How to deal with breathing disorders in practice?

Respiratory emergencies in children are challenging. As is so often the case in pediatrics, interviewing the patients themselves is difficult. The information provided by parents is therefore all the more important – but it must also be critically scrutinized.

You are presented with an eight-month-old infant with respiratory distress. He reacts to you by crying and the examination is correspondingly difficult. On the mother’s arm, the infant calms down and you notice strained breathing and a respiratory rate of 50/min. The mother tells you that he drinks, but this morning he was now febrile.

Possibilities and limits of outpatient care

Respiratory emergencies present a challenge to all involved on an almost daily basis. As is so often the case in pediatrics, interviewing patients is difficult because they are either too young, too sick, or simply unwilling to provide information after three nights without sleep. The information provided by parents must be taken seriously, but also questioned.

Especially with regard to breathing, the patients resp. their caregivers use certain terms completely differently than the treating professionals. Specifically, the whistling breathing sound is mentioned, which – if one has the nerve to pretend – is often not confirmed by the affected person or caregiver. Often, even after a detailed anamnesis, it is not clear how the child breathed “funny”. Is it carping, expiratory or inspiratory whistling, throat clearing, snorkeling, rapid superficial breathing, or just frequent sighing? If there is enough time, we ask patients or their caregivers to record the breath sound with their smartphone. This attracts interest and can also be a diagnostic tool and therapy for functional complaints.

Unfortunately, we don’t have many examination methods besides our eyes and ears to objectively assess respiratory disorders. Pulse oximetry is generally accepted and has become an indispensable part of everyday life. It is used less for diagnosis than for triage with regard to necessary hospitalization or treatment. Control of the success of an initiated therapy in practice provides good service. Baby sensors are available for all common systems and significantly facilitate signal derivation.

X-ray machines are becoming less common in primary care practices. Ultrasound, which can be used to good effect in the diagnosis of pneumonia in particular, requires the appropriate know-how, since the time window for examining an infant is rather short due to cooperation. In many cases, however, diagnostic imaging measures are not necessary [1].

The analyses possible in the practice laboratory, such as a differentiated blood count and C-reactive protein, do not provide sufficient certainty, even in children, to distinguish a bacterial from a viral respiratory disease.

The banal upper respiratory tract infection

The most common reason for presentation in pediatric practice is airway infections. Although generally masculine viral illnesses, a cold can turn into a respiratory emergency.

First and foremost, our youngest patients are sometimes severely affected by airway infections. Especially in the first three months, it is difficult to distinguish between a trivial viral infection and the serious bacterial infections of the neonatal period and beyond. With few exceptions, a febrile infant belongs to the “septic work-up” during the first two months of life and is admitted to a pediatric hospital for monitoring. These children are particularly at risk in terms of dehydration or even respiratory insufficiency because of the incomplete alveolarization, the functional residual capacity is close to the residual volume and thus the respiratory reserve is very small. Certain pathogens can cause severe apnea (pertussis or even RSV) – another reason to hospitalize these infants.

Infant assessment must include the following:

General condition: awake, interested
Respiration: respiratory rate, auxiliary respiratory muscles, retractions, nasal wings, nudging respiration, moaning, O2 saturation.
Hydration: drinking behavior, capillary filling time <3 seconds, urine production.
Fever
Other symptoms: Skin rash, reddened throat, eardrums, lymph node enlargement, fontanel.

If no warning signs can be identified, much can be accomplished with weight-adapted analgesia (NSAIDs are preferable to acetaminophen), good nasal irrigation with physiologic or hypertonic saline, and oral hydration. However, close monitoring is essential at this age.

Foreign body aspiration

Despite increasing knowledge and education of caregivers, foreign body aspirations are still numerous. The typical age is between six months and four years. Aspirated objects are mainly foods such as nuts, grapes, carrots, but in older children also small toys and utensils. Mortality after foreign body aspiration is up to 3.4% according to the literature and is predominantly event related.

