Pediatric presentation

Cough and respiratory distress in children

Bronchiolitis, croup, asthma and pneumonia are separated by the age, the sound and the effort, not by the X-ray.

What are you worried about?
- Impending respiratory failure: exhaustion, a quiet chest, drowsiness, a falling respiratory rate
- Upper airway obstruction: stridor at rest, drooling, tripod position
- Apnea in the young infant with bronchiolitis or pertussis
- The inhaled foreign body
Differential, by age
Newborn birth to 28 days
Sepsis presenting as breathing difficulty
Congenital heart disease
Bronchiolitis with apnea
Pertussis
Infant 1 to 12 months
Bronchiolitis
Pneumonia
Pertussis
Heart failure from a shunt lesion
Toddler 1 to 3 years
Croup
Viral-induced wheeze
Foreign body aspiration
Pneumonia
Preschool 3 to 5 years
Asthma
Croup
Pneumonia
Foreign body
School age 6 to 11 years
Asthma
Pneumonia, including Mycoplasma
Anaphylaxis
Adolescent 12 to 17 years
Asthma
Pneumonia
Pneumothorax
Vaping-associated lung injury
Pulmonary embolism with risk factors
Key history
- Onset and tempo: sudden (foreign body, anaphylaxis, pneumothorax) versus days of coryza first (bronchiolitis, croup)
- The sound: bark, stridor, wheeze, grunt, whoop
- Feeding: the volume taken, coming off the breast or bottle to breathe
- Fever, colour changes, apneas, the night pattern (croup peaks at night)
- Prematurity, chronic lung disease, congenital heart disease, previous wheeze, asthma control, smoke exposure
- Immunizations (pertussis, Haemophilus influenzae type b, pneumococcus)
Key examination
- Work of breathing from the doorway: rate, nasal flaring, head bobbing, tracheal tug, retractions (subcostal, intercostal, suprasternal), grunting
- Ability to feed, talk, or play; level of alertness
- Where the noise lives: inspiratory (upper airway) versus expiratory (lower airway)
- Air entry and its symmetry; crackles; the silent chest
- Saturation, and how much oxygen it is taking to hold it
- Hydration and perfusion
Red flags
- Saturation below 90 percent, or a rising oxygen requirement
- Grunting, head bobbing, severe retractions, a silent chest
- Apnea or cyanotic episodes, especially under 3 months or ex-preterm
- Exhaustion: drowsiness, a slowing respiratory rate, rising carbon dioxide
- Stridor at rest, drooling, inability to swallow
- Intake below about half of usual, or no wet diaper in 12 hours
Initial investigations
- Bronchiolitis and croup are clinical diagnoses: no X-ray, no viral swab, no blood test routinely
- Chest X-ray for focal signs, a suspected foreign body, a first severe wheeze, or failure to improve
- A blood gas when exhaustion is a question
- Inflammatory markers and cultures only when bacterial pneumonia or sepsis is suspected
How to interpret them
- Wheeze responsiveness to bronchodilator separates asthma physiology from bronchiolitis, which does not respond
- Hyperinflation on a bronchiolitis film is expected and is not pneumonia
- A normal saturation on high-flow oxygen is not a normal child
When the child is deteriorating
- Escalate oxygen delivery stepwise; high-flow nasal cannula in bronchiolitis; nebulized epinephrine and dexamethasone in croup
- Asthma: bronchodilator, steroid, then magnesium and senior review; a falling heart rate with a quiet chest is peri-arrest
- Know the numbers that trigger the call: oxygen requirement, respiratory rate trend, mental status, gas
Cases and practice
Cough, and not finishing her bottles5 months old · A 5-month-old with three days of a cold is breathing fast and has stopped feeding well. Her mother is worried about the pauses.A barking cough at two in the morning2 years old · A 2-year-old woke his parents with a cough 'like a seal' and a noise when he breathes in. In the car he seemed better; in the waiting room it started again.The puffer is not working6 years old · A 6-year-old with known asthma has been wheezy for two days; today her blue inhaler lasts an hour. Her father has given ten puffs in the car.
Practice drills Acute pediatrics

See it

Frontal chest radiograph of an infant with bronchiolitis showing hyperinflated lungs, flattened diaphragms and patchy atelectasis — Bronchiolitis in a 16-day-old: hyperinflation with flattened diaphragms and bilateral atelectasis (right apical, left basal). The film is not needed to diagnose bronchiolitis; it is here to show what hyperinflation looks like in an infant.Di Nardo M, Perrotta D, Stoppa F, Cecchetti C, Marano M, Pirozzi N (Journal of Medical Case Reports, via Wikimedia Commons) · CC BY 2.0 · source

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Recognizing Respiratory Distress by M. Kleinman

OPENPediatrics (Boston Children's Hospital) · embedded with attribution; their teaching, not ours

The clinical signs of respiratory distress in a child, from the effort to the sounds to the level of consciousness, taught by a pediatric intensivist.

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