8. Respiratory Distress in Children

Question 1

Signs of increased work of breathing include what? (6)

Answer 1

• lude head bob
• nasal flare
• tracheal tug
• substernal and intercostal retractions
• subcostal recessions
• paradoxical thoraco-abdo movement

Question 2

Describe: Respiratory failure (2)

Answer 2

• defined by inadequate gas exchange (oxygenation or ventilation)
• and can be classified into Type I and Type II.

Question 3

Describe Respiratory failure Type 1 and Type 2

Answer 3

• Type I (hypoxemia): decreased oxygen exchange (Pao2 < 60 mm Hg).
  
  • This is most often due to ventilation-perfusion (V/Q) mismatch, but can also be caused by anemia, poor blood flow to the lungs (sepsis, cardiac failure), or toxins affecting the utilization of oxygen at a tissue level (cyanide).
• Type II (hypercapnia) is characterized by decreased removal of carbon dioxide (Paco2 > 50 mmHg or pH < 7.35)
  
  • This can be caused by decreased respiratory rate (bradypnea) or decreased tidal volume (shallow breaths).

Question 4

Name Causes of pediatric respiratory distress: Upper airway (7)

Answer 4

• Croup
• Epiglottitis
• Laryngeal edema (postextubation)
• Foreign body
• Retropharyngeal Abscess
• Laryngomalacia
• Tracheitis

Question 5

Name Causes of pediatric respiratory distress: Lower airway (8)

Answer 5

• Bronchiolitis
• Asthma
• Allergy or anaphylaxis
• Acute infectious (bacterial or viral pneumonia)
• Chronic infectious (tuberculosis)
• Tracheo-esophageal fistula
• Cystic fibrosis
• Bronchopulmonary dysplasia

Question 6

Name Causes of pediatric respiratory distress: Pulmonary vasculature (2)

Answer 6

• Pulmonary embolism
• Pulmonary vasoocclusive disease

Question 7

Name Causes of pediatric respiratory distress: Pleura (3)

Answer 7

• Pneumothorax
• Pleural effusion
• Empyema

Question 8

Name Causes of pediatric respiratory distress: Neurologic (2)

Answer 8

• Hypotonia
• Myopathy (i.e., spinal muscular atrophy, botulism)

Question 9

Name Causes of pediatric respiratory distress: Cardiovascular (1)

Answer 9

Congestive heart failure

Question 10

Name Causes of pediatric respiratory distress: Metabolic (1)

Answer 10

Metabolic acidosis (DKA, metabolic conditions causing lactic acidosis)

Question 11

Name Causes of pediatric respiratory distress: Hematologic (3)

Answer 11

• Acute hemolytic anemia
• Sickle cell disease (chest crisis)
• Carbon monoxide poisoning

Question 12

Name Causes of pediatric respiratory distress: Other (8)

Answer 12

• Congenital diaphragmatic hernia
• Scoliosis
• Acute abdo
• Mediastinal mass (malignancy)
• Vascular ring
• Cold
• Exercise
• Drug-induced (opiates)

Question 13

Describe: Acute Management of Respiratory Distress (6)

Answer 13

• Airway—ensure that the airway is patent
• Breathing—observe breathing and movement of chest wall/Abdo, auscultate lung fields, measure oxygen saturation, consider supplemental oxygen by face mask
• Circulation—blood pressure, heart rate, peripheral pulses, capillary refill time, consider IV access and laboratory investigations
• Obtain a SAMPLE Hx—Signs and symptoms, Allergies, Medications, PMHx, Last meal, Events surrounding the acute event
• Management—based on the clinical exam and Hx
• Call for help—EMS, if in hospital—respiratory therapy team or anesthesia

Question 14

Describe HX: Respiratory Distress in Children (6)

Answer 14

• Identification:
  
  • Age, PMHx, presenting symptoms
• History of Present Illness:
  
  • Preceding events/exposures, duration of respiratory distress, aggravating/alleviating factors, associated symptoms, missed days of school, medications used and response, visits to health care practitioners or ED, any investigations already performed
• Past Medical History
  
