And be sure to review all of the great cases included in the podcast, the cases will critically reinforce your learning.
Here are excerpts from the transcript:
Respiratory distress in the child is an emergency and can quickly progress to life-threatening respiratory failure.
You are 3d year clerk working in an emergency department at a Children’s Hospital. A very distressed parent has brought their three-year-old daughter in because she is gasping for breath. The parent tells you that the child is been so short of breath that she is unable to speak, and seems to be turning blue! When you look at the child, she is clearly struggling to breathe with audible inspiratory wheeze and is leaning forward in a tripod position while sitting in her parent’s lap.
We will be returning to this case throughout the podcast.
Signs of respiratory distress in a child’s vitals include tachypnea, tachycardia, and hypoxia.
The WHO considers respiratory rate to be an essential marker for acute respiratory illness in infants and children.
According to the WHO approved standards, tachypnea is defined as over 60 breaths per minute and an infant under two months of age, over 50 in an infant to to 12 months, over 40 in a child aged 1 to 5, and over 30 in a child over five years of age.
You may observe the child using accessory muscles to assist with breathing or you may see some costal or intercostal in drawing or sternal retractions. Other observable signs that suggest increased work of breathing include tripod position, leaning forward propped up by their arms, in an attempt to make breathing easier.
On physical exam, you may hear the child running or making other accessory sounds of breathing such as Strider or wheeze the child may have decreased air entry, or crackles on inspiration, depending on the underlying cause of respiratory distress. Assessing air entry is particularly important. Child in our scenario as tachypnea tripod and cyanosis and inability to speak.
The first step is to assess the child’s ABCs. You need to determine the severity of the situation and in any emergency interventions are required. This should always be your initial approach to any child in an emergency scenario prior to conducting a history and physical examination.
Airway: the first step in managing a child in an emergency scenario is to determine [and safeguard, if necessary] there airway status.… Assess whether the patient can speak or cry and look for signs of airway obstruction by choking and cyanosis. If the patient is at risk for losing their airway, consider the need to establish an alternative airway.
Breathing: to assess breathing counter respiratory rate look for symmetry chest rise, use of accessory muscles, and listen for airway movements and quality of breath sounds bilaterally. Make note of any adventitious breath sounds such as wheezing or Strider, which are clues to the underlying diagnosis. Again, decreasing air entry and/or fatigue due to increased work of breathing are ominous signs.
Circulation: examine the child’s skin color – do they appear pale or ashen? Check to capillary refill time by pressing on the nail beds of the fingers or toes.*Assess multiple peripheral pulses such as radial and femoral for quality, strength, and rate. Based on your findings you may need to establish IV access to supply fluids and/or medications after the airway is been secured.
*[There is disagreement on the utility and on the optimal way of checking capillary refill time. Please see:
The Diagnostic Value of Capillary Refill Time for Detecting Serious Illness in Children: A Systematic Review and Meta-Analysis [PubMed Abstract] [Full Text HTML] [Full Text PDF]. PLoS One. 2015 Sep 16;10(9):e0138155. doi: 10.1371/journal.pone.0138155. eCollection 2015
A capillary refill time of 3 seconds or more is an important warning sign for serious illness and
risk of death in children, and can easily be used in a wide range of settings and with only minimal training. Normal CRT in children does not make a serious outcome less likely, and should not be used to rule out serious illness. Standardization of CRT measurement would likely increase the diagnostic utility of this test.
Resuming excerpts from the transcript:
Once you have confirmed that your patient is stable through assessing and addressing their ABCs, you can move on to conducting a more specific history and physical examination it is helpful to consider the differential diagnosis of a child presenting in respiratory distress first, to help you focus on your encounter.
The differential diagnosis of a child in respiratory distress is broad. We feel it is useful to use a structured approach when considering this presentation.
Pulmonary causes are the most frequent underlying etiologies of respiratory distress. Common and/or important upper airway pathologies include a laryngeal foreign body, croup, epochal otitis, and retro pharyngeal abscesses. Lower airway pathologies that can cause respiratory distress include acute asthma exacerbations, acute respiratory distress syndrome, infections such as pneumonia or tuberculosis, bronchiolitis and a lower airway foreign body plural pathologies include pneumothorax, pneumothorax and pleural effusion can also present as respiratory distress.
Of non-pulmonary causes, cardiac causes of respiratory distress are among the most important to consider. The child in respiratory distress may be experiencing congestive heart failure or pulmonary edema.
Other important diagnoses to consider include central nervous system disturbances, meningitis, metabolic acidosis, and anaphylactic reactions.
