Pediatric Potpourri: An Overview of Select Pediatric Conditions

Few encounters cause greater anxiety for medical caregivers than a pediatric patient experiencing a life-threatening situation. Although pediatric calls only account for approximately 10% of all EMS calls, they can be among the most stressful.1–5 Caregivers need to be prepared to face these challenges, as prompt recognition and treatment of potentially life-threatening diseases in children in the prehospital setting may have a significant impact on the outcome of the patient’s experience.

Of the 10% of EMS calls that involve pediatric patients, fewer than 5% are for life- or limb-threatening situations.1–3 When EMS does respond to a pediatric call, treatment such as administering oxygen, starting an IV or performing endotracheal intubation can be involved in more than 50% of the cases.

In addition to impacting EMS systems, emergent pediatric situations are also encountered in emergency departments.1–5 Children accounted for nearly 21-million ED visits in 1996.6 In light of these statistics, it is critical for healthcare providers, regardless of their level of training, to be prepared to respond to a call for help that involves a pediatric patient.

This article provides an overview of a potpourri of pediatric topics, including croup, epiglottitis, foreign body obstruction, bronchiolitis, asthma and stridor, all of which may result in a life-threatening situation.

Assessment of the Pediatric Patient With Respiratory

Complaints

Upon initial patient contact, quickly establish the patient’s overall appearance, including vital signs and stability of their ABCs. This can be accomplished by observing the patient, as well as conducting a rapid, yet thorough, physical assessment. Additional tools, such as an EKG, pulse oximeter and capnometer, may also be applied.

If any life-threatening conditions exist, intervention should not be delayed. Providers should attempt to obtain an accurate history. Factors like the presence of fever, time of onset and current medications may influence the care to be provided. Additional historical and physical assessment parameters should include monitoring the patient’s airway, auscultation of breath sounds, noting accessory muscle use, circulation, temperature, neurological status, fluid intake/output and overall appearance/behavior.1,12,13,15

EMS providers should ask the following questions when assessing a child with a complaint: Is this episode chronic or acute? What are the associated symptoms? Is there respiratory distress, fever, toxicity, drooling or cyanosis? Has this condition progressed with age? If so, have the episodes increased in frequency? Have the episodes increased in severity? What causes the patient’s signs and symptoms to worsen (e.g., supine versus sitting, or crying)? Has anything made the child better (e.g., over-the-counter medications)? Has the child experienced any changes in feeding patterns? What are his/her baseline noises? Is the quality of the patient’s cry and voice normal? Table I provides examples of additional factors to consider. By considering the answers to questions like these, in combination with the provider’s clinical judgment and assessment findings, treatment options may become more readily apparent.1,12,13,15

Croup

Croup, or laryngotracheobronchitis, is a contagious viral infection of the subglottic airway region. It is responsible for most cases of stridor after the neonatal period. Children aged six months to three years are most commonly affected, with a peak incidence between 12 and 24 months. As children get older, the incidence of croup declines considerably, especially after age six.

Croup tends not to be as clinically significant in children older than six years because of their mature airway anatomy. Due to the smaller and less-developed airway of the younger patient, airway edema and inflammation have a greater impact in a smaller child than an older, more mature child. While these cases can be successfully managed, there is a 5% recurrence rate. 1,7–13

Fortunately, croup is usually a benign, self-limited disease, and most children with croup do not experience significant respiratory compromise. Croup-related morbidity is infrequent and death is rare. While the exact mortality rate for croup is unknown, it is reported that a higher mortality rate tends to be seen in younger male patients.9,10 More than 75% of croup-related deaths are observed in patients younger than three years.9,10 “Super-infections,” such as croup with bronchopneumonia and measles, can complicate the outcomes. When super-infections occur simultaneously with croup, there tends to be a higher mortality rate.7–13

The reported incidence of croup varies in the literature. Some sources indicate that there is an equal division between males and females, whereas others suggest that croup is more common in males, especially under six months of age.9,10 Croup is less common in school-aged children, but can be seen in older children with preexisting disease processes, such as subglottic stenosis. Croup is more common in Caucasian than African- American children.9 It is more commonly encountered in the late fall or early winter, although it can occur at any time of year.6–12

Pathology

Croup is usually spread through one of two routes. Either the patient breathes in airborne droplets containing viruses, or the patient comes in contact with objects contaminated by these droplets. The specific cause of croup can vary with geography and season. Parainfluenza virus tends to cause more cases of croup in the fall, while the respiratory syncytial virus (RSV) is more common during the winter. Croup due to the influenza virus type B is more common in the spring. Additional potential causes are provided in Table II.6–12