  • Atopy (asthma, eczema, allergies), past ED visits or hospitalizations, admissions to ICU, other medical conditions (preterm, underlying cardiorespiratory disease), current medications (and compliance), known allergies, immunization status
• Family History
  
  • Atopy, genetic conditions (risk of congenital cardiac disease), cystic fibrosis, other major medical conditions
• Social History
  
  • Country of origin (recent immigration from country with different exposure risks—i.e., TB), exposure to smokers, pets, carpets/curtains, living situation, and other people in household (presence of wood-burning stove, contacts with communicable illnesses)
• Review of Symptoms
  
  • Recent viral URTI or current signs and symptoms (coryza, cough), sick contacts, exercise tolerance, nighttime cough, fever, emesis and voiding (as indicators of ability to tolerate feeding and hydration), dysphagia (RPA), drooling or hoarse voice (epiglottitis), travel Hx, Hx of choking episode (foreign body aspiration)

Question 15

Describe physical exam: Respiratory Distress in Children (9)

Answer 15

• Vital signs: tachycardia, tachypnea, decreased oxygen saturation, low BP, fever
• General: cyanosis, tripod positioning, unable to speak in full sentences
• HEENT: drooling,appearance of oropharynx (deviation of the uvula—peritonsillar abscess), sunken fontanelle and dry mucous membranes (if not tolerating fluids), lymphadenopathy (TB, malignancy), allergic shiners (dark coloration beneath eyes, can indicate atopy)
• Respiratory: increased work of breathing (described above, in Overview), inspiratory crackles, expiratory or biphasic wheeze or stridor, cough, localized or wide- spread reduced air entry, bronchial breath sounds
• Cardiovascular: extra or muffled heart sounds, murmurs, heaves, displaced point of maximal impulse, prolonged capillary refill time
• Abdo: paradoxical thoraco-abdo breathing, distended abdo, pain on palpation (referred from diaphragmatic inflammation due to an intrathoracic process), hepatomegaly
• Dermatologic: rash (postviral), erythematous pruritic patches (eczema)
• Neurologic: may be agitated, drowsy, or confused pelvic exam: in sexually active females with lower abdo pain
• Consider PRAM scoring as a method to quantify the level of respiratory distress

Question 16

True or False

Children may appear comfortable during mild respiratory distress.

Answer 16

True

It is important to expose the entire chest and abdo to inspect for signs of work of breathing.

Question 17

Describe: Pediatric respiratory assessment measure (PRAM)

Answer 17

Question 18

Describe investigations: Respiratory Distress in Children (4)

Answer 18

• The use of investigations will be guided by the suspected underlying etiology. If bronchiolitis or an asthma exacerbation is suspected by Hx and physical exam, further investigations are not usually indicated. In general, the following investigations can be considered in a patient with respiratory distress.
• Laboratory
  
  • CBC and differential, electrolytes, creatinine, urea, glucose, ammonia
  • Arterial or venous blood gas to evaluate oxygenation and ventilation (if significant respiratory distress)
• Imaging
  
  • AP and lateral CXR (not indicated in bronchiolitis or asthma. Useful for pneumonia, empyema, pulmonary edema, pneumothorax, cardiomegaly, rib fracture, mediastinal mass, etc.)
  • Lateral neck radiograph (RPA, epiglottitis)
  • Forced expiratory or bilateral decubitus chest radiograph (foreign body)
• Other
  
  • Electrocardiogram or echocardiogram

Question 19

Describe investigations: Respiratory Distress in Children (4)

Question 20

Describe: Management of Bronchiolitis (7)

Answer 20

• Supportive therapy, including suctioning of the nares to remove secretions (not deep suctioning), is key to the management of bronchiolitis.
• Provide supplemental oxygen to maintain saturations > 90%
• +/- Bronchodilators:
  
