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A wheezing toddler
Clinical Report
www.jpedhc.org
Case Studies
Section Editor Carol Rudy, MPH, ARNP, CPNP Rockwood Clinic Pediatrics Spokane, Washington Sally Walsh, MSN, RN, CPNP Pediatric Associates of Norwood Boston, Massachusetts Jo Ann Serota, MSN, RN, CPNP Ambler Pediatrics Ambler, Pennsylvania
At the time of preparation of this manuscript, Patricia R. McGahey-Oakland was a Pediatric Critical Care Nurse Practitioner in the Intensive Care Service at the Texas Children’s Hospital and an Instructor at the Baylor College of Medicine, Houston, Texas. She is currently an Acute Care Pediatric Nurse Practitioner in the Blood and Marrow Transplant Unit at the Cincinnati Children’s Medical Center, Cincinnati, Ohio. Reprint requests: Patricia R. McGaheyOakland, RN, MSN, CPNP-AC, 3482 Ault View Ave, Cincinnati, OH 45208. J Pediatr Health Care. (2005). 19, 176177, 192-194. 0891-5245/$30.00 Copyright © 2005 by the National Association of Pediatric Nurse Practitioners.
A Wheezing Toddler Patricia R. McGahey-Oakland, RN, MSN, CPNP-AC
Matthew is a 22-month-old previously healthy male who woke up from his afternoon nap with sudden onset of rapid, labored breathing and restlessness. He is taken to a nearby emergency center for evaluation. On examination in the emergency center, he is grunting and is in moderate respiratory distress. A chest radiograph shows bilateral hyperinflation. The patient’s persistent wheezing and need for continuous bronchodilator therapy prompts transfer via specialty transport service to a nearby tertiary pediatric hospital, where he can be closely monitored in a pediatric intensive care unit (PICU). The patient’s review of systems is negative except for a coughing episode approximately two weeks ago, which resolved spontaneously and quickly by parental report. There is no report of fever, nausea, vomiting, or history of foreign body ingestion. He has no known drug allergies. He has no food allergies. He has never been hospitalized or undergone any surgery. His past medical history is negative for episodes of bronchiolitis,
pneumonia, asthma, gastroesophageal reflux, and swallowing dysfunction. His immunizations are up to date by parental report. He is developmentally appropriate. The family history is negative for asthma or other respiratory problems. He lives at home with mom and dad. The parents deny smoking and the use of drugs or alcohol in the home. They also deny the presence of environmental factors at home such as new carpet, remodeling, or the presence of potent fumes. Physical examination on admission to the tertiary hospital is as follows. Vital signs: temperature is 98° Fahrenheit axillary, heart rate is 160, respiratory rate is 55, blood pressure is 126/59. Pulse oximeter is 99% on 5 liters oxygen via facemask. He is in moderate-to-severe respiratory distress, as evidenced by tachypnea and use of accessory respiratory muscles. Other remarkable features of the physical examination indicative of his distress include fair-to-poor air exchange with audible inspiratory stridor, diffuse wheezes and rales bilater-
CASE STUDIES QUESTIONS: 1. Based on the clinical presentation and physical examination findings, what are your differential diagnoses? 2. What diagnostic studies might be helpful in this scenario? 3. What salient features of the patient’s history and physical examination might direct the clinician to a particular diagnosis? 4. What is your diagnosis? 5. What is the definitive treatment for this diagnosis? Answers are on pages 192-194.
doi:10.1016/j.pedhc.2005.03.001
176
Volume 19 • Number 3
Journal of Pediatric Health Care
ally, tachycardia without an audible murmur, and restlessness but comforted by mother. Continuous bronchodilator therapy is started at the outside hospital and is continued. Intravenous terbutaline sulfate and dexamethasone is started for persistent wheezing. In-
Journal of Pediatric Health Care
haled racemic epinephrine is initiated as needed for stridor. He is given nothing by mouth in light of his respiratory status and intravenous fluids are started. The chest radiograph from the emergency center where the child was taken before he was brought to the tertiary care PICU is
of good quality, so it is not repeated on admission to the tertiary center. On the morning after admission, Matthew has a sudden increase in his work of breathing with unequal breath sounds, which are diminished on the right side.