The medical history can be indicative, e.g., in the case of a child playing with sudden onset of respiratory symptoms (overview 1). In most cases, the symptoms improve spontaneously within hours. However, sometimes anamnestic evidence is lacking and children sometimes present weeks later with a chronic cough or prolonged respiratory infection.

Auscultation typically reveals an asymmetric breath sound that is attenuated or may even be absent on the affected side. Here, too, an expiratory whistling resp. an inspiratory or expiratory stridor can be auscultated. However, normal auscultation does not rule out foreign body aspiration.

As a rule, foreign bodies are not radiopaque, i.e., a chest X-ray for foreign body detection is rarely useful. Circumscribed hyperinflation, if any, is seen on the foreign body side by a valvular mechanism, possibly with mediastinal displacement to the opposite side. In cases of prolonged foreign bodies, poststenotic atelectasis or pneumonic infiltrate may also be visible and should not detract from the suspicion of foreign bodies. In an emergency, a chest radiograph should be omitted because endoscopy must be performed in any case.

The procedure for acute foreign body aspiration is as follows:

Suffocative breathing and cough reflex: no manipulation, directly emergency department
Compromised breathing, absent cough reflex, acute asphyxiation symptoms: Maneuver (Fig. 1)
Unconsciousness: resuscitation.

In any case, enoral manipulations with the intention of manually removing the foreign body must be refrained from. On the one hand, a foreign body can be pushed even deeper and on the other hand, there is a risk of vomiting and consecutive aspiration.

Acute viral bronchiolitis

Over 75% of all infants become infected with respiratory syncytial virus (“RS”) or another airway virus during the first year of life. Of these children, one in five will develop a relevant illness, and 2-3% will require hospitalization for a viral respiratory infection. Although RS virus is the most commonly isolated virus in children with bronchiolitis (lower respiratory tract infection), many other viral pathogens exist (e.g., rhinovirus, influenza virus, meta-pneumovirus). Typically, these infections accumulate during the fall and winter seasons.

Affected infants present with febrile illness with rhinitis, dry cough, and tachydyspnea. It is not uncommon to notice nudging rapid breathing with subcostal, intercostal, or sternal retractions and nostrils. There is no “wheezing”, no gieving, but fine-bubble discontinuous background noise (“crackling”). Bronchiolitis represents a clinical diagnosis. Neither laboratory chemistry nor diagnostic imaging measures are recommended. Infants at risk for a severe course include preterm infants <35 SSW and infants with cyanotic cardiac vitium, chronic lung disease (e.g., bronchopulmonary dysplasia of prematurity), neuromuscular disease, and also immunocompromised infants.

The maximum symptomatology usually manifests between the third and fifth day of illness. This should be communicated to the parents. Hypoxemia should be sought in all children by pulse oximetry (O2 saturation <92%). Because of rapid labored breathing and often obstructed nose, many infants do not drink enough. Dehydration further weakens children, leads to reduced mucus clearance, and is therefore a reason to hospitalize a child. Table 1 shows a classification of the severity of bronchiolitis.

Unfortunately, no really convincing therapies exist [2]. In addition to the advice to give the infants additional fluids, antipyretic therapy and to keep the nose clear if possible (NaCl 0.9% or 2.3% nasal spray, decongestant nasal drops), these infants require close monitoring. We are also frequently asked about RSV vaccination (Palivizumab, ^Synagis®). Based on efficiency data, this is only indicated and approved for special risk groups. In 2017, a fact sheet for parents was published by the Swiss Society for Pediatric Pneumology (www.sgpp-sspp.ch/de/bronchiolitis.html). Here, not only the course of the disease is explained, but also the supportive therapy in the hospital is discussed.

Bacterial superinfection is very rare in acute respiratory tract infection in the first 12-24 months of life and does not need to be routinely sought. Typical of a superinfection is a two-peak course of fever.

