Obstruction of a child’s airway results in dyspnea and may progress to severe respiratory distress. Physical examination may reveal a child with wheezing or stridor, tachypnea, tripodding, intercostal and substernal retractions, and choking. Multiple etiologies can result in obstruction of the upper airway and include foreign bodies, epiglottis, croup, tonsillar hypertrophy, retropharyngeal abscess, anaphylaxis, bacterial tracheitis, and congenital anomalies.
Identification of the underlying cause and timely management of obstruction relief are critical. Chest x-ray and lateral x-rays of the soft tissues of the neck can aid in identification of foreign bodies if they are radiopaque. Children can aspirate small objects such as nuts, coins, beads, and toys with resultant obstruction in multiple sites along the trachea and bronchial tree. Chest x-ray with a dedicated expiratory view will reveal a unilateral hyperexpansion on the affected side if the foreign body is lodged in the bronchus.
Asphyxiation from inhaled foreign bodies is a leading cause of accidental death in young children. The foreign body must be removed to relieve the obstruction. The timing and location of the removal is dependent upon the severity of the child’s symptoms. Children in acute respiratory distress mandate evaluation of the airway and, if visible, removal of the object via direct visualization. If the object cannot be visualized and respiratory failure is imminent, endotracheal intubation is warranted. If the object causing the obstruction prevents endotracheal intubation and cannot be removed, emergent crichothyrotomy may be required. Fiberoptic laryngoscopy, if available, can assist with removal. For the child who is not in respiratory distress, removal with rigid bronchoscopy under general anesthesia is the gold standard as well as the safest route. (See also Chapter 33.)
Anatomic causes for airway obstruction include epiglottitis, croup, tonsillar hypertrophy, retropharyngeal abscess, and laryngeal edema.
Epiglottitis should be managed carefully as any attempts to visualize or manipulate the airway can result in worsening symptoms. Children with this condition are now rarely seen due to vaccination against Haemophilus influenza. Children with epiglottitis should be evaluated in the OR by an anesthesiologist and a surgeon should tracheostomy be required.
Croup results in swelling of the larynx and trachea. It is identified by a barking cough and stridor. The classic “steeple sign” is visible on anteroposterior (A-P) view radiograph of the neck. Treatment includes supplemental oxygen as needed, single-dose steroids, and nebulized epinephrine for moderate to severe cases.
Tonsillar hypertrophy is a common pediatric finding. Children with this condition are often noted to be snore while sleeping and may even have intermittent episodes of brief apnea while asleep. Acute inflammation of the tonsils, such as in cases of tonsillitis, may result in an anatomic obstruction to the upper airway. Treatment should include supplemental oxygen as needed, single-dose steroid, and antibiotics for acute tonsillitis. These children should be referred to an ear, nose, and throat (ENT) surgeon for evaluation of elective tonsillectomy. Severe hypertrophy causing acute respiratory distress should be managed with endotracheal intubation.
Retropharyngeal abscesses can also cause an anatomic upper airway obstruction. Supplemental oxygen should be administered in addition to IV antibiotics. Surgical incision and drainage is necessary. For cases of imminent respiratory compromise, endotracheal intubation is required.
Congenital Upper Airway Abnormalities
Common congenital upper airway abnormalities include laryngomalacia, vocal cord dysfunction/paralysis, and subglottic stenosis. Other causes include obstructive sleep apnea, tumors, vascular anomalies, micrognathia, retrognathia, cleft palate, and a number of rare conditions.
Clinical presentation may range from minor to severe respiratory distress depending upon the underlying etiology. As congenital abnormalities are structural in nature, mild airway irritation or trauma may lead to significant swelling and subsequent respiratory distress. Patients may present with stridor, tachypnea, retractions, hypoxia, and tachycardia.
Supplemental oxygen should be initiated. Use of PPV with BiPAP may be helpful in some patients, depending on the underlying etiology. Should endotracheal intubation be required, the emergency department physician should be familiar with, and have at his or her disposal, difficult airway adjuncts to assist with intubation. The physician should investigate other potential causes for the child’s acute respiratory distress, such as infections, trauma, or exacerbations of other comorbid conditions and treat accordingly.