The pathogens involved in croup result in swelling of the airway lining. The swelling, or edema, tends to be specific to the area just below the larynx. Significant airway narrowing occurs in the lateral walls of the subglottic larynx. Because the area below the glottic opening (subglottic larynx) and the tracheal lumen is narrow in infants and children, any decrease in diameter can be critical. This can result in a significant increase in airway resistance and subsequent increase in the work of breathing. Older children tend to have milder symptoms because their airway diameter is larger and more developed. Croup can still create severe illness in older children, especially those with congenital or acquired subglottic stenosis.7–13

Spasmodic croup

Spasmodic croup, or laryngismus stridulus, is different from viral croup. It manifests more commonly at night and occurs less frequently than viral croup. Two pathways are involved in spasmodic croup: (1) subglottic noninflammatory edema and (2) spasm of the glottis with closure of the crowded aryepiglottic folds. Spasmodic croup often presents with signs and symptoms that are similar to viral croup. Onset of symptoms tends to be sudden with dyspnea, a bark-like cough and stridor. In contrast to viral croup, a fever is rarely present. Spasmodic croup often subsides quickly when the child is exposed to humidified air. It may recur over the next few days.13

Symptoms

Viral croup usually starts as a common cold. There is a 1–5-day prodrome of cough and runny nose, followed by a 3–4-day period of the classic barking cough. This unusual-sounding cough is often described as brassy or seal-like. In severe croup, stridor may be heard with each inspiration. The symptoms tend to improve in the morning and increase in severity during the night, often awakening the child from sleep.7–13

In addition to a barking cough, hoarseness and inspiratory stridor, varying degrees of respiratory distress may be encountered. Tachypnea and intercostal retractions may be present. Depending on the severity of the case, the child with croup may present with bronchoconstriction, lower airway edema and atelectasis. While croup is usually self-limited, it may also lead to severe airway obstruction.7–13 Table III provides an example of a croup classification system.

Retractions with croup can be suprasternal, intercostal or sternal. An increase in chest wall retractions may occur as the pleural pressure becomes increasingly negative and often correlates with the severity of the upper airway obstruction. Paradoxical movement between the rib cage and abdominal wall may develop as respiratory compromise increases. Hypoxemia is rare, but if it does develop, the child may present with a depressed level of consciousness or cyanosis. Upon auscultation, breath sounds are often normal, although stridor may be heard.

Treatment

Most children have a mild form of croup and require no specific treatment. Any patient experiencing hypoxia should receive supplemental oxygen, although this has the potential to further agitate the child. Consider having a parent administer blow-by oxygen, if necessary.14,15

Additional treatment may be initiated in the prehospital setting. For example, nebulized epinephrine (0.05 ml/kg per dose, up to 5 ml of 2.25% solution) should be used to treat moderate to severe cases. Children who develop stridor only when irritated or upset do not require epinephrine. Although intubation should always be performed when indicated, fewer than 1% of the patients with croup will require intubation.16

Epiglottitis

Epiglottitis, also referred to as supraglottitis, is an acute, severe, life-threatening disease of the upper airway (supraglottic tissues) caused by a bacterial infection. First described in the mid-1800s, it involves inflammation of the structures above the insertion site of the glottis. In the past, this disease occurred most frequently in children aged 2–7 years and was commonly caused by Haemophilus influenzae type B (HIB). Following the introduction of Haemophilus influenzae type B vaccine in 1988, the incidence and demographics of epiglottitis have changed significantly, and a median age of presentation is shifting to older children/teenagers and adults.17–23

Epiglottitis occurs with different peaks in both children and adults. It typically peaks in children aged 2–4 years and between ages 20–40 in adults. Epiglottitis in children under age 1 is unusual and occurs in fewer than 4% of cases. Studies suggest a 60% male predominance.17–22

Introduction of the HIB vaccine has resulted in a significant reduction in the incidence of epiglottitis. Vaccination only prevents typeable H influenzae; nontypeable H influenzae can also cause epiglottitis.20 In immunized children, most cases are due to Gram-positive organisms, such as Strep-tococcus or Staphylococcus. In immunocompromised children, herpes, Candida or varicella should be considered.17–22 Table IV provides a summary of possible etiologies.

