Clinical Practice Case 1
Case 1
Introduction:
A 2-year-old is brought to the emergency department with a history of labored breathing for the past 2 days that has progressively worsened. Initially the child had symptoms of an upper respiratory infection. Yesterday he began to have a barky cough, and today he is making a high-pitched sound on inspiration. Although the child was playful earlier today and took fluids well, he now seems very anxious. His breathing is clearly different than earlier. His parents are concerned.
General assessment
As you enter the room, you see an anxious toddler who is sitting on his mom's lap and working hard to breathe. He has obvious nasal flaring and intercostal and suprasternal retractions. His breathing is labored but not rapid. You hear a high-pitched inspiratory sound with each breath. He has an occasional harsh, barky cough. His mucus membranes and skin color appear pale.
1 A
What are the 3 elements of the general assessment?
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1 B
What is your initial impression of the child's condition based on your general assessment?
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The child is in respiratory distress with increased work of breathing. The main breathing difficulty occurs during the inspiratory phase of the respiratory cycle, which suggests upper airway obstruction. His anxious appearance and pale skin colour may indicate significant hypoxemia or hypercarbia, or both.
1 C
Does the child need immediate intervention?
If so, what intervention is indicated?
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You should be worried about this child. He is not clearly in respiratory failure but is at risk. Treatment should begin quickly while you complete your primary assessment.
The most appropriate immediate interventions are to:
- provide oxygen in a non-threatening manner (remember: increased agitation worsens upper airway obstruction)
- place a pulse oximeter
- begin appropriate therapy with nebulized epinephrine or racemic epinephrine
Allow the child to remain in a position of comfort (such as on the mother's lap) rather than place the child on a stretcher to minimize agitation.
Although the PALS course suggests a linear approach to patient evaluation and treatment (Evaluate - Identify - Intervene), providing care for the patient often involves a mixture of these interventions.
Your initial actions should focus on life-saving or stabilizing interventions. Your later actions will likely be more focused on specific treatment. Base subsequent treatment on further assessment and categorization of the patient's condition with consideration of the likely etiology. These assessments and revised approaches to therapy occur continuously during your patient encounter.
Primary assessment
The toddler's heart rate is 165/min, respiratory rate is 22/min, blood pressure is 115/75 mm Hg, and temperature (axillary) is 99.2°F (37.3°C). On blow-by oxygen, his oxyhemoglobin saturation (Sp02) is 97%.
The airway and lung examination are notable for transmitted highpitched, inspiratory upper airway sounds heard centrally and diminished air entry heard over the axillary regions bilaterally. You don't hear rales or wheezes.
The heart sounds are normal with a regular rhythm. His pulses are brisk with warm extremities. Capillary refill in his fingers is 2 seconds.
1 D
What are the elements of the next assessment step, the primary assessment?
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The primary assessment comprises an ABCDE (Airway, Breathing, Circulation, Disability, and Exposure) evaluation with vital signs (including pulse oximetry).
1 E
What is your categorization of the patient's condition now?
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This toddler has upper airway obstruction. Based on the history, it is most likely from a viral infection leading to croup. You should consider that a foreign-body airway obstruction (FBAO) may be present, but the history of relatively slow onset and gradual worsening of symptoms makes an FBAO unlikely. The high-pitched upper airway sounds also suggest that the upper airway obstruction is at a level just below the vocal cords (subglottic). Because the child is now watching you and does not appear as anxious, you note that his respiratory function and clinical condition have improved in response to oxygen administration.
1F
What are your next decision and action steps?
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Appropriate next steps include administration of nebulized epinephrine or racemic epinephrine to reduce upper airway obstruction. Administration of oral dexamethasone would also be appropriate. You should carefully observe this child for worsening symptoms and the possible need for additional intervention. You can now obtain a more complete history and perform a more thorough exam. The exam (secondary assessment) may be deferred until the child is breathing more comfortably after the epinephrine inhalation treatment.
Relevant history questions include asking if the child was premature, was mechanically ventilated (which increases the risk of upper airway injury, predisposing to upper airway obstruction with subsequent infections), or has had episodes of croup in the past. A history of croup suggests an underlying airway problem (eg, subglottic stenosis, an airway hemangioma, or laryngeal papillomatosis). At present, there is a little indication for laboratory studies, such as an arterial blood gas (tertiary assessment).
1 G
Does a normal Sp02 rule out respiratory failure? If not, why not?
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Respiratory failure is defined as inadequate oxygenation, ventilation, or both. Pulse oximetry does not evaluate the effectiveness of ventilation (ie, elimination of carbon dioxide). Children may develop hypoventilation with significant hypercarbia, yet if they are receiving supplementary oxygen they may maintain normal Sp02. Although a normal Sp02 is somewhat reassuring, the child still needs careful assessment to determine if ventilation is adequate.
Case progression
After helping the child's mother administer oxygen by a high-flow device and 3 mL of racemic epinephrine, you reassess the patient.
The child appears less distressed and is more interactive with his parents. His retractions have diminished, and there is better air entry in the distal lung fields with minimal inspiratory stridor. His Sp02 rises to 99% to 100% while the heart rate decreases to 130/min.
1 H
What other conditions cause upper airway obstruction?
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Many conditions can cause upper airway obstruction. The child's symptoms can give clues to the site of the obstruction. For example, high-pitched inspiratory stridor is seen with croup; snoring inspiratory sounds are heard with a floppy pharynx and tongue occlusion. Prominent retractions and intermittent complete upper airway obstruction can be seen in a sleeping infant or child with enlarged tonsils and adenoids. Foreign bodies, peritonsillar and retropharyngeal abscess, laryngomalacia, and airway hemangiomas and polyps are other examples of conditions causing upper airway obstruction.
Summing up
Based on the examination, the child has clearly improved, but he still requires careful observation. His symptoms may recur as the therapeutic effects of the epinephrine subside. If not already given, a dose of oral dexamethasone is appropriate in this setting.
In summary, upper airway obstruction causes respiratory distress that is most apparent during inspiration. Remember that if endotracheal intubation is needed in a patient with respiratory failure due to upper airway obstruction that is thought to be at or below the vocal cords, an endotracheal tube smaller than the normally predicted size is appropriate secondary to anticipated narrowing of the airway. Other children with upper airway obstruction may improve with simple maneuvers to extend the head and move the jaw forward or with the placement of a nasopharyngeal airway.