Sometimes, a lab result or radiograph will indicate need for

emergent directed treatment (eg, foreign body). It is

extremely important to frequently reassess the patient after

each treatment to determine response and make decisions

for further management. Clinical status can change very

quickly in patients with respiratory distress (Figure 49-5).

TREATMENT

Croup. Administer humidified oxygen, and all patients

should get dexamethasone 0.6 mg!kg/dose (max 16 mg)

intramuscular (IM) or by mouth (PO) regardless of the

RESPIRATORY DISTRESS

severity. If there is stridor at rest, give racemic epinephrine

0.5 mL of 2.25% solution in 3 mL of normal saline (NS) via

a nebulizer.

Foreign body aspiration. Definitive management is to

remove in the operating room by laryngoscopy or bronchoscopy. In the setting of critical airway obstruction or

impending/actual respiratory arrest, attempt to force the

foreign body out with back blows or chest or abdominal

thrusts depending on the age and size of the patient. These

are all safer methods than the blind finger sweep, which can

convert a partial obstruction to a complete obstruction.

Other life-saving measures include laryngoscopy and direct

retrieval with Magill forceps, passing the endotracheal tube

beyond the obstruction and forcing the foreign body into

either mainstem bronchus, or needle cricothyrotomy.

Epiglottitis or bacterial tracheitis. It is particularly

important to allow the patient to assume a position of comfort, and if they are in the sniffing position, this is an omi ­

no us sign for severe obstruction. Ideally these patients should

have a definitive airway placed in the operating r oom by the

most skilled physician in difficult airway techniques, but if

there is respiratory arrest, then immediate endotracheal intubation or needle cricothyrotomy should be performed.

Anaphylaxis and severe angioedema. Treat with epinephrine, steroids, H1 and H2 blockers.

Asthma. Treat with �-adrenergic agonists: albuterol

2.5 mg every 20 minutes as needed or 15 mg in NS nebulized

over 1 hour continuously. For moderate to severe exacerbations, add anticholinergics (ipratropium bromide 500 meg

every 20 minutes for 3 doses) and steroids. If tolerating oral

intake with no impending respiratory failure, administer

prednisone 1-2 mg/kglday; otherwise use N steroids (SoluMedrol 2 mglkg, max 125 mg). If the patient's respiratory

effort is poor and respiratory failure is imminent, administer

IM epinephrine 0.0 1 mg/kgldose (max 0.5 mg) 1:1,000,

which can be repeated every 20 minutes for 2 more doses.

Terbutaline 2-10 meg N loading dose then 0.1-0.6 meg/kg/

min can also be used. Magnesium sulfate (50 mg/kg over

20 minutes to max 2 g) should be considered in patients

with moderate to severe exacerbations or those who do not

improve after initial therapy. Heliox, a mixture of helium

and oxygen, improves laminar flow through the bronchioles,

resulting in decreased work of breathing. There is some

evidence showing it improves pulmonary function in

patients with severe obstruction. The maximum amount of

oxygen in the mixture is 30%, so if the patient is hypoxic and

requires more than 30% FlO 2, then Heliox is not an option.

Bronchiolitis. Attempt a trial with �-agonists and/or

nebulized epinephrine. Clinical trials demonstrate that

corticosteroids are of no benefit in the treatment of bronchiolitis, but they may be useful in patients with a history

of reactive airway disease. High-flow humidified oxygen

via nasal cannula is a more novel treatment that is showing

some promising utility, especially in patients with RSV

and hypoventilation. The proposed mechanisms are

improvement of respiratory mechanics, washout of naso ­

pharyngeal dead space, and decreased work of breathing.

Some recent studies showed that it may decrease need for

endotracheal intubation. Hypertonic saline (3-5%) with

or without bronchodilators is another new therapy being

studied, with minimal side effects.

Pneumonia. Administer antibiotics early and oxygen as

needed.

DISPOSITION

..... Admission

Admission is indicated in respiratory failure requiring

mechanical ventilation, respiratory distress not reversible

with definitive therapy or requiring intensive monitoring,

pneumonia in patients <6 months, foreign body aspirations

with respiratory symptoms, or new oxygen requirements.

