Foreign body (FB) aspiration, though uncommon, accounts for 7% of deaths in children under 4 years of age. Most aspirated FBs become lodged in the bronchi because their size allows for passage through the larynx and glottis. Large FBs may become impacted in the larynx or trachea, potentially causing complete obstruction, a true emergency. Nuts and seeds are the most commonly aspirated objects. Beans and seeds absorb water and can swell in the airway over time. Organic FBs can cause a surrounding tissue reaction leading to severe inflammation; nuts and seeds release linolic acid, which can cause unilateral or bilateral wheezing.
Figure 6.1 ▪ Aspiration/Asphyxiation by Food Products.
(A) The most commonly aspirated food products by infants and children include peanuts, chunky peanut butter, hot dogs, popcorn, seeds, grapes, raisins, carrots, meat, and hard candies. Children too young to chew and swallow carefully (usually <5 years of age) should not be given these foods. (B) A piece of hot dog is seen lodged in the trachea of a 2.5-year-old child presenting in cardiopulmonary arrest. For children <5 years, hot dogs should be cut longitudinally and not into round pieces. (Photo contributor: Binita R. Shah, MD [A] and Charles Catanese, MD [B].)
Aspirated FBs can be difficult to diagnose as clinical symptoms may mimic asthma, recurrent pneumonia, or URI. Sudden choking and gagging with dyspnea are the first signs of aspiration. However, in up to 50% of cases, the choking episode is not witnessed. After the initial phase of choking and paroxysms of cough, children often enter into an asymptomatic phase that lasts for hours or even weeks as the FB becomes lodged. In cases of FBs of the larynx or trachea, children may present with hoarseness, stridor, and possibly cyanosis. Children with bronchial FB often present with a triad of cough, wheezing, and decreased breath sounds. However, only about two-thirds of children have all components of this triad. When these symptoms are prolonged or atypical, FB should be suspected. Unilateral decreased air entry on chest auscultation is only present in one-third of cases. Untreated, patients may enter into the third phase of the disease course, resulting in complications from atelectasis to pneumonia.
Most FBs are not radiopaque and small FBs may cause symptoms but no radiologic changes. Frontal view of chest may show air trapping secondary to obstructive emphysema. Bronchial FB results in obstruction during expiration, where air entry is possible during inspiration due to a partial obstruction (“ball-valve”) or can result in complete obstruction with poor pneumatization and atelectasis. The sensitivity of plain chest radiograph is increased when inspiratory and expiratory films are taken. Mediastinal shift to the opposite side on the expiratory phase is diagnostic. Patients who are not old enough to obtain inspiratory and expiratory films should have right and left lateral decubitus radiographies performed. The lung positioned in the dependent position will deflate under the weight of the heart unless it is obstructed. Fluoroscopy is also an option, if available, and may demonstrate air trapping or mediastinal shift. Computed tomographic scan of the chest may also be useful in detection of an FB but is not obtained initially unless the patient presents with complications or plain radiographs are nondiagnostic.
Figure 6.2 ▪ Radiolucent Foreign Body Aspiration.
(A) Single frontal view of the chest shows hyperinflation of the left lung. This 18-month-old toddler presented with persistent wheezing of several days duration. (B) Shell of a sunflower seed that was removed from the right mainstem bronchus. It is conceivable that initially FB was in the left mainstem bronchus and subsequently got dislodged during coughing and moved to the right mainstem bronchus. (Photo contributor: Johnathan Cohen, MD.)
The criterion standard for the diagnosis and management of tracheobronchial FB is bronchoscopy and removal. Patients with suspected airway FB must have specialty evaluation early. Consult otolaryngology and pediatric pulmonary services. Children with laryngotracheal FBs may present in acute and severe airway obstruction. Attempt standard back blows or abdominal thrusts first and if unsuccessful in dislodging the FB, attempt laryngoscopy and removal. If the FB cannot be removed by direct laryngoscopy in the emergency department (ED), use intubation to advance the FB into a bronchus. Bronchial FBs rarely require emergent intervention. Give supportive care with oxygen or heliox and monitor closely, including continuous pulse oximetry. Give steroids to reduce airway inflammation as needed.
Figure 6.3 ▪ Radiolucent Foreign Body Aspiration.
