Respiratory Distress

Respiratory distress is one of the most common chief concerns among children who present for pediatric emergency care. Approximately 10% of pediatric emergency department (ED) visits, 20% of pediatric admissions, and 30% of pediatric intensive care unit (ICU) admissions are due to respiratory concerns. Respiratory distress may be caused by upper or lower airway obstruction or by pathology of the lung parenchyma or interstitium.

Upper Airway Emergencies

Upper airway obstruction is common in infants and young children in part because of their airway anatomy: a short, narrow trachea and a high, soft, and easily collapsible larynx. Additionally, infants aged <4 months are obligate nose breathers and as a result, substantial nasal congestion can lead to significant respiratory distress. Listed below are some “can’t miss” etiologies of upper airway emergencies and management in the ED. Other etiologies such as croup (laryngotracheobronchitis) are discussed in the Pediatric Urgent Care rotation guide.

Foreign Body Aspiration

Full obstruction of the airway is an emergency.

Epidemiology:

• most common in children ages 1 to 5 years

• foods (grapes, meat, hot dogs, candy) are more common than man-made objects (balloons, beads, small balls)

Signs/symptoms:

• stridor, monophonic wheeze, tachypnea, retractions, dysphagia, choking/gagging with cyanosis, persistent cough

• witnessed swallowed foreign body (although often unwitnessed)

Diagnosis:

• partial obstruction: anteroposterior-view x-ray of chest, neck, and/or abdomen; radiopaque objects can be confirmed and localized on x-ray; radiolucent objects can produce findings such as air trapping, atelectasis, mediastinal shift, and consolidation on x-ray; and inspiratory and expiratory films may demonstrate unilateral air trapping

  • Note: A coin and a button battery are similar in appearance on plain film; the former may require endoscopic removal after a period of observation, but the latter requires emergent removal and immediate mobilization of a surgical team.

Management:

• complete obstruction: back blows (infants), Heimlich maneuver (children); CPR for any age if the child becomes unresponsive

  • extraction of object (e.g., with Magill forceps) if able to visualize it; do not attempt blind finger sweep

• partial obstruction: bronchoscopy, depending on type and location of object

(Source: Foreign-Body Aspiration in a Child. N Engl J Med 2022.)

Epiglottitis

Cellulitis of the epiglottis and adjacent supraglottic structures that can result in abrupt and complete airway obstruction is a true emergency.

Epidemiology:

• Haemophilus influenzae type b (Hib): historically, Hib caused 75% of cases; incidence has significantly declined with routine Hib vaccination

• other (non-Hib) bacteria, viral and fungal infections

Signs/symptoms:

• abrupt onset of fever, dysphagia, drooling, muffled voice, stridor, labored breathing

Diagnosis:

• initial: history and clinical presentation

• definitive: direct visualization of swollen, friable epiglottis by laryngoscopy

Management:

• airway stabilization with artificial airway as needed

  • Consider having a surgical team available to establish an emergent operative airway (e.g., cricothyrotomy) should endotracheal intubation prove impossible.

• intravenous (IV) antibiotics

• avoid agitation: keep a child with suspected epiglottitis sitting upright and calm, using distraction techniques to avoid worsening symptoms

(Source: Epiglottitis. N Engl J Med 2019.)

Retropharyngeal Abscess (RPA)

RPA is infection and subsequent abscess formation of a lymph node in the potential space between the prevertebral fascia and the posterior pharyngeal wall.

Epidemiology:

• children aged <4 years

• recent ear, nose, or throat infection

Signs/symptoms:

• gradual onset of fever, dysphagia, drooling, decreased intake, stiff neck, muffled voice

Diagnosis:

• lateral neck x-ray in extension will demonstrate widened prevertebral space

• CT of neck

Management:

• surgical evaluation (otolaryngology) and potential drainage

• IV antibiotics

(Source: Retropharyngeal Abscess. N Engl J Med 1997.)

Peritonsillar Abscess (PTA)

PTA is bacterial invasion and subsequent abscess formation in the space between tonsillar tissue and its surrounding capsule.

Epidemiology:

• more common in adolescents and young adults; can be a complication of a previous bacterial pharyngitis (see group A streptococcal pharyngitis in the Pediatric Urgent Care rotation guide)

Signs/symptoms:

• fever, sore throat, trismus, lymphadenopathy, dysphagia

Diagnosis:

• physical exam: unilateral, erythematous, bulging tonsil with or without exudate

• may cause uvular deviation to the unaffected side

Management:

• surgical evaluation (otolaryngology) and potential drainage

• IV antibiotics

(Source: Bilateral Peritonsillar Abscesses. N Engl J Med 2008.)

Lower Airway Emergencies

Lower airway obstruction is often due to inflammation and bronchospasm in children. The most common causes of lower airway emergencies in children are asthma, bronchiolitis, and anaphylaxis. Each of these etiologies can lead to respiratory failure and can cause significant morbidity.

Asthma

Asthma is the most common chronic childhood illness and is defined as a chronic disorder of the airways characterized by airflow obstruction, bronchial hyperresponsiveness, and inflammation. This section will focus on the acute management of asthma in the emergency department.