Discharge or admission depends on the severity of the patient’s condition and the etiology of the acute event. Any concern for potential deterioration of the child’s respiratory status warrants hospital admission.
Anaphylaxis is caused by the rapid release of inflammatory mediators in response to a specific trigger, most commonly food, medicines, or insect stings/bites in children. This is a potentially life-threatening condition that requires immediate action by the emergency physician. The child may present with tachypnea, tachycardia, swelling (localized or diffuse), hives, wheezing, stridor, and itching.
Epinephrine (0.01 mg/kg) as intramuscular injection (repeated every 5-20 minutes up to three doses as indicated) is the first line of treatment. Other treatments include nebulized bronchodilators, antihistamines (diphenhydramine), and corticosteroids. Severe anaphylaxis may result in hypotension, so monitor and treat with fluid resuscitation as needed. Manage the child’s respiratory status with supplemental oxygen as needed and be prepared for more advanced respiratory support (BiPAP or endotracheal intubation) if respiratory status deteriorates.
Patients with very mild symptoms should be observed after treatment for a minimum of 4 hours and discharged home if stable. All other patients require admission.
Children will present with symptoms that can include a cough (barking cough similar to croup), stridor, tachypnea, retractions, tachycardia, sore throat, and fever. Patients with bacterial tracheitis will not respond to the standard treatment for croup and typically appear more ill. The inflammatory process in the larynx, trachea, and bronchi results in the formation of a mucopurulent membrane. The membrane can dislodge that results in airway obstruction. Radiography of the neck may reveal a “steeple sign” similar to croup, or an irregular border of the upper airway.
Provide supplemental oxygen and assess respiratory status. If endotracheal intubation is indicated, use a slightly smaller endotracheal tube (ETT) to accommodate for the swelling of the airway and to minimize potential trauma. Intravenous antibiotics should be initiated and should include a third-generation cephalosporin or clindamycin. Toxic appearing children should be given vancomycin.
All patients with bacterial tracheitis require hospital admission.
Bronchiolitis is a unique pediatric clinical presentation occurring most commonly in children aged 6 months to 2 years. Strong consideration of this diagnosis should be applied to a child younger than 2 years who presents with rhinorrhea, wheezing, and tachypnea especially in the winter and early spring months. Respiratory syncytial virus (RSV), rhinovirus, adenovirus, human metapneumovirus, influenza, and parainfluenza virus have been named as culprits in this disease entity with RSV being the most common. The pathology of the disease is caused from the edema, inflammation, and epithelial necrosis and sloughing into the infant-sized bronchioles. Hypoxia may occur from the variable obstruction that is resultant from these factors. The course of bronchiolitis can be variable and prolonged with the child experiencing more than one episode of illness within the same season. Diagnostic studies are not always required as bronchiolitis is a clinical diagnosis. Recent studies have shown there to be a higher rate of concomitant urinary tract infections and/or acute otitis media in infants younger than 3 months with RSV.
A typical CXR in an infant with uncomplicated bronchiolitis reveals a variable combination of hyperinflation, peribronchial cuffing, and possible atelectasis. Chest x-ray is not indicated as routine workup in the current American Academy of Pediatrics (AAP) guidelines for bronchiolitis. Viral panels may reveal the culprit for the specific episode of bronchiolitis, but have rare effect on the actual clinical management.
Treatment of bronchiolitis is based on supportive care. Nasal suctioning can be an initial and simple treatment that may clinically improve the infant significantly due to their obligate nasal breathing. Hydration status of the child should be considered as this can be an issue in bronchiolitis due to the insensate losses from tachypnea and poor feeding due to respiratory effort.
The AAP practice guidelines recommend supplemental oxygen if the SpO2 is less that 90%. Oxygen may be delivered by nasal cannula or blow-by oxygen if better tolerated. Inhaled bronchodilator therapy has not been shown to have a significant benefit to be standard therapy. Many clinical practitioners do a trial dosage of β-adrenergic agonist. Subsequent dosing should be performed only if the initial dosage provided a clear benefit. Albuterol has the advantage of possible home usage upon discharge as opposed to other inhaled therapies that may be trialled in bronchiolitis that include racemic epinephrine or hypertonic saline. Corticosteroids and antibiotics do not have a role in standard therapy unless other disease entities that require these treatments exist. As with asthma, intubation should be considered last resort in a child with bronchiolitis. Many of the complications that occur with the intubated asthmatic can occur with the intubated bronchiolitic including air trapping and barotrauma.
