Acute Causes of Wheezing and Stridor in Children Case File

Acute Causes of Wheezing and Stridor in Children Case File

Eugene C. Toy MD, Donald Briscoe, MD, FA  AFP, Bruce Britton, MD, Joel J. Heidelbaugh, MD, FA  AFP, FACG

Case 39

You were busy seeing patients in your outpatient clinic when you heard a commotion coming from the waiting room. You went to check and found a very frantic mother and her 2-year-old son who is clutching his throat, coughing, drooling, and visibly struggling to breathe. The mother endorses that just a few minutes ago, the child was running around while eating grapes when she suddenly heard him gagging and wheezing. Her son has an appointment for well-child examination and he is apparently doing well. He has no significant history of respiratory illness. The toddler is still conscious but unable to talk, and his cough is becoming weaker. Breath sounds are decreased bilaterally, with wheezing and stridor heard on auscultation. You tried to ventilate the patient with the chin-lift maneuver but the chest fails to rise. You opened the mouth but you are unable to see any foreign object.

⯈ What is the most likely diagnosis?

⯈ What is the next step in the management of this patient?

ANSWER TO CASE 39

Acute Causes of Wheezing and Stridor in Children

Summary: A 2-year-old boy had acute onset of coughing, choking, drooling, and wheezing while eating grapes. He is unable to speak and his cough is weak. He was in a good state of health prior to the incident and has no history of respiratory illness. Physical examination reveals decreased breath sounds, wheezing, and stridor. There is no chest rise on ventilation attempt. No foreign object could be seen on his mouth.

• Most likely diagnosis: Foreign-body airway obstruction (FBAO)
• Next step in the management for this patient: Heimlich maneuver (subdiaphragmatic abdominal thrusts)

ANALYSIS

Objectives

1. Identify the illnesses, other than asthma, that cause acute wheezing in children.
2. Understand the steps in the diagnosis and management of a wheezing child.

Considerations

Acute onset of wheezing in an otherwise healthy child similar to the above case should raise the suspicion for FBAO. Witnessed swallowing followed by choking is not necessary for diagnosis, but as much information should be gathered surrounding the onset of symptoms. FBAO is common among children aged 6 months to 3 years, accounting for approximately 70% of cases. Small toys and objects, balloons, and food ( eg, nuts, grapes, and candies) are high-risk objects for aspiration. Older children may be able to identify the object they swallowed and assume the posture of clutching their neck with their hand (universal choking sign). Symptoms such as weak cough, inability to speak or cry, high-pitched sounds, or no sounds during inhalation, cyanosis, choking, vomiting, drooling, wheezing, blood-streaked saliva, and respiratory distress are clues to the diagnosis of FBAO. Physical findings of unilateral wheezing, unequal or decreased breath sounds, and stridor are common. In children, the foreign body could lodge on either side of the airway. Eight out of 10 times, the foreign body lodges in one of the bronchi. If the foreign body lodges in the esophagus, acute wheezing is still possible when the obstruction compresses on the airways.

One should not attempt to remove the foreign object in a child who is actively coughing and able to vocalize. Blind finger sweep is not recommended because of the danger of further obstruction or injury. Although the patient mentioned above is still conscious, he seems to have ineffective coughing and is beginning to get tired. Ventilation should be attempted while opening the airway with the head-tilt maneuver, which could also relieve the obstruction. In the above case, an attempt to remove the foreign object was initiated when ventilation was unsuccessful.

If a child older than 1 year is no longer able to cough, vocalize or breathe a series of abdominal thrusts (Heimlich maneuver) should be the next step to try to expel the foreign body. In children less than 1 year, instead of abdominal thrust, a series of five back blows alternating with chest thrusts is performed. If the child continues to deteriorate even after 1 minute of resuscitative efforts and the above maneuvers fail to expel the foreign object, the emergency medical services (EMS) system should be activated while continuing cardiopulmonary resuscitation (CPR).

