Pocket Emergency Medicine (Pocket Notebook Series) 3rd Ed.

RESPIRATORY COMPLAINTS

PNEUMONIA

History

• Fever, cough; quality of sputum usually unascertainable (children often swallow secretions); recent URI, malaise, lethargy, N/V, SOB, nasal flaring & grunting

• Older children: Abdominal pain, neck stiffness

• Infants/neonates: Difficulty feeding, tachypnea, restlessness or lethargy (JAMA 1998;279:308)

• RFs: Lack of immunizations/incomplete immunizations, travel, daycare

Bacterial (10–40%)

• Abrupt, follows URI, appearing ill, usually <5 yr

Atypical

• Fever, malaise & myalgia, HA, photophobia, sore throat, & gradually worsening nonproductive cough

Viral

• Nontoxic, associated upper airway sxs (runny nose, nasal congestion)

Physical Exam

• Fever, tachypnea (most sens), oxygen saturation; full pulmonary exam (rales, rhonchi, decreased breath sounds)

Evaluation

• Labs: Chem 7 (severe dehydration), CBC (elevated WBC), blood cultures (if seriously ill); consider viral panel (including RSV)

• Imaging: CXR

Treatment

• Supportive: IVFs (if dehydrated), O2 monitoring & therapy

• Viral: Supportive

• Abx (duration is 14 d for neonates, o/w 7–10 d), add vancomycin if critically ill

• Neonate – ampicillin + 3rd-generation cephalosporin or gentamicin inpt

• 1–3 mo – 3rd-generation cephalosporin + macrolide inpt

• 3 mo–5 yr – 3rd-generation cephalosporin + macrolide (inpt) or high-dose amoxicillin (outpt)

• 5–18 yr – 3rd-generation cephalosporin + macrolide (inpt) or macrolide alone (outpt)

Disposition

• Home: Immunizations up to date, HD stable, on room air, >3 mo

• Admit: <3 mo, temp >38.5°C, tachypnea (>70 breaths in <12 mo & >50 breaths in older children), retractions in infants, respiratory distress, nasal flaring, cyanosis or hypoxemia (oxygen <92%), intermittent apnea, grunting, poor POs, signs of dehydration, social concerns, inadequate f/u, sepsis, immunosuppressed, comorbidities, cx, virulent pathogens (Thorax 2002;57(suppl 1))

ASTHMA AND BRONCHIOLITIS

History

Asthma

• Cough (usually early), dyspnea & wheezing (generally worse at night). Consider frequency, severity, duration, home txs, required past txs, baseline peak flow, number of ED visits, hospitalizations, ICU admissions, intubations.

• Triggers: Exercise, infection, cold air, allergens, any respiratory irritant

Bronchiolitis (usually <2 yr of age)

• Fever (usually ≤38.3°C), cough, wheezing, mild respiratory distress; etiology from viral exposure (usually RSV, but may also parainfluenza, adenovirus, influenza, rhinovirus). Often preceded by a 1–3-d h/o nasal congestion & mild cough.

• RFs for severity: Prematurity, low birth weight, <12 wk old, congenital dz

Physical

Asthma

• Tachypnea, tachycardia, inspiratory/expiratory wheezes, decreased or no air movement, use of accessory muscles, anxious/agitated, signs of dehydration

Bronchiolitis

• Same as asthma; may hear crackles & have signs of other infections such as OM

Evaluation

• Pulse ox: Continuous, unless very mild sxs

• Labs: Usually not necessary, consider RSV testing (bronchiolitis) if admission

• Imaging: CXR only if concomitant PNA suspected or 1st-time wheezer

• Peak flow (asthma): In children >6 yr (compare to predicted based on height)

Treatment

• Supportive: ABCs, oxygen therapy (O2 sat >90%)

Asthma

• Mild/moderate:

• Albuterol: 0.15 mg/kg (max 5 mg) q20–30min × 3 doses (short acting β-agonist)

• Ipratropium bromide: 250 μg/dose (<20 kg) OR 500 μg/dose (>20 kg) q20–30min × 3 doses may decrease need for hospitalization

• Steroids: Prednisolone/prednisone 2 mg/kg PO (max 60 mg) OR methylprednisolone 1–2 mg/kg IV (max 125 mg) OR dexamethasone 0.6 mg/kg PO (max 16 mg)

• Severe (add):

• Albuterol: As above but may be used continuously

• Magnesium: 75 mg/kg IV (max 2.5 g) over 20 min (optimal dose unknown)

• Heliox: 80% helium/20% O2. Use only if oxygen saturation can be maintained above 90%.

