What is the most likely diagnosis?You were busy seeing patients in your outpatient clinic when you heard a commotion coming from the waiting room. You went to check and found a very frantic mother and her 2-year-old son who is clutching his throat, coughing, drooling, and visibly struggling to breathe. The mother endorses that just a few minutes ago, the child was running around while eating grapes when she suddenly heard him gagging and wheezing. Her son has an appointment for well-child examination and he is apparently doing well. He has no significant history of respiratory illness. The toddler is still conscious but unable to talk, and his cough is becoming weaker. Breath sounds are decreased bilaterally, with wheezing and stridor heard on auscultation. You tried to ventilate the patient with the chin-lift maneuver but the chest fails to rise. You opened the mouth but you are unable to see any foreign object.
What is the most likely diagnosis?
What is the next step in the management of this patient?
Summary: A 2-year-old boy had acute onset of coughing, choking, drooling, and wheezing while eating grapes. He is unable to speak and his cough is weak. He was in a good state of health prior to the incident and has no history of respiratory illness. Physical examination reveals decreased breath sounds, wheezing, and stridor. There is no chest rise on ventilation attempt. No foreign object could be seen on his mouth.
• Most likely diagnosis: Foreign-body airway obstruction
• Next step in the management for this patient: Heimlich maneuver (subdiaphragmatic abdominal thrusts)
1. Identify the illnesses, other than asthma, that cause acute wheezing in children.
2. Understand the steps in the diagnosis and management of a wheezing child.
Acute onset of wheezing in an otherwise healthy child similar to the above case should raise the suspicion for foreign-body airway obstruction (FBAO). Witnessed swallowing followed by choking is not necessary for diagnosis, but as much information should be gathered surrounding the onset of symptoms. FBAO is common among children aged 6 months to 3 years old, accounting for approximately 70% of cases. Small toys and objects, balloons, and food (eg, nuts, grapes, and candies) are high-risk objects for aspiration. Older children may be able to identify the object they swallowed and assume the posture of clutching their neck with their hand (universal choking sign). Symptoms such as weak cough, inability to speak or cry, high-pitched sounds, or no sounds during inhalation, cyanosis, choking, vomiting, drooling, wheezing, blood-streaked saliva, and respiratory distress are clues to the diagnosis of FBAO. Physical findings of unilateral wheezing, unequal or decreased breath sounds, and stridor are common. In children, the foreign body could lodge on either side of the airway. If the foreign body lodges in the esophagus, acute wheezing is still possible when the obstruction compresses on the airways.
One should not attempt to remove the foreign object in a child who is actively coughing. Blind finger sweep is not recommended because of the danger of further obstruction or injury. Although the patient mentioned above is still conscious, he seems to have ineffective coughing and is beginning to get tired. Ventilation should be attempted while opening the airway with the head-tilt maneuver, which could also relieve the obstruction. In the above case, an attempt to remove the foreign object was initiated when ventilation was unsuccessful.
Since no foreign object is visualized, a series of abdominal thrusts (Heimlich maneuver) should be the next step to try to expel the foreign body. In infants, back blows and chest thrusts are performed instead of abdominal thrusts, which could cause iatrogenic trauma to the liver and stomach, which are not protected by the rib cage at that age. If the child continues to deteriorate even after 1 minute of resuscitative efforts and the above maneuvers fail to expel the foreign object, the emergency medical services (EMS) system should be activated while continuing cardiopulmonary resuscitation (CPR).
In the hospital setting, a bronchoscopic procedure is the treatment of choice. Chest x-ray is often normal, but in some cases shows a radiopaque foreign object or identifies localized hyperinflation and/or atelectasis. Most deaths from FBAO occur in children younger than 5 years of age; 65% are infants.
HEIMLICH MANEUVER: Performed by standing or sitting behind the person who is choking and placing the thumb side of one fist between the navel and the xiphoid process. The other hand grasps the fisted hand and a series of upward abdominal thrusts are delivered to create an “artificial cough” in a choking victim in an effort to dislodge the object blocking the airway.
STRIDOR: Wheezing coming from obstruction of the large airway that has a constant pitch and intensity throughout the entire inspiratory effort.
WHEEZING: A musical sound heard on pulmonary auscultation produced by the oscillating walls of airways that had been narrowed by mucus, inflammation, and so on.
Among the many causes of wheezing in children, asthma and viral infections are most common. Worldwide studies show that approximately 10% to 15% of infants wheeze in the first 12 months of life. The diagnosis of wheezing hinges on accurate history, physical examination, laboratory tests, and even response to treatments. It is also important to gather information regarding the age of onset, exposure to cigarette smoke, presence of allergic signs and symptoms, frequency of wheezing, association with vomiting or feeding, and other accompanying symptoms.