In the hospital setting, a bronchoscopic procedure is the treatment of choice. Chest x-ray is often normal, but in some cases shows a radiopaque foreign object or identifies localized hyperinflation and/ or atelectasis. Most deaths from FBAO occur in children younger than 5 years; 65% are infants.

Approach To:

Wheezing and Stridor

DEFINITIONS

HEIMLICH MANEUVER: Performed in children greater than 1 year and in adults by standing or sitting behind the person who is choking and placing the thumb side of one fist between the navel and the xiphoid process. The other hand grasps the fisted hand and a series of upward abdominal thrusts are delivered to create an "artificial cough" in a choking victim in an effort to dislodge the object blocking the airway.

STRIDOR: Wheezing coming from obstruction of the large airway that has a constant pitch and intensity throughout the entire inspiratory effort.

WHEEZING: A musical sound heard on pulmonary auscultation produced by the oscillating walls of airways that had been narrowed by mucus, inflammation, and so on.

CLINICAL APPROACH

Among the many causes of wheezing in children, asthma and viral infections are most common. Worldwide studies show that approximately 10% to 15% of infants wheeze in the first 12 months of life. The diagnosis of wheezing hinges on accurate history, physical examination, laboratory tests, and even response to treatments. It is also important to gather information regarding the age of onset, exposure to cigarette smoke, presence of allergic signs and symptoms, frequency of wheezing, association with vomiting or feeding, and other accompanying symptoms.

The etiology of acute wheezing in children could be infectious ( eg, bronchiolitis) or mechanical obstruction (eg, FBAO). Recurrent wheezing, on the other hand, encompasses anomalies of the tracheobronchial tree (eg, bronchomalacia), cardiovascular disease (eg, vascular rings and slings), gastroesophageal reflux, and immunologic disorders (eg, bronchopulmonary dysplasia, cystic fibrosis). This case concentrates on acute onset of wheezing other than asthma in children (Case 56 provides a more detailed discussion of asthma).

Bronchiolitis

Bronchiolitis affects more than one-third of children less than 2 years and is the most common acute cause of wheezing, especially in infants who are 1 to 3 months old. Infants younger than 6 months are most severely affected, owing to smaller, more easily obstructed airways and a decreased ability to clear secretions. It is a viral infection causing nonspecific inflammation of the small airways and usually during the winter months. Respiratory syncytial virus (RSV) accounts for 50% to 80% of cases; the rest are caused by parainfluenza, adenovirus, influenza, Mycoplasma pneumoniae, Chlamydia pneumoniae, and metapneumovirus. These viruses and atypical bacteria elicit inflammatory and immune responses that produce mucus, edema, and cellular debris that block the small airways. Influenza vaccinations in infants and toddlers have reduced the incidence of bronchiolitis caused by the flu virus.

Initially, the child develops nasal congestion and rhinorrhea for 1 to 2 days, followed by low-grade fever, wheezing, cough, irritability, and varying degrees of dyspnea. As a result, the child may have poor oral intake and possibly dehydration.

Symptoms reach a peak in 2 to 5 days and gradually resolve in 1 to 2 weeks. Physical examination may reveal wheezing, fine crackles, prolonged expiratory phase, tachypnea, and increased work of breathing as evidenced by nasal flaring, intercostal retraction, and even apnea. Other physical findings may include otitis media, irritability, and hypothermia or hyperthermia.

The diagnosis of bronchiolitis is based on clinical presentation, the patient's age, seasonal occurrence, and findings from the physical examination. Tests are typically used to exclude other diagnoses, such as bacterial pneumonia, sepsis, or congestive heart failure, or to confirm a viral etiology and determine required infection control for patients admitted to the hospital.

