Questions and Answers
Which of the following is listed as one of the most common causes of wheezing in infants and toddlers?
Paradoxical breathing is a sign of very severe respiratory distress.
True
What is the mainstay of treatment for an acute episode of asthma?
anti-inflammatory therapy with corticosteroids and bronchodilation with beta-2 agonists such as albuterol
______ syncytial virus (RSV) is the most common cause of acute bronchiolitis in infants.
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What is the common peak age of incidence for croup?
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Which of the following are common viruses that can cause croup?
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Viral pneumonia is typically treated with antibiotics.
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The treatment for bacterial pneumonia includes appropriate ____________ and supportive care.
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Match the lung exam finding with its description:
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What radiographic findings would you expect with an aspiration obstructing the right airway?
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Asymmetric wheezing is a key finding in the radiographic diagnosis of foreign body aspiration.
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Which history question helps assess for dysphagia and potential aspiration?
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What is the significance of asking about the child's birth history in clinical reasoning?
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Study Notes
Causes of Wheezing in Infants and Toddlers
- Viral bronchiolitis
- Asthma
- Foreign body aspiration
- Gastroesophageal (GE) reflux
- Tracheomalacia
- Extrinsic compression (e.g. due to adenopathy, mass, vascular ring or sling or other anatomic airway lesion)
- Cystic fibrosis
Diagnosing Wheezing Episodes
- Ask about:
- Timing of the wheeze
- Association of symptoms with feeding
- Change of symptoms with position or activity
- Other exacerbating factors
- Past history of wheezing episodes and response to treatment with bronchodilators or steroids
Signs of Respiratory Distress
- Paradoxical breathing (thoracoabdominal dissociation): almost always a sign of severe respiratory distress due to respiratory muscle fatigue
- Tachypnea: mild, moderate, or severe depending on the severity of the underlying process
- Retractions: use of accessory muscles to augment breathing during respiratory distress
- Suprasternal, supraclavicular, and intercostal retractions
- Subcostal retractions
- Nasal flaring: seen in younger children with significant respiratory distress, indicating use of accessory muscles
- Grunting: forced expiration against a partially closed glottis, helping infants generate positive pressure to stent airways open
- Head bobbing: use of accessory muscles of respiration (neck strap muscles) in young infants
Causes of Cough
- Viral upper respiratory tract illnesses
- Pneumonia
- Post-nasal drip due to allergies and/or sinusitis
- Foreign body aspiration
- Gastroesophageal reflux
- Cough can be dry or wet/junky, with different implications for diagnosis and treatment
Bacterial Respiratory Infections in Children
- Bordetella Pertussis (Whooping Cough)
- Triphasic course: catarrhal stage, paroxysmal stage, and convalescent stage
- Complications: difficulty feeding, central nervous system complications such as apnea
- Immunization: acellular pertussis vaccine, but even with full immunization, vaccine efficacy is only 70-90%
- Epiglottitis
- Life-threatening emergency, rare due to widespread immunization
- Etiology: Haemophilus influenzae type b (Hib), staphylococcal or streptococcal organisms
- Signs and symptoms: fever, stridor, drooling, dysphonia, dysphagia, respiratory distress
- Emergent intervention: prompt intervention in a controlled environment to secure the airway
Asthma
- Pathophysiology: airway obstruction due to inflammation, mucus hypersecretion, and mucosal edema
- Signs and symptoms:
- Acute exacerbations: cough, wheezing, tachypnea, dyspnea
- Chronic symptoms: recurrent episodes of dyspnea and/or cough
- Radiographic findings: hyperinflation due to air trapping, increased interstitial markings, patchy atelectasis
- Treatment:
- Acute exacerbations: anti-inflammatory therapy with corticosteroids, bronchodilation with beta-2 agonists
- Maintenance therapy: daily controller medication (inhaled corticosteroid), with an inhaled beta-agonist as needed for breakthrough symptoms
Bronchiolitis
- Acute viral disease of the lower respiratory tract, most common cause of wheezing in infants
- Pathophysiology: bronchiolar obstruction due to edema, mucus, and cellular debris
- Signs and symptoms: wide spectrum of disease, including mild upper respiratory tract symptoms, fever, cough, wheezing, dyspnea
- Radiographic findings: hyperinflation, increased interstitial markings, peribronchial cuffing, scattered atelectasis
- Treatment: supportive, aimed at maintaining adequate oxygenation and hydration### Choking in Children
- Choking is a significant injury risk in children, particularly in older infants and toddlers who explore the world by putting things in their mouths.
- The risk of choking is greatest in this age group, and parents should be advised on methods to reduce this risk.
Vital Signs in Children
- When evaluating a pediatric patient, it's essential to assess the stability of their condition to initiate urgent interventions or treatments.
- Vital signs vary by age in children; for example, a respiratory rate of 55 may be normal in a newborn, but not in a 10-month-old.
History Considerations with Cough
- When taking a family history, ask about heritable conditions that affect the respiratory tract, such as asthma, environmental allergies, and cystic fibrosis.
- Explore social and environmental history, including:
- Exposure to sick contacts, which increases the likelihood of an infectious process.
- Childcare, which increases the risk of sick contacts.
- Tobacco smoke exposure, which can cause or contribute to a chronic cough.
Examining an Infant or Toddler
- Adjust your approach to the child according to their age.
- Infants (9-10 months) may develop stranger anxiety and cry when approached by strangers; having the parent hold the patient can reduce anxiety.
- Older infants, toddlers, and some preschoolers can also become frightened when approached; use a calm and unhurried approach to examine them.
Anticipatory Guidance
- After treating a child for an incident involving their safety at home, provide anticipatory guidance to prevent future events.
- Counsel the family on how to prevent future events in a gentle, non-accusatory manner.
Radiographic Findings in Foreign Object Aspiration
- In foreign object aspiration, radiographic findings may include:
- Flattened right hemidiaphragm on PA film, suggesting unilateral hyperexpansion on the right.
- Fixed hyperinflation of the right lung on right decubitus.
- Hyperinflation and air trapping with each breath, causing an expiratory wheeze.
Radiographic Diagnosis of Foreign Body Aspiration
- Asymmetric wheezing is key to diagnosing foreign body aspiration, but it can also be caused by mucus plugging from asthma or bronchiolitis.
- Radiography is necessary to further evaluate the etiology of wheezing, including inspiratory and expiratory films to demonstrate unilateral air trapping.
Clinical Reasoning
- Key information in the cough history includes:
- "Is she still drinking?" to assess hydration status, breathing difficulty, and dysphagia.
- "Has she had a fever?" to assess for infectious processes.
- "Did the cough begin suddenly? Did you see her choke on anything?" to assess for foreign body aspiration.
- "Has her voice or cry been hoarse?" to assess for upper airway problems.
- "Has her cough been barky? Does she make any noises when she breathes?" to assess for croup or laryngotracheobronchitis.
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Description
This quiz covers the common and less common causes of wheezing in infants and toddlers, including viral bronchiolitis, asthma, and extrinsic compression.