Pediatric Respiratory

Emergencies:
Beyond the Runny Nose
Christopher Strother, MD
Mount Sinai School of Medicine
Department of Emergency Medicine
June 25 27, 2009

Quick Preview
6 month old with cough, fever and

wheezing
2 year old with fever and stridor
4 year old with dehydration and
tachypnea
4 month old with sudden onset distress

Case 1
6 month old male presents with 4 days cough,
congestion, fever to 101.5, poor appetite,
increased work of breathing today
RR 55 HR 150 BP 95/58 SpO2 95%
Alert, tired appearing, lots of nasal congestion
and runny nose, MM moist
Flaring and retractions, tachypnea, scattered
wheezing, rhonchi, and upper airway noises

Treatment?
A: Reassurance
B: Dexamethasone
C: Nebulized Albuterol
D: Nebulized Epinephrine
E: Dexamethasone and Epinephrine

Case 1
Patient responds to albuterol with
decreased distress, resolution of
wheezing

What next?
A: Send him home with some albuterol
B: Send him home with albuterol and
steroids
C: Admit for observation
D: Get a chest x-ray first, then decide

Not All That Wheezes is

Asthma (Or Bronchiolitis)
First time wheezers deserve an x-ray

Although some disagree

Mahabee-Gittens EM, et al. Chest radiographs

in the pediatric emergency departement for

children < or = 18 months of age with
wheezing. Clin Pediatr (Phila). 1999
Jul;38(7):395-9.
Retrospective review of predictors of CXR
findings in wheezing

21% normal
61% c/w RAD or bronchiolitis
18% focal infiltrates (predicted by T, O2, & exam)
1% other

Suggests selective use of chest xray

Case 1b
Patient fails to improve with albuterol,
continued wheezing, tachypnea, mild
distress, sats stable

Now What?
A: Admit with no further treatment, nothing
works for bronchiolitis anyway
B: Trial nebulized epinephrine
C: Give steroids and continue albuterol
every couple of hours as it may help
later
D: Send him home anyway, SpO2 is OK

Bronchiolitis
Viral lower airway infection (RSV #1)
Often involves, mimics, or may even cause
reactive airway disease
At risk for severe disease are the very
young (especially < 60 days), expremies, and those with chronic disease
(both for more severe pulmonary
disease and for RSV induced central
apnea)

Bronchiolitis Treatment
Airway and Oxygen as needed
Clear Congestion, Ensure fluid intake
Bronchodilators Studies show no definite
benefit, but many recommend a trial,
especially if there is asthma in family

Diagnosis and
management of
bronchiolitis.
Pediatrics 2006;
118:1774.

Albuterol: 0.15mg/kg to 5mg or 4-6 puffs

Epinephrine: 0.05ml/kg to 0.5ml
Reassess in 1 hour after each to determine
effect, continue if helpful

Bronchiolitis: steroids?
Mixed evidence and more confusion with
reactive airway disease component
Meta-analysis and largest study to date
show no improvement

Patel, H, Platt, R, Lozano, J, Wang, E. Glucocordicoids

for acute viral bronchiolitis in infants and young
children. Cochrane Database Syst Rev 2004;
3:CD004878
Corneli, HM, Zorc, JJ, Majahan, P, et al. A multicenter,
randomized controlled trial of dexamethasone for
bronchiolitis. N Engl J Med 2007; 357:331

Bronchiolitis: steroids?
Recent study showing possible synergy of
dexamethasone and epinephrine
Randomized trial of 800 infants 6 weeks to 12
months of age
Neb epi x 2 and dex x 6days, epi only, dex only,
or placebo
Individual med groups showed no change
Dex and Epi group showed a reduction in
hospitalization rate, but analysis adjusting for
multiple comparisons rendered it not
significant (p = 0.07)
Plint, AC et al. Epinephrine and Dexamethasone in Children
with Bronchiolitis. N Engl J Med. 2009 May

Bronchiolitis Treatment
Antibiotics: If they have another reason

Dont forget to work up fevers!

Ribavirin: In select immune-compromised

Heliox: Small studies show limited benefit
IVIG: Not shown to help
Surfactant: Shows promise, but needs study
Hypertonic Saline: Promise, but needs study
Montelukast: Studies not showing benefit

Case 2
2 year old male with no past medical history or
family history
URI x 2 days, worsening barky cough today,
mother heard wheezing at home
From the hallway he sounds like a seal
Alert, nontoxic, no distress, normal exam except
clear rhinorrhea, normal VS, lungs clear no
wheezing heard
Develops mild stridor while crying during med
students exam, resolves when calm

Treatment?
A:
B:
C:
D:
E:

Nebulized Albuterol
Racemic Epinephrine
Dexamethasone
Humidified Air
Reassurance Only

Case 2b
Patients twin sister however, is tachypneic
though not retracting, but has some
stridulous noise at rest, worse with
crying and cough

Treatment for Sister?

