Pediatric wheezing: It’s not always asthma
By Jennifer Bach, EMT, and Arthur Hsieh
Pediatric patients present special challenges to prehospital professionals. When a child is sick, it can be difficult to conduct a SAMPLE history or physical exam due to anxiety on the part of the child, the parent or even the EMS provider. This anxiety can be exacerbated when the chief complaint concerns the pediatric patient’s airway or breathing.
There are several pediatric lung diseases that, on first appearance present with asthma-like symptoms to prehospital care providers. However, with careful assessment and history taking, a differential impression can be formed.
Asthma is a serious chronic lung condition that affects 6.8 million children in the United States. This translates to 9.3 percent of the entire U.S. population under 18 years of age. Severe asthma exacerbation causes considerable emotional and financial distress to the pediatric patient, their families, and public health resources.
Parents of children with asthma often do not have an education past high school and lack proper understanding of how to correctly use short and long acting preventative inhaled asthma medications. Many of these families suffer from a lack of asthma action plans, peak flow meters, and have a higher incidence of being non-compliant with their inhaled asthma medications.
Hospitalization of pediatric patients with asthma exacerbation in the United States is common, causing more than 600,000 children to visit the emergency department annually. Frequent hospitalizations cause financial stress on families and the need for additional training, staff and hospital beds causes resource stress to hospitals.
A child with asthma exacerbation will present to prehospital care providers with wheezing, usually during exhalation, nonproductive cough that may be exacerbated at night or with exercise, tachycardia, tachypnea, dyspnea, chest tightness, or loss of interest in feeding. The patient will generally talk in words instead of sentences. The fewer words the child can speak in between breaths, the greater respiratory distress.
Physical examination may reveal accessory muscle use, tripod body positioning, cyanosis and retractions. The assessment of the patient’s level of retractions may paint a clearer picture of their distress level. A mild asthma exacerbation may present with subcostal retractions, a moderate exacerbation may present with intercostal or suprasternal retractions, and a severe exacerbation may present with sternocleidomastoid retractions.
Many asthmatic children and their caregivers are professionals in the management of their disease process. Paying careful attention to the patient and their caregiver’s interpretation of their clinical symptoms will serve as a guide in assessing the severity of their current exacerbation and can supplement the prehospital providers clinical assessment of the child.
Children living with asthma are likely to present to prehospital professionals with severe hypoxia and life threatening asthma exacerbations after unsuccessful attempts to control their asthma at home. Accurate documentation of the present illness and a detailed verbal report to the receiving emergency department provides a framework for treatment the child will receive in the hospital.
Respiratory failure from asthma stems from poor oxygenation of the blood and carbon dioxide wastes from the gas exchange are not able to ventilate out of the lungs, which leads to hypercarbia, and hypoxemia develops. Children have the ability to compensate for respiratory insults for extended periods of time, but when they decompensate, the onset of cardiovascular compromise is rapid and severe. Early intervention and treatment is paramount to positive outcomes for pediatric asthma patients as respiratory failure is the most common precursor to pediatric cardiac arrest.
Careful oxygenation and ventilation of children suffering an asthma exacerbation is important as hypoxemia and hypercarbia can lead to respiratory failure. It may be necessary to support a child’s ventilation with a bag valve mask attached to 100 percent oxygen, or in extreme cases, the child may have to be intubated. SpO2 and ETCO2 monitoring will help the prehospital professional titrate the proper oxygenation and ventilation rate.
Prehospital treatment of an asthma exacerbation includes administration of bronchodilators such as albuterol, inhaled ipratropium and inhaled corticosteroids.
Although asthma is the most common chronic childhood disease, it is important for prehospital professionals to recognize that pediatric patients who present with asthma-like symptoms may be suffering from a completely different disease process such as rhinovirus, RSV, bronchiolitis, NEHI, chILD, pneumonia, and cystic fibrosis.
Viral respiratory infections
The two most common respiratory viruses that affect the pediatric population are rhinovirus and respiratory syncytial virus (RSV). Patients with rhinovirus present with nasal congestion, sneezing, nose and eye pruritus (itching), cough, dyspnea, wheezing and tightening or pain in the chest. Treatment for rhinovirus consists of nasal suctioning and irrigation with normal saline.