  • not currently recommended
  • however, a trial is an option, particularly for children with a FHx of asthma or Hx of prior response to bronchodilators.
• Hospitalization is indicated for patients who are hypoxemic (unable to maintain their oxygenation > 90% on room air, after appropriate supportive therapy is initiated), unable to maintain their hydration status (generally for tachypnea > 60 breaths/min), or those who have underlying risk factors for severe bronchiolitis (preterm, significant cardiopulmonary disease).
• There is no evidence to support the use of systemic corticosteroids for bronchiolitis.
• Antiviral medications are not indicated, and antibiotics should be used only if there is evidence of a coexisting bacterial infection.
• High-risk children should receive RSV prophylaxis (palivizumab).

Question 21

Describe: Management of an Acute Asthma Exacerbation MILD (PRAM 0-3) (3)

Answer 21

• Provide supplemental oxygen as needed to maintain saturations > 94%
• Short-acting bronchodilator (Salbutamol) q20min × 1 to 3 doses, then q1h PRN
• Consider systemic steroids

Question 22

Describe: Management of an Acute Asthma Exacerbation MODERATE (PRAM 4-7) (4)

Answer 22

• Provide supplemental oxygen as needed to maintain saturations > 94% •
• Continuous oxygen saturation monitoring
• Salbutamol ± Ipratropium bromide q20min × 3, then q30min PRN
• System steroids

Question 23

Describe: Management of an Acute Asthma Exacerbation SEVERE (PRAM >8) (8)

Answer 23

• Provide supplemental oxygen as needed to maintain saturations > 94%
• Continuous oxygen saturation monitoring
• Salbutamol and Ipratropium bromide q20min × 3, followed by salbutamol q30min PRN
• Systemic steroids—consider IV if not tolerating oral intake
• Consider IV fluids containing potassium
• If not improving, treat with magnesium sulfate
• If respiratory distress persists, consider continuous salbutamol infusion and admission to ICU
• Be prepared for rapid sequence intubation

Question 24

Name: Conditions causing stridor in children (3)

Answer 24

• Croup
• Epiglottitis
• Foreign body aspiration

Question 25

Describe croup (6)

Answer 25

• Inflammation of the larynx and trachea, often secondary to a viral infection (parainfluenza accounts for 65% of cases)
• Occurs in children 1–6 yr of age
• Hx: preceding viral URTI (cough, coryza, fever)
• SSx: “ barking” cough, inspiratory stridor
• Ix: steeple sign on PA radiograph of upper airway
• Tx: systemic steroids ± nebulized epinephrine

Question 26

Describe: Epiglottitis (5)

Answer 26

• Infection and inflammation of the epiglottis, with a high risk of upper airway obstruction
• Most commonly due to Haemophilus influenzae type b (Hib) (important to ask about vaccination status of the child)
• SSx: toxic appearance, drooling, muffled voice, tripod positioning
• Ix: “thumb print sign” on lateral neck radiograph
• Tx: intubation, antibiotics

Question 27

Describe: Foreign body aspiration (4)

Answer 27

• Must be considered in a stridorous child regardless of Hx
• Peanuts are the most common aspirated foreign body in children.
• Ix: AP radiographs can determine if there is a radiopaque object present; lateral decubitus radiographs may demonstrate air trapping on the side with the foreign body present.
• Tx: bronchoscopy

Question 28

The ideal administration of salbutamol is how? (1)

Answer 28

is by MDI via an AeroChamber; however, it can also be delivered via nebulizer.

Question 29

Describe: Systemic Steroids in Asthma (2)

Answer 29

The CPS recommends the following doses of oral corticosteroids:

• Prednisone (or prednisolone) 1 to 2 mg/kg/d (max 60 mg)
• or Dexamethasone 0.15 to 0.3 mg/kg/d (max 10 mg) for 3 to 5 d total course

Question 30

Describe influence of salbutamol in K+ (2)

Answer 30

• Salbutamol shifts K+ into cells, lowering serum K+ .
• If multiple treatments with salbutamol are required, K+ must be monitored closely to prevent hypokalemia.