Clinical status of the bronchiolitic child should be the basis of disposition. Young age and comorbid conditions are the most useful predictors of severity. Factors such as oxygen requirement to keep SpO2 above 90%, or inability to feed and stay hydrated indicate a need for admission. Another consideration should be the ability of the caretaker to return for acute therapy if the child should worsen at home.
Before a patient with bronchiolitis is discharged home, the caretaker should have education, including suctioning instructions, possible bronchodialator therapy, hydration instructions, and explicit return instructions. Infants younger than 3 months should be considered for admission. If there is an infant history of apnea with the illness course, admission should occur. The decision to admit to the hospital floor versus PICU should be based on each institution’s ability to care for the patient. A patient with significant respiratory distress or ventilatory support requirements (noninvasive or intubation) should be monitored in the PICU.
Pertussis is a bacterial respiratory infection that is extremely contagious via droplet contact to respiratory epithelium. Incidence has been increasing with several localized endemic outbreaks occurring in the United States. The classic clinical presentation occurs in sequence: catarrhal, paroxysmal, and convalescent phases. The symptoms associated with each phase are listed in Table 12–1. Pertussis should be high on the differential in a patient with persistent cough without other signs of overt illness such as lung sounds, fever, sore throat, or flu-like symptoms. A common presentation may be an afebrile adolescent with persistent cough longer than 1 week. Another presentation may be a nontoxic toddler who has a rapid prolonged coughing spell with posttussive emesis. Children may exhibit evidence of prolonged episodes of increased intrathoracic pressure from the coughing with upper body petechiae or subconjunctival hemorrhage. Young infants may be a more challenging diagnosis. History of cyanosis, apnea, and a prolonged worsening convalescent phase may be present. A significant leukocytosis may be present usually in the catarrhal stage.
Table 12–1.Symptoms for the clinical phases of pertussis. |Favorite Table|Download (.pdf) Table 12–1. Symptoms for the clinical phases of pertussis.
URI type symptoms
Intermittent dry irritating cough
Persistent paroxysms of coughing
Possible characteristic “whoop” at end of cough
Child is infectious during this phase until resolution of treatment
Symptoms gradually decrease
infants cough may worsen during this period
Treatment is generally aimed at supportive care with special caution to avoid stimuli that may trigger a cough, including allergens, cold temperatures, and vigorous physical activity. Antihistamines and corticosteroids are not of significant clinical value. Antibiotic treatment can be used presumptively based on clinical findings. The benefits of antibiotic treatment include reduction in disease severity, symptoms, and potential transmission. Macrolides are the generally recommended class of antibiotics with azithromycin being the most commonly prescribed due to safety profile and simplicity of dosing.
If treatment is not provided at point of care, close follow-up with laboratory results should occur. Household contacts should be treated if a positive test occurs in a symptomatic patient. Immunity is not obtained from natural disease and immunization does not confer lifelong immunity. The decision to hospitalize the patient is based on clinical picture including severity of illness, comorbid conditions, age, hydration status, history of apnea or cyanosis. If hospitalization is required, the child should be placed on isolation within the institution until diagnosis is confirmed or denied.
Pulmonary embolism (PE) in children often occurs with major risk factors. Risk factors include hematologic disorders (sickle cell disease, leukemias, inherited thrombophillias), neoplasms, trauma, congenital heart disease, or presence of central venous lines. Most cases occur in adolescents and risk factors, similar to adults, such as oral contraceptive use, smoking, pregnancy, and abortion, should be considered when suspecting PE.
Historical findings of unexplained dyspnea, pleuritic chest pain, cough (with or without hemoptysis), tachypnea, fever, extremity pain, or swelling can be elicited in PE. Because of the strong correlation with central venous lines, upper extremity deep vein thrombosis (DVT) should be a consideration in the pediatric population with history or presence of central line.