Current literature does not support the routine use of laboratory tests as they do not alter clinical outcomes unless the child is less than 90 days with the need to rule out secondary bacterial infection. If the diagnosis is doubtful or the clinical presentation is concerning for other diagnoses, one may request a chest x-ray. Radiologic findings in individuals with bronchiolitis are variable and may include bronchial wall thickening, tiny nodules, linear opacities, and patchy atelectasis. Infiltrates and lobar consolidation are more consistent with pneumonia. RSV bronchiolitis is a self-limited disease and can be safely managed in an outpatient setting. However, disease manifestation can be variable, and risk factors for severe disease include preexisting cardiac or pulmonary disease, premature birth, very young age ( <2-3 months), nosocomial RSV infection, and, in some studies, low socioeconomic status. Patients who are in severe respiratory distress, younger than 3 months or premature, those with comorbid conditions, lethargy, hypoxemia, or hypercarbia, and those with atelectasis or consolidation in chest radiograph need to be hospitalized. The single best indicator of severity is low pulse oximetry. Indicators of mild disease include good PO intake, age greater than 2 months, oxygen saturation greater than or equal to 94%, and normal age-based respiratory rate (<45 breaths/min for 0-2 months old, <43 breaths/min for 2-6 months old, and <40 breaths/min for 6-24 months old).

The Agency for Healthcare Research and Quality (AHRQ), in collaboration with the American Academy of Family Physicians (AAFP) and the American Academy of Pediatrics (AAP), recommends supplemental oxygen if the SpO2 is less than 90% and supportive care as the modes of treatment with clear evidence of effectiveness in RSV bronchiolitis.

Supportive care should consist of supplemental humidified oxygen, fluids, and the suctioning of nasal and pharyngeal secretions. The most important therapy is humidified oxygen. Medications have a limited role in the management of bronchiolitis. Several drugs are commonly used, but little or inconclusive evidence supports the routine use of any drug in the management of bronchiolitis. Nebulized bronchodilators, cool mist, steroids, antibiotics, and ribavirin have insufficient evidence or have not been shown to help in previously healthy children. Administration of RSV immunoglobulin (RespiGam) and palivizumab (Synagis) just before the beginning of RSV season is proven effective preventive therapy for children younger than 2 years with increased risks from chronic lung disease, history of prematurity ( <35-week gestation), or with congenital heart disease.

Croup

Croup is a very common cause of airway obstruction in children aged 6 months to 6 years, and is a leading cause of hospitalization for children younger than 4 years. It is a viral infection that causes inflammation of the subglottic region of the larynx that produces the characteristic barking cough, hoarseness, stridor, and different degrees of respiratory distress that are more severe at night. The croup syndrome encompasses laryngotracheitis, laryngotracheobronchitis, laryngotracheobronchopneumonitis, and spasmodic croup.

Croup usually occurs during fall and winter. The parainfluenza viruses (I, II, III) are responsible for as many as 80% of croup cases, with parainfluenza I accounting for most episodes and hospitalizations. Other pathogens include enterovirus, human bocavirus, influenza virus A and B, RSV, rhinovirus, and adenovirus in approximate order of frequency. In communities with low measles immunization rates, measles should be listed as a rare but possible cause. Influenza A has been implicated in children with severe respiratory compromise.

The prodrome is characterized by 12 to 72 hours of runny nose and low-grade fever followed by a barking cough and variable levels of respiratory distress, usually at night. Hypoxia only occurs in severe cases. These symptoms peak from 1 to 2 days, and in most cases, resolve in 1 week.

Diagnosis is made through clinical presentation. However, imaging studies confirm the diagnoses. Frontal neck x-rays show the "steeple sign;' which is indicative of subglottic narrowing of the tracheal lumen. When the diagnosis is uncertain, computed tomography (CT) scan of the neck offers a more sensitive evaluation.

Treatment is geared toward the severity of the croup (the level of respiratory distress). The most reliable clinical features to test severity are resting stridor and chest wall retractions. Use of pulse oximetry can help assess severity.

Emergency management of croup should begin with assessment of airway obstruction; oxygen should be used liberally. Chest radiographs rarely are of use, but can be considered if other pulmonary conditions are strongly considered.