Patients with RSV present with a cough, nasal congestion, sore throat, fever, listlessness, poor sleeping, poor feeding and possibly brief periods of apnea. Treatment for RSV includes oxygen administration, mucus suctioning, and acetaminophen to reduce fever, ribavirin aerosol (an antiviral medication) and inhaled albuterol to reduce wheezing. It has been recognized through clinical observation that children who suffer from RSV and acquire bronchiolitis early in life are at increased risk for the development of childhood asthma.
Infants who suffer from viral respiratory infections and atopic sensitization (a predisposition toward developing an IgE- mediated reaction or hypersensitivity) are at increased risk for the development of childhood asthma and to suffer from asthma into adulthood.
Bronchiolitis is a common lung infection in young children and infants. Bronchiolitis, with an underlying diagnosis of RSV, was the number one cause of infant hospitalization in the United States from 1997-2000. An estimated 96,000 infants were hospitalized nationwide during that three year period. Patients with bronchiolitis may present with fever, difficulty feeding, wheezing, tachycardia, tachypnea, accessory muscle use, nasal flaring, intercostal retractions, peripheral cyanosis and developing hypoxia.
Bronchiolitis exacerbation is more common in the winter months and commonly affects children with exposure to people with symptomatic respiratory infections. Pertinent medical history findings such as premature birth, congenital heart disease, immune deficiency, hypoxia and chronic lung disease are conditions that can complicate the course of bronchiolitis. Prehospital treatment for bronchiolitis is mainly supportive with oxygen.
Shortness of breath acronyms: NEHI and chILD
Neuroendocrine cell hyperplasia of infancy (NEHI) is a form of childhood interstitial lung disease. Patients with NEHI present with rapid and labored breathing, hypoxia, crackles, and wheezing. NEHI may initially be mistakenly diagnosed as asthma or prolonged respiratory infections.
Children’s interstitial and diffuse lung diseases (chILD) are a category of rare pediatric lung diseases characterized by tachypnea, hypoxia, and crackles that present without a diagnosed underlying disease process.
Both chILD and NEHI are rare and have similar clinical presentations to common childhood lung diseases which makes preliminary field treatment decisions complicated for the prehospital professional. Prehospital treatment of NEHI and chILD is supportive with oxygen administration and treatment of wheezing with bronchodilators.
Pneumonia is lung inflammation caused by a bacterial or viral infection. Children present with a high fever, productive cough, sweating, chills, flushed skin, peripheral cyanosis, wheezing or grunting, dyspnea, tachypnea, intercostal retractions and nasal flaring.
Treatment for pneumonia includes oxygen, antibiotics for bacterial pneumonia, albuterol for bronchodilation and fluid replacement if the patient is dehydrated. It is important to note physical assessment findings in the pediatric patient who may be dehydrated, including dry mucous membranes, sunken fontanels and decreased urine output.
Cystic Fibrosis is a genetic disorder that produces excess, thick mucous that affects the lungs, pancreas and digestive system. Infants are screened for cystic fibrosis with genetic testing and blood tests that determine whether the infant’s pancreas is working. If cystic fibrosis is not diagnosed with testing in infancy, it is recognized and tested for if a child has had repeated lung infections or severe growth problems. Patients with cystic fibrosis present with persistent cough, wheezing, dyspnea, and inflamed nasal passages.
The big picture
Effective evaluation of respiratory function in infants and preschool aged children is difficult due to the patient’s level of cognitive function and their lack of cooperation with the evaluator. Recent progress has been made in developing tools that help assess lung function in pediatric patients. These developments have led to improved clinical understanding of cystic fibrosis, asthma, recurrent wheezing, primary ciliary dyskinesia, and other pediatric lung disease processes.
EMS providers must avoid clinical tunnel vision when treating any pediatric patient’s medical symptoms. Often the parents and caregivers of children with chronic lung diseases are ‘experts’ in the day-to-day management of their child’s disease process. When parents call EMS to help manage their child’s airway or breathing emergency it is likely that something out of the ordinary is occurring with their child.
Rapidly triaging patients, or jumping ahead in the assessment based on routine findings, can lead prehospital professionals down a treatment path that may not be appropriate for all pediatric patients with an airway or breathing complaint. Taking the time to elicit a thorough history and patient assessment will help the prehospital professional describe a more accurate picture of the patient’s current condition to hospital staff, which will translate to a more appropriate treatment plan for the patient.
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About the Author
Jennifer Bach is an EMT in Sonoma County, California. She is completing her studies at Santa Rosa Junior College to become a paramedic.
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