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.
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.
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.
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.
July 1, 2011