It's an early October evening, and the tones sound. Dispatch resonates, "Respond to a child in respiratory distress." En route, potential causes of pediatric dyspnea run through your head.
On entering the house, you hear a seal bark cough coming from the living room, and a 2-year-old boy sitting on the floor playing with building blocks. His mother tells you he has had a runny nose and low-grade fever for the past couple of days. This evening he developed a loud cough. She became concerned and called 9-1-1.
Your assessment reveals a conscious boy named Bryce who does not appear to be in severe distress but does have inspiratory stridor and a course cough. He is warm to the touch and still has a runny nose. You note supraclavicular retractions upon examination of his chest. Although his breathing is noisy and labored, he appears to be managing his airway. He is able to open his mouth, and you don't see any foreign objects. You place Bryce on humidified oxygen and suggest to his mother that he be transported for evaluation in the emergency department (ED). On the way to the hospital, you keep him comfortable and monitor his breathing. When you arrive, Bryce looks better. His coughing has decreased, and he is breathing easier. The charge nurse takes your report and says it looks like another case of croup.
Croup, also known as laryngotracheobronchitis, is a viral airway infection affecting the larynx and trachea. This culprit virus is most commonly the Parainfluenza virus. The virus causes inflammation of the larynx, trachea and bronchials. It typically occurs in late fall and winter months but can be seen any time during the year. Ages three months to three years are most commonly affected with croup, but it has been documented in children as old as 12. Croup usually begins with cold symptoms, such as a runny nose and low-grade fever. After a couple of days, the telltale "seal bark" cough appears.
Children with croup don't usually appear toxic. High fevers are rare, and the child is able to eat and drink without difficulty. Breath sounds may present with expiratory wheezes or may be clear. Although usually self-limiting, croup can acutely occlude the airway, resulting in respiratory failure. This occurs most commonly in children under the age of one. Advanced maneuvers, such as oral tracheal intubation, are reported necessary in less than 2% of all cases.
There is a non-viral variant of the illness known as spasmodic croup, which typically presents at night with a sudden onset of the seal bark cough. There's no infection or fever. It's thought to be allergy related.
EMS treatment for children with croup is mostly supportive, remaining vigilant to possible airway occlusion. Humidified oxygen, as tolerated by the child, may be of benefit. Over the years, croup has been treated with cool mist. Studies have shown no difference between children who receive cool mist therapy and those who do not. Steam should be avoided because scalding has been reported.
In severe cases, nebulized racemic epinephrine may decrease the inflammation in the airway. IV placement, if allowed in your scope of practice, should be avoided in these children. Making the child cry or scream may worsen the inflammation. If the child develops severe respiratory distress or failure, the airway can be managed with a bag-valve mask (BVM). Position the head, and make a tight seal to help force air past the swollen tissue. If intubation is attempted, it should only be done by skilled, practiced providers. Aggressive and repeated intubation attempts may exacerbate the swelling.
Epiglottitis is another cause of pediatric dyspnea that should be considered by the EMT when evaluating children in respiratory distress. Epiglottitis is bacterial in nature, caused most commonly by Haemophilus Influenza Type B. It affects children three to eight years of age but can be seen in older children and adults. Non-infectious versions of epiglottitis have been reported secondary to thermal burns caused by drinking hot liquids.
Epiglottitis causes the epiglottis to swell and appear thumb shaped. The swollen epiglottis threatens to block the trachea. Children with epiglottitis, in contrast to those with croup, appear sick. They have a sudden onset of a high fever. They will be sitting silently with their head in a sniff position. They will not talk, eat or drink, and drooling can be seen in more than 50% of all cases. The child may present cyanotic with decreased breath sounds.
These children should be transported quickly and gently to the hospital. Humidified oxygen as tolerated is appropriate. Avoid any manipulation of their neck or throat; it may worsen swelling. Treatments with epinephrine and steroids have been used but are not generally effective. As with the child with croup, interventions that could upset the child, such as IV therapy, should be avoided.
The airway of the child with epiglottitis is best managed in the ED or operating room. If respiratory failure presents in the field, the airway can be managed with a BVM, maintaining proper head position and a tight seal. Extreme cases may require a surgical airway.
As an EMT, caring for a child in respiratory distress can be challenging and scary. Remember the basics. Recognize the problem. Always consider the potential for foreign body obstruction. Keep the child calm. Administer oxygen via mask or blow by as tolerated. Gently transport them to the ED. Watch for signs of respiratory failure, including fatigue, cyanosis and bradycardia. In cases of respiratory failure, BLS airway maneuvers may serve the patient and EMT best.
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Scolnik D, Coates AL, Stephens D, et al: "Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: A randomized controlled trial."JAMA.295(11):1274 1280, 2006.
Alberta Medical Association:"Guideline for the diagnosis and management of croup."Alberta Clinical Practice Guidelines 2005 Update.