• Terbutaline or epinephrine: Terbutaline 0.01 mg/kg SC (max 0.4 mg) q20min × 3 doses &/or epinephrine 0.01 mg/kg SC (max 0.4 mg) q20min × 3 doses then repeated q4–6h

• Ventilation:

• Noninvasive (BiPAP): May reduce respiratory fatigue & improve oxygenation/ventilation

• Intubation: For impending respiratory failure; use large ETT; consider permissive hypercapnia (increased expiratory time & low tidal volumes to prevent barotraumas). Consider ketamine for induction (bronchodilating properties).

Bronchiolitis

• Supportive tx is the mainstay including humidified oxygen, suctioning, oral hydration

• Trial of albuterol, can continue only after documented response

• Nebulized hypertonic saline is a/w clinical improvement & decreased hospital LOS

• Racemic epinephrine may be helpful

• <2 yr: 0.25 mL of 2.25% solution via nebulizer diluted in 3 mL NS

• ≥2 yr: 0.5 mL of 2.25% solution via nebulizer diluted in 3 mL NS

• Consider ribavirin if documented RSV bronchiolitis w/ severe dz or immunosuppression &/or HD unstable

Disposition

Asthma

• Reassess pt in 3 h (more frequent if sxs more severe) after nebulizers, steroids, oxygen therapy

• Home: Improved peak flow (to >70% predicted), significant improvement in RR/oxygen saturation; d/c w/ inhaled β-agonist, steroid burst × 5 d (See Adult Asthma Table for further home management) w/ close f/u

• Admission:

• Floor: Persistent wheezing w/ nasal flaring, tachypnea, hypoxia & unable to tolerate POs

• ICU: If pt maintains severe wheezing/poor air movement w/ peak flow <50% & worsening tachypnea or possible impending respiratory fatigue, PCO2 >42 mmHg, intubated, requiring continuous nebs, heliox, or terbutaline

Bronchiolitis

• Home: Age >2 mo, no h/o intubation, eczema, RR <45, no/mild retractions, O2 sat >93%, tolerating PO, fewer albuterol/epinephrine txs in 1st hour (Pediatrics 2008;121(4):680)

• Admission: Age <6 wk, hypoxia, persistent respiratory distress, significant comorbidities or immunosuppression

BRONCHOPULMONARY DYSPLASIA

Definition

• Chronic lung dz in preterm neonates w/ h/o ICU, malnutrition, exposure to high oxygen concentrations, inflammation, infection (sepsis, chorioamnionitis, funisitis, postnatal infections), & PPV → impaired alveolar/pulmonary vascular development

History

• Preterm birth, h/o ICU stay w/ mechanical ventilation, recent respiratory infection, poor feeding, increased oxygen requirement

Physical Exam

• Abnl VS, nasal flaring, retractions, grunting, wheezes, rales, decreased breath sounds

Evaluation

• CXR – hyperinflation, scarring; RSV testing will identify those who require hospitalization

Treatment

• Supportive; O2, bronchodilators (see Pediatric Asthma); consider inhaled & systemic corticosteroids, abx (see Pediatric Pneumonia), furosemide (1 mg/kg q6–12h, titrate to effect)

Disposition

• Admission: If increased respiratory distress, hypoxia, hypercarbia, new pulmonary infiltrates, inability to maintain oral hydration, RSV infection

UPPER AIRWAY EMERGENCIES

Definition

• Actual or impending obstruction of the upper airway

Approach to the Patient

History

• Agitation or fidgeting, cyanosis, AMS, choking, SOB, increased work of breathing, panic, unconscious, unusual breathing noises

• ROS (fever, drooling), PMH/MEDS (see differential chart)