The etiology of acute wheezing in children could be infectious (eg, bronchiolitis) or mechanical obstruction (eg, FBAO). Recurrent wheezing, on the other hand, encompasses anomalies of the tracheobronchial tree (eg, bronchomalacia), cardiovascular disease (eg, vascular rings and slings), gastroesophageal reflux, and immunologic disorders (eg, bronchopulmonary dysplasia, cystic fibrosis). This case concentrates on acute onset of wheezing other than asthma in children (Case 56 provides a more detailed discussion of asthma).
Bronchiolitis is the most common acute cause of wheezing in children younger than 2 years of age, especially in infants who are 1 to 3 months old. Infants younger than 6 months are most severely affected, owing to smaller, more easily obstructed airways and a decreased ability to clear secretions. It is a viral infection causing nonspecific inflammation of the small airways and peaks during the winter months. Respiratory syncytial virus (RSV) accounts for 70% of cases; the rest are caused by parainfluenza, adenovirus, influenza, Mycoplasma pneumoniae, Chlamydia pneumoniae, and metapneumovirus. These viruses and atypical bacteria elicit inflammatory and immune responses that produce mucus, edema, and cellular debris that block the small airways. Influenza vaccinations in infants and toddlers have reduced the incidence of bronchiolitis caused by the flu virus.
Initially, the child develops rhinorrhea and wheezing followed by low-grade fever. On succeeding days, rhinorrhea will be more copious and the child may also experience cough, irritability, and varying degrees of dyspnea. As a result, the infant may have poor oral intake and possibly dehydration.
Profuse coryza, congestion, pharyngitis, nasal discharge, and fever usually characterize the clinical syndrome in children. Primary RSV infections are confined to the upper airways in more than 50% of patients. Symptoms reach a peak in 2 to 5 days, with involvement of the lower respiratory tract. Typical symptoms include cough, dyspnea, wheezing, and poor feeding.
Physical examination may reveal wheezing, fine crackles, prolonged expiratory phase, tachypnea, and increased work of breathing as evidenced by nasal flaring, intercostal retraction, and even apnea. Other physical findings often include otitis media, irritability, and hypothermia or hyperthermia.
The diagnosis of bronchiolitis is based on clinical presentation, the patient’s age, seasonal occurrence, and findings from the physical examination. Tests are typically used to exclude other diagnoses, such as bacterial pneumonia, sepsis, or congestive heart failure, or to confirm a viral etiology and determine required infection control for patients admitted to the hospital.
Current literature does not support the routine use of laboratory tests as they do not alter clinical outcomes. If the diagnosis is doubtful or the clinical presentation is unusual, one may request a chest x-ray. Radiologic findings in individuals with bronchiolitis are variable and may include bronchial wall thickening, tiny nodules, linear opacities, atelectasis, patchy alveolar opacities, and lobar consolidation. A complete blood count (CBC) is usually normal. There are available rapid assays for RSV and influenza that often are unnecessary, unless antibiotics are being considered and/or the patient is to be admitted and placed in a room with other RSV-positive infants. Sputum culture is requested if bacterial superinfection or pneumonia is suspected.
RSV bronchiolitis is a self-limited disease and can be safely managed in an outpatient setting. However, disease manifestation can be variable, and risk factors for severe disease include preexisting cardiac or pulmonary disease, premature birth, very young age (<2-3 months), nosocomial RSV infection, and, in some studies, low socioeconomic status. Patients who are in respiratory distress, younger than 3 months old or premature, those with comorbid conditions, lethargy, hypoxemia, or hypercarbia, and those with atelectasis or consolidation in chest radiograph need to be hospitalized.
The Agency for Healthcare Research and Quality (AHRQ), in collaboration with the American Academy of Family Physicians (AAFP) and the American Academy of Pediatrics (AAP), recommends supplemental oxygen if SpO2 <90% and supportive care as the modes of treatment with clear evidence of effectiveness in RSV bronchiolitis.
Supportive care should consist of supplemental humidified oxygen, fluids, and the suctioning of nasal and pharyngeal secretions. The most important therapy is humidified oxygen. Medications have a limited role in the management of bronchiolitis. Several drugs are commonly used, but little or inconclusive evidence supports the routine use of any drug in the management of bronchiolitis. Nebulized bronchodilators, cool mist, steroids, antibiotics, ribavirin have insufficient evidence or have not been shown to help in previously healthy children. Steroids and bronchodilators may help if there is underlying asthma, but should be discontinued if initial trials fail to show significant clinical improvement.