(A) Frontal view of the chest shows hyperinflation of the left lung. (B, C) Bilateral decubitus views of the chest show persistent hyperinflation of the left lung with decubitus positioning, consistent with air trapping. (D) CT scan shows overinflated left lung with air trapping. (E) CT scan showing impacted FB in left mainstem bronchus (arrow). (Photo contributor: Rafael Rivera, MD.)
Lack of witnessed choking episode and/or normal chest films are the most important factors contributing to delayed diagnosis.
The presence of an airway FB should be considered for all patients with new onset of noisy breathing or wheezing (especially in toddlers) or unexplained persistent or recurrent pulmonary findings (eg, pneumonia) regardless of the history of an aspiration event.
The authors acknowledge the special contributions of Binita R. Shah, MD, to prior edition.
Pertussis, or whooping cough, is infection of the respiratory tract by Bordetella pertussis, a gram-negative pleomorphic bacillus. Humans are the only known hosts and transmission is by respiratory droplets.
A viral prodrome and mild cough (catarrhal stage) is followed by a paroxysmal stage of progressive, repetitive, and severe episodes of coughing that lead to a forceful inspiration, producing the characteristic whoop. Symptoms take weeks to months to resolve (convalescent stage). Pertussis is most severe in the very young, presenting as gagging, gasping, or apnea without characteristic whoop. Complications among infants include bronchopneumonia, seizures, encephalopathy, cerebral anoxia, and sudden unexpected death. Submucosal bleeding, diaphragmatic rupture, umbilical and inguinal hernias, and rectal prolapse have been reported. Complications among adolescents include syncope, sleep disturbance, incontinence, rib fractures, and pneumonia. A number of other pathogens can cause pertussis-like symptoms (eg, adenoviruses, RSV, para influenza viruses, influenza viruses, mycoplasma). Leukocytosis with absolute lymphocytosis (total count >50,000 cells/mm) may be seen at the beginning of the paroxysmal stage. Chest radiograph may show perihilar, patchy, or diffuse infiltrates. Diagnosis is confirmed by culturing a nasopharyngeal sample on special media (Regan-Lowe; a negative culture does not exclude the diagnosis) or polymerase chain reaction assay using a nasopharyngeal sample for detection of B pertussis. In the absence of immunization within 2 years, an increasing titer or a single IgG anti-Pertussis toxin value 100 EU/mL or greater can be used for diagnosis.
Provide supportive care, including suctioning of secretions, humidified oxygen for hypoxia, and maintenance of adequate hydration and nutrition, and treat both the patient and his or her contacts with macrolide antibiotics (azithromycin, erythromycin, or clarithromycin). Use azithromycin in patients under a month old as there is an association between orally administered erythromycin and infantile hypertrophic pyloric stenosis. Trimethoprim-sulfamethoxazole is an alternative for patients more than 2 months old who cannot tolerate macrolides. Macrolides given as soon as possible to an exposed person (preferably during the incubation period) will prevent or modify the course of the disease. Pertussis vaccine (follow standard immunization schedule) should also be given to unimmunized or incompletely immunized exposed children who are under 7 years of age. Admit patients under 1 year of age and those with apnea or cyanosis during episodes, pneumonia, or respiratory distress. Initiate respiratory droplet precautions for 5 days after initiation of antibiotic therapy or until 3 weeks after the onset of paroxysms without antibiotic therapy.
Pertussis is a life-threatening infection and is preventable by universal immunization.
Neither infection nor immunization provides lifelong immunity to pertussis.
Figure 6.5 ▪ Bilateral Subconjunctival Hemorrhages and Periorbital Ecchymosis; Pertussis.
Violent episodes of coughing leading to hemorrhages (subconjunctival and periorbital) were the presenting complaints of pertussis in this unimmunized adolescent boy from El Salvador. His nasopharyngeal aspirate that was positive for Bordetella pertussis. (Important: These findings of subconjunctival hemorrhages and ecchymoses can be mistaken for inflicted injuries from child abuse.). (Photo contributor: Binita R. Shah, MD.)
Croup is an acute viral inflammation of the larynx and structures inferior to the larynx classically described as acute laryngotracheitis or laryngotracheobronchitis. A distinction is made from spasmodic croup, which is thought to have an allergic component and presents with noninflammatory edema in the subglottic region.
