Pediatric emergency medicine trisk 1663 1663
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readings. In otherwise healthy children with no feeding difficulty or respiratory
distress, recent American Academy of Pediatrics recommendations suggest that a
pulse oximeter reading of 90% or greater is acceptable for patients with
bronchiolitis. Patients suspected of having reversible bronchospasm should be
given an inhaled bronchodilator, such as albuterol, while proceeding with further
evaluation and management.
Expeditious management is essential in patients with poor baseline pulmonary
function because they can develop respiratory failure quickly. Such patients
include children with significant CLD and advanced cases of progressive chronic
lung disorders such as CF. Moreover, in patients with chronic respiratory
insufficiency, careful titration of inspired oxygen concentration is important to
avoid respiratory drive suppression.
CHILDREN YOUNGER THAN 1 YEAR OLD
An algorithm for elucidating the cause of wheezing in the child younger than 1
year old is presented in Figure 84.1 . It is important to note that age cutoffs are
not absolute. The abrupt onset of wheezing, often immediately preceded by an
episode of choking, gagging, or vomiting, is highly suggestive of pulmonary
aspiration of a foreign body. If wheezing is subacute in presentation and
accompanied or preceded by fever or respiratory symptoms, bronchiolitis or
asthma should be considered. Most infants who present with a first episode of
wheezing have bronchiolitis. A similar complex of physical findings in an older
infant with a history of bronchiolitis or wheezing and clear improvement after
bronchodilator administration is characteristic of asthma.
The remaining disorders are often found in infants who have overt evidence of
chronic or severe underlying illness and who typically present with recurrent or
persistent episodes of wheezing and respiratory distress. Pulmonary aspiration of
gastric contents may occur in infants and children with neurologic disability, as
well as the occasional otherwise healthy child or adolescent. A report of
mechanical ventilation at birth and/or a prolonged neonatal intensive care unit
admission may be a clue to CLD. Recurrent pneumonia, failure to thrive, and
steatorrhea are characteristic of infants with CF, whereas pneumonia in
association with repeated extrapulmonary infection is suggestive of an immune
deficiency. A heart murmur and other clinical findings consistent with congestive
heart failure are indicative of congenital heart disease and pulmonary edema.
Wheezing accompanied by stridor commonly indicates the coexistence of viral
croup but may reflect intrinsic congenital airway narrowing, such as
tracheobronchomalacia or extrinsic compression by a mediastinal mass. In the
