Child with Respiratory Distress

Question 1

FB aspiration

Answer 1

Stridor and airway obstruction in kids 6 mo – 4 yr
CXR +/- FB seen
Bronchoscopy for direct visualization

Tx:
Keep pt calm
Heimlich if can’t breath at all
Tracheostomy w/ continued obstruction
Bronchoscopy to retrieve

Question 2

Croup

Answer 2

Acute inflammation of larynx

Causes: parainfluenza virus type 1, 2, and 3; RSV; influenza; adenovirus/ Mycoplasma

Presentation:
affects children 3 mo - 5yrs
Nasal congestion
fever
Barky, harsh, seal-like cough - worse at night
If severe:
-Dyspnea, retractions, increased work of breathing
-Stridor (inspiratory)
-Wheezing (expiratory)

Diagnostic: CXR might show narrowing trachea “steeple sign”

Tx:
-Changes in ambient temperature or humidity, humidified oxygen
Dexamethasone 0.6 mg/kg single dose for mild cases
Racemic epi for moderate to severe cases -> inpatient obstruction

Question 3

Epiglottitis

Answer 3

MC d/t HIB (unimmunized), Staph, and Strep spp.

Inflammation and swelling -> upper airway obstruction

Presentation:
2-7 yo
High fever, poor oral intake, sore throat, dysphagia
Toxic appearing, drooling, respiratory distress, stridor, hypoxia, voice change or muffled crying, tripoding

Diagnosis:
CALL anesthesia and ENT
Only examine the oropharynx when prompt intubation is needed
Don’t upset the patient -> possible airway loss
XR may show “thumb sign”

Tx:
keep child calm until able to intubate if necessary (usually required for 2-3 days)
Tracheostomy if intubation is unsuccessful
Cx of blood and epiglottis
Abx: linda or van (S. aureus), ceftriaxone or cefotaxime (HIB) for 7-14 days

Question 4

Bronchiolitis

Answer 4

MC: RSV, influenza, parainfluenza 3, adenovirus
Winter or spring
Children under 2yo
-risk severe respiratory compromise in premies, asthma, congenital heart disease, CF

1-3 days of mild URI
-copious nasal secretions
-Wet cough
-fever
-poor feeding
Wheezing or noisy breathing - "washing machines"

Exam:
tachypnea
expiratory wheeze
crackles and hyperreasonance
Respiratory distress - retractions, tachypnea, nasal flaring, grunting, apnea, or cyanotic episodes

CXR airway trapping
patchy perihilar infiltrates
+/- discrete infiltrates - PNA complication of bronchiolitis

Tx:
Supportive care
-Supplemental O2 (up to 15L high flow)
-IVF
STEROIDS NOT EFFECTIVE OR INDICATED

Ppx: RSV vaccines for premies and comorbid conditions - Palavizumab (Synagis)

Question 5

Asthma classifications: day/night time episodes, FEV1, tx

• mild intermittent
• Mild persistent
• Moderate persistent
• Severe persistent

Answer 5

Mild intermittent:

• less than or equal to 2 daytime episodes/week OR
• less than or equal to 2 nighttime episodes/month
• FEV1 80% or more
• Tx: prn albuterol

Mild persistent:

• 3-6 daytime episodes/week OR
• 3-4 night time episodes/month
• FEV1 80% or more
• Tx: PRN albuterol PLUS: low dose ICS, +/- montelukast, +/- cromolyn

Moderate persistent:

• daily daytime episodes OR
• > 1 nighttime episode per week
• FEV1 60-80%
• Tx: PRN albuterol PLUS: moderate dose ICS, +/- LABA, +/- montelukast

Severe persistent:
-continual daytime episodes OR frequent nighttime symptoms
-FEV1 less than 60%
Tx: PRN albuterol PLUS: high dose ICS, LABA, and PO steroids, +/- montelukast, +/- theophylline

Question 6

Asthma triggers, risk, symptoms and PE

Answer 6

Triggers:
Allergens
URI
Bblockers
exercise/stress
rarely - aspirin

Risk:
FHx asthma
Allergies
atopic dermatitis
low socioeconomic status

Can improve with age
Older - chronic cough especially after colds

Sxs:
cough, dyspnea, wheezing, chest tightness

PE:
Tachypnea, tachycardia, prolonged expiratory duration, diminished breath sounds, accessory muscle use, cyanosis, low sats

Question 7

Asthma exacerbation

Answer 7

Peak expiratory flow rate is decreased
ABG: Mild hypoxia, respiratory alkalosis

Severe factory cases: Methylprednisolone, prednisone - Takes four hours to kick in IV or PO

Question 8

Theophylline overdose

Answer 8

Toxic level hit at different dosing, patient specific
Give benzodiazepines for seizures
Verapamil or beta blocker for tachycardia
+/- Hemodialysis

Question 9

Status asthmaticus

Answer 9

Prolonged nonresponsive asthma attack
Can be fatal
Treat with an aggressive bronchodilator therapy, Corticosteroids, supplemental oxygen
\+/- Intubation
Goal SpO2 >94%