Pediatric Respiratory Emergencies: An Expert Interview with Karen Santucci,

From Medscape Medical News
Daniel Keller, PhD

February 18, 2010 —
In this interview, Medscape Emergency Medicine discussed the topic with Karen Santucci, MD. Dr. Santucci is medical director and section chief of pediatric emergency medicine at Yale-New Haven Children's Hospital and is associate professor of pediatrics at the Yale University School of Medicine in New Haven, Connecticut.

Medscape: What do you look for first when a pediatric patient presents to you in respiratory distress?

Dr. Santucci: The first thing I do is a very careful physical exam. Oddly enough, sometimes you can do your best physical starting outside the exam room. Pediatric emergency medicine is a little bit different from adult emergency medicine, in that there's a huge anxiety component, particularly in older infants and younger toddlers. Sometimes I pause outside the exam room for 5 or 6 seconds just to get a look at the status of the child in terms of increased work of breathing, because once you walk into the room, you introduce a new variable in terms of frightening the kid to death.

You can get a good sense of their baseline respiratory rate and what their affect looks like. Are they frightened because they have a partial airway obstruction or because they are really having a lot of difficulty breathing, or are they frightened because you just walked in the room and they associate any of us in healthcare with an immunization, a needle? There's a huge fear factor.

So standing outside the room, getting a sense of how they're interacting in their comfort zone with their family member and whether or not they're manifesting any head bobbing, which would be movement of their head with every respiration, which would be an indication of increased work of breathing and accessory muscle use, and if they might even have nasal flaring, which is also evidence of severe respiratory distress. The physical exam is certainly critical, but I think it starts outside the exam room.

And then doing a good lung exam and observing how they're moving air, using all your senses in terms of whether you hear stridor. Is there evidence of congestion? Is there audible wheezing? Feeling them in terms of their capillary refill, tapping on their nail bed, seeing how long it takes to refill, feeling their distal extremities, whether or not they're warm and well perfused or cool, because children are at increased risk of becoming dehydrated with respiratory distress because of insensible losses. Certainly, if they're manifesting with a fever, they'll also have increased insensible losses, and they're more at increased risk of dehydration.

Medscape: Once you've gone through the physical exam findings, are there any questions or particular areas you focus on when taking the history of a pediatric patient?

Dr. Santucci: One of the major things that tends to be missed in pediatrics is asking about potential risk for a foreign-body exposure, and I probably spend half of the talk on that because it is so pediatric-specific in terms of occult exposure to a foreign body that could have been missed.

Medscape: Is there a risk of clinicians becoming complacent and missing the less common causes of obstruction?

Dr. Santucci: A lot of what we see in terms of respiratory distress is associated with more common things; for example, at this time of year — January, February — we're seeing a lot of [respiratory syncytial virus]–related bronchiolitis, particularly in children less than 2 years of age. What I would caution the clinician about is tending to think, it's bronchiolitis season, so if an infant or toddler is presenting with respiratory distress, it's probably bronchiolitis. I think maintaining the possibility of it being something else is so critically important.

Increased work of breathing and some congestion, and a little bit of a wheeze . . . could also be something like an inborn error of metabolism, and the child is actually presenting with what appears to be increased work of breathing because they're developing increased respiratory drive to compensate for a metabolic acidosis.

In one case we had, what was felt to be bronchiolitis in a 10-month old was actually a salicylate overdose secondary to a mother giving increased amounts of Maalox Extra Strength for gastroesophageal reflux. We discovered that this baby had an increased anion gap . . . and, had we not erred on the side of sending a tox screen and had not this been recognized in real time, this child would have died. . . . Ask about over-the-counter meds and ointments and preparations because they can kill an individual — so [that is] very significant information.

One of the hugest points that I've learned over the years is maintaining a differential diagnosis when the points don't seem to fit, delving and asking some questions, maybe sending a few extra labs to err on the side of being overly cautious and not just accepting things at face value. Even if you can't figure things out in the emergency department, sharing that you're really perplexed by a patient with the accepting team upstairs when you're admitting a patient and making sure that they follow up on the lab tests as quickly as possible and initiate a pretty comprehensive work-up can absolutely be life saving.