Lateral neck films can be considered if there is concern for epiglottitis or bacterial tracheitis. There is no proof that humidified air is of value and mist tents should be avoided. Hospitalization is appropriate if severe croup is clinically apparent. Severe croup is exemplified by cyanosis, decreased level of consciousness, progressive stridor, severe stridor, severe retractions, markedly decreased air movement, toxic appearance, severe dehydration, and social factors limiting adequacy of outpatient monitoring. Children who are hospitalized with croup should be monitored closely and frequent physical examination needs to be performed.

The current cornerstones of treatment are glucocorticoids and nebulized epinephrine. Steroids have proven beneficial in severe, moderate, and even mild croup. Dexamethasone 0.60 mg/kg by mouth or parenterally as a single dose is beneficial because of its long half-life and anti-inflammatory action, whereby laryngeal mucosa! edema is decreased. They also decrease the need for salvage nebulized epinephrine. Nebulized racemic (mixture of cl-isomers and l-isomers) or L-epinephrine is typically reserved for patients in moderate-to-severe distress. It works by adrenergic stimulation, which causes constriction of the precapillary arterioles, thereby leading to fluid resorption from the interstitium and improvement in the laryngeal mucosal edema. Its β2-adrenergic activity leads to bronchial smooth muscle relaxation and bronchodilation. The following medications should be avoided: sedatives, opiates, expectorants, and antihistamines.

Epiglottitis

Epiglottitis is a bacterial infection of the supraglottic tissue and surrounding areas that causes rapidly progressive airway obstruction. It usually affects children younger than 5 years and is most commonly caused by bacteria, with Streptococcus pyogenes (β-hemolytic Streptococcus group A) and Haemophilus influenzae as the most frequent bacterial causes in children. With the introduction of the H influenzae type b (Hib) vaccine, there has been a 10-fold decrease in cases of childhood epiglottitis, with group A Streptococcus now the leading infectious etiology.

Within 24 hours, the patient with epiglottitis would appear "toxic" and develop fever, severe sore throat, muffied speech ("hot potato voice"), drooling, and dysphagia. The child usually is noticeably anxious and assumes the sniffi position, leaning forward on outstretched arms with chin thrust forward and neck hyperextended (tripod position) so as to increase the airway diameter.

With progression of airway obstruction, the patient may begin to have wheezing and stridor. Epiglottitis is a medical emergency and visualization to confirm the presence of severely erythematous epiglottis is preferably done in the operating room with experienced surgeon or anesthesiologist. Mortality rates as high as 10% can occur in children whose airways are not protected by endotracheal intubation. With endotracheal intubation, mortality is less than 1%.

Medical treatment begins by evaluating airway, breathing, and circulation. The patient should be kept in a calm environment to prevent sudden airway obstruction. Supplemental oxygen administration, a nonthreatening initial step, is easily accomplished with blow-by oxygen administered by a parent. Place the equipment needed for emergent airway management at the bedside. Keep the patient in view at all times. The clinician should avoid oral and throat examinations which can provoke anxiety and acute obstruction.

The radiographic finding that is characteristic of epiglottitis is the "thumb sign" or protrusion of the enlarged epiglottis from the anterior wall of the hypopharynx seen on a lateral neck x-ray. Blood tests should be considered after there is rapid access to ability to intubate, to reduce the risk of anxiety-provoking testing. A complete blood count (CBC) usually shows leukocytosis, neutrophilia, and bandemia.

If acute respiratory arrest occurs, ventilate the child with 100% supplemental oxygen, using a bag-valve-mask device, and arrange for intubation. When a child has a respiratory arrest and appropriate surgical personnel are unavailable, the attending physician may attempt intubation.

Alternative methods to gain immediate control of the airway, such as needle cricothyrotomy, are considered temporary until a more permanent procedure ( eg, tracheostomy) can be performed. The best setting for an endotracheal intubation is in an operating room with the patient under general anesthesia.