..... Discharge

The decision to discharge a patient is dependent on several

factors: clinical response to treatment, work of breathing,

hypoxia, hydration status, preexisting medical conditions,

and social factors. Keep in mind that respiratory status can

change quickly, and it is crucial to monitor a patient for a

significant amount of time after treatment to make sure

their clinical status does not deteriorate again. If the

patient continues to have increased work of breathing and

there is concern for impending respiratory failure, these

patients should not go home. Ensure the patient is well

hydrated and can tolerate oral intake before discharge.

Make sure the patient has reliable caregivers who can

administer treatments and medications and will bring the

patient back if they worsen again. Lastly, arrange secure

follow-up for the patient with his or her pediatrician or

specialist.

 

Soft tissue neck radiograph may reveal a thumbprint

sign of epiglottitis (Figure 49-3), the steeple sign of croup,

or a widened retropharyngeal space seen in retropharyngeal abscess (Figure 49-4). Neck computed tomography

may be required for definitive diagnosis of retropharyngeal

abscess or other deep space infections of the neck causing

airway obstruction.

RESPIRATORY DISTRESS

.&. Figure 49-2. Bi lateral decubitus chest x-rays in a

patient showing right-sided air trapping. Note that on the

left lateral decubitus view (A) the left lung is compressed

as expected. However, when the child is placed right-side

down (B), the right lung remains relatively hyperinflated.

This child was taken to the operating room, where a

peanut was found in the right mainstem bronchus.

Electrocardiogram may reveal decreased QRS amplitude

(pericardia! effusion), electrical altemans (severe pericardia!

effusion or cardiac tamponade), conduction delay (myocarditis), or ST segment and T wave changes (pericarditis).

Figure 49-3. The epig lottis is located by tracing the

base of the tongue inferiorly unti l it reaches the vallecula.

The structure immediately posterior is the epiglottis. If

the epiglottis is enlarged (thumb print) and the vallecula

is shallow, then epiglottitis is present (arrow).

MEDICAL DECISION MAKING

Assess and stabilize airway, breathing, and circulation as a first

priority. Apply pulse oximetry, cardiac monitor, and provide

supplemental oxygen and intravenous (N) fluids immediately. Respiratory arrest means that cardiac arrest will either

be present or imminent. These patients require endotracheal

intubation. Jaw thrust, suction of airway secretions, and use

of bag-valve mask is performed if needed before intubation.

If there are signs of impending respiratory failure (eg,

depressed level of consciousness, decreased response to

pain, agitation, cyanosis despite oxygen therapy, tachy ­

pnea, bradypnea, apnea, irregular respirations, absent

breath sounds, stridor at rest, grunting, severe retractions,

.&. Figure 49-4. Enlarged retropharyngeal soft tissues

showing a retropharyngeal abscess (li nes). The normal

retropharyngeal soft tissue space is <7 mm at C2 and

<22 mm at C6.

Assess

Place IV

Give IV fluid bolus

G ive oxygen

Place on monitor

Signs of impending respiratory failure?

Airway:

• Stridor at rest

• Irregular respirations

· Apnea

Breathing:

• Severe retractions

• Grunting, nasal flaring

• Poor aeration

• Progressive fatigue

Circulation

• Poor color (cyanotic, ashen, mottled)

• Sluggish capillary refill

Mental status

• Decreased level of consciousness

· Agitation

• Decrea sed response to pain

Allow patient to assume position of comfort

CHAPTER 49

Obtain brief history and begin treatment based on suspected disease process

Order labs and imaging as indicated

Continue to reassess patient and obtain additional history

Immediate resuscitation

Clear airway

Assist ventilations

Chest compressions

IV, 02, monitor, IVF

Prepare for assisted

ventilation including

Bipap, endotracheal

intubation

Figure 49-5. Respiratory distress diagnostic algorithm. ABCs, airway, breath ing, and circulation; IM,

intramuscu lar; IVF, I ntravenous fluids.

and use of accessory muscles), direct treatment toward the

suspected cause of distress.