The morbidity and mortality rates associated with epiglottitis vary. The outcomes are influenced by factors such as the actual time of diagnosis, the interventions that are implemented once epiglottitis is diagnosed and the use of established treatment protocols.17–22 In hospitals with a pediatric expertise and defined protocols, the mortality rate of epiglottitis approaches zero and the morbidity rate, or medical complication rate, is often less than 4%.20 When delays in diagnosis occur, mortality rates of up to 18% have been reported.20

Pathophysiology

Epiglottitis usually begins as an inflammation (swelling) between the base of the tongue and the epiglottis. This is followed by invasion of the epiglottis. The bacteria may penetrate the mucosal barrier, allowing for invasion of the bloodstream, resulting in bacteremia. The epiglottis, aryepiglottic folds, false vocal cords and supraglottic structures become inflamed and edematous, leading to narrowing of the airway and respiratory compromise. Inspiratory airway occlusion may occur prior to total occlusion from supraglottic edema.17–22

Symptoms

Symptoms of epiglottitis include abrupt onset of high fever, sore throat, stridor, dysphagia (difficulty swallowing), muffling or changes in the voice, difficulty speaking and drooling due to difficulty swallowing. The triad of drooling, dysphagia and distress are considered to be classic findings. Fever and respiratory distress occur in most patients. Drooling occurs in up to 80% of cases. The patient may maintain his/her neck in a hyperextended position in an attempt to maintain airway patency. While the onset of symptoms may develop over only a few hours, cases may also progress over a period of one or two days. According to some reports, more than three-quarters of patients were symptomatic for less than 24 hours.17–22

In pediatric epiglottitis, the child appears ill. He tends to sit in a tripod or “sniffing” position, with the neck extended, chin forward and tongue protruding. In contrast to croup, there is usually no cough. If the infection extends to the vocal cords, the patient’s voice may be altered. Retractions (suprasternal, subcostal and intercostal) and stridor may be present. In addition, the pediatric patient tends to be restless, irritable and extremely anxious. In infants younger than one year, signs and symptoms such as fever, drooling and upright posturing may all be absent. This may complicate recognition of the acute condition. Infants may present with cough and a history of an upper respiratory infection, neither of which initially appears to be alarming. Because of such variables, it can be very difficult to determine if an infant has epiglottitis. In children old enough to express complaints, the diagnosis is suggested by a sore throat, a normal-appearing oropharynx and marked tenderness with movement of the hyoid bone. 17–22

Treatment

Prehospital treatment of a child with suspected epiglottitis includes supplemental oxygen and allowing the child to choose the position he/she is placed in, which is usually sitting up next to a parent or other familiar figure. Nebulized epinephrine has been effective in some children. Avoid intravenous (IV) placement so as to not further irritate the child. If respiratory arrest occurs, bag-valve-mask ventilation is often successful for short periods of time. Endotracheal intubation may be extremely difficult or impossible and should be attempted only as a last resort.1,15

Stridor

Stridor is the sound that is heard when there is an upper airway obstruction. Stridor occurs when there is an obstruction of the glottis and the subglottic areas resulting in airflow that has increased turbulence and velocity. As high-velocity airflow passes the vocal cords and aryepiglottic folds, these structures vibrate, resulting in stridor.12,13,24

While stridor is commonly associated with croup, it should be noted that not all stridor is from croup. Stridor can have a variety of causes depending upon the age of the patient and presence of coexisting processes. Causes of stridor can include other infectious diseases, vocal cord paralysis, hypopharyngeal abscess, foreign body aspiration and a variety of other medical and nonmedical conditions.12,13,24

Symptoms

Depending on the specific location of the obstruction, stridor may sound different with each episode. For example, stridor with a sonorous, gurgling or coarse quality tends to be located in the nose or pharynx. Stridor that occurs primarily with inspiration and is high-pitched is more commonly associated with supraglottic and subglottic occlusions.

Although most commonly thought of as inspiratory in nature, stridor can also be expiratory or biphasic. Biphasic stridor occurs during both inspiration and expiration. It tends to be more commonly associated with obstructions at the glottic or cricoid ring level. Stridor that occurs during expiration is associated with lower tracheal involvement, including tracheitis and foreign body obstruction. Stridor is normally not influenced by positioning. It can increase if the child cries or becomes otherwise agitated. 12,13,24

Foreign body aspiration

Foreign body aspiration is most common in children between ages six months to four years, with a peak incidence between ages 12 and 36 months. According to the 1998 National Safety Council statistics for the United States, 3% of all unintentional deaths among children under age 15 were secondary to inhalation or ingestion of food or objects (IOFO).25,26 IOFO is reported as the fifth-leading cause of death in the United States for children ages six months to four years and accounts for 3,000 deaths each year.25,26 In children under six months, the cause is generally secondary to a feeding by a well-intentioned sibling. Nearly 75,000 foreign body ingestions by patients ages 19 years and younger were reported to 67 poison control centers in 1996.25,26

