Expiratory wheezing is a hallmark finding in the patient with an acute asthmatic attack. In a severe asthma exacerbation, air exchange may be so limited that wheezing is not appreciated (e.g., silent chest). The patient also has sensitive but nonspecific signs of respiratory distress, including retractions, nasal flaring, cyanosis, accessory muscle use, and eventually altered mental status. Peak expiratory flow also is diminished and should be measured to gauge both acuity and patient’s response to therapy. Patient history may reveal past exacerbations that necessitated the use of home medications. The number and frequency of home treatments are important indicators of acuity. In addition, hospital admission, especially intensive care, is another important piece of history that should be collected in determination of the potential severity of the respiratory difficulty.

The primary goals of asthma treatment are reversal of hypoxemia and control of contributing inflammatory responses. First-line therapy continues to be supplemental oxygen and the use of beta-adrenergic and anticholinergic aerosols. ¹⁸ The most common are Albuterol and ipratropium bromide delivered via a nebulizer.

The frequency of administration of these medications is a much-debated subject. As with any clinical intervention, patient response should be closely monitored. A key component of asthma therapy is the control of inflammation, which is now believed to contribute to chronic airway changes. Acute inflammation is controlled with steroid therapy.

Patients generally present with a history of fever and coryza (cold symptoms). As the illness progresses, inspiratory stridor may be present as may a characteristic “barking” cough. If the inflammation extends to the bronchi, rhonchi and wheezing may also be present. Care must be taken to rule out epiglottitis and retropharyngeal abscess because the presentations can be similar. ⁸

Treatment for croup is primarily supportive and centers on treatment of dehydration and the respiratory distress. In rare severe cases, upper airway edema or obstruction may necessitate endotracheal intubation for ventilation and airway protection. Medications include racemic epinephrine aerosols, intramuscular (IM) or oral (PO) dexamethasone, and prednisolone.

Epiglottitis is second only to croup as a cause for infectious stridor. The course of epiglottitis is differentiated from other presentations because of its abrupt nature. Symptoms often occur rapidly and cause parents to seek medical attention in 24 hours of the initial symptoms. Patients present with fever, stridor, labored respirations, and often drooling, because of supraglottic edema. The appearance of these children is also helpful in diagnosing of epiglottitis. They are often anxious and present in a classic tripod position, sitting forward with their arms supporting them with their jaws thrust forward. This position is assumed by the patient to increase air entry. Clinicians must recognize this presentation because of the life-threatening nature of airway involvement.

The focus of treatment with epiglottitis is rapid recognition and treatment of airway obstruction. Patients in extremis must have the airway controlled before any other intervention, including laboratory work and intravenous access. Before dealing with these patients, creation of a well-defined epiglottitis algorithm is crucial. A lateral neck radiograph may be helpful in delineating epiglottitis from the much more common causes of stridor and respiratory distress. If endotracheal intubation is indicated, the support from anesthesiologist or ear, nose, and throat (ENT) staffs is invaluable. Use of the operating room with inhalation induction and rapid access to tracheostomy equipment is the optimal method of airway control. In situations without this support, endotracheal intubation should only be undertaken by staff capable of securing the airway, surgically if necessary. Airway control before transport is best for the patient with epiglottitis. Current antibiotic recommendations include cefuroxime, cefotaxime, and ceftriaxone. ¹⁸

All patients with epiglottitis need intensive care admission.

The majority of lower airway foreign body aspirations occur in children under 3 years of age. The difficulty in treatment of these aspirations is the wide range of presentations and the difficulty in imaging nonradioopaque objects. A high index of suspicion must be maintained for at-risk age groups (6 months to 3 years) with respiratory distress.