Croup affects children aged 6 months to 6 years and occurs in early fall and winter. Patients present with 1 to 3 days of upper respiratory tract symptoms and fever with progression to the characteristic barking cough, hoarseness, stridor, and respiratory distress. Tachypnea, retractions, hypoxia, and altered mental state are often ominous signs of worsening obstruction. The commonest etiologic agents include Para influenza viruses (two-thirds cases), respiratory syncytial virus (RSV), influenza viruses A and B, and adenovirus. Differential diagnosis includes epiglottitis, bacterial tracheitis, foreign body aspiration, retropharyngeal abscess (RPA), peritonsillar abscess, angioneurotic edema, congenital anomaly, mediastinal mass (eg, lymphoma), and diphtheria. Routine laboratory studies are not helpful. Plain radiographs of the neck are not routinely indicated and should be used only when diagnosis is unclear to exclude other conditions such as retropharyngeal abscess or foreign body aspiration.
Figure 6.7 ▪ Foreign Body Ingestions Presenting with Stridor; Differential Diagnosis of Croup.
(A) Frontal view of the chest shows impacted coin in a child with “noisy breathing” and drooling. (B) Frontal view of the neck in a different child shows a jack in the region of the esophagus. This child also presented with a stridor and difficulty swallowing. (Photo contributor: John Amodio, MD.)
Figure 6.8 ▪ Laryngeal Papillomatosis Presenting with Stridor; Differential Diagnosis of Croup.
(A) Respiratory papillomatosis of the left half of the larynx, obstructing the glottic inlet in a patient presenting with hoarseness, stridor, and airway obstruction. (B) Papillomatous lesions involving both vocal cords in a different patient with stridor and difficulty breathing. (Photo contributor: Bhuvanesh Singh, MD.)
Management of croup depends on the severity of upper airway obstruction. For mild to moderate croup, the treatment is oral or parenteral or nebulized steroids, including dexamethasone, prednisolone, or nebulized budesonide. For severe croup, nebulized racemic epinephrine should be given urgently as 2.25% solution diluted in 3 mL of normal saline given over 15 minutes. If racemic epinephrine is not available then nebulized l-epinephrine 1:1000 can be administered. Improvement of symptoms should occur within 10 to 30 minutes of administration. If after 2 hours of observation, there is no stridor or chest retractions and the child appears well, he or she may be discharged home. Hospitalize any child who does not improve after adrenaline administration. Intubate and admit patients with signs of respiratory failure who do not respond to racemic epinephrine and steroids. Helium oxygen mixture (Heliox) may be useful in the treatment of severe croup as it reduces work of breathing enough to prevent intubation and allow other medications to reach therapeutic peak. There is no evidence for the use of humidified or cold air, prophylactic antibiotics, or antitussive agents.
Croup is the most common form of acute upper airway obstruction in infants and children.
Regardless of the level of illness acuity, corticosteroid therapy (dexamethasone either orally or intramuscularly) is now the standard of care.
Drooling, dysphagia, high fever, and toxic appearance are notably absent in viral croup suggesting another diagnosis.
Figure 6.9 ▪ Laryngeal Hemangioma Presenting with Stridor; Differential Diagnosis of Croup.
Subglottic hemangioma causing airway narrowing. This patient had a beard-distribution cutaneous hemangioma (see Figure 7.94) and presented with biphasic stridor and respiratory distress. (Photo contributor: Sydney C. Butts, MD.)