May/June 2005
177
Clinical Report
www.jpedhc.org
Questions & Answers
Questions and Answers Patricia R. McGahey-Oakland, RN, MSN, CPNP-AC (Data on pages 176-177.)
Reprint requests: Patricia R. McGaheyOakland, RN, MSN, CPNP-AC, 3482 Ault View Ave., Cincinnati, OH 45208. J Pediatr Health Care. (2005). 19, 192194. 0891-5245/$30.00 Copyright © 2005 by the National Association of Pediatric Nurse Practitioners. doi:10.1016/j.pedhc.2005.03.001
192
Volume 19 • Number 3
1. Based on the clinical presentation and physical examination findings, what are your differential diagnoses? Many diagnoses must be considered in a previously healthy child who presents with new wheezing and respiratory distress, including: infections (bronchiolitis, laryngotracheal bronchitis, pneumonia, bacterial tracheitis, peritonsillar abscess, retropharyngeal abscess), asthma, epiglottitis, cystic fibrosis, foreign body aspiration, and esophageal foreign body aspiration (Fakhoury, 2004). Anatomical abnormalities must also be considered in episodes of new wheezing. It is helpful to subdivide abnormalities as extrinsic to airway (lymphadenopathy, tumor, diaphragmatic hernia) or intrinsic to airway (bronchomalacia, foreign body, endobronchial tumors, vocal cord dysfunction, bronchopulmonary dysplasia, vascular anomalies) (Schwartz, 2000). Aspiration secondary to either gastroesophageal reflux or swallowing dysfunction can also cause wheezing and should be considered. 2. What diagnostic studies might be helpful in this scenario? For any child who presents with respiratory distress the most important and most helpful diagnostic study is a chest radiograph to rule out life-threatening emergen-
cies such as a pneumothorax. This child’s chest radiograph (Figure 1) revealed normal bony structures and soft tissues, normal heart size (approximately 2/3 of entire chest diameter), hyperexpanded lungs with 10-rib expansion, and flattened diaphragms bilaterally. There is no focal infiltrate or atelectasis. There is equal lung expansion. Asymmetry in lung expansion may be suggestive of a foreign body aspiration, however; normal chest radiographs are also often seen in children with foreign body aspiration (Tokar, Ozkan, & Illhan, 2004; Schwartz, 2000). Few laboratory studies are helpful in the assessment of a wheezing child. However, a complete blood count with cell count differential might be helpful in identifying a leukocytosis or increased bands (immature white blood cells) in a child in whom you are suspicious of infection. 3. What salient features of the patient’s history and physical examination might direct the clinician to a particular diagnosis? The information provided by the parents that Matthew had a spontaneous, self-resolving coughing spell two weeks prior to admission is pertinent as well as the abrupt, sudden onset of his respiratory distress. Both pieces of information should Journal of Pediatric Health Care
FIGURE 1. Chest radiograph after acute change in respiratory status
FIGURE 2. Image under direct laryngoscopy and therapeutic bronchoscopy
prompt the clinician to consider foreign body aspiration as a cause of his respiratory distress. Common signs and symptoms of foreign body aspiration include choking, coughing, wheezing, and decreased breath sounds (Tokar, Ozkan, & Illhan, 2004). The clinician did ask the parents during the initial interview if they recalled Matthew ingesting anything. Despite the denial of aspiration, it should not be excluded as a possible diagnosis as foreign bodies often migrate up and down in the airways causing more distress in one position than another. Persistent wheezing that presents with sudden onset is consistent with foreign body aspiration (Fakhoury, 2004). The presence of inspiratory stridor is also suggestive of airway obstruction, particularly extrathoracic obstruction (Fakhoury, 2004). A clinical pearl to remember is extrathoracic abnormalities (ie, foreign body, external airway compression, or edema) are usually heard on inspiration (stridor) whereas intrathoracic abnormalities (ie, bronchoconstriction with asthma) are heard on expiration (prolonged expiratory phase with wheezing). 