defect.
Pneumonia
Life-threatening bacterial pneumonia is common after an upper respiratory tract infection or cold. Pneumocystis carinii pneumonia commonly affects children infected with human immunodeficiency virus. It causes grunting respirations accompanied by high fever, tachypnea, a productive cough, anorexia, and lethargy. Auscultation reveals diminished breath sounds, scattered crackles, and sibilant rhonchi over the affected lung. As the disorder progresses, the patient may also develop severe dyspnea, substernal and subcostal retractions, nasal flaring, cyanosis, and increasing lethargy. Some infants display GI signs, such as vomiting, diarrhea, and abdominal distention.
Respiratory distress syndrome
The result of lung immaturity in a premature infant (less than 37 weeks’ gestation) usually of low birth weight, this syndrome initially causes audible expiratory grunting along with intercostal, subcostal, or substernal retractions; tachycardia; and tachypnea. Later, as respiratory distress tires the infant, apnea or irregular respirations replace the grunting. Severe respiratory distress is characterized by cyanosis, frothy sputum, dramatic nasal flaring, lethargy, bradycardia, and hypotension. Eventually, the infant becomes unresponsive. Auscultation reveals harsh, diminished breath sounds and crackles over the base of the lungs on deep inspiration. Oliguria and peripheral edema may also occur.
Special considerations
Closely monitor the patient’s condition. Keep emergency equipment nearby in case respiratory distress worsens. Prepare to administer oxygen using an oxygen hood or tent. Continually monitor arterial blood gas levels and deliver the minimum amount of oxygen possible, to avoid causing retinopathy of prematurity from excessively high oxygen levels.
Begin inhalation therapy with a bronchodilator, and administer an I.V. antimicrobial if the patient has pneumonia (or, in some cases, status asthmaticus). Follow these measures with chest physical therapy as necessary.
Prepare the patient for chest X-rays. Because sedatives are contraindicated during respiratory distress, the restless child must be restrained during testing, as necessary. To prevent exposure to radiation, wear a lead apron and cover the child’s genital area with a lead shield. If a blood culture is ordered, be sure to record on the laboratory slip any current antibiotic use.
Remember to explain all procedures to the patient’s parents and to provide emotional support.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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