Respiratory Distress in Infants and Young Children: An Update
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Difficulty Breathing In Infants And Young Children: An Update

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Table of Contents
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Critical Appraisal Of The Literature
    1. Asthma Literature
    2. Anticholinergics
    3. Magnesium Sulfate
    4. Theophylline
    5. Ketamine
    6. Bronchiolitis Literature
    7. Beta-agonists
    8. Epinephrine
    9. Steroids
    10. Apnea
    11. Other Treatment Modalities
    12. Croup Literature
      1. Steroids
    13. Cool Mist
    14. Heliox
    15. Foreign Body Aspiration Literature
    16. Anaphylaxis Literature
  4. Epidemiology
  5. Pathophysiology
  6. Etiology / Differential Diagnosis
    1. Upper Airway Etiologies
    2. Lower Airway Etiologies
    3. Chest Wall / Pleural Cavity
    4. Cardiac
    5. Nervous System
    6. Gastrointestinal
    7. Metabolic
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. History
    2. Timing
    3. Preceding Symptoms
    4. Type Of Cough
    5. Vomiting
    6. Past Medical History
    7. Family History
    8. Physical Examination
      1. General Appearance And The Work Of Breathing
      2. How fast?
      3. How hard?
      4. How loud?
      5. Vital Signs
      6. Head Examination
      7. Neck Examination
      8. Chest Examination
      9. Abdominal Examination
      10. Skin Examination
      11. Neurological Examination
  9. Diagnostic Studies
    1. Radiology
    2. Neck X-Rays
    3. Blood Gases
    4. Capnometry
    5. Pulse Oximetry
    6. Respiratory Syncytial Virus Testing
  10. Treatment
    1. Airway Management
      1. Oxygen
      2. Bag-Valve-Mask / Assisted Ventilation
      3. Endotracheal Intubation
      4. Alternative Airways
      5. Surgical Airways
      6. Foreign Body Removal
    2. Pharmacologic Therapy
      1. Bronchodilators
      2. Vasoconstrictors
      3. Anticholinergics
      4. Steroids
      5. Antibiotics
  11. Special Circumstances
    1. H1N1 Influenza
    2. Cystic Fibrosis
    3. Sickle Cell Anemia
    4. Bronchopulmonary Dysplasia / Chronic Lung Disease
    5. Immunosuppressed Children
    6. Steroid Dependent Asthmatics
    7. Neuromuscular Disorders
  12. Controversies/Cutting Edge
    1. Noninvasive Ventilation
    2. Isomeric Albuterol
    3. Helium Oxygen Mixture
    4. Ketamine
  13. Disposition
  14. Summary
  15. Clinical Pathway: Emergency Department Evaluation Of Infants/Toddlers With Respiratory Distress (Not Wheezing)
  16. Clinical Pathway: Emergency Department Evaluation Of Wheezing Infants And Toddlers
  17. Clinical Pathway: Emergency Department Approach to Infant/Child Difficulty Breathing
  18. Risk Management Pitfalls In The Treatment Of Difficulty Breathing
  19. Tables and Figures
    1. Table 1. Differential Diagnosis Of Difficulty Breathing Upper Airway
    2. Table 2. Rapid Sequence Intubation
  20. References


Pediatric respiratory distress is a common and troubling presenting complaint to the emergency department (ED). Although many respiratory illnesses are due to upper respiratory tract infections, which are self-limited and need only parental reassurance, the emergency clinician must constantly be alert and prepared for the few children with an underlying condition that can progress to respiratory compromise or failure. Emergency clinicians must utilize clues from both the history and physical examination to uncover the cause of the distress and then employ the most up-to-date modalities to prevent the child’s deterioration. Although uncommon, respiratory failure can rapidly ensue in some instances and cause cardiopulmonary arrest. Respiratory failure is the most common cause of cardiac arrest in children.1 The unexpected and rapid respiratory collapse of the pediatric patient can most often be avoided by early recognition of the severity of illness and should prompt initiation of appropriate therapies.

Case Presentations

You’ve just come in for the early morning shift. You finish taking sign-outs. As you walk toward the coffee machine, the triage nurse runs by you carrying a toddler in her arms who is coughing, crying, and gasping for air. You follow her to the room, squeeze past 2 frightened parents, a crying grandparent, 2 other nurses, and an EMT student trying to get to the child. They are all trying to keep him on the gurney, place monitor leads, place a nasal cannula for oxygen, and start looking for IV sites. In the meantime, the child’s distress continues to worsen, and everyone in the room starts looking at you.

Critical Appraisal Of The Literature

Due to the number of conditions that result in respiratory distress, the literature on this topic is quite extensive and diverse. While certain illnesses are well-studied, the literature on other disease states is sparse. For instance, the scope of the literature on foreign body aspiration is limited to case reports and case series. This is due to the fact that there are only a handful of cases each year that present to a single ED, making it difficult to conduct large studies. On the other hand, there are many large randomized trials and systematic reviews on asthma, bronchiolitis, and croup.

Risk Management Pitfalls In The Treatment Of Difficulty Breathing

  1. “It can’t be asthma – the child wasn’t wheezing.” Children with asthma who are very sick may present with a “silent chest” due to very poor air exchange. The severe degree of bronchoconstriction seen in these patients is thought to obstruct airflow sufficiently to impede wheezing. Many times, the initiation of beta-agonist therapy with albuterol will result in the patient manifesting wheezing.
  2. “What do you mean he’s now apneic? His respiratory rate was normal just a little while ago!” As children progress from respiratory distress to respiratory fatigue, they will start to breathe more slowly. It can be dangerous to assume that a child who is breathing more slowly is clinically improving.
  3. “Congestive heart failure!? The baby didn’t have rales.” Congestive heart failure in infants may not typically manifest with rales. Instead, assessing the presence of hepatomegaly on physical examination or noting a history of sweating during feeds will more likely identify cases of congestive heart failure in infants.
  4. “It couldn’t be pertussis – the baby was not whooping.” Few infants with pertussis infection have the classis paroxysmal cough. Be suspicious of pertussis infection with a history of prolonged cough or apnea, in under-immunized infants.
  5. “How could this be a foreign body – there was no history, and the chest x-ray was clear?” Often, a foreign body aspiration will not have an accompanying history, and a child will present with new onset wheezing (occasionally unilateral) without predisposing factors. A normal chest x-ray does not rule out a foreign body. A high index of suspicion is often necessary to make the diagnosis.
  6. “The patient’s croup got better after the epinephrine treatment — so I sent her home.” Although the theoretical “rebound” effect of racemic epinephrine has not been substantiated in the literature, patients with croup and resting stridor require additional treatment and evaluation after the effects of the epinephrine have worn off.

Tables and Figures

Table 1. Differential Diagnosis Of Difficulty Breathing Upper Airway


Evidence-based medicine requires a critical appraisal of the literature based on study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available.

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