4. What is your diagnosis? On the morning after admission to the tertiary hospital, when Matthew had a sudden increase in respiratory distress with unilateral breath sounds on the right side, the index of suspicion for a foreign body is heightened. The saying that “all that wheezes is not asthma” is true in this scenario (Schwartz, 2000). Although the patient presented with bilateral wheezing and respiratory distress, which were treated appropriately with bronchodilators and steroids, his condition rapidly deteriorated with unequal breath sounds and increased work of breathing. A pediatric otolaryngology consult was made, and the patient underwent emergent bronchoscopy. The bronchoscopy revealed the actual
Journal of Pediatric Health Care
May/June 2005
193
cause of his distress was a kernel of corn lodged in his right mainstem bronchus. This is a common location for foreign body aspiration since the right mainstem anatomically branches off just before the left mainstem, allowing foreign bodies to follow the path of least resistance and become lodged in the right mainstem. However, in children, foreign bodies can be lodged in any bronchus without predilection to the right side (Fakhoury, 2004). 5. What is the definitive treatment for this diagnosis? The definitive treatment for foreign body aspiration is removal under direct largyngoscopy and bronchoscopy by a skilled pedi-
194
Volume 19 • Number 3
atric otoloaryngologist. Bronchoscopy (Figure 2) revealed a kernel of corn in the right mainstem bronchus. Interestingly, while the otolaryngologist was obtaining consent for the emergent procedure, he questioned about any food or objects within the child’s reach at home. The parents did indicate they keep a bucket with raw corn in the back yard to feed animals. As a developmentally appropriate curious toddler, Matthew found the corn! The accurate diagnosis of foreign body aspiration requires a high index of suspicion by the clinician. Bronchosocopy should always be considered when the history or clinical findings are suggestive of possible foreign body aspiration
(Tokar, Ozkan, & Illhan, 2004). Pediatric nurse practitioners in all clinical settings must keep foreign body aspiration high on the list of differential diagnoses for the child who presents with wheezing. REFERENCES Fakhoury, K. (2004). Approach to wheezing in children. UpToDate. Available online: http://www.utdol.com. Accessed August 22, 2004. Schwartz, M.W. Ed. (2000). Wheezing. The five minute pediatric consult. Second edition. Philadelphia: Lippincott Williams & Wilkins. Tokar, B., Ozkan, R. and Illhan, H. (2004). Tracheobronchial foreign bodies in children: importance of accurate history and plain chest radiography in delayed presentation. Clinical Radiology, 59, 609-615.
Journal of Pediatric Health Care
www.jpedhc.org
Case Studies
Section Editor Carol Rudy, MPH, ARNP, CPNP Rockwood Clinic Pediatrics Spokane, Washington Sally Walsh, MSN, RN, CPNP Pediatric Associates of Norwood Boston, Massachusetts Jo Ann Serota, MSN, RN, CPNP Ambler Pediatrics Ambler, Pennsylvania
At the time of preparation of this manuscript, Patricia R. McGahey-Oakland was a Pediatric Critical Care Nurse Practitioner in the Intensive Care Service at the Texas Children’s Hospital and an Instructor at the Baylor College of Medicine, Houston, Texas. She is currently an Acute Care Pediatric Nurse Practitioner in the Blood and Marrow Transplant Unit at the Cincinnati Children’s Medical Center, Cincinnati, Ohio. Reprint requests: Patricia R. McGaheyOakland, RN, MSN, CPNP-AC, 3482 Ault View Ave, Cincinnati, OH 45208. J Pediatr Health Care. (2005). 19, 176177, 192-194. 0891-5245/$30.00 Copyright © 2005 by the National Association of Pediatric Nurse Practitioners.
