RESPIRATORY SYMPTOMS are one of the most common reasons parents seek medical attention for their child. But determining the cause of respiratory distress in a child can be particularly difficult; even if the child is old enough to talk, he may not have the vocabulary to describe his symptoms in a clinically useful way. This can put your knowledge and assessment skills to the test.
In this article, I'll examine four common pediatric respiratory diseases—status asthmaticus, croup, epiglottitis, and pneumonia—and explain how to recognize and respond to them in the emergency department (ED). For a quick reference on differentiating these diseases, see Trouble in the Air.
Stopping status asthmaticus
Twelve-year-old Brian is in your ED with an asthma exacerbation. He uses ipratropium and albuterol metered-dose inhalers (MDIs) to manage his asthma at home. He developed wheezing after being in a room with a cat and used his albuterol MDI three times in the last hour, but his symptoms have worsened.
When you examine him, you note respirations of 30 (normal for his age is 15 to 25), mild subcostal retractions, and diffuse expiratory wheezing. He also exhibits tracheal tugging. Because of his respiratory distress, he gives one-word answers to your questions.
You place Brian on a pulse oximeter; his SpO2 is 87%, so you administer oxygen via mask. Suspecting status asthmaticus—increasingly severe asthma that doesn't respond to short-acting (rescue) bronchodilators—you page the ED physician.
Asthma therapy consists of maintenance medications and rescue medications. Maintenance medications include inhaled mast cell stabilizers, inhaled steroids, and leukotriene antagonists, taken alone or in combination. Rescue medications are fast-acting inhaled bronchodilators such as albuterol, which can be given by an MDI or nebulizer.
Status asthmaticus can be triggered by upper respiratory infections or exposure to an allergen. Children at high risk meet these criteria:
- diagnosed with asthma before age 1
- history of frequent ED visits because of poor asthma control
- history of intensive care unit (ICU) admissions for asthma
- recurrent need for oral corticosteroids
- living in poverty or urban settings
- an SpO2 below 92% despite supplemental oxygen.
Signs and symptoms of status asthmaticus include change in mentation, hypoxemia, hypercapnia, inability to lie supine, metabolic acidosis, electrocardiogram changes such as ventricular arrhythmias and T-wave and ST-segment changes, and pulsus paradoxus (a difference of more than 10 mm Hg in systolic arterial blood pressure between inspiration and expiration). Head bobbing is a sign of dyspnea in infants lying supine.
Treatment for a child experiencing status asthmaticus starts with a fast-acting bronchodilator, such as inhaled albuterol or levalbuterol via nebulizer. But if he won't keep the mask in place, you may need to give the bronchodilator intravenously (I.V.). Initiate parenteral bronchodilators such as terbutaline with a bolus dose, followed immediately with a continuous infusion. Place the child on continuous cardiac monitoring and assess him for ventricular arrhythmias or signs of myocardial ischemia.
Besides bronchodilators, anticholinergic medications (such as ipratropium) and glucocorticoids generally are indicated. Anticholinergics relieve bronchospasm, and glucocorticoids reduce the inflammation and edema associated with asthma. Because they don't take effect for several hours, give them promptly.
An adjunct to drug therapy is heliox, a mixture of helium and oxygen; this is an alternative to the standard nitrogen and oxygen mixture. Helium is seven times lighter than nitrogen, which promotes diffusion (gas flow around obstructed areas) and improves oxygen delivery. Heliox decreases turbulent airflow and decreases work of breathing.
Heliox must be heated before delivery to the patient, so a heater is added to the circuit. Because the gas is so light, the mask must fit well to ensure that the treatment is delivered to the patient and not the room. This therapy isn't appropriate for patients who can't tolerate the mask.
In extreme cases, magnesium sulfate therapy may be used. Magnesium inhibits calcium uptake into cells, relaxing smooth muscle and relieving bronchospasm. More pediatric studies are needed to establish the benefits of this treatment.
If drug therapy isn't effective, the child may require noninvasive positive-pressure ventilation or intubation and mechanical ventilation to support respiration.
Brian is admitted and given an albuterol nebulizer treatment every 4 hours. He receives an I.V. dose of methylprednisolone and is discharged the next day on a 5-day course of oral prednisone.
Thirteen-month-old Angelica is brought to your ED by her mother, who says her daughter has had a runny nose and congestion for the last 2 days. Her older brother has had a cold for the last week. Tonight her parents awoke to her barky cough. They took her into the bathroom and tried steam from a hot shower, but she didn't improve, although she improved slightly when they went outside into the cool air.
Angelica's symptoms suggest croup. After evaluating her and finding that her SpO2 is 90%, you start 4 liters/minute of supplemental oxygen with cool mist via mask to get her SpO2 above 92%. Start an albuterol nebulizer treatment, establish peripheral I.V. access, and begin an infusion of dexamethasone, a corticosteroid. Corticosteroids decrease inflammation and prevent further destruction of ciliated epithelium in the upper airways.
