Clinical Practice Case 2

1- The initial appearance is worrisome in view of the child's anxiety and labored breathing with prolonged, forced expiratory effort. The child is still alert, which suggests she is not in respiratory failure, but you should be worried by the child's general assessment.

2- Essentially you should give oxygen to all children with significant respiratory effort and distress while you rapidly proceed to your primary assessment.

The prolonged, forced expiratory effort and the significance of the child's overall respiratory effort are the most striking elements of the child's physical examination. The presence of prolonged, forced exhalation strongly suggests that the child has lower airway obstruction. When the lower airway obstruction is severe, as seen in this child, an increase in both inspiratory and expiratory effort is required to overcome the small airway obstruction. An increased effort throughout the breathing cycle is always more worrisome than an isolated increase in expiratory effort.

1- This child has marked respiratory distress due to lower airway obstruction. The inability to speak using more than one word at a time is very worrisome and confirms that this child's tidal volume is limited.

2- This child requires urgent therapy to improve oxygenation.

3- Administer oxygen while directly treating the cause of the lower airway obstruction. In children, the initial specific treatment is typically nebulized albuterol therapy combined with corticosteroid therapy. Parenteral corticosteroids are indicated only in children with severe distress who cannot safely take oral therapy (eg, oral therapy is commonly used in the ED). Given this child's severe distress, if medical control or protocol allows, IV administration of corticosteroids would be reasonable. Once the child arrives in the ED, inhaled ipratropium bromide should be used in children with severe asthma. See Chapter 2: Management of Respiratory Distress and Failure in the PALS Provider Manual and Pharmacology on the student CD for more details on medications for the treatment of asthma.

In infants wheezing and a prolonged expiratory effort is most commonly seen with bronchiolitis, a viral infection of the small airways. In older children, these signs are most commonly seen in association with asthma.

1- The variability in this child's palpable pulse volume is a sign of pulsus paradoxus. Note that this pulse volume variation may result in inaccurate pulse oximetry readings.

2- Severe air trapping in the lower airways causes hyperinflation. With each inspiratory effort, the heart is squeezed by the overinflated lungs and by the pericardium. The pericardial compression develops because the pericardium attaches to the diaphragm, and the diaphragm is flattened in patients with severe asthma. Each time the patient breathes in, the diaphragm moves downward. This adds additional tension to the pericardium and impedes filling of the heart. Thus stroke volume is decreased during inspiration, resulting in pulsus paradoxus. See the Figure.

Figure 1. Chest x-ray of a child with asthma illustrates the relationship between the lungs and heart. As the lung volume increases, the heart is compressed. In addition, the parietal pericardium is attached to the diaphragm. As the child inhales, the diaphragm flattens further and pulls the pericardium more tightly around the heart. Both of these actions impede venous return and thus impair stroke volume during inspiration, leading to the pulsus paradoxus.

1-

Signs and symptoms
Allergies
Medications
Past medical history
bast meal
Events leading to presentation

2- The answers to the SAMPLE mnemonic questions for this child include the following:

• Signs and symptoms began 2 days ago with a cold that progressed to more coughing today. At times the child's coughing resulted in emesis, and she has not been able to take much orally.
• She has a history of allergic rhinitis but no other allergies.
• The only medications her mother gave was a cough syrup, which has not helped.
• Her Past medical history is notable for a history of coughing with previous colds, but she has never been this ill before. She also coughs frequently at night and has complained of tightness in her chest and coughing after she runs.
• Her last oral intake was several hours ago.
• There was no event leading to this illness other than the recent cold.

You need to maintain vigilance, however, since her respiratory distress may worsen as the initial effects of the albuterol treatment fade. You should monitor and reexamine the child frequently during transport to the emergency department. Ideally, continuous pulse oximetry should be maintained during transport.

In addition to asthma, viral or mycoplasma infection may cause inflammation of the small airways. In infants this presents as bronchiolitis, with respiratory syncytial virus (RSV) being the most common cause. In older children (~5 years) mycoplasma is the most common cause of wheezing-associated lower respiratory tract infection. Inhalation injury and anaphylaxis may also cause bronchospasm, leading to wheezing and signs of lower airway obstruction.