A Wheezing Toddler Patricia R. McGahey-Oakland, RN, MSN, CPNP-AC
Matthew is a 22-month-old previously healthy male who woke up from his afternoon nap with sudden onset of rapid, labored breathing and restlessness. He is taken to a nearby emergency center for evaluation. On examination in the emergency center, he is grunting and is in moderate respiratory distress. A chest radiograph shows bilateral hyperinflation. The patient’s persistent wheezing and need for continuous bronchodilator therapy prompts transfer via specialty transport service to a nearby tertiary pediatric hospital, where he can be closely monitored in a pediatric intensive care unit (PICU). The patient’s review of systems is negative except for a coughing episode approximately two weeks ago, which resolved spontaneously and quickly by parental report. There is no report of fever, nausea, vomiting, or history of foreign body ingestion. He has no known drug allergies. He has no food allergies. He has never been hospitalized or undergone any surgery. His past medical history is negative for episodes of bronchiolitis,
pneumonia, asthma, gastroesophageal reflux, and swallowing dysfunction. His immunizations are up to date by parental report. He is developmentally appropriate. The family history is negative for asthma or other respiratory problems. He lives at home with mom and dad. The parents deny smoking and the use of drugs or alcohol in the home. They also deny the presence of environmental factors at home such as new carpet, remodeling, or the presence of potent fumes. Physical examination on admission to the tertiary hospital is as follows. Vital signs: temperature is 98° Fahrenheit axillary, heart rate is 160, respiratory rate is 55, blood pressure is 126/59. Pulse oximeter is 99% on 5 liters oxygen via facemask. He is in moderate-to-severe respiratory distress, as evidenced by tachypnea and use of accessory respiratory muscles. Other remarkable features of the physical examination indicative of his distress include fair-to-poor air exchange with audible inspiratory stridor, diffuse wheezes and rales bilater-
CASE STUDIES QUESTIONS: 1. Based on the clinical presentation and physical examination findings, what are your differential diagnoses? 2. What diagnostic studies might be helpful in this scenario? 3. What salient features of the patient’s history and physical examination might direct the clinician to a particular diagnosis? 4. What is your diagnosis? 5. What is the definitive treatment for this diagnosis? Answers are on pages 192-194.
doi:10.1016/j.pedhc.2005.03.001
176
Volume 19 • Number 3
Journal of Pediatric Health Care
ally, tachycardia without an audible murmur, and restlessness but comforted by mother. Continuous bronchodilator therapy is started at the outside hospital and is continued. Intravenous terbutaline sulfate and dexamethasone is started for persistent wheezing. In-
Journal of Pediatric Health Care
haled racemic epinephrine is initiated as needed for stridor. He is given nothing by mouth in light of his respiratory status and intravenous fluids are started. The chest radiograph from the emergency center where the child was taken before he was brought to the tertiary care PICU is
of good quality, so it is not repeated on admission to the tertiary center. On the morning after admission, Matthew has a sudden increase in his work of breathing with unequal breath sounds, which are diminished on the right side.
May/June 2005
177
Clinical Report
www.jpedhc.org
Questions & Answers
Questions and Answers Patricia R. McGahey-Oakland, RN, MSN, CPNP-AC (Data on pages 176-177.)
Reprint requests: Patricia R. McGaheyOakland, RN, MSN, CPNP-AC, 3482 Ault View Ave., Cincinnati, OH 45208. J Pediatr Health Care. (2005). 19, 192194. 0891-5245/$30.00 Copyright © 2005 by the National Association of Pediatric Nurse Practitioners. doi:10.1016/j.pedhc.2005.03.001
192
Volume 19 • Number 3
1. Based on the clinical presentation and physical examination findings, what are your differential diagnoses? Many diagnoses must be considered in a previously healthy child who presents with new wheezing and respiratory distress, including: infections (bronchiolitis, laryngotracheal bronchitis, pneumonia, bacterial tracheitis, peritonsillar abscess, retropharyngeal abscess), asthma, epiglottitis, cystic fibrosis, foreign body aspiration, and esophageal foreign body aspiration (Fakhoury, 2004). Anatomical abnormalities must also be considered in episodes of new wheezing. It is helpful to subdivide abnormalities as extrinsic to airway (lymphadenopathy, tumor, diaphragmatic hernia) or intrinsic to airway (bronchomalacia, foreign body, endobronchial tumors, vocal cord dysfunction, bronchopulmonary dysplasia, vascular anomalies) (Schwartz, 2000). Aspiration secondary to either gastroesophageal reflux or swallowing dysfunction can also cause wheezing and should be considered. 2. What diagnostic studies might be helpful in this scenario? For any child who presents with respiratory distress the most important and most helpful diagnostic study is a chest radiograph to rule out life-threatening emergen-