Symptomatic treatment includes head elevation, suctioning of secretions after spraying the nasal passages with saline, antipyretics for fever, humidified oxygen for hypoxemia, and adequate hydration. If the infant is at high risk for aspiration, IV fluids may be the safest way to deliver nutrients. A therapeutic trial with albuterol, especially in infants with personal or family history of allergies, could identify a few responders. Parents of infants with bronchiolitis should be instructed not to expose the infant to cigarette smoke and educated on frequent hand washing to prevent transmission of the disease.
For infants with congenital heart disease or chronic lung disease, the antiviral agent ribavirin via aerosol can be considered, but has not been proven to alter mortality and length of illness. Administration of RSV immunoglobulin (RespiGam) and palivizumab (Synagis) just before the beginning of RSV season are proven effective preventive therapy for children younger than 2 years with increased risks from chronic lung disease, history of prematurity (less than 35-week gestation), or with congenital heart disease. The cost-effectiveness of prophylaxis, however, is still debatable. In most cases, the illness is self-limited with usual duration of 2 to 4 days. A protracted course (months) can occur in around 20% of patients. Mortality is less than 1% and could be attributed to apnea, respiratory acidosis, and severe dehydration. The single best indicator of severity is low pulse oximetry. Indicators of mild disease include good PO intake, age greater than 2 months, oxygen saturation greater than or equal to 94%, and age-based respiratory rate (<45 breaths/min for 0-2 months old, <43 breaths/min for 2-6 months old, and <40 breaths/min for 6-24 months old). Children who had experienced bronchiolitis are at higher risk of developing asthma.
Croup is the most common cause of airway obstruction in children aged 6 months to 6 years, and is the leading cause of hospitalization for children younger than 4 years. It is a viral infection that causes inflammation of the subglottic region of the larynx that produces the characteristic barking cough, hoarseness, stridor, and different degrees of respiratory distress that are more severe at night. The croup syndrome encompasses laryngotracheitis, laryngotracheobronchitis, laryngotracheobronchopneumonitis, and spasmodic croup.
Croup usually occurs during fall and winter. The parainfluenza viruses (I, II, III) are responsible for as many as 80% of croup cases, with parainfluenza I accounting for most episodes and for 50% to 70% of hospitalizations. Other pathogens include adenovirus, respiratory syncytial virus (RSV), measles, coxsackievirus, rhinovirus, echo-virus, reovirus, metapneumovirus, varicella, herpes simplex virus, human bocavirus, coronavirus, and influenza A and B. Influenza A has been implicated in children with severe respiratory compromise. The prodrome is characterized by 12 to 72 hours of runny nose and low-grade fever. Hypoxia only occurs in severe cases. These symptoms peak from 1 to 2 days, and in most cases, resolve in 1 week.
Diagnosis is made through clinical presentation. However, imaging studies confirm the diagnoses. Frontal neck x-rays show the “steeple sign,” which is indicative of subglottic narrowing of the tracheal lumen. When the diagnosis is uncertain, computed tomography (CT) scan of the neck offers a more sensitive evaluation.
Treatment is geared toward the severity of the croup (ie, the level of respiratory depression). Several assessment systems have been developed. In all of the assessment systems, the critical clinical features are resting stridor and chest wall retractions. One well-studied clinical assessment tool is the Westley croup score. Each element is given a point value. Scores >8 indicate severe croup with the need to consider hospitalization.
• Level of consciousness: Normal, including sleep = 0; disoriented = 5
• Cyanosis: none = 0; with agitation = 4; at rest = 5
• Stridor: none = 0; with agitation = 1; at rest = 2
• Air entry: normal = 0; decreased = 1; markedly decreased = 2
• Retractions: none = 0; mild = 1; moderate = 2; severe = 3
The total score ranges from 0 to 17.
Mild croup (Westley score ≤2) does not require any specific therapy, but a single dose of corticosteroid may reduce the need for hospitalization. Moderate croup (Westley score 3-7) requires additional measures, such as epinephrine, to prevent hospitalization. Severe croup entails a more comprehensive and intense approach.
Emergency management of croup should begin with assessment of airway obstruction; oxygen should be used liberally. There is no proof that humidified air is of value and mist tents should be avoided. Hospitalization is appropriate if severe croup is clinically apparent. Severe croup is exemplified by cyanosis, decreased level of consciousness, progressive stridor, severe stridor, severe retractions, markedly decreased air movement, toxic appearance, severe dehydration, and social factors limiting adequacy of outpatient monitoring. Children who are hospitalized with croup should be monitored closely and frequent physical examination needs to be performed.