Treatment consists of appropriate antibiotics (second- or third-generation cephalosporins or ampicillin/sulbactam) and airway management, usually in an intensive care unit (ICU) setting with a team ready to respond for intubation or tracheostomy.

Bacterial Tracheitis

Bacterial tracheitis is an uncommon life-threatening infection most often seen in 5- to 8-year olds. It often follows an upper respiratory infection that suddenly worsens with high fever, stridor, and cough. Patients appear toxic. Secretions are so thick that they threaten upper air way obstruction. Patients should be treated similarly to epiglottitis with patient ideally going to the operating room for sedation, intubation, and bronchoscopy for cultures and suctioning of thick secretions. X-rays can be done, but airway stabilization takes priority. If done, a steeple sign much like croup may be seen. Staphylococcus aureus is most commonly isolated. S pyogenes, Moraxella catarrhalis, H influenzae, and anaerobes are also seen. Ampicillin/ sulbactam, third-generation cephalosporins with clindamycin cover most likely causative organisms. Vancomycin should be considered in communities with high rates of methicillin-resistance S aureus.

Abscesses

Deep abscesses of the neck are less common causes of acute wheezing, but they have the potential to be very serious. They are located in the peritonsillar, retropharyngeal, and pharyngomaxillary spaces.

Retropharyngeal abscess affects children of 2 to 4 years. The abscess is usually caused by extension of pharyngeal infection, penetrating trauma, iatrogenic instrumentation, or foreign body. Children with this condition are present with fever, drooling, dysphagia, odynophagia, stridor, and respiratory distress. Physical examination may indicate tender enlarged cervical lymphadenopathy, cervical spine range-of-motion limitation, possible stridor, and wheezing. Diagnosis is made by lateral neck films which show bulging in posterior pharynx (prevertebral soft tissue more abundant in children during expiration). Treatment utilizes antibiotics such as cephalosporins or antistaphylococcal penicillins. Incision and drainage is also an option.

Peritonsillar abscess is an infection of the superior pole of the tonsils and is more common in young teenagers. Fever, severe sore throat, muffled voice, drooling, trismus, and neck pain are typical symptoms. Enlarged tonsils with abscess, cervical adenopathy, and deviation of the uvula may be obvious on physical examination. CT scan of the neck is the most helpful diagnostic modality for identifying deep neck abscesses. The predominant pathogens are S pyogenes, S aureus, and anaerobes. The administration of ampicillin-sulbactam or clindamycin (if penicillin allergic) for 14 days is appropriate treatment. Drainage of the abscess is indicated either as first-line treatment or when antimicrobial agents fail to produce adequate result. Serious complications from deep abscesses result from airway obstruction, septicemia, aspiration, jugular vein thrombosis/thrombophlebitis, carotid artery rupture, and mediastinitis.

CASE CORRELATION

• See Cases 2 (Dyspnea), 24 (Pneumonia) and case 56 (Asthma).

COMPREHENSION QUESTIONS

39.1 A 7-month-old infant was brought by her mother to an outpatient clinic because of a 2-day history of fever, copious nasal secretions, and wheezing. The mother volunteered that the baby has been healthy and has not had these symptoms in the past. The infant's temperature is noted to be 100.7°F (38.l°C), her respiratory rate is 50 breaths/min, and her pulse oximetry is 95% on room air. Physical examination reveals no signs of dehydration, but wheezing is heard on bilateral lung fields on auscultation. The infant shows no improvement after three treatments with nebulized albuterol. Which of the following is the recommended treatment?

A. Continued nebulized albuterol every 4 hours.

B. Antihistamines and decongestants.

C. Antibiotics for 7 days.

D. Initiate Synagis.

E. Supportive care with hydration and humidified oxygen.

39.2 A 9-year-old girl is being seen in your office with fever and difficulty breathing. You are concerned about the diagnosis of epiglottitis. Which of the following is the most accurate statement regarding epiglottitis?