Acute airway inflammation is especially dangerous for infants and children under age 3, whose airway diameters are much smaller than those of older children or adults. Even a small amount of swelling can obstruct these small airways.
Croup encompasses a group of acute viral conditions characterized by a brassy or barky cough. The child also may have stridor, hoarseness, and signs of respiratory distress from laryngeal swelling. The infection may involve the trachea and bronchi. The child may have a mild fever (below 102° F [38.9° C]); respiratory symptoms are typically worse at night.
Croup is the most common form of acute upper airway obstruction in children under age 3, and it's more common in boys than girls. The reasons are unclear, but some studies implicate sex-linked differences in anatomy or intrinsic airway resistance.
Viruses that commonly cause croup include parainfluenza types 1, 2, and 3; rhinovirus; and enteroviruses. Respiratory syncytial virus (RSV) may cause croup in younger infants; Mycoplasma pneumoniae may cause croup in children ages 5 and older.
Pathophysiologic changes of croup include inflammatory edema, destruction of ciliated epithelium in the upper airways, and exudate from inflamed airways. However, secondary bacterial infection is uncommon.
The typical patient has a short history of upper respiratory tract infection with rhinorrhea. As the upper airway became progressively compromised, the brassy cough and stridor begin. Lateral neck X-rays may show ballooning of the hypopharynx, a normal epiglottis, and narrowing of the subglottic area. The frontal view shows the classic “steeple sign” in which the airway in the subglottic area narrows like a steeple or pencil tip.
As the obstruction worsens, so does the cough, and stridor may become nearly continuous. The child also may exhibit intercostal retractions, tracheal tugging, and nasal flaring. If the bronchi are inflamed, respiratory distress increases and exhalation may become labored and prolonged.
Treatment for croup is primarily supportive. Mild cases can be managed safely at home. Children with croup and progressive stridor, stridor at rest, respiratory distress, hypoxemia, restlessness, cyanosis, or altered mental status may need hospitalization.
The hospitalized child will likely be placed on cool humidified oxygen via mask, head hood, or tent to ease airway irritation and decrease edema. Monitor her respiratory rate and work of breathing continuously or frequently. Let her assume a position that's comfortable and make sure she's disturbed as little as possible; agitation and crying will worsen symptoms.
The child may need I.V. fluids to prevent or treat dehydration. If she's in moderate or severe respiratory distress, keep her N.P.O. and on I.V. fluids to reduce the risk of aspiration if she needs endotracheal intubation. Aerosolized racemic epinephrine may help relieve symptoms of moderate to severe respiratory distress by producing vasoconstriction and reducing edema.
A child who's very ill may be treated with inhaled heliox in the ICU. Very few children with croup require endotracheal intubation or tracheotomy.
Angelica is admitted and continues receiving cool mist oxygen, steroids, and I.V. fluids. Within 48 hours, her symptoms are much improved, and she's discharged home.
Russ, 4, has a high fever, difficulty breathing, sore throat, and trouble speaking. You note that he's drooling and prefers to sit leaning forward with his neck extended. His mother says his symptoms started this morning and have significantly worsened during the day.
Taking Russ's history, you learn that he hasn't had all his vaccinations and doesn't see a pediatrician for well-child care. Because of his symptoms and history, you suspect epiglottitis.
Typically affecting children ages 2 to 5, epiglottitis has become much less common since routine immunization against Haemophilus influenzae Type B (the most common cause of epiglottitis) began in the mid-1980s. Because epiglottitis can cause complete airway obstruction, it's a medical emergency.
Respiratory distress, generally the first manifestation, may progress to complete airway obstruction and death within hours if not treated. In order to breathe, the child may sit in the “tripod” position—leaning forward with his neck hyperextended. Because swallowing is painful, drooling is a key sign of epiglottitis.
Keep the child calm and dim the lights. Don't leave him alone. Administer supplemental oxygen if possible, but don't force therapy on him if he resists; agitation could worsen his condition.
Diagnosing epiglottitis requires direct examination or laryngoscopy, but examining the child's throat with a tongue blade may induce laryngospasm, putting him at substantial risk for aspiration, complete airway obstruction, or cardiac arrest. Examination is usually performed in the operating room with tracheotomy setup and anesthesiology and otolaryngology staff present. Neck X-rays may be helpful—visible upper airway narrowing indicates croup and rules out epiglottitis—but may not be possible if the child is distressed.
After epiglottitis has been diagnosed, the anesthesiologist will establish an airway and place I.V. lines to administer antibiotic therapy to combat the bacterial infection. The patient may have a positive blood culture for H. influenzae Type B. If he has symptoms of meningitis coexisting with epiglottitis symptoms, he may need a spinal tap.