The following medications should be avoided: sedatives, opiates, expectorants, bronchodilators, and antihistamines.
The current cornerstones of treatment are glucocorticoids and nebulized epinephrine, although steroids have proven beneficial in severe, moderate, and even mild croup. Corticosteroids are beneficial because of their anti-inflammatory action, whereby laryngeal mucosal edema is decreased. They also decrease the need for salvage nebulized epinephrine. Nebulized racemic (mixture of d-isomers and l-isomers) or L-epinephrine is typically reserved for patients in moderate-to-severe distress. It works by adrenergic stimulation, which causes constriction of the precapillary arterioles, thereby leading to fluid resorption from the interstitium and improvement in the laryngeal mucosal edema. Its beta-2-adrenergic activity leads to bronchial smooth muscle relaxation and bronchodilation. Although a child who is symptomatic enough to receive epinephrine may be discharged after at least 3 hours of observation, anyone receiving epinephrine should also be given corticosteroids.
Epiglottitis is a bacterial infection of the supraglottic tissue and surrounding areas that causes rapidly progressive airway obstruction. It usually affects children younger than 5 years old and is most commonly caused by bacteria such as Haemophilus influenzae, H parainfluenzae, Streptococcus pneumoniae, Staphylococcus aureus, and β-hemolytic Streptococcus A, B, and C. With the introduction of the H influenzae type b (Hib) vaccine, there has been a steady decline in cases of epiglottitis. Within 24 hours, the patient with epiglottitis would appear “toxic” and develop fever, severe sore throat, muffled speech (“hot potato voice”), drooling, and dysphagia. The child usually is noticeably anxious and assumes the sitting position, leaning forward on outstretched arms with chin thrust forward and neck hyperextended (tripod position) so as to increase the airway diameter.
With progression of airway obstruction, the patient may begin to have wheezing and stridor. Epiglottitis is a medical emergency and visualization to confirm the presence of severely erythematous epiglottis is preferably done in the operating room with experienced surgeon or anesthesiologist. Mortality rates as high as 10% can occur in children whose airways are not protected by endotracheal intubation. With endotracheal intubation, mortality is less than 1%.
The patient should be kept in a calm environment to prevent sudden airway obstruction. CBC usually shows leukocytosis, neutrophilia, and bandemia. The radiographic finding that is characteristic of epiglottitis is the “thumb sign” or protrusion of the enlarged epiglottis from the anterior wall of the hypopharynx seen on a lateral neck x-ray. Cultures of the blood and epiglottis yield the pathogenic bacteria.
Medical treatment begins by evaluating airway, breathing, and circulation.
Supplemental oxygen administration, a nonthreatening initial step, is easily accomplished with blow-by oxygen administered by a parent. Place the equipment needed for emergent airway management at the bedside. Keep the patient in view at all times.
If acute respiratory arrest occurs, ventilate the child with 100% supplemental oxygen, using a bag-valve-mask device, and arrange for intubation. When a child has a respiratory arrest and appropriate surgical personnel are unavailable, the attending physician may attempt intubation.
Alternative methods to gain immediate control of the airway, such as needle cricothyrotomy, are considered temporary until a more permanent procedure (eg, tracheostomy) can be performed. The best setting for an endotracheal intubation is in an operating room with the patient under general anesthesia.
Treatment consists of appropriate antibiotics (oxacillin or nafcillin; cefazolin; clindamycin and ceftriaxone or cefotaxime) and airway management, usually in an ICU setting with a team ready to respond for intubation or tracheostomy. Death results from hypoxia, hypercapnia, and acidosis that lead to cardiorespiratory failure.
Deep abscesses of the neck are less common causes of acute wheezing, but they have the potential to be very serious. They are located in the peritonsillar, retropharyngeal, and pharyngomaxillary spaces.
Retropharyngeal abscess affects children 2 to 4 years. The abscess is usually caused by extension of pharyngeal infection, penetrating trauma, iatrogenic instrumentation, or foreign body. Children with this condition present with fever, drooling, dysphagia, odynophagia, stridor, and respiratory distress. Physical examination may indicate tender enlarged cervical lymphadenopathy, cervical spine range of motion limitation, possible stridor, and wheezing. Diagnosis is made by lateral neck films which show bulging in posterior pharynx (prevertebral soft tissue more abundant in children during expiration). Treatment utilizes antibiotics such as cephalosporins or antistaphylococcal penicillins. Incision and drainage is also an option.
