Pediatric emergency medicine trisk 1411 1411
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dysphagia suggest partial airway obstruction. Children with abnormal
auscultatory findings (i.e., wheeze, rales, rhonchi, and/or asymmetric breath
sounds) and fever are likely to have infectious etiologies (e.g., pneumonia or
bronchiolitis).
Patients can be further categorized on the basis of tachypnea ( Fig. 71.1B ).
Children with rapid respirations and fever may have pneumonia, even in the
absence of rales; empyema, pulmonary embolism, and encephalitis are also
important considerations. Tachypnea without fever points to trauma, cardiac
disease, metabolic disturbances, toxic ingestions, or exposures. Febrile children
without tachypnea may have apnea or bradypnea as late manifestations of CNS
infection. In afebrile patients, considerations include CNS depression, spinal cord
injury, neuromuscular disease, and neonatal apnea.
Diagnostic tests should be performed selectively to evaluate for diagnoses
suggested by history and physical examination ( Table 71.9 ). Laboratory tests
can inform respiratory status and diagnosis.
Airway and chest radiographs can be helpful in determining the site and often
the etiology of respiratory distress, and may provide insights into the likely
clinical course. Flexible nasopharyngoscopy can help identify some etiologies of
upper airway obstruction, as indicated. Ultrasound may also provide information
on diagnosis, as well as guide the management ( Table 71.10 ). Pulmonary
ultrasound can be used to evaluate for pneumonia, pleural effusion,
pneumothorax, and hemothorax. Cardiac ultrasound can be used to detect
presence of a pericardial effusion and assess overall cardiac function. As
appropriate, ultrasound findings can then be confirmed with chest x-ray or formal
echocardiogram. For complete details on pulmonary and cardiac ultrasound
technique and findings, please refer to Chapter 131 Ultrasound .
Treatment
Regardless of the cause of respiratory distress, aggressive treatment must be
initiated immediately to rapidly address airway patency, oxygenation and
ventilation ( Table 71.6 ). In the alert patient, establish and maintain the position
that maximizes respiratory function. Every effort should be made to avoid
agitating the child. Supplemental oxygen can be administered using nasal
cannula, high-flow nasal canula, and simple or nonrebreather mask. Noninvasive
positive pressure ventilation, in the form of CPAP or BPAP may be trialed to
decrease work of breathing and improve respiratory status. In the patient with
decreased sensorium, positioning the airway by chin lift (contraindicated if neck
injury is suspected) or jaw thrust may relieve soft tissue obstruction of the airway.
The oral cavity should be cleared of secretions, vomitus, blood, and visible