A strong evidence base supports the following goals of care for asthma management in the ED:

• rapid assessment and categorization of asthma severity

• early treatment with inhaled bronchodilators and systemic glucocorticoids

• decreased hospitalization rate

• decreased length of ED stay

Assessment: Acutely ill and young children are often unable to perform the lung-function tests that are routinely used in adults to stratify asthma severity. Instead, multiple validated clinical-scoring systems are available to stratify the severity of asthma exacerbations in children. Most algorithms are derived from a combination of exam findings, subjective symptoms, and objective measures (e.g., pulse oximetry). One of the most commonly used clinical tools is the Pediatric Asthma Severity Score (PASS).

Management: The cornerstones of acute asthma management are:

• early beta-agonist therapy

• prompt systemic glucocorticoid administration

• addition of anticholinergic therapy for severe exacerbations (shown to reduce rate of hospitalization)

Many hospitals have created treatment pathways for children presenting with asthma exacerbations. One such algorithm is show below.

Abbreviations: MDI, metered dose inhaler; q20min, every 20 minutes; PRN RT, as needed respiratory therapy assessments; SQ, subcutaneous; IV Mg, intravenous magnesium; WOB, work of breathing; Tx, treatment; Q2 (q2h), every 2 hours (Adapted from ED Pathway for Evaluation/Treatment of Children with Asthma. Children’s Hospital of Philadelphia 2020.)

Bronchiolitis

Bronchiolitis is a viral lower respiratory tract infection in infants and is characterized by acute inflammation, edema, and increased muus production of the medium and small airways. The most common causative viral pathogens include respiratory syncytial virus (RSV), rhinovirus, and human metapneumovirus.

Bronchiolitis is more common in the winter months (October-April) and is the leading cause of hospitalization in infants younger than 12 months in the United States. An estimated one-third of children will acquire bronchiolitis during the first 2 years of life. Given the high hospitalization rate and cost associated with bronchiolitis, best practices for the care of infants with bronchiolitis have been studied extensively.

Diagnosis: Bronchiolitis is diagnosed based on a constellation of clinical signs and symptoms. The AAP guidelines recognize bronchiolitis as an entity in children younger than 2 years who present with a subset of the following symptoms after a viral upper respiratory tract prodrome:

• increased respiratory effort (grunting; nasal flaring; intercostal retractions, subcostal retractions, or both)

• cough

• wheeze

• rhinorrhea

• fever

Laboratory (viral testing) and radiologic studies (chest radiograph) are not recommended for routine diagnosis.

Management: Supportive care is the cornerstone of treatment, with management tailored to the severity of the individual infant’s illness. All patients receive supportive care with bulb suctioning as needed for nasal secretions; those with severe disease may require wall suctioning and high-flow nasal cannula (HFNC) oxygen therapy. The care team should maximize hydration status in infants with bronchiolitis and may place a peripheral IV or nasogastric tube in infants whose respiratory status makes oral feeding impossible. All patients require frequent clinical assessment and measurement of oxygen saturation.

Risk factors: Children with the following characteristics are at high risk for severe disease:

• age <12 weeks

• gestational age <35 weeks

• respiratory rate >70 respirations per minute

• congenital heart disease, immunodeficiency, chronic lung disease

Patients who can maintain oxygen saturation levels >90%, who demonstrate adequate oral intake, have only mild-to-moderate work of breathing, and have a reliable caretaker and outpatient follow-up available can be discharged home from the ED.

Anaphylaxis

Anaphylaxis is a potentially life-threatening manifestation of a type I hypersensitivity reaction.

Diagnosis: Anaphylaxis is highly likely when any one of the following three sets of criteria is fulfilled:

• acute onset of illness after exposure to a possible allergen with involvement of the skin, mucosal tissue, or both (e.g., generalized hives, pruritis or flushing, swollen lip-tongue-uvula) and at least one of the following:

  • respiratory compromise (dyspnea, wheeze, bronchospasm, stridor)

  • reduced blood pressure (BP) or associated symptoms of end-organ dysfunction

• two or more of the following that occur rapidly after exposure to a likely allergen for the patient:

  • involvement of the skin, mucosal tissue, or both

  • respiratory compromise

  • reduced BP or associated symptoms

  • persistent gastrointestinal (GI) symptoms (e.g., vomiting)

• reduced BP after exposure to a known allergen for the patient

Management: If a patient displays signs of anaphylaxis, management is as follows:

• immediate administration of intramuscular (IM) epinephrine

  • can be repeated every 5-15 minutes as needed

AND

• assessment of ABCs, removal of any offending agent, placement in supine position with lower extremities elevated (Trendelenburg position) if hemodynamically unstable

• other considerations:

  • IV access

  • volume resuscitation

  • supplemental oxygen

  • airway support

Epinephrine is the first-line therapy for anaphylaxis. Second-line therapy includes administration of histamine-1- and histamine-2-blocking antihistamines and glucocorticoids for symptomatic relief. However, there is a paucity of studies examining the efficacy of these adjunctive agents in children, and they have little role in the acute treatment of cardiovascular compromise.

Severe or recurrent symptoms requiring more than one dose of epinephrine merit admission to the hospital for further management and close observation. Children only requiring one dose of epinephrine may be observed in the ED to ensure that recrudescence of symptoms does not occur. Children who remain clinically stable throughout that observation period can be discharged home with a prescription for and instruction about the use of an epinephrine auto-injector.