If the patient has known trauma and unilateral decreased

breath sounds, assume a tension pneumothorax and perform

needle thoracostomy initially. For definitive management,

then perform a tube thoracostomy (see Chapter 7). If foreign

body is suspected, perform appropriate maneuvers to relieve

the obstruction based on age and the size of the patient. If

there is severe stridor at rest and fever, assume epiglottitis/

bacterial tracheitis/retropharyngeal abscess and arrange for

emergent definitive airway to be placed in the operating

room with the physician most skilled in difficult airway techniques. In some cases, the ED physician must perform emergent endotracheal intubation in the ED. It is extremely

important to have all difficult airway backup equipment,

including a needle tracheotomy tray immediately available. If

the patient is presenting with a severe asthma exacerbation or

allergic reaction and does not have adequate respiratory

effort, give epinephrine via intramuscular route immediately

while preparing for emergent intubation, if no response to

initial treatment. With severe wheezing not responsive to

bronchodilator therapy alone, if the patient is at an age when

they can cooperate and are still alert, an initial attempt with

positive pressure ventilation with bilevel positive airway pres ­

sure can be very helpful to decrease work of breathing and

prevent need for intubation. New evidence suggests that

high-flow nasal cannula with humidified oxygen can prevent

need for endotracheal intubation in some cases.

If there are no signs of impending respiratory failure

and no immediate life-saving intervention is needed, then

let the patient assume a position of comfort to optimize

respiratory effort and do not agitate. Obtain a brief history

and start treatment based on the suspected disease process.

Order labs and imaging that may help with the diagnosis.

 

Pneumonia incidence varies inversely with age, whereas the

etiology changes based on the season and age of the patient.

Important secondary causes of respiratory distress

include congenital heart disease, cardiac tamponade,

myocarditis/pericarditis, tension pneumothorax, central

nervous system infection, toxic ingestion, peripheral nervous system disease (eg, Guillain-Barre syndrome, myasthenia gravis, botulism), metabolic disorders ( eg, diabetic

ketoacidosis), hyperammonemia, and anemia.

CLINICAL PRESENTATION

..,._ History

Initial treatment may be required for stabilization before a

complete history and physical examination can be performed.

Ask for a description of respiratory problems, including

onset, duration, and progression of symptoms. Keep in

mind that respiratory distress can present as difficulty with

feedings in infants and decreased activity or feeding in toddlers. Inquire about precipitating or exacerbating factors.

Ask if there was any recent history of choking, as this may

be the only clue for a foreign body aspiration. Inquire if

they have ever had a similar presentation in the past.

Review all prior medications (chronic and acute) and note

time of administration. For example, how many times

albuterol was given per day in the past several days and the

last time given before coming to the ED. Ask if immunizations are up to date, as failure to do so could put the child

at risk for rare diseases (ie, epiglottitis, pertussis). Review

in detail all past medical history. Infants born prematurely

may have bronchopulmonary dysplasia (BPD), making

reactive airway disease, respiratory infections, hypoxia, and

hypercarbia more likely. When treating children with

asthma, ask about frequency of exacerbations, if they ever

required intubation or positive pressure ventilation, previous admissions (ED, general floor, intensive care unit) and

the last time they were on steroids. A history of chronic

cough or multiple previous episodes of pneumonias may

be suggestive of a congenital condition, undiagnosed reactive airway disease, or foreign body aspiration.

..,._ Physical Examination

The assessment should be conducted in a calm, efficient

manner, with assistance from parents. Agitating a child can

worsen symptoms and even precipitate acute decompensation, especially in suspected upper airway obstruction.

Allow the child to assume a position of comfort. Take extra

caution if the patient is presenting in the sniffing position

(head and chin are positioned slightly forward), as this may

indicate severe upper airway obstruction. Likewise, if the

patient is presenting in the tripod position (leaning forward

and supporting the upper body with their hands), this indicates severe lower airway obstruction, and this position will

optimize their accessory muscle use. Respiratory rate varies

in relation to age: newborn (30-60); 1-6 months (30-40);

6-12 months (25-30); 1-6 years (20-30); > 6 years (15-20).