Russ's parents and siblings should have H. influenzae Type B prophylaxis with rifampin to prevent spread of the infection. With appropriate treatment, including mechanical ventilation and antibiotics, Russ should recover in 2 to 3 days.
Sophie, 1, has had a fever for 2 days, reaching as high as 102° F. She hasn't had much to drink in the last 24 hours and is coughing. Her mother says that last night, Sophie was fretful and started to breathe harder and faster.
Examining Sophie, you find that her respiratory rate is 50 (normal for her age, 20 to 40), her skin is hot to the touch, and her mucous membranes are dry. You also note nasal flaring, tracheal tugging, and mild subcostal retractions.
Next, you listen to her lungs and hear coarse breath sounds with crackles in the bases and diminished breath sounds on the left side. The ED physician also examines Sophie, echoes your findings, and diagnoses pneumonia. She orders pulse oximetry monitoring, supplemental oxygen, chest X-ray (posterior-anterior and lateral views), complete blood cell count, and an I.V. infusion of 0.9% sodium chloride solution at 10 ml/kg.
Pneumonia, an inflammation of lung parenchyma, is usually caused by microorganisms. In otherwise healthy infants and children, the most common causative pathogens are respiratory viruses, M. pneumoniae, and bacteria. Noninfectious causes of pneumonia include aspiration of food or gastric contents, foreign bodies, hypersensitivity reactions, or radiation.
Viral pneumonia is most common in children under age 3; it's less common in children older than 3. The most common offending viruses are RSV, parainfluenza, influenza, and adenoviruses.
Viral pneumonia occurs more frequently in the winter. The type and severity of the illness is influenced by the patient's age and immune status, the season, and environmental factors such as overcrowding and pathogens common in the community.
Symptoms of viral pneumonia include a several-day history of rhinorrhea and cough; other family members may be ill with similar symptoms. The child may have a fever of under 103° F (39.4° C); bacterial pneumonia typically causes higher temperatures. On physical exam, you'll also find tachypnea, retractions, and nasal flaring.
If the infection is severe, the child may become cyanotic, with respiratory fatigue and occasional apnea. On auscultation, you may hear widespread crackles and wheezing.
The chest X-ray is characterized by diffuse or focal infiltrates; hyperinflation due to air trapping is common. In viral pneumonia, the white blood cell (WBC) count tends to be normal or only slightly elevated (less than 20,000 cells/mm3), with lymphocytes predominating.
A definitive diagnosis requires isolating the virus from a mucus or sputum sample from the respiratory tract. Growing the virus can take 5 to 10 days, but rapid tests are available for common viruses such as RSV, influenza, and adenovirus.
Treatment for viral pneumonia is supportive. Most children recover from mild cases with only minimal supportive care, but those with more severe cases may require hospitalization and I.V. fluids, supplemental oxygen, and possibly assisted ventilation.
The only specific treatments available for viral pneumonia are oral amantadine (or rimantadine) and ribavirin. Amantadine and rimantadine are effective against influenza A isolates, but these drugs appear to help only if started within the first 48 hours of symptom onset. Ribavirin is effective in vitro against RSV and may be beneficial for some hospitalized patients, but its use is controversial.
Most children who suffer from viral pneumonia will recover uneventfully and have no long-term complications, although recent studies link recurrent viral infections in infants and young children with a higher risk of asthma.
Children can experience life-threatening infections from RSV, particularly infants with a history of prematurity, underlying cardiac disease, pulmonary disease, or immunosuppression. Adenovirus (particularly types 1,3,4,7, and 21) can progress to fulminant acute fatal pneumonia or chronic lung disease, but this is uncommon.
Bacterial pneumonia: Less common, more severe
Bacterial pneumonia is more common in children who are school-aged than in younger children. Overall, it's less common than viral pneumonia, except in children with an underlying disorder, such as cystic fibrosis or immunodeficiency. However, bacterial pneumonia tends to be more severe than the viral form, especially if the child has underlying health problems.
The most common causes of bacterial pneumonia in an otherwise healthy child are Streptococcus pneumoniae, Streptococcus pyogenes (Group A strep), and Staphylococcus aureus. Bacterial pneumonia often appears as a secondary infection after a viral upper respiratory infection (URI). Symptoms vary slightly based on the infecting organism; usually, symptoms from the viral URI appear for a few days, followed by the abrupt onset of fever, occasionally shaking chills, restlessness, dry hacking cough, ileus, abdominal pain, and signs of respiratory distress. If an effusion or empyema develops, chest excursion over the affected area may decrease significantly.
Bacterial pneumonia in children can be differentiated from other forms of pneumonia with microbiologic studies, such as a sputum or endotracheal tube culture, or WBC counts, which will be elevated in bacterial infection. Chest X-ray changes don't always correlate with clinical observations: Consolidation on X-ray may be noted before changes in exam are appreciable, and resolution of the infiltrate on X-ray may take several weeks.