| Level of Severity | Characteristics |
|---|---|
| Mild | Occasional barky cough, no audible stridor at rest, and no to mild suprasternal and/or intercostal indrawing |
| Moderate | Frequent barky cough, easily audible stridor at rest, and suprasternal and sternal wall retraction at rest, without agitation |
| Severe | Frequent barky cough, prominent inspiratory and—occasionally—expiratory stridor, marked sternal wall retractions, and significant distress and agitation |
| Impending respiratory failure | Barky cough (often not prominent), audible stridor at rest (occasionally hard to hear), sternal wall retractions (may not be marked), lethargy or decreased level of consciousness, and often dusky appearance without supplemental oxygen |
Bacterial tracheitis is a potentially fatal acute infectious upper airway obstruction, occurring in children of age 3 months to 5 years, predominantly in fall and winter. A prodrome of coryza, sore throat, cough, and pyrexia of 1 to 3 days is followed by acute onset of stridor and rapidly worsening respiratory distress, which can lead to airway obstruction and respiratory arrest. Patients with bacterial tracheitis are toxic appearing and show little response to inhaled steroids or adrenaline. Visualization of the airways reveals subglottic inflammation, edema of the tracheal mucosa, and copious purulent endotracheal secretions. Staphylococcus aureus is the most common bacterial pathogen followed by Streptococcus pneumoniae, Streptococcus pyogenes, Haemophilus influenzae nontypeable, Moraxella catarrhalis, and Pseudomonas aeruginosa. Viral coinfection is common with Influenza A, Parainfluenza, RSV, and adenovirus. Differential includes viral croup, epiglottitis, foreign body aspiration, and retropharyngeal abscess. Complications include cardiorespiratory arrest, acute respiratory distress syndrome, hypotension, toxic shock syndrome, renal failure, pneumothorax, pulmonary edema, and subglottic stenosis. White blood cell count is usually elevated or abnormally low. Chest and lateral neck radiographs show subglottic narrowing on posterior-anterior view, a hazy tracheal air column and irregular soft-tissue densities in trachea (indicating purulent exudate), pneumonia, and pulmonary edema.
Figure 6.10 ▪ Bacterial Tracheitis.
Lateral neck view of patient with bacterial tracheitis. Note presence of irregular tracheal margins (arrows). (Courtesy W. McAlister, MD, Washington University School of Medicine, St. Louis, MO.) (Reproduced with permission from Tintinalli JE, Stapczynski JS, Ma OJ, et al. (eds): Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed. McGraw-Hill, New York.)
Figure 6.11 ▪ Retropharyngeal Abscess; Differential Diagnosis of Bacterial Tracheitis.
Lateral view of the neck shows collection of air in retropharyngeal soft tissues compatible with abscess. Stridor, drooling, and respiratory distress in a highly febrile child were the presenting signs mimicking bacterial tracheitis. (Photo contributor: John Amodio, MD.)
Figure 6.12 ▪ Foreign Body Ingestion; Differential Diagnosis of Bacterial Tracheitis.
Frontal and lateral views (A, B) of the chest show a button battery impacted in the esophagus at the level of the aortic arch in a child presenting with stridor and respiratory distress. (Photo/legend contributors: Nooruddin R. Tejani, MD/John Amodio, MD.)
Adequate airway protection with intubation is the single most important therapeutic intervention. Obtain tracheal bacterial cultures at intubation and send secretions for direct immunofluorescent identification of viral agents. Treat hypotension aggressively with normal saline fluid boluses and inotropic support. Begin empirical therapy with anti-staphylococcal agent (eg, vancomycin) and a third-generation cephalosporin (eg, ceftriaxone or cefotaxime). Admit all intubated patients to the intensive care unit (ICU). With appropriate antimicrobials and aggressive supportive care, rapid improvement and extubation within 72 to 96 hours is possible.
The clinical hallmark of bacterial tracheitis is toxic appearance and worsening stridor 1 to 3 days after a viral prodrome.
In contrast to viral croup, patients with bacterial tracheitis show little response to inhaled steroids or adrenaline.
Visualization of airway shows presence of purulent tracheal secretion.
Epiglottitis is an acute life-threatening inflammation of supraglottic structures involving the epiglottis, aryepiglottic folds (false vocal cords), arytenoids, and vallecula. It is usually seen in children aged 2 to 7 years and has become rare since the introduction of H influenzae type b (Hib) conjugate vaccines in 1991. The most common organisms include S pyogenes, S aureus, S pneumoniae, Moraxella, and Candida species. H influenzae type b is still seen in nonimmunized children. Non infectious causes include direct trauma and thermal injuries (eg, scalding burns of face, drinking hot liquids). Symptoms occur with rapid progression and include fever, irritability, and toxic appearance, difficulty swallowing, and drooling. Croupy cough is absent and stridor is a late finding. The child usually sits upright with the chin pushed forward (tripod position) to open the airway. Gentle visualization of the oropharynx without the use of a tongue depressor may reveal an erythematous epiglottis protruding at the base of the tongue. Use radiographs when the diagnosis of epiglottitis is unlikely and to exclude retropharyngeal abscess and foreign bodies. Lateral neck radiograph is the image of choice, and the classic finding of epiglottitis is the “thumbprint sign.” Contrasted CT scan of the neck may also indicate the presence of epiglottic edema and possibly phlegmon or abscess in the epiglottis or the base of tongue.