Pseudocroup

Pseudocroup or acute laryngotracheobronchitis, particularly caused by swelling in the area of the not very flexible cricoid cartilage (complete cartilaginous ring), is another common respiratory condition that regularly leads to emergency consultations. It affects preschool-aged children, triggered by viral respiratory infections (primarily parainfluenza viruses) with peak timing in early fall. The children’s general condition is usually only slightly impaired. They present with a barking (seal-like) cough and a more or less pronounced hoarseness. If the swelling of the upper respiratory tract resp. the work of breathing increases (e.g., when crying), one hears an inspiratory or biphasic stridor.

The first question in practice is about vaccination status, as pseudocroup can be confused with an early phase of epiglottitis. In addition to reassuring the patient and parents, antiphlogistic medications help. Although the benefit of NSAIDs has not been proven in studies, these medications relieve the sore throat and swallowing pain that is often present, thereby calming the children. You will get the best effect with the administration of systemic steroids. For reasons of application (dissolvable tablets) betamethasone (^Betnesol®) is recommended. Most often, due to the long half-life of betamethasone, pseudocroup infants require only one dose, and tapering is not necessary. If symptoms are severe, epinephrine can be inhaled using a compression nebulizer (two to five ampoules of 1 mg). However, children after epinephrine inhalation must be monitored for four to eight hours because of the short duration of action and thus the possibility of rebound.

The epiglottitis

Before the introduction of hemophilus influenzae (Hib) vaccination, epiglottitis was an infectious disease feared by every pediatrician; fortunately, today it has become extremely rare. However, the risk should not be neglected due to the increasing refusal to vaccinate. Therefore, it is still necessary to think about this serious clinical picture. The children, in contrast to the pseudocroup patients, are severely ill, highly febrile, quiet, with an elongated head, and often present salivation with inability to swallow. At the slightest suspicion, these children must be immediately transferred to a pediatric emergency department by ambulance under anesthesia escort. Enoral manipulation can inevitably lead to airway obstruction.

The obstructive bronchitis

We refer to repetitive obstructive bronchitis as “episodic viral wheeze.” They are significantly more common than early childhood bronchial asthma, in which children usually show obstructive symptoms outside of viral infections (e.g., exertion, allergies). The children with acute obstructive bronchitis are usually older than those with bronchiolitis, show a higher incidence of bronchitis in relatively trivial resp. asymptomatic viral airway infections an expiratory whistle, retractions subcostally, intercostally, or sternally, and (in younger children) nasal flaring. It is advisable, especially with “unfamiliar” children, to first perceive the breathing at a distance, to count it and to pay particular attention to the prolonged expiration.

Attempts to influence breathing by administering short-acting betamimetics (e.g. ^Ventolin® metered-dose inhaler with preswitch chamber and face mask suitable for infants) often confirm the diagnosis. Success is achieved within minutes. Betamimetics should be administered by inhalation rather than perorally whenever possible (faster onset of action, fewer systemic side effects, better control of therapy). Metered dose inhaler must be inhaled with a priming chamber (e.g. ^Vortex®, Aerochamber ^plus®). Alternatively, a wet nebulizer with 0.25 ml of concentrated ^Ventolin® solution in 2 ml of NaCl 0.9% can be used, The dose should be adjusted to the symptoms. Depending on severity, two to six strokes may be started (inhale each stroke individually, wait 20 minutes, then two to six strokes again). This procedure is recommended for severe exacerbation in the first hour.

The use of systemic corticosteroids remains controversial. The benefit in children with pure “episodic viral wheeze” is not proven. However, studies indicate that children with bronchial asthma (higher likelihood of eosinophilic endobronchial inflammation) benefit most. In practice, however, I consider it legitimate to administer a dose of corticosteroids as a last attempt if hospitalization is imminent (Tab. 2) . In infants, betamethasone tablets 0.5 mg (^Betnesol®: 0.6 mg/kg as a single dose dissolved in a little water) are recommended for easier administration [3]. Inhaled steroids are not effective in the treatment of obstructive bronchitis as well as acute exacerbation of bronchial asthma. The hospitalization criteria can be found in the overview 2.

