Respirations, grunting
Respirations, grunting: Excerpt from Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
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 in adults, grunting respirations demand immediate medical attention.
Act Now: If the patient exhibits grunting respirations, quickly place him in a comfortable position and check for signs of respiratory distress:
accessory muscle use
cyanotic lips or nail beds
decreased level of consciousness.
hypotension (less than 90/60 mm Hg in adults or poor capillary refill in children)
nasal flaring
substernal, subcostal, or intercostal retractions, or shoulder elevations
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 than age 5, or 100 beats/minute in adults)
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)
wheezing
If you detect any of these signs, monitor oxygen saturation, and administer oxygen and prescribed medications such as a bronchodilator. Also, have emergency equipment available and prepare to intubate the patient if necessary. Obtain arterial blood gas (ABG) analysis to determine oxygenation status.
Assessment
History
After addressing the child’s respiratory status, ask his parents when the grunting respirations began. Is he usually healthy with normal growth and development? 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.
Physical examination
Begin the physical examination by inspecting the rate, depth, and ease of respirations and any signs of respiratory distress. Auscultate the lungs, especially the lower lobes. Note diminished or abnormal sounds, such as crackles or sibilant rhonchi, which may indicate mucus or fluid buildup. Also, characterize the color, amount, and consistency of discharge or sputum. Note the characteristics of the cough, if any. Observe for abrupt behavior changes and lowered level of consciousness.
Medical causes
Asthma
Grunting respirations and wheezing may be apparent during a severe asthma attack, usually triggered by an upper respiratory tract infection or an allergic response. As the attack progresses, dyspnea, chest tightness, and coughing occur. Patients may have a silent chest if air movement is poor. Immediate bronchodilator and corticosteroid 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 (jiroveci) pneumonia commonly affects children infected with human immunodeficiency virus. It causes grunting respirations accompanied by high fever, tachypnea, nonproductive or scantly productive cough, anorexia, and lethargy. Auscultation reveals diminished breath sounds, scattered crackles, and sibilant rhonchi over the affected lung. As the disorder progresses, patients 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. Oxygen therapy is often needed.
Respiratory distress syndrome
The result of lung immaturity in a premature infant (less than 37 weeks’ gestation) usually of low birth weight, respiratory distress syndrome initially causes audible expiratory grunting along with intercostal, subcostal, or substernal retractions accompanied by 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. This disease can occur in all age groups, as a result of aspiration, infection, embolism, shock, trauma, and other causes. Findings are similar in all ages.
Nursing 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 ABG 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. (See Positioning an infant for chest physical therapy, pages 254 and 255.)
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 current antibiotic use.
Remember to explain all procedures to the patient’s parents and to provide emotional support.
Patient teaching
Teach the patient’s parents how to perform respiratory care and therapy in the home. Instruct them in the proper use of prescribed medications. Explain signs and symptoms that require immediate attention. If the grunting is related to asthma, teach the parents measures to assist them in managing the condition and reducing allergins in the home environment.
Pictures
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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