In the history, inquire about the onset, course and duration of the episode, as well as if the child has experienced any similar events in the past.
Illustrative examples to help elicit shortness of breath on history including infant not able to feed, or an older child unable to speak in full sentences.
Ask about associated symptoms. If the child has a cough, this can indicate an infection like bronchiolitis, pneumonia, or tuberculosis.
The presence of fever also offers suggests infection.
A change in the child’s voice plus fever can indicate an upper airway abnormality like a retro pharyngeal abscess.
If the child is afebrile and has no other symptoms of an upper respiratory tract infection like sore throat, a diagnosis of metabolic acidosis may be more likely.
Vomiting and abdominal pain can point towards an underlying metabolic abnormality [like DKAor a surgical abdomen]
Choking, gurgling, drooling and dysphagia all suggest and obstructive cause for the respiratory distress such as foreign body aspiration or epiglottitis.
Anytime a foreign body inhalation has been possibly witness this diagnosis must be excluded.
Chest pain and hemoptysis can be present in cases of trauma and could indicate lung injury such as pneumothorax or hemothorax.
Relevant risk factors that you should ask about include any infectious or sick contacts, particularly pertussis or tuberculosis. Ask about travel outside the country. Check if their immunizations are up to date, and don’t forget to ask about the flu shot. Take a focused medical history, including asking about immunocompromised status and previous respiratory diseases, such as a previous diagnosis of asthma. Ask about trauma which may suggest a pneumothorax; although these patients will be quite second presentation. Ask about exposure to allergens or toxins which could precipitated asthma or anaphylactic attack.
Obtaining a relevant past medical history can help you guide your differential diagnosis. Relevant conditions to specifically ask about include asthma, a copy – in particular eczema and allergies – and any previous episodes consistent with the current presentation, including treatments that were used in whether they work. Also ask about any underlying medical issues such as congenital heart disease neuromuscular disorders or hematologic conditions like sickle-cell disease. Complete a brief screening for relevant family history of asthma, atopic and cardiac disease.
Finally, do not forget to confirm current medications and any allergies that the child may have.
Once you assess the girl’s ABCs and are satisfied that she is stable and has a patent airway, you ask the parents further questions. He learned that the girl has recently been prescribed a puffer by her family doctor for asthma.
She was playing with some small toys when her parents noticed see she seemed to be choking and struggling for air. The child does not have a cough, and is not been exposed any sick contracts recently. He doesn’t have a recent history of any trauma, and there is no family history of asthma or heart condition.
Based on this history, you’re starting to suspect either an acute asthma exacerbation or a foreign body obstruction as a cause of this child’s respiratory distress. In order to not miss other important causes, you move on to completing a physical examination while she is on her parents lap.
Always start with the vital signs. Assess the patient’s heart rate, respiratory rate, oxygen saturation, blood pressure, and temperature. Don’t estimate the respiratory rate. Ideally count the respiratory rate for 30 seconds using a watch or clock [or your cell phone], and then multiply by two or more details of normal ranges for pediatric vital signs by each group he’s referred to the Pediatrics Vitals Sign Reference Chart available at www.pedscases.com.
Determine oxygen saturation accurately through pulse oximetry monitoring. If the oxygen saturation is low [less than 92%], provide supplemental oxygen as needed, using either a nasal cannula or facemask to ensure oxygen saturation is above 94%.
Determine heart rate, rhythm, and character. Tachycardia is common in children presenting with respiratory distress.
Observe the child’s level of consciousness. Do they appear anxious, irritable, or lethargic?
[Bradycardia in a child with respiratory distress suggests a pre-terminal event and requires immediate assisted ventilation with high flow oxygen. Therefore, it’s a good idea to apply the three lead ECG monitor in a child with respiratory distress if a monitor is available.]
When faced with the child in respiratory distress, a good strategy is to use your history and physical to help prioritize your differential diagnosis, then ordered targeted investigations if necessary to rule key diagnoses in around. Let’s check in with our clinical case for an example.
After conducting a physical examination and coupled with information you obtained from the patient on history, you have ruled out cardiac, infectious, anaphylactic, and traumatic causes for the girls respiratory distress. On auscultation, she has decreased air entry bilaterally and fixed the high-pitched wheeze. For SpO2 is that 91%, so you provide supplemental oxygen with a facemask and for SpO2 increases to 98%. When examining her mouth and throat you are unable to visualize any object in the oropharynx, but feel imaging is necessary to rule out a foreign body and her airway. You order a chest x-ray with AP and lateral views that show small object lodged in the right mainstem bronchus. You consulted pediatric otolaryngologist to remove the object with the rigid bronchoscopy.