Figure 6.13 ▪ Epiglottitis.
(A) Lateral view of the airway shows enlargement of the epiglottis (arrow), thickening of the aryepiglottic folds (A), and amputation of the vallecula (V) leading to the “thumbprint sign”. (B) Endoscopic view of almost complete airway obstruction secondary to epiglottitis in a different patient. Note the slit-like opening of the airway. (Photo contributors: John Amodio, MD [A] and Department of Otolaryngology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH [B].) (Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ: Atlas of Emergency Medicine, 3rd ed. McGraw-Hill, New York, 2010.)
Assemble a multidisciplinary team including pediatric intensive care, anesthesiology, and otolaryngology. Bring the patient to the operating room emergently to confirm diagnosis by direct visualization. Edema with intense erythema of epiglottis (often described as cherry-red appearance) and surrounding structures including arytenoids and aryepiglottic folds and vocal cords are seen. Perform intubation or tracheostomy as needed. Admit the patient to the ICU for continuous monitoring. Postpone diagnostic tests and placement of IV lines until the airway is secure. Obtain CBC with differential and cultures of the blood and epiglottal surface for precise microbiologic diagnosis. Treat empirically with a second- or third-generation cephalosporin or ampicillin/sulbactam. Children usually require intubation for 24 to 72 hours, until reduction in airway edema occurs.
Figure 6.14 ▪ Epiglottitis.
(A) Lateral view of the neck shows marked enlargement of the epiglottis, amputation of the vallecula (black arrow) and thickening of the aryepiglottic folds (white arrow) in a 21-year-old patient presenting with history of sore throat, fever, and difficulty handling secretions. His epiglottal culture was positive for Streptococcus pyogenes. (B) Fiberoptic laryngoscopy showing an edematous epiglottis and glottic area with marked airway compromised in an adult with epiglottitis. (Photo contributors: Michael Secko, MD [A] and Edward C. Jauch, MD [B].) (Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ: Atlas of Emergency Medicine, 3rd ed. McGraw-Hill, New York, 2010.)
Do not force the patient to lie in a supine position as a gravity-induced change in the position of the epiglottis may lead to total obstruction.
Do not use a tongue blade to examine the pharynx as it may induce life-threatening laryngospasm.
Confirm epiglottitis with direct visualization rather than radiography as patients may develop life-threatening laryngospasm when attempting to hyperextend the neck for the radiograph.
Bronchiolitis is defined as a constellation of clinical symptoms and signs including a viral upper respiratory prodrome followed by increased respiratory effort and wheezing. It occurs in children under 2 years old, primarily between late fall and spring. RSV account for 50% to 80% of cases followed by para influenza viruses, influenza, and human metapneumovirus. An upper respiratory tract infection (URI) prodrome is followed by cough, tachypnea, tachycardia, grunting, flaring, supraclavicular and intercostal retractions, and head bobbing. Nonspecific symptoms include poor feeding and irritability. Examination may reveal chest hyperinflation with costal retraction, and fine inspiratory crackles and expiratory wheeze on auscultation. Hypoxemia is primarily due to ventilation/perfusion mismatch, and hypercapnia is a late phenomenon. Progression to respiratory failure may occur. Factors associated with severe disease include age <3 months, gestational age <34 weeks, toxic appearance, respiratory rate >70 breaths per minute, chronic lung disease, congenital cardiac abnormalities, neuromuscular disease, or immune deficiencies. Differential diagnosis includes pneumonia, laryngotracheomalacia, foreign body, gastroesophageal reflux, congestive heart failure, vascular ring, cystic fibrosis, mediastinal mass, bronchogenic cyst, and tracheoesophageal fistula.
Figure 6.15 ▪ Bronchiolitis.
(A) An infant presenting with new onset of wheezing associated with subcostal and intercostal retractions and pulling inward of the sternum with exacerbation of the pectus excavatum deformity. (B) Frontal view of chest shows hyperinflation, peribronchial cuffing, and increased pulmonary markings compatible with bronchiolitis. (Photo contributor: Binita R. Shah, MD.)
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