A. Child usually prefers to be in prone position.

B. Radiographic finding of "steeple sign:'

C. Every effort should be made to visualize the epiglottis in the office to confirm the diagnosis.

D. Diagnosis is decreasing in incidence.

39.3 A 5-year-old child is brought into the office due to the mother's concern of difficulty breathing. On examination, the child appears toxic, has a high fever, cough productive of thick mucopurulent expectorant, and stridor with wheezing. Which of the following is the most likely condition and organism that requires antibiotic therapy?

A. Epiglottis-H influenzae

B. Tracheitis-S aureus

C. Epiglottis-S pyogenes (β-hemolytic Streptococcus group A)

D. Tracheitis-S pyogenes (β-hemolytic Streptococcus group A)

E. Retropharyngeal abscess-S aureus

39.4 A 12-year-old girl was brought to the emergency department because of severe sore throat, muffled voice, drooling, and fatigue. She had been sick for the past 3 days and is unable to eat because of painful swallowing. The parents deny any history of recurrent pharyngitis. The patient still managed to open her mouth and you were able to see an abscess at the upper pole of the right tonsil with deviation of the uvula toward the midline. Examination of the neck reveals enlarged and tender lymph nodes. Which of the following is the most appropriate management?

A. Analgesics for pain

B. Oral antibiotics

C. Nebulized racemic epinephrine

D. Incision and drainage of the abscess

E. Tonsillectomy and adenoidectomy

ANSWERS

39.1 E. Bronchiolitis is the most likely diagnosis in this case. There is no established treatment for bronchiolitis except for supportive management of the patient's symptoms. Because the infant did not respond to an albuterol trial, there is no justification for continuing its use. Antihistamines, decongestants, and antibiotics are not effective. Synagis is not helpful in the acute setting.

39.2 D. The incidence of epiglottitis has markedly reduced since the introduction of the Hib vaccine. Children with epiglottitis are more likely to be in the tripod position than prone. The "steeple sign" is seen in croup; the "thumb" sign is seen in epiglottitis. Visualization of the epiglottis should preferentially occur in an operating room, where immediate intubation or tracheostomy can occur.

39.3 B. Tracheitis matches the symptom description and is usually caused by S aureus. Group A streptococci are now the leading cause of epiglottis, but the symptom constellation is more likely due to tracheitis. Retropharyngeal abscess usually presents insidiously with neck pain with swelling, fever, dysphagia, and drooling.

39.4 D. This patient is suffering from peritonsillar abscess. Of the choices listed, incision and drainage is the most appropriate. Tonsillectomy is only indicated if there are confirmed cases of recurrent pharyngitis and peritonsillar abscess

CLINICAL PEARLS

⯈ Sufficient airflow is required for the airway to produce a wheezing sound. Disappearance of wheezing in a patient who initially presents with wheezing is an ominous sign that suggests complete blockage of the airway or imminent respiratory failure.

⯈ Bronchiolitis is the most common lower respiratory disease of infants and the most common reason for hospitalization for infants younger than 1 year.

⯈ Never perform a blind finger sweep of a foreign object aspirated by an infant or child.

⯈ Epiglottitis and tracheitis are medical emergencies that require the ability to rapidly secure airways.

REFERENCES

Acevedo JL, Lander L, Choi S, Shah RK. Airway management in pediatric epiglottitis: a national perspective. Otolaryngol Head Neck Surg. 2009;140( 4):548-551. 

Dawson-Caswell M, Muncie HL. Respiratory syncytial virus infection in children . Am Fam Physician. 2011;83(2):141-146. 

Gunn JD. Stidor and drooling. In: TintinalliJE, Stapczynski S, Ma OJ, et al., eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY: McGraw-Hill Education; 2011. Available at: http:/ /www.accessmedicine.com. Accessed May 11, 2015. 

Zoorob R, Sidani M, Murray J. Croup: an overview. Am Fam Physician. 2011;83(9):1067-1073.

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