Hundreds of objects have been identified as potential causes of airway obstruction. Round-shaped foods are common and include raisins, grapes, peanuts, large round candies and hot dogs. Non-food objects include pen caps and coins. Of interest, toy balloons, including those made from surgical gloves, have been associated with nearly one-third of all deaths from foreign body aspiration.25,26

Symptoms

The impact of foreign material ingested is influenced by numerous factors. When aspirated, smaller objects that pass through the subglottic space tend to lodge in the bronchus or a more distant portion of the airway. Immediate signs of obstruction may not be obvious. In fact, many patients will be completely asymptomatic. In contrast, larger objects tend to lodge in the upper airway or trachea and the child has more obvious signs of obstruction, including drooling, dyspnea, stridor and cyanosis.1,2,5,26,27 Signs of complete airway obstruction can include poor air exchange, ineffective cough, severe distress and cyanosis. Depending on the size and location of the object that is involved, once aspirated, specific clinical responses may occur. Up to one-third of foreign body aspirations are not witnessed; therefore, this diagnosis should be considered in all children with unilateral wheezing.25, 28 Table V summarizes these findings.

The interventions provided by EMS personnel should be in accordance with local protocols and scope of practice. Treatment will be influenced by factors such as the age or size of the patient, the patient’s level of distress and quality of the patient’s air exchange. Any of the following may be involved: back blows, chest thrusts (under one year), abdominal thrusts and head positioning to aid the child. If a foreign body is caught at the cords, causing partial or even complete obstruction, direct visualization may be lifesaving. Removal of the foreign body or pushing it further down the trachea may be necessary. If none of the above is successful, emergency cricothyrotomy may be considered.1,25–27

Asthma

Asthma is a chronic disease of the tracheobronchial tree that results in airway obstruction, inflammation and hyperresponsiveness. An asthma attack involves a cascade of events that leads to mucus plugging, airway edema and obstruction. The inflammation in the airway increases the airway’s hyperresponsiveness to various stimuli and results in variable airflow obstruction, which can be corrected with treatment.29–32

Asthma has a significant impact. It affects nearly five million children under age 18 and more than one million under age five. In the United States from 1987–1992, the rate of hospitalization for children with asthma under age 14 increased from 2.84 to 3.44 per thousand. Children under age four accounted for more than 40% of pediatric admissions in 1979 and more than 50% of admissions in 1987. The asthma death rate for children ages 5–14 almost doubled from 1980 to 1993.29–32

Children and Asthma in America, a pediatric asthma survey, revealed that more than 50% of all children with asthma had a severe attack within the last year. Of this population, more than 25% experienced an attack so acute that it was perceived to be life- threatening.31 Asthma accounts for 14 million ambulatory care visits per year and one in six pediatric emergency visits, and is cited as a primary reason for school absence.29, 31

Asthma often begins during childhood. It is reported that more than 50% of the children with asthma will present with their first episode of symptoms before age five.29–32 Factors associated with asthma include allergies, family history of asthma or allergy, perinatal exposure to smoking, viral respiratory infections, exposure to environmental toxins, smaller airways in early life, male gender and low birth weight. In children, there is a 6% risk of developing asthma if neither parent has asthma, a 19% risk if one parent has asthma and more than 50% risk if both parents have asthma.29–32 It is also reported that up to 25% of all children experience wheezing before age three, though only a minority eventually develop asthma.29–32

The etiology of asthma varies depending on the patient’s age. Males are more commonly affected than females during the prepubescent years, after which the distribution becomes more equal. Allergens and irritants are some of the more common causes of asthma in children over age two. Viral respiratory infections are thought to be the primary trigger in children under age two. Other triggers include air pollution, temperature extremes, high humidity, tobacco smoke, animal feces, molds, pollens and gastroesophageal reflux. Most children with asthma will experience an attack that will result in seeking medical attention before age eight.29–32

Pathophysiology

Asthma can be classified as extrinsic (antibody [IgE] mediated), intrinsic (infection- induced) or mixed. Bronchoconstriction occurs due to certain chemical releases, including histamine and leukotriene (early phase). Airway mucosal edema with mucus plugging then occurs (late phase). Several factors, including bronchospasm, mucosal edema and mucus plugging, result in variable and reversible airflow problems. These factors lead to air trapping and reduced oxygen exchange.12,13,29,30

When the chemicals involved in asthma, including histamine, are released, “early phase reactions” occur. This results in smooth muscle constriction, bronchoconstriction, decreased mucociliary function, microvascular permeability, airway edema and cellular inflammatory responses. Additional bronchial hyperresponsiveness and vasoconstriction occurs. Respiratory epithelial breakdown can also develop. These events usually occur 4–12 hours after the initial triggering insult.12,13,29–32