Diagnostics

• CXR or neck films, esp if abnl O2 sat & temp

Treatment

• O2, calm the child, head tilt, chin lift, “position of comfort” (upright while leaning forward)

Disposition

• Largely will depend on hemodynamic stability & airway issues

FOREIGN BODY/UPPER AIRWAY OBSTRUCTION (SEE ADULT RESPIRATORY SECTION)

Croup (Laryngotracheobronchitis)

Definition

• Viral infection primarily of the larynx & trachea (often parainfluenza), age 6 mo–6 yr

History

• Hoarseness, barking cough, & inspiratory stridor w/ variable degree of respiratory distress; preceded by nonspecific respiratory sxs (rhinorrhea, sore throat, cough); fever is usually low grade

Physical Exam

• Inspiratory stridor, retractions, decreased air entry

Evaluation

• Labs: None

• Imaging: Labs & imaging not routinely indicated

• CXR: PA view may show steeple sign, (subglottic narrowing), lateral view may reveal a distended hypopharynx (ballooning) during inspiration

Treatment

• Supportive: Humidified air, oxygen, keep child as comfortable as possible

• Steroids: Dexamethasone (0.6 mg/kg ×1, max of 10 mg)

• Racemic epinephrine: Below dosing mixed w/ 3 cc NS (may repeat q20–30min), for children w/ stridor at rest, requires 2–3 h observation for “rebound stridor”

• <20 kg: 0.25 mL

• 20–40 kg: 0.5 mL

• >40 kg: 0.75 mL

Disposition

• Home: If maintaining oxygen saturation; advise symptomatic tx w/ Tylenol & humidified air

• Admit: If hypoxia, depressed sensorium, moderate to severe respiratory distress, stridor at rest, poor oral intake, dehydration

Epiglottitis

Definition

• Pharyngeal infection classically due to H. influenzae; incidence in children has declined since introduction of H. influenzae vaccine, most common organisms now include S. pyogenes, S. aureus, S. pneumoniae, Moraxella

History

• Fever is usually 1st sx w/ abrupt onset sore throat, stridor, labored breathing, drooling muffled/hoarse voice, age 2–7 yr, lack of cough

Physical Exam

• Toxic, irritable, anxious, sitting in tripod or sniffing position (chin hyperextended & leaning forward), drooling, retractions, adenopathy; may visualize edematous epiglottis on oral exam

Evaluation

• Labs: Postpone IV & labs until airway secured; CBC, blood cultures, Chem 7

• Imaging: Lateral neck x-ray: Swollen epiglottis (ie, thumbprint sign), thickened aryepiglottic folds, obliteration of the vallecula, & dilation of the hypopharynx

Treatment

• Supportive: Oxygen therapy, keep child as comfortable as possible; place child & mom in a quiet & controlled for complete eval/tx

• Airway: Preferable secured in OR under controlled environments but if not available, consider partial sedation & fiberoptic intubation. Cricothyrotomy kit at bedside for emergent surgical airway; tracheostomy.

• Abx: Ceftriaxone 100 mg/kg IV q12h (max 2 g/d)

• Consult: ENT or anesthesia for STAT OR airway

Disposition

• Admit: All to the ICU

Pearls

• Avoid procedures which may cause distress to the pt & further thereby compromise airway

• Give child or parent Yankauer suction to maintain secretions & alleviate associated anxiety

Bacterial Tracheitis

Definition

• Infection of subglottic region causing edema, pseudomembrane formation; polymicrobial (S. aureus, S. pneumoniae, H. influenzae, Pseudomonas, Moraxella), average age 3 yr

History

• Preceding URI infection w/ rapid deterioration, high fevers, age 3 mo–5 yr

Physical Exam

• Stridor, retractions, tachypnea, barking cough, wheezing, high fevers, toxic appearing

Evaluation

• Labs: None

• Imaging: X-ray shows subglottic & tracheal narrowing, irregular tracheal margins, PNA

Treatment

• Supportive: Oxygen, frequent suctioning, use one size smaller ETT

• Broad spectrum abx (3rd-generation cephalosporin, vancomycin)

Disposition

• ICU