Pleural reaction to the pneumonia may cause a pleural effusion. The child's WBC count may be elevated to between 15,000 and 40,000 cells/mm3 with a predominance of polymorphonuclear cells. Hemoglobin is normal or only slightly decreased.
Treat bacterial pneumonia with antibiotics tailored to the offending microorganism, plus supportive care (supplemental oxygen, I.V. fluids, pulmonary toilet, and assisted ventilation if needed).
Determining the cause of respiratory distress in children may take some detective work. Your savvy assessment and ability to recognize differentiating clues can put your patient firmly on the path to recovery.
SELECTED WEB SITES
National Heart, Lung, and Blood Institute asthma page http://www.nhlbi.nih.gov/health/prof/lung/index.htm
Children's Hospital of Iowa, Virtual Children's Hospital http://www.vh.org/pediatric
American Lung Association http://www.lungusa.org
Last accessed on August 1, 2003.
Bachur, R.: “Occult Pneumonias: Empiric Chest Radiographs in Febrile Children with Leukocytosis,” Annals of Emergency Medicine
. 33(2):166–173, February 1999.
Mandell, G., et al., eds: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases
, 5th edition. New York, N.Y., Churchill Livingstone, Inc., 2000.
Werner, H.: “Status Asthmaticus in Children: A Review,” Chest
. 119(6):1913–1929, June 2001.
Pinpointing the cause of pediatric respiratory distress
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Pinpointing the cause of pediatric respiratory distress
GENERAL PURPOSE To provide professional nurses with current information on common causes of pediatric respiratory distress. LEARNING OBJECTIVES After reading the preceding article and taking this test, you should be able to: 1. Identify signs and symptoms of common pediatric respiratory emergencies requiring nursing care. 2. Outline diagnostic and therapeutic interventions to manage common pediatric respiratory emergencies.
1. A child with a respiratory rate of 29, mild subcostal retractions, and diffuse expiratory wheezing most likely has
a. viral pneumonia.
b. bacterial pneumonia.
d. status asthmaticus.
2. Pulsus paradoxus is best described as
a. a difference in systolic and diastolic BP.
b. a difference of more than 10 mm Hg in systolic arterial BP between inspiration and expiration.
c. a difference in diastolic BP between inspiration and expiration.
d. a difference in radial and apical pulse between inspiration and expiration.
3. A barky cough that improves slightly with exposure to cool air is a symptom associated with
c. status asthmaticus.
4. A child who's drooling; who has a high fever, difficulty breathing, and trouble speaking; and who prefers the “tripod” position may have
a. acute viral pneumonia.
b. status asthmaticus.
c. acute bacterial pneumonia.
5. A child with diminished breath sounds, crackles at the lung bases, fever, and increased respiratory rate most likely has
a. early status asthmaticus.
6. Cough is seen with all of the following except
7. Which are characteristics of epiglottitis?
a. cough, stridor, wheezing
b. cough, wheezing, tripod position
c. increased work of breathing, tripod position, cough
d. tripod position, fever, drooling
8. Stridor is commonly associated with
9. Which of the following is more common in school-aged children than younger children?
a. bacterial pneumonia
b. viral pneumonia
10. According to the author, one of the most common reasons parents seek medical attention for their child is
a. questions about parenting.
b. respiratory symptoms.
c. age-appropriate behavior issues.
d. shortness of breath with play activities.
11. Which respiratory condition often occurs after a viral upper respiratory infection?
a. bacterial pneumonia
b. viral pneumonia
d. extreme fatigue
12. Criteria to determine children at high risk for status asthmaticus include all of the following except
a. diagnosed with asthma before age 1.
b. recurrent need for oral corticosteroids.
c. living in poverty or an urban setting.
d. an SpO2 above 92%.
13. Treatment for a child experiencing status asthmaticus may include parenteral use of
14. Glucocorticoids are used in status asthmaticus to
a. reduce inflammation and edema.
b. dry up secretions.
c. decrease bronchospasm.
d. decrease turbulent airflow.
15. Aerosolized racemic epinephrine works by
a. producing vasodilation.
b. reducing edema.
c. reducing agitation.
d. reducing respiratory rate.
16. Epiglottitis is diagnosed by
a. report of illness history.
b. chest X-ray.
c. examining the oral cavity with a tongue blade.
d. direct examination or laryngoscopy.
17. The only specific treatment available for viral pneumonia is
b. heliox and concentrated oxygen.
d. amantadine and ribavirin.
Wright, R., et al.: “New Approaches to Respiratory Infections in Children. Bronchiolitis and Croup,” Emergency Medicine Clinics of North America
. 20(1):93–114, February 2002.