A:
B:
C:
D:
E:

Reassurance / Observation Only

Nebulized Epinephrine Only
Dexamethasone Only
Epinephrine and Dexamethasone
Call ENT for intubation in the OR

Croup
Parainfluenza Laryngotracheitis
Supportive Care
Warm mist, cool nights, drink fluids
Mist has not been scientifically shown to work, but parents
swear by it

Dexamethasone for everybody

0.6 mg/kg up to 10mg (PO, IM or IV)

Nebulized Rac - Epi: 0.05ml/kg to 0.5ml

For distress or strider at rest
Repeat q 15 minutes as needed (admit if repeat)
Observe 3-4 hours before discharge for rebound

Case 2c
Triplets!
The third child was sick a few days earlier
than the other two, now with two days
fever of 104+, today with severe distress,
no PO intake
Distressed, tachypneic, drooling, retracting,
sitting forward on the bed, drooling,
unwilling to change position for exam

Now What?
A: RSI immediately
B: Use a tongue depressor to see what
the heck is going on in there
C: Dexamethasone Only
D: Epinephrine and Dexamethasone
E: Call ENT for intubation in the OR

Epiglottitis
Yes, it still exists (at least on your boards)
H. Flu vaccine drastically reduced
incidence
Strep. Pneumo. and Pyogenes
Often super infection of viral
DONT TOUCH!!!! (at least not until you
have as much support as possible and
tracheotomy set up near by)

Retropharyngeal abscess
Another important cause of stridor and

fever in children
Likely more toxic than croup
Likely more neck pain and difficulty
moving the neck

Case 3
(Only one this time I promise.)

4 year old male, no past, no family history

URI x 5 days, no fever, two days
increasing fatigue and respiratory
distress
Ill appearing, MM dry, tachypneic,
retracting
Normal sats, clear lungs, no other physical
findings

Most likely Diagnosis

A:
B:
C:
D:
E:

Swine Flu
Foreign Body Aspiration
DKA
Vascular Ring
Toxic Ingestion

Diabetic Ketoacidosis
Acidosis leads to hyperpnea
Kussmaul Respirations
Can be mistaken for respiratory process,

especially in young children atypical age

for DKA and other metabolic diseases

Case 4
4 month old male sudden onset respiratory
distress, brought in by EMS, lethargic,
cyanotic, tachypneic
HR 167 RR 40 BP SpO2 92% on RA
Increased responsiveness with 100%
NRB, more comfortable sitting up,
increased distress when laid flat

Most likely Diagnosis

A:
B:
C:
D:
E:

Swine Flu
Foreign Body Aspiration
Congenital Heart Defect
Epiglottitis
Toxic Ingestion

CXR

Normal CXR may miss a

non-opaque FB

Bilateral decubitus films can

reveal unilateral hyperinflation

Quick Review
Bronchiolitis:
Trial albuterol and / or racemic epinephrine
No evidence for routine steroid use yet
Croup:

Dexamethasone for everybody

Racemic Epi if stridor at rest or distress

Watch out for non-pulmonary diseases

presenting as respiratory symptoms

Always consider aspiration or ingestion in
infants and toddlers

Any Questions?
Thank you!!!!

References

Diagnosis and management of bronchiolitis. Pediatrics 2006; 118:1774.

Gadomski, AM, Bhasale, AL. Bronchodilators for bronchiolitis. Cochrane
Database Syst Rev 2006; 3:CD001266
Hartling, L, Wiebe, N, Russell, K, et al. Epinephrine for bronchiolitis. Cochrane
Database Syst Rev 2004; :CD003123
Patel, H, Platt, R, Lozano, J, Wang, E. Glucocordicoids for acute viral bronchiolitis
in infants and young children. Cochrane Database Syst Rev 2004; 3:CD004878
Corneli, HM, Zorc, JJ, Majahan, P, et al. A multicenter, randomized controlled trial
of dexamethasone for bronchiolitis. N Engl J Med 2007; 357:331
Plint, AC et al. Epinephrine and Dexamethasone in Children with Bronchiolitis. N
Engl J Med. 2009 May 14;360(20)2130-3.
Mahabee-Gittens EM, et al. Chest radiographs in the pediatric emergency
department for children < or = 18 months of age with wheezing. Clin Pediatr
(Phila). 1999 Jul;38(7):395-9.
Geelhoed, GC, Turner, J, Macdonald, WB. Efficacy of a small single dose of oral
dexamethasone for outpatient croup; a double blind placebo controlled clinical
trial. BMJ 1996; 313:140
Bjornson, CL, Klassen, TP, Williamson, J, et al. A randomized trial of a single dose
of oral dexamethasone for mild croup. N Engl J Med 2004; 351:1306