Heart rate also varies with age: newborn ( 140-1 60),

6 months (120-160), 1 year (100-140), 2 years (90-140),

4 years (80-l lO), 6-14 years (75-100), > 14 years (60-90).

Keep in mind that tachycardia is typical with albuterol

treatment.

Skin exam can show diaphoresis, cyanosis (peripheral

or central), rash (eg, hives), bruising, or trauma and can be

a clue to the cause of respiratory distress. Make sure to fully

unclothe the patient, taking care not to worsen distress.

Stridor indicates upper airway obstruction, and the

phase of the respiratory cycle in which it occurs is a clue to

the location of obstruction. Inspiratory stridor is seen with

subglottic/glottis obstruction above the larynx ( eg, epiglottitis). Nasal flaring, dysphonia, and hoarseness also suggest

upper airway obstruction. Expiratory stridor is consistent

with obstruction below the larynx, in the bronchi or lower

trachea. Croup is the most common cause, but also consider foreign body, epiglottitis, anaphylaxis, angioedema,

peritonsillar abscess, retropharyngeal abscess, tracheomalacia, laryngomalacia, or obstructing mass.

Inspect the chest for depth, rhythm, and symmetry of

respirations. Retractions indicate accessory muscle use.

As the involved muscle groups move more superiorly (subcostal, intercostal, suprasternal, supraclavicular), airway

obstruction is more severe. Also examine the chest and

neck for any crepitus.

Lung exam is particularly important. Pneumothorax is

suggested by unilateral decreased or absent breath sounds,

but this finding is not always present. Wheezing and a prolonged expiratory phase indicate lower airway obstruction.

It is important to note that in patients with very severe

lower airway obstruction, wheezing may be absent as a

CHAPTER 49

result of poor aeration. Crackles, rhonchi, and decreased or

asymmetric breath sounds are found with alveolar disease.

Grunting prevents alveolar collapse and preserves func ­

tional residual capacity (FRC). Its presence implies severe

respiratory compromise.

 

 It accounts for 10% of pediatric visits to the ED, 20% of pediatric admissions, and

20% of deaths in infants. Respiratory distress can potentially lead to respiratory failure (the inability of oxygen ­

ation and ventilation to meet metabolic demands) and

should be recognized and treated promptly.

Several anatomic and physiologic characteristics put

pediatric patients at higher risk for respiratory compro ­

mise. Infants <4 months of age are obligate nose breathers.

Nasopharyngeal obstruction significantly increases the

work of breathing. The location of the narrowest part of

the airway, where a foreign body is likely to lodge, differs in

adults (vocal cords) and children (cricoid cartilage). The

diameter of the pediatric airway is a third that of adults.

Narrowing of the airway leads to a greater relative increase

in resistance to airflow ( 1-mm occlusion decreases crosssectional diameter by 20% in adults vs. 75% in children).

Abdominal musculature is a primary contributor to respiratory effort in children. Abdominal distension and muscle

fatigue can negatively impact ventilation. Pediatric 1 ungs

have a lower functional residual capacity (FRC) with less

reserve potential. PaO 2 decreases more rapidly when ventilation is interrupted.

• Initial treatment may be req uired for sta bil ization

before a complete history and physical examination

can be performed.

• Patient appearance and clinical status always

su persede lab va l ues and imaging.

Respiratory distress may result from either upper air ­

way obstruction, lower airway disorders, or other organ

dysfunction compromising the respiratory system. Upper

airway obstruction is the leading cause of life-threatening

acute respiratory distress. Upper airway obstruction is

defined as blockage of airflow in the larynx or trachea. It is

characterized by stridor, an inspiratory sound caused by air

flow through a partially obstructed upper airway. The age

of the patient can aid in diagnosis.

Common causes of upper airway obstruction in chil ­

dren <6 months include laryngotracheomalacia (chronic,

usually resolves by age 2) and vocal cord paresis or

paralysis. Laryngomalacia and tracheomalacia are con ­

genital conditions that affect the structural integrity of

supporting structures in the upper airway. This leads to

collapse of the affected tissues into the airway during

respiration.

