Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists.
I'm Pradip Kamat and I'm Rahul Damania. We are coming to you from Children's Healthcare of Atlanta - Emory University School of Medicine.
Welcome to our episode of a three-year-old girl presenting with a cough and difficulty breathing
Here's the case presented by Rahul:
A previously healthy 3-year-old girl presented to the OSH for difficulty breathing. She had a two-day h/o of cough (worse at night) and congestion but no fever. She has no h/o of emesis, h/o recent travel, or exposure to some/toxins. Initially, she received steroids, albuterol, and O2 but due to continued worsening of breathing and hypoxia-She was transferred to our PICU for initiation of High Flow Nasal Cannula. She has no allergies and her immunizations are up to date. There is a strong family history of asthma and atopic dermatitis. The mother also noted that the patient has h/o of coughing episodes while playing outside with her siblings.
Initial Vitals: Temp 37.9, HR 100, BP 97/73, respiratory rate 49, SPO2 98% on 15LPM HFNC at 60% FIO2 , weight 17.5kg
On PE: The child is awake, playful. she is tachycardic with no murmur. She has subcostal, intercostal, supra-sternal retractions. There is bilateral symmetric chest expansion. The air entry is decreased with diffuse (B) wheeze. There is atopic dermatitis in the flexor areas of the elbows/knees. The rest of the physical examination was normal. No hepatosplenomegaly.
Viral panel: positive for HMP, SARS COV-2 negative
CXR: Atelectasis superimposed upon viral pneumonitis versus multifocal bronchopneumonia. No evidence of parapneumonic effusion or air leak.
CBC and BMP are normal.
To summarize key elements from this case, this 3-year-old girl has:
Let's transition into some history and physical exam components of this case?
Rahul, what are key history features in this child who presents with increased work of breathing?
Not all respiratory distress arises within the respiratory tract. Important physical examination to note in any infant or toddler with increased work of breathing is to palpate for hepatomegaly as well as carefully listen for bilateral inspiratory crackles. The presence of hepatomegaly or (B) crackles should raise concern for myocarditis or congestive heart failure. In Newborns with respiratory distress-always make a habit to feel femoral pulses. Acidosis, intracranial hemorrhage, foreign body, panic attacks can also present as respiratory distress.
To continue with our case, Pradip, the patient’s labs/diagnostic were consistent with:
OK, to summarize, we have: A 3-year-old with acute respiratory distress, wheezing, hypoxia after 2 days h/o of cough/congestion.
Rahul, let's start with a short multiple-choice question:
A 15-year-old teenager with know h/o asthma presents to the ED in severe respiratory distress, increased work of breathing, hypoxia, and diffuse wheezing. Of the following the presentation that would most likely require intubation in this teenager include-
Rahul, this is an excellent question. The correct answer here is D-Deteriorating mental status. While choice A-inability to talk in complete sentences as well as Choice C-presence of pulsus paradoxus in a patient with asthma correlate with severity of acute asthma, those choices are not indications for intubation. In early asthma -in a patient who is tachypneic and breathing hard the blood gas should have hypocapnia and a mild respiratory alkalosis. I would be more worried about a normal gas or a rising PCO2 in a patient with status asthmaticus.
So just for our listeners, indications for intubation and mechanical ventilation in a child with asthma should be based on clinical judgment and include: cardiac and respiratory arrest; severe hypoxia as well as rapid deterioration in the child’s mental status. Progressive exhaustion despite maximal therapy constitutes a relative indication for intubation on a case-by-case basis. The traditional rule that respiratory acidosis dictates intubation has become outdated.
Rahul, can you comment on the commonly used Clinical Respiratory Score (CRS) ?
The Clinical Respiratory Score (CRS) is a tool that was developed based on the National Asthma Education Program’s guidelines for the diagnosis and management of asthma. The CRS contains six equally weighted variables. It uses both objective and subjective criteria when evaluating a child with asthma to calculate a score. A CRS assessment requires a member of the care team to calculate a respiratory rate and record the room air oxygen saturation using a pulse oximeter. Auscultation of the lung fields, assessing the use of accessory muscles, mental status, and the child’s color also contribute to the CRS. Respiratory rate scores are differentiated by normal values for age. Each of the 6 categories are then categorized as mild (score = 0), moderate (score = 1), or severe distress (score = 2), and the total score is calculated from 0 to 12. The CRS is a reliable asthma severity scoring tool for pediatric patients presenting with an acute asthma exacerbation when utilized across care team members. (McLaughlin P. et al Journal of Asthma 2021).
Rahul also what are risk factors for severe acute asthma?
In a review by Werner H (Chest 2001; 119:1913-1929), risk factors for acute severe asthma were classified as medical factors include: Previous attack with severe, unexpected, rapid deterioration, respiratory failure, seizure or LOC, attacks precipitated by food.
Psychosocial factors: denial or failure to perceive the severity of illness associated depression or psychiatric disorders, non-compliance, dysfunctional family unit, inner-city residents
Ethnic factors:...