cies such as a pneumothorax. This child’s chest radiograph (Figure 1) revealed normal bony structures and soft tissues, normal heart size (approximately 2/3 of entire chest diameter), hyperexpanded lungs with 10-rib expansion, and flattened diaphragms bilaterally. There is no focal infiltrate or atelectasis. There is equal lung expansion. Asymmetry in lung expansion may be suggestive of a foreign body aspiration, however; normal chest radiographs are also often seen in children with foreign body aspiration (Tokar, Ozkan, & Illhan, 2004; Schwartz, 2000). Few laboratory studies are helpful in the assessment of a wheezing child. However, a complete blood count with cell count differential might be helpful in identifying a leukocytosis or increased bands (immature white blood cells) in a child in whom you are suspicious of infection. 3. What salient features of the patient’s history and physical examination might direct the clinician to a particular diagnosis? The information provided by the parents that Matthew had a spontaneous, self-resolving coughing spell two weeks prior to admission is pertinent as well as the abrupt, sudden onset of his respiratory distress. Both pieces of information should Journal of Pediatric Health Care
FIGURE 1. Chest radiograph after acute change in respiratory status
FIGURE 2. Image under direct laryngoscopy and therapeutic bronchoscopy
prompt the clinician to consider foreign body aspiration as a cause of his respiratory distress. Common signs and symptoms of foreign body aspiration include choking, coughing, wheezing, and decreased breath sounds (Tokar, Ozkan, & Illhan, 2004). The clinician did ask the parents during the initial interview if they recalled Matthew ingesting anything. Despite the denial of aspiration, it should not be excluded as a possible diagnosis as foreign bodies often migrate up and down in the airways causing more distress in one position than another. Persistent wheezing that presents with sudden onset is consistent with foreign body aspiration (Fakhoury, 2004). The presence of inspiratory stridor is also suggestive of airway obstruction, particularly extrathoracic obstruction (Fakhoury, 2004). A clinical pearl to remember is extrathoracic abnormalities (ie, foreign body, external airway compression, or edema) are usually heard on inspiration (stridor) whereas intrathoracic abnormalities (ie, bronchoconstriction with asthma) are heard on expiration (prolonged expiratory phase with wheezing). 4. What is your diagnosis? On the morning after admission to the tertiary hospital, when Matthew had a sudden increase in respiratory distress with unilateral breath sounds on the right side, the index of suspicion for a foreign body is heightened. The saying that “all that wheezes is not asthma” is true in this scenario (Schwartz, 2000). Although the patient presented with bilateral wheezing and respiratory distress, which were treated appropriately with bronchodilators and steroids, his condition rapidly deteriorated with unequal breath sounds and increased work of breathing. A pediatric otolaryngology consult was made, and the patient underwent emergent bronchoscopy. The bronchoscopy revealed the actual
Journal of Pediatric Health Care
May/June 2005
193
cause of his distress was a kernel of corn lodged in his right mainstem bronchus. This is a common location for foreign body aspiration since the right mainstem anatomically branches off just before the left mainstem, allowing foreign bodies to follow the path of least resistance and become lodged in the right mainstem. However, in children, foreign bodies can be lodged in any bronchus without predilection to the right side (Fakhoury, 2004). 5. What is the definitive treatment for this diagnosis? The definitive treatment for foreign body aspiration is removal under direct largyngoscopy and bronchoscopy by a skilled pedi-
194
Volume 19 • Number 3
atric otoloaryngologist. Bronchoscopy (Figure 2) revealed a kernel of corn in the right mainstem bronchus. Interestingly, while the otolaryngologist was obtaining consent for the emergent procedure, he questioned about any food or objects within the child’s reach at home. The parents did indicate they keep a bucket with raw corn in the back yard to feed animals. As a developmentally appropriate curious toddler, Matthew found the corn! The accurate diagnosis of foreign body aspiration requires a high index of suspicion by the clinician. Bronchosocopy should always be considered when the history or clinical findings are suggestive of possible foreign body aspiration
(Tokar, Ozkan, & Illhan, 2004). Pediatric nurse practitioners in all clinical settings must keep foreign body aspiration high on the list of differential diagnoses for the child who presents with wheezing. REFERENCES Fakhoury, K. (2004). Approach to wheezing in children. UpToDate. Available online: http://www.utdol.com. Accessed August 22, 2004. Schwartz, M.W. Ed. (2000). Wheezing. The five minute pediatric consult. Second edition. Philadelphia: Lippincott Williams & Wilkins. Tokar, B., Ozkan, R. and Illhan, H. (2004). Tracheobronchial foreign bodies in children: importance of accurate history and plain chest radiography in delayed presentation. Clinical Radiology, 59, 609-615.
Journal of Pediatric Health Care