In children >6 months, important causes of upper airway obstruction include viral croup, foreign body aspiration, epiglottitis, bacterial tracheitis, retropharyngeal

abscess, peritonsillar abscess, airway edema from trauma,

thermal or chemical burn, or allergic reaction. Croup

(laryngotracheobronchitis) is the most common cause of

upper airway obstruction and stridor in children aged

3 months to 3 years. It occurs in 5% of children during

their second year of life and is caused by a viral infection

206

RESPIRATORY DISTRESS

affecting the subglottic region. The patient presents with a

barking cough, inspiratory stridor, and fever.

Upper airway obstruction from foreign body aspiration

is most common in children aged 1 to 4 years. About

3,000 patients die each year from asphyxia related to foreign body aspiration.

Bacterial infections in the upper airway include epiglottitis and tracheitis. Epiglottitis is less common now since

routine immunization against Haemophilus influenzae type B.

Currently, tracheitis is more likely to be the cause of acute

respiratory failure from airway obstruction than epiglottitis.

Lower airway obstruction has several causes, including

asthma, bronchiolitis, pneumonia, allergic reaction, respiratory distress syndrome, aspiration, and environmental or

traumatic insults. Asthma is the most common chronic

disease in children, affecting 5-10% of the population.

Bronchiolitis is most famously caused by respiratory syncytial virus (RSV), although other pathogens include parainfluenza, influenza, and adenovirus. It is a respiratory

infection that causes inflammation of the bronchioles.

Edema and mucous production lead to obstruction of the

airways with V/Q mismatch and hypoxia. It is most common in infants 2 to 6 months and is associated with

increased likelihood of asthma developing in the future.

 

Age

Qual ifications

Physical Examination

Lab values to determine

low-risk stratification

Treatment for High risk

patients

Treatment for Low risk

patients

Study outcome statistics

Rochester Criteria

<60 days

Term infant

No perinatal antibiotics

No underlying disease

Not hospitalized longer than the

mother at birth

Well-appearing

No ear, soft tissue, or bone infection

WBC >5,000 and <15,000/�L

Absolute band count <1,500/�L

UA <10 WBC/HPF

Hospital admission

Empiric antibiotics

Home

No antibiotics

Follow-up required

Sensitivity 92%

Specificity 50%

PPV 1 2.3%

NPV 98.9%

Philadelphia Protocol

29-60 days

Not specified

Well-appearing

Unremarkable exam

WBC <15,000/�L

Band-neutrophil ratio <0.2

UA <1 0 WBC/HPF

Urine Gram stain negative

CSF <8 WBC/�L

CSF Gram stain negative

Chest radiograph: no infi ltrate (if done)

Hospital admission

Empiric antibiotics

Home

No antibiotics

Follow-up required

Sensitivity 98%

Specificity 42%

PPV 1 4%

NPV 99.7%

Boston Criteria

28-89 days

No immunizations within

preceding 48 hours

No antimicrobial within 48 hours

Not dehydrated

Well-appearing

No ear, soft tissue, or bone infection

WBC <20,000/�L

CSF <10/�L

UA <1 0 WBC/HPF

Chest radiograph: no infiltrate

(if done)

Hospital admission

Empiric antibiotics

Home

Empiric antibiotics

Follow-up required

Sensitivity-NA

Specificity 94.6%

PPV-NA

NPV-NA

CSF, Cerebrospina l Flu id; HPF, high-power field; NA, not available; N PV, negative predictive va lue; PPV, positive predictive va lue; UA, urinaly ­

sis; WBC, white blood cel ls.

supportive care with no additional laboratory studies or

antibiotic therapy is appropriate.

Toxic-appearing febrile infants and children, regardless of age, require a full septic work-up, broad-spectrum

antibiotics, and admission. Fever in immunocompromised

children should also be aggressively managed as outlined

previously followed by prompt communication with their

subspecialty providers. Antibiotics should never be delayed

to complete a septic evaluation.

TREATMENT

Fever may be treated with an antipyretic such as

acetaminophen ( 10-15 mglkg) every 4 hours or ibuprofen

(5-10 mg/kg) every 6 hours as needed to ensure patient comfort. It is important to note that correlation between defervescence with an antipyretic and incidence of SBI has not

been established and should not affect clinical decision making. Ample fluid intake should be encouraged. Some patients

may require intravenous fluids if dehydration is present.