The pneumonia

In pneumonia, too, the diagnosis is based almost exclusively on clinical signs and history, in accordance with current guidelines. In the foreground is usually a preceding upper respiratory tract infection with fever. Children with prolonged fever (longer than three days) and/or poorly lowerable fever with adequate antipyretics (check dose!), tachypnea even after reduction of fever and reduced general condition are very likely to suffer from pneumonia (overview 3). Auscultation of the lungs is always disappointing, especially in younger children. The absence of discontinuous secondary murmurs and a symmetrical breath sound do not rule out pneumonia. With an expiratory whistle, the likelihood of bacterial pneumonia is small. If you are unsure whether tachypnea is simply due to status febrilis, antipyresis and in-office monitoring for one to two hours are recommended. If tachypnea persists under adequate antipyretic therapy, this substantially supports the diagnosis. In the outpatient setting, neither an X-ray nor a determination of the infection parameters in the blood (differentiated blood count as well as C-reactive protein) is recommended. Children with the above clinical signs can be treated without further workup.

During the first two years of life, viral pathogens predominate. This leads to the recommendation in guidelines that if these children are in good or only mildly reduced general health and merely subfebrile, they should not be treated with antibiotics. However, close monitoring is recommended. Positive pneumococcal vaccination status may support this approach. All other children should be treated with antibiotics for the appropriately mentioned symptoms. The choice of antibiotic is based on the most common pathogens (Streptococcus pneumoniae, Streptococcus group A, Staphylococcus aureus, Haemophilus influenzae, Moraxella catarrhalis). It is given empirically. Amoxicillin 50 mg/kg/d (up to 90 mg/kg/d) for five to seven days is primarily recommended. Macrolide antibiotics should not be used primarily, but only in children requiring hospitalization in whom atypical pathogens are a possibility based on the constellation and findings. There is still controversy regarding the efficacy of macrolide antibiotics in atypical pneumonia.

Children with pneumonia must be followed up in the office 48 to 72 hours after starting antibiotic therapy. Look for signs of effusion (attenuated breath sound, muffled tapping sound, asynchronous movement of the thorax) as well as dehydration, and feel free to question whether the juice is being taken at all!

Take-Home Messages

The majority of respiratory infections in childhood are viral in origin and do not require antibiosis.
Infants can suffer severe courses of lower respiratory tract infection (bronchiolitis) and require fluids and oxygen for therapy.
One should not perform blind enoral manipulations for foreign body aspiration.
Inhaled betamimetics should be used in high doses in a child with obstructive bronchitis. This always via a suitable upstream chamber. Systemic steroids for wheezing rarely prevent hospitalization.
A child with fever and tachypnea after adequate antipyretic therapy without signs of airway obstruction has pneumonia until proven otherwise. Auscultation is rarely helpful.

Thanks: I would like to thank Iris Bachmann Holzinger, MD, senior physician, emergency department, and my boss and mentor PD Alexander Möller, MD, head of the department of pneumology, both at the University Children’s Hospital Zurich, for their critical review of this article and their valuable support. I would also like to thank Sibylle Immoos and Esther Diethelm, certified anesthesia nurses, University Children’s Hospital Zurich.

Disclosure: The author has no financial or personal affiliations related to this article.

Literature:

Rose M, et al: S2k guideline “Management of community-acquired pneumonia in children and adolescents”. German Society for Pediatric Infectious Diseases, Society for Pediatric Pneumology 2017. www.awmf.org
Barben J, Hammer J: Treatment of acute bronchiolits in infancy. Switzerland Med Forum 2004; 4: 251-253.
Augsburger F, et al: Care and therapy of acute asthma attack in children in the emergency department. Swiss Medical Forum 2017; 17(11): 258-263.