Wheezing is the most common presenting symptom, often with an accompanying 2-day to 5-day course of coryza and cough. These patients are often tachypnic, with respiratory rates reaching 80 to 100 breaths/min in some cases. Nonspecific signs of respiratory distress such as nasal flaring and intercostal retractions are also present. Most cases occur in the winter months, with the majority of infections in children from ages 2 to 8 months. Apnea in children younger than 3 months is also characteristic of RSV infections. ⁸

Once other causes for wheezing have been ruled out (asthma, foreign body aspiration, pneumonia), care is generally supportive. Supplemental oxygen, antipyretics, and adequate hydration are all helpful for patients in mild distress. Children may benefit from nebulized albuterol aerosols and oral albuterol solution. Oral albuterol solutions are not indicated for patients who do not respond to aerosol therapy. Corticosteroids are not indicated for the treatment of bronchiolitis. Patients in severe distress who are unresponsive to therapy may need intubation and mechanical ventilation. ⁸

Bacterial pneumonia generally has a rapid onset with accompanying high fevers, chills, and cough. The patient with bacterial pneumonia may also have grunting respirations, decreased breath sounds, and tachypnea, which are all nonspecific signs. Viral pneumonia, in contrast, has a more gradual onset over 2 to 4 days with cough coryza and low-grade fevers. Patients with viral pneumonia may also have rales, grunting respirations, tachypnea, and decreased breath sounds. In truth, bacterial and viral pneumonia are difficult to distinguish based on clinical examination results alone. Leukocytosis over 15,000/mm is a more predominant finding in bacterial pneumonia and weighs against a viral diagnosis. ^9,10 A chest radiograph can be helpful in diagnosis. Bacterial pneumonia often shows a lobar consolidation, whereas viral pneumonia causes hyperaeration or diffuse interstitial infiltrate without consolidation.

Treatment involves supportive measures with appropriate antibiotic therapy for bacterial infections. Dehydration and hypoxia are common complications of pneumonia, so adequate intake, whether oral or intravenous, and supplemental oxygen may be essential. Antipyretics lower fevers and increase patient comfort. Drugs most commonly used in children for antipyretics include acetaminophen and ibuprofen. ¹⁸

Sensitivity to these drugs should be determined before administration. Currently, little data exist on the lower age limits for ibuprofen therapy, so caution should be used in younger children (<6 months). The practice of alternating these medications in patients is also being investigated. Supplemental oxygen for children in distress is indicated. As with other respiratory illnesses, some children may need intubation and mechanical ventilation, depending on the severity of pulmonary dysfunction. Streptococcus pneumoniae and H. influenzae remain the major bacterial causes for pediatric pneumonia. Medication therapy is dependent on the causative microorganism.

Children who need hospital admission for pneumonia include⁵:

Because of varying rates of closure of the ductus arteriosus, clinical presentations of respiratory distress from congenital heart disease can be seen anywhere from a few days to 6 weeks after birth. The list of both cyanotic and acyanotic lesions that can cause respiratory distress in newborns is too lengthy for discussion in this chapter. Cardiac processes should be kept on the list of differential diagnoses for children in this age group. ⁵

Tachypnea from metabolic acidosis is a common clinical finding in pediatric patients. Respiratory buffering of acidosis may be the most obvious clinical finding in these situations. Tachypnea without an obvious cardiac or respiratory source should be further investigated to rule out metabolic acidosis. ⁵

Causes of metabolic acidosis in children include:

Identification and management of the cause of the acidosis must occur quickly. Supplemental oxygen including intubation and mechanical ventilation may be necessary during the acute treatment phase of these disorders.

Because of children’s smaller size and surface area, energy from traumatic injuries imparts more force per unit of body area. The relative lack of body fat, the decreased elasticity of connective tissue, and the close proximity of internal organs to surface tissue all increase the potential for multiple injuries in this population. Increased body surface area also lends itself to increased thermal loss. Hypothermia becomes a major clinical concern. ^{1.2.3.4.5.6. and 7.}

Incomplete calcification of the child’s skeleton predisposes children to underlying soft tissue and organ injury without obvious overlying bony deformity. Multiple growth centers in the pediatric skeleton may also have clinical implications in care. Skeletal fractures in children, especially in the thorax, should heighten clinical suspicion of a high-energy injury with resultant trauma to underlying structures. ^{1.2.3.4. and 5.}

Children of different ages present with different emotional and developmental needs. Familiarity with these issues allows the clinician to tailor the clinical approach and anticipate the patient’s needs. Injuries and stress may cause regression in psychologic behavior, which in turn can complicate clinical management.