Medscape: What are some of the tools that physicians can use to work through and manage respiratory distress in children?

Dr. Santucci: One specific case was a case of a 4-year-old girl presenting in the winter with some stridor, and she had some tripodding, which means she was leaning forward because she was trying to maximize airflow through the upper airway, and she was febrile to 104 degrees. This was a little girl who presented with all the classic signs and symptoms of epiglottitis. Even at a major tertiary-care center, there were specialists who just didn't believe in epiglottitis any more. Ever since we've introduced Haemophilus influenzae type B vaccination, and this has become routine, we have reduced the incidence of epiglottitis so immensely that many people in healthcare don't believe that it exists anymore.

The [attending ENT] was able to successfully intubate her in the operating room, but she clearly had epiglottitis and a near-complete airway obstruction, because the epiglottis was so inflamed and swollen, so edematous. The only way they were able to secure her airway on direct laryngoscopy was to squeeze her thorax and create a small air bubble. This could be a life-saving technique if you can't get the child to the operating room, to squeeze the chest. While you're doing direct laryngoscopy, there can be an air bubble, which will delineate where to pass the endotracheal tube.

Medscape: Besides H influenzae type B, are there other organisms that can cause epiglottitis?

Dr. Santucci: We almost always attribute it to H influenzae type B, but there are other types of bacteria — Staphylococcus, Streptococcus, and other serotypes of H influenzae — that can cause epiglottitis. Quite amazingly, there are other etiologies for epiglottitis — inhalational if someone is inhaling different types of illicit drugs. We've had a couple of cases associated with cold weather where people will take a gulp of some hot chocolate while they're outside, and this thermal injury to the epiglottis will cause inflammation of the epiglottis.

So epiglottitis is still out there. We still need to maintain an index of suspicion for this, just like with foreign bodies. If you don't think about it, you're going to miss it, and someone's going to die.

Have an index of suspicion for things like foreign bodies, and what kids are doing. They like to put stuff in their mouths, and so that's a huge risk factor for morbidity and mortality if it's not recognized early.

Medscape: Can a child's activities before coming to the emergency department raise your suspicion of a foreign body?

Dr. Santucci: When you have a really sick kid, a lot of people mobilize, and they want to be at the bedside, but one thing that I've learned over the last couple of decades is that having a person break off from the bedside to talk to the family . . . it can be life-saving just to take a moment to go back and do a really thorough history.

Medscape: To wrap things up, can you give me a couple of bullet points that a physician should keep in mind when seeing a child in respiratory distress?

Dr. Santucci: An increased respiratory rate is not always a respiratory problem, so remember that tachypnea is not always a respiratory etiology and that sometimes that increase in respiratory rate is because of a compensatory mechanism for a metabolic problem. Propionic acidemia [propionyl-CoA carboxylase deficiency] is one example, and another would be diabetic ketoacidosis.
Another thing is to remember the developmental status of children, particularly older infants and toddlers, and that whole foreign-body spectrum.

With regard to increased respiratory rate and increased work of breathing, when someone is presenting with acute anaphylaxis and severe allergic reaction, all the studies support getting epinephrine in within the first 30 minutes — it can absolutely save a life.
If you delay that intramuscular injection of epinephrine, the cascade has already taken place in terms of what's going on chemically, and you may have irreversible anaphylaxis. If you're thinking about epinephrine, it would be better to give the epinephrine than to delay it.

We do not give the epinephrine intravenously. We give it intramuscularly. It's going to be absorbed very nicely from an [intramuscular] route, and it's extremely safe to give it intramuscularly.

Even in adults, giving intramuscular epinephrine is really quite safe. Anaphylaxis absolutely affects the heart as well, and if you don't treat the anaphylaxis, someone might actually develop an acute myocardial infarct because of the anaphylaxis and the strain on the myocardium. So when you weigh all the pros and cons, you're better off erring on the side of giving the epinephrine intramuscularly. That's a huge critical life-saving point.