You Take My Breath Away

     Attack One responds to a report of a child having difficulty breathing. This cold winter day has produced a number of similar calls. On entering the house, the crew can hear a child wheezing in a back room. They are greatly concerned as they enter that room and see a young boy sitting in the tripod position, with his arms behind him. He is in severe distress and can only communicate by making eye contact with the crew and shaking his head yes or no. His mother has to provide his history.

     The boy is about 6 years old and has had wheezing episodes in the past, usually resulting from exposure to cigarette smoke and certain plants. He has never had to be treated at an emergency department, but his father has asthma, and his mother is familiar with the use of nebulizers and inhalers. The boy began wheezing overnight, and it worsened as the day progressed, especially when a relative came to the house and was smoking cigarettes. He has had no recent illness, no fever and no sore throat. No one else has been ill. He is usually healthy other than the allergies, and he's had all his childhood immunizations.

     The Attack One crew recognizes the child is in trouble—he can't move enough air to speak effectively. He prefers to be near his mother, but her clothing smells of cigarette smoke, so the more she's near him, the worse his breathing becomes. The crew counts his respiratory rate at about 50 breaths per minute, and his pulse oximetry reading is 98%. He does not feel warm to touch and has no rash.

     The child is started on a nebulizer treatment with albuterol in saline. Mom is asked to assist in explaining this to the child, and to let him know his father uses the same treatment. Once that's started, the mother is asked if she could change her clothes and quickly wash her skin and brush her hair to remove as much of the cigarette smoke as she can.

     The child continues with his nebulizer treatment, but his respiratory effort is not improving. He continues to breathe about 50 times a minute and still cannot talk. His pulse oximetry reading remains about 98%. The crew continues to explain the treatment and reassure the child.

     When Mom returns, she notes the child is still in severe discomfort. The crew then elects to administer epinephrine to the child by a subcutaneous injection. The dose is related to the weight of the child, which is about 45 pounds (20 kg). He is given 0.2 cc of 1:1,000 epinephrine in the skin on his upper arm, with Mom again assisting in the explanation. The child is told the shot will help his breathing improve more quickly as the nebulizer treatment continues.

     The child is prepared for transport, and within minutes of receiving the epinephrine, his respiratory distress decreases. His eyes brighten, he sits back on the head of the stretcher, and he can speak 2–3 words at a time. His mom is safely belted into a seat in the patient compartment to accompany him, and assists in reassuring the child about the care he'll get at the ED. His respiratory rate drops to about 28. By the time they arrive at the hospital, he's saying the most reassuring words a child can utter: "I'm hungry!"

Hospital Course
     On arrival at the ED, the patient is assessed by the emergency physician and a respiratory therapist. He is given another nebulizer treatment with albuterol and an oral dose of steroids. A few tests are performed and show no other problems. He is to be given a course of steroids and started on a home nebulizer with albuterol, and Mom is asked not to let adults smoke cigarettes around him.

Case Discussion
     EMS providers frequently manage children with asthma, and many of these children present with significant respiratory distress. The EMS provider must be skilled and confident in dealing with this group of patients, and able to instill both parents and child with a sense of reassurance. Respiratory distress has a wide variety of potential causes, from the upper airway to the alveoli. The most common problem with the alveoli in the EMS environment is pneumonia, and pneumonia causes poor oxygenation, cough, fever and weakness. Alveolar disease causes shortness of breath due to poor oxygenation.

     But many cases of respiratory distress are due to problems in the larynx, trachea and bronchi. This set of tubes is responsible for transporting air and oxygen into the lungs, and moving exhaled and CO2-rich air out of the lungs. Narrowing of the air tubes anywhere between the larynx and the lungs will first compromise the person's ability to exhale, then later the ability to inhale. Oxygenation is not compromised until the patient is transporting essentially no air.

     A child in respiratory distress should thus be assessed for the ability to ventilate and oxygenate. A pulse oximeter reading will measure the oxygenation of the child's hemoglobin. Fortunately, most children will be oxygenating well. A much more important parameter to measure is the child's ability to ventilate, and the physical examination will be the critical method for doing that. A child in distress will be breathing more rapidly than usual and using extra muscles to assist in breathing, and will have noise produced as air moves through the airway. We make these observations when we count the respiratory rate; note the child's use of accessory muscles in the neck, chest wall and abdomen, and listen to the lungs with a stethoscope. The first findings we expect in a child with asthma are increased respiratory rate, use of the chest wall muscles to assist in exhalation, and wheezes on exhalation. The most extreme form of exhalation is coughing, so a child early in their disease will have wheezing when they cough. As the child worsens, they will wheeze on inhalation; use muscles in the neck, abdomen and even shoulders to assist in breathing; and assume the tripod position to coordinate all those muscles to assist in moving air. At that point, air trapping will compromise the flow of oxygenated air to the point where pulse oximetry readings may begin to fall.

     Treatment for respiratory distress in children is targeted to opening airways and, if needed, supplementing oxygenation. The most frequent causes of respiratory distress in children presenting to EMS are asthma, croup, inhalation of a foreign body and inhalation of an irritating substance. EMS treatment options include placing the child in a position of comfort, reassuring the child and the parent, removing the child from an environment that's irritating (with things like cigarette smoke, pepper spray, smoke, etc.), providing supplemental oxygen when needed and providing humidified air to assist the airways.

     Various medications have been used through the years to cause maximal dilation of the airway, particularly the bronchi. The earliest of the medicines observed to dilate airways was epinephrine. Essentially all medications used for this since then are derived from it. These medicines generally work when delivered through the blood or directly into patients' airways. Side effects tend to be less when lower doses can be delivered directly down airways. But those medicines can only be effective when the patient is moving air well enough to deliver the medication down to the lower segments of the airways. When the patient is in the most distress is when emergency providers must consider delivering medications through the bloodstream.

     That returns us to the days when the routine treatment for asthma was subcutaneous injections of epinephrine (or terbutaline). The subcutaneous route is the easiest, quickest and least painful. Patients with asthma are perfusing their skin well (in anaphylaxis, the patient in shock may not perfuse the skin well enough to pick up the medicine and deliver it where it's needed), so the medicine will be quickly absorbed and delivered to the lungs. Children are particularly well served by subcutaneous epinephrine because the medicine is rapidly available to the receptors in the lung, and an IV line need not be started.

     Some research is now being done on the use of IV epinephrine for asthmatic patients presenting in severe distress. The results have been impressive and complications rare, so that method of delivery may be available in the future.

     Most EMS protocols now call for the use of respiratory nebulizers, with saline and albuterol appropriate for the size of the child, as the treatment for wheezing and respiratory distress. But EMS providers should consider the use of subcutaneous epinephrine for those children in severe distress who may benefit from that additional medication making the albuterol more effective.

James J. Augustine, MD, FACEP, serves on the clinical faculty in the Department of Emergency Medicine at Emory University, Atlanta, GA. He also serves as Medical Director for the Atlanta Fire Department, which includes operationsat Hartsfield-Jackson AtlantaInternational Airport. He has served 23 years as a firefighter and EMT-A, and is a member of EMS Magazine's editorial advisory board.