Peritonsillar abscess is an infection of the superior pole of the tonsils and is more common in young teenagers. Fever, severe sore throat, muffled voice, drooling, trismus, and neck pain are typical symptoms. Enlarged tonsils with abscess, cervical adenopathy, and deviation of the uvula may be obvious on physical examination. CT scan of the neck is the most helpful diagnostic modality for identifying deep neck abscesses. The predominant pathogens are Streptococcus pyogenes, S aureus, and anaerobes. The administration of ampicillin-sulbactam or clindamycin (if penicillin allergic) for 14 days is appropriate treatment. Drainage of the abscess is indicated either as first-line treatment or when antimicrobial agents fail to produce adequate result. Serious complications from deep abscesses result from airway obstruction, septicemia, aspiration, jugular vein thrombosis/thrombophlebitis, carotid artery rupture, and mediastinitis.
39.1 A 7-month-old infant was brought by her mother to an outpatient clinic because of a 2-day history of fever, copious nasal secretions, and wheezing. The mother volunteered that the baby has been healthy and has not had these symptoms in the past. The infant’s temperature is noted to be 100.7°F (38.1°C), her respiratory rate is 50 breaths/min, and her pulse oximetry is 95% on room air. Physical examination reveals no signs of dehydration, but wheezing is heard on bilateral lung fields on auscultation. The infant shows no improvement after three treatments with nebulized albuterol. Which of the following is the recommended treatment?
A. Continued nebulized albuterol every 4 hours.
B. Antihistamines and decongestants.
C. Antibiotics for 7 days.
D. Initiate Synagis.
E. Supportive care with hydration and humidified oxygen.
39.2 A 9-year-old girl is being seen in your office with fever and difficulty breathing. You are concerned about the diagnosis of epiglottitis. Which of the following is the most accurate statement regarding epiglottitis?
A. Child usually prefers to be in prone position.
B. Radiographic finding of “steeple sign.”
C. Every effort should be made to visualize the epiglottis in the office to confirm the diagnosis.
D. Diagnosis is decreasing in incidence.
39.3 A 5-year-old child is brought into the office due to the mother’s concern of difficulty breathing. On examination wheezing is noted. In which of the following conditions is antibiotic therapy most appropriate?
A. Asthma
B. Epiglottitis
C. Croup
D. Bronchiolitis
E. Foreign-body aspiration
39.4 A 12-year-old girl was brought to the emergency department because of severe sore throat, muffled voice, drooling, and fatigue. She had been sick for the past 3 days and is unable to eat because of painful swallowing. The parents deny any history of recurrent pharyngitis. The patient still managed to open her mouth and you were able to see an abscess at the upper pole of the right tonsil with deviation of the uvula toward the midline. Examination of the neck reveals enlarged and tender lymph nodes. Which of the following is the most appropriate management?
A. Analgesics for pain
B. Oral antibiotics
C. Nebulized racemic epinephrine
D. Incision and drainage of the abscess
E. Tonsillectomy and adenoidectomy
39.1 E. Bronchiolitis is the most likely diagnosis in this case. There is no established treatment for bronchiolitis except for supportive management of the patient’s symptoms. Because the infant did not respond to an albuterol trial, there is no justification for continuing its use. Antihistamines, decongestants, and antibiotics are not effective. Synagis is not helpful in the acute setting.
39.2 D. The incidence of epiglottitis has markedly reduced since the introduction of the Hib vaccine. Children with epiglottitis are more likely to be in the tripod position than prone. The “steeple sign” is seen in croup; the “thumb” sign is seen in epiglottitis. Visualization of the epiglottis should preferentially occur in an operating room, where immediate intubation or tracheostomy can occur.
39.3 B. Epiglottitis is usually a bacterial infection treated with antibiotics.
39.4 D. This patient is suffering from peritonsillar abscess. Of the choices listed, incision and drainage is the most appropriate. Tonsillectomy is only indicated if there are confirmed cases of recurrent pharyngitis and peritonsillar abscess.
Sufficient airflow is required for the airway to produce a wheezing sound.
Disappearance of wheezing in a patient who initially presents with wheezing is an ominous sign that suggests complete blockage of the airway or imminent respiratory failure.
Bronchiolitis is the most common lower respiratory disease of infants and the most common reason for hospitalization for infants younger than 1 year.
Never perform a blind finger sweep of a foreign object aspirated by an infant or child.
Epiglottitis is a medical emergency.
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