Physical examination of the patient with PE may reveal tachycardia, tachypnea, increased work of breathing, abnormal lung sounds, or cyanosis. Physical findings of DVT, which has a strong incidence of subsequent pulmonary embolism, include extremity swelling, tenderness, erythema, warmth, and venous distension. There are no clinical prediction rules currently specific to the pediatric population. Laboratory findings such as d-dimer are often not as useful in children because many children with PE already have a high pretest probability. Imaging diagnostic modalities for PE include chest x-ray (CXR), ventilation perfusion scan, pulmonary angiography, and CT pulmonary angiography. The choice of imaging should be made in concert with radiology colleagues as each study has varying specificity and sensitivity in varying age and body habitus for detection of PE.
With DVT and high suspicion or when diagnostics detect a PE, treatment should not be delayed. If possible, treatment should be in cooperation with a pediatric hematologist. Consultation should not delay treatment of the child. Air, breathing, and circulation (ABC) should be the initial priority.
After the patient’s airway is deemed stable, medical therapy should ensue. General recommendations are divided by age. The unfractionated heparin IV loading dose from neonate to adolescent is 70-75 units/kg.
Infants < 1 year, initial IV infusion rate starts at 28 units/kg/h.
Children 1-16 years, IV infusion rate of 20 units/kg/h with a maximum of 1650 units per hour.
Adolescents > 16 years, IV infusion rate of 15 units/kg/h with a maximum of 1650 units per hour. Low molecular weight heparin via subcutaneous (SC) route reaches therapeutic range more quickly.
Child ≥ 2 months initial dosing is 1 mg/kg SC twice daily.
Infants < 2 months dosing should be increased to 1.6 mg/kg SC twice daily.
Patients with equivocal imaging or studies, but evidence by history or physical examination should be considered for treatment and hospital admission in a monitored setting. Patients with a diagnosis of new DVT or PE should be admitted. The pediatric intensive care setting should be strongly considered for children with confirmed PE.
Adolescents are most likely to present with hyperventilation in the emergency department. Although a diagnosis of exclusion, it can be made based on past episodes and some subtle but useful physical examination findings. The adolescent subset of patients often presents with history of acute dyspnea and anxiety that may have been preceded by stressful personal events. If the patient is hyperventilatory to the point of tetany, it is strongly in favor of the diagnosis. Patients also report light headedness (cerebral vasoconstriction), and perioral and/or limb paresthesias. The dyspnea may improve with exercise. The patient often times can be calmed enough to speak clearly and halt the very loud breathing pattern. Normal pulse oximetry on room air and lower lung sounds that are clear can be helpful physical examination findings. Screening laboratories reveal only a low arterial PCO2, normal or high PO2, and an elevated pH. Organic etiology should be considered, but often patients can be diagnosed in the emergency department. After calming and reassurance, the patient will often completely resolve in the emergency department.
No specific treatment is required. Reassurance may help in the medical environment. In older adolescent patients with symptomatic hypocapnea (perioral tingling, carpopedal spasm, tetany) or marked respiratory alkalosis (pH > 7.55), breathing into a patient-held air-tight bag may help alleviate the hypocapnic symptoms.
The patient should not be sent home with continued symptoms. If symptoms resolve, outpatient follow-up with a pediatrican or pediatric pulmonologist may be helpful for complete workup and reassurance.
et al.: Symptomatic treatment of the cough in whooping cough. Cochrane Database Syst Rev
GL: Common pediatric respiratory emergencies. Emerg Med Clin North Am
SJ: The upper airway: Congenital malformations. Paediatr Respir Rev
PG: The anesthetic considerations of tracheobronchial foreign bodies in children: A literature review of 12,979 cases. Anesth Analg
R: Pulmonary complications of congenital heart disease. Paediatr Respir Rev
et al.: EAACI task force on anaphylaxis in children. The management of anaphylaxis in childhood: position paper of the European academy of allergology and clinical immunology. Allergy
S: Venous thromboembolism in children. Circulation
GQ: Pediatric respiratory infections. Emerg Med Clin North Am
RH: Neonatal pulmonary hypertension. Pediatr Crit Care Med
RS: Pediatric airway foreign body retrieval: surgical and anesthetic perspectives. Paediatr Anaesth
. 2009;19(Suppl 1):109–17