Patients with an identifiable focus of infection should be

treated with the most appropriate antibiotic regimen. For

fever without a source, empiric antibiotics may be given,

based largely on the patient's age and r isk stratification.

Infants who are <1 month of age should be treated

with antibiotic therapy directed at the most common

pathogens causing SBI in this age group (Listeria,

Escherichia coli, Group B Strep, and other gram-negative

organisms).

 

as a single generalized tonic-clonic seizure that lasts

< 1 5 minutes in children aged 6 months to 6 years with no

resulting focal neurologic deficits. These seizures occur in

the setting of fever in previously healthy children with no

history of epilepsy or signs of central nervous system ( CNS)

infection. Three percent to 5% of all children will have a

simple febrile seizure. A source should be investigated for

a patient presenting with a simple febrile seizure, but an

extensive work-up is usually not indicated. A febrile

seizure is considered complex if it has focal features, lasts

longer than 15 minutes, or occurs more than once in

24 hours. A more extensive work-up including laboratory

studies, imaging, and lumbar puncture should be strongly

considered in those presenting with complex febrile

seizures.

..... Physical Examination

Vital signs and general appearance should always be e valuated before proceeding with the remainder of the physical

exam. Heart rate can be elevated approximately 10 bpm for

every 1 °C of elevation in temperature. However, tachycardia

out of proportion to fever can indicate sepsis. Children and

infants with sepsis differ from adults as they often do not

demonstrate hypotension until very late in the course due

to a compensatory increase in cardiac output. Thus a normal blood pressure is not necessarily reassuring.

Tachycardia and poor peripheral perfusion occur before

hypotension and can be early signs of impending

circulatory collapse.

Evaluating the general appearance of an infant or child

with fever is also crucial. Infants or children who are

lethargic or demonstrate paradoxical irritability ( eg,

inconsolable when held by parents) may have a CNS

infection. A head-to-toe physical exam should be

performed. Special attention should be paid to the anterior fontanelle in infants; a bulging tense fontanelle may

indicate meningitis, whereas a sunken fontanelle may

indicate severe dehydration. In older children, assessment

of neck pain, stiffness, and range of motion may also

be useful in helping establish a diagnosis of CNS infection.

Evaluate the lung fields for crackles, asymmetry, and work

of breathing. Forced expiration and percussion may assist

in the detection of areas of consolidation. Carefully

examine the skin to identify any rashes, petechiae, or

purpura. Meningococcemia should be assumed in

a febrile, ill-appearing child with a petechial or purpuric

rash until proven otherwise. Additionally, jaundice in a

neonate may indicate the presence of sepsis but is not a

specific finding. The extremities should be examined

closely for erythema, swelling, warmth, focal tenderness,

and decreased range of motion, as this may indicate

osteomyelitis, pyomyositis, or septic arthritis. These

infections are more common in children than in adults. A

reassuring clinical examination in infants <3 months does

not necessarily rule out an SBI and should not be used in

isolation to guide management in this age group.

DIAGNOSTIC STUDIES

..... Laboratory

Laboratory tests to consider include a complete blood

count, urinalysis, urine culture, blood culture, and cerebrospinal fluid (CSF) studies. The appropriate tests to

order, if any, depend on the history and physical examination, clinical appearance, age, and risk factors for SBI.

..... Imaging

A chest x-ray (CXR) may be helpful in identifying pulmo ­

nary infection in patients with tachypnea, cough, hypoxia,

or other signs of lower respiratory tract disease. Signs of

osteomyelitis may not be apparent on plain radiographs

until the infection has been present for at least 7-10 days.

Additional imaging, including computed tomography for

intra-abdominal infection, may be helpful depending on

the patient's specific signs and symptoms.

MEDICAL DECISION MAKING

The differential diagnosis for acute fever in an infant or

child is broad and includes minor illnesses, such as viral

infections, upper respiratory infections, and otitis media,

to more significant illnesses, including pneumonia, pyelo ­

nephritis,