In severe cases, the child who is experiencing an asthma attack is at risk for respiratory failure. The compliance of the rib cage and immature diaphragm results in paradoxical respirations. A combination of this with an inward displacement of the ribs during inspiration contributes to increased work of breathing and respiratory muscle fatigue. The child’s young lung tissue lacks elastic recoil and is more prone to atelectasis (collapse of the alveoli) that can result in ventilation-perfusion mismatch. The pediatric airway walls are thicker and therefore greater narrowing occurs with bronchoconstriction. Relief of symptoms depends largely on resolution of mucosal inflammation, which can take days to weeks.12,13,29–32

Symptoms

The signs and symptoms exhibited by a patient who is experiencing asthma can include a wide spectrum of findings. Dyspnea, wheezing, coughing and chest discomfort or tightness are some of the more classic findings. Nighttime coughing may be an early indicator of asthma, even in the absence of other symptoms.1,12,13,29–32

Additional examples of asthma signs are listed in Table VI. It should be noted that not all individuals experience the same asthma symptoms. A patient’s symptoms will be influenced by the nature of the asthma (Table VII), as well as the severity of the episode (see Table VIII on page 58).

Treatment

Albuterol is the mainstay of acute therapy and can be administered as episodic treatments (0.15 mg/kg per dose) every 15–20 minutes, or as a continuous nebulization (up to 5 mg/kg/hr or up to 15 mg in most cases). The provider should be aware that a decrease in oxygen saturation may accompany effective therapy due to the ventilation-perfusion mismatch. Ipratropium bromide (the generic name for Atrovent) can be considered for asthma exacerbations when available. Magnesium sulfate may benefit a subset of children with severe exacerbation. Subcutaneous epinephrine (0.01 ml/kg of 1:1000 solution) can be considered when patients are in severe distress and are unresponsive to therapy.12,13,29–33

Bronchiolitis

Bronchiolitis is an acute lower respiratory infection that causes inflammation of smaller airways and results in obstruction and reactive airway disease. It is most common in children under age two and has a peak incidence at 2–9 months of age. More than 75% of the cases involve patients under age one. In the United States, the incidence rate is 11 cases per 100 children during the first year of life. Bronchiolitis typically occurs from October to May. Death is rare and hospitalization occurs in 3% of all cases. Bronchiolitis accounts for at least 15% of all infant hospitalizations.12,13

Pathophysiology

Bronchiolitis involves viral infection that occurs in the small bronchials and leads to necrosis of the respiratory tract. Because portions of the respiratory tract lack cilia (hair-like structures that help remove foreign or dead materials), the secretions can occlude the smaller airways. Areas of edema, hyperinflation and atelectasis may occur. Respiratory syncytial virus (RSV) causes up to 70% of cases. Parainfluenza I, II and III are also common etiologies. Other pathogens can include adenovirus, rhinovirus and influenza. Bronchiolitis is rarely caused by bacteria.12,13

Children may experience single or multiple episodes of bronchiolitis. It has been reported that some children may progress to develop asthma, although the rate at which this occurs is unknown. Infants are at a higher risk of respiratory failure from airway obstruction. This is due to a variety of factors, including smaller airway diameter, high airway resistance, poor elastic recoil and rib cage compliance.

Symptoms

The patient with bronchiolitis may present with 3–5 days of nasal congestion and a cough. The cough increases and symptoms of respiratory distress are often present. The patient may be fussy and experience a decreased appetite. Fever, if present, can be low grade or high. As the respiratory distress progresses, the patient may experience tachypnea, tachycardia or intercostal retractions. Wheezing and/or fine rales may be auscultated. In severe cases, there may be nasal flaring, retractions and grunting. Irritability or lethargy may be seen if hypoxia and hypercarbia develop. Decreased breath sounds or absence of breath sounds signifies severe bronchoconstriction. Altered mental status, particularly when accompanied by cyanosis or signs of impending respiratory failure, is an ominous finding.1,12,13

Treatment

The child with bronchiolitis may respond to albuterol, particularly if there is a history of reactive airway disease.34 Nebulized epinephrine may also be beneficial.12,13 Supplemental oxygen is always indicated.

Conclusion

Requests for medical assistance involving pediatric patients with respiratory complaints can present unique challenges. Prehospital providers should conduct a thorough patient assessment to check for retractions, tachypnea and signs of wheezing or stridor. A working knowledge of the illnesses discussed in this article may better prepare the provider to respond to such emergencies in concert with local protocols. n

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