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Common Respiratory Problems In Children. Case 1 :. 4 months old One day history of excessive crying Sent home with the diagnosis of windy colic with anti-spasmodics Next day: Grunting, respiratory distress, fever. Admitted ,oxygen, IV ceftriaxone. Case (contd). Second day:

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Common Respiratory





Case 1:

  • 4 months old
  • One day history of excessive crying
  • Sent home with the diagnosis of windy colic with anti-spasmodics
  • Next day:
    • Grunting, respiratory distress, fever.
    • Admitted ,oxygen, IV ceftriaxone.
case contd
Case (contd)
  • Second day:
    • Mother felt better but continues to be tachypnoeic, chest indrawing, fever persisting.
    • Vancomycin added with oxygen
case contd4
Case (contd)
  • Third day
    • Severe respiratory distress
    • Pus drained through water seal drainage
    • Antibiotics contd.
    • Discharged after 2 wk.

Strepto.pneumoniae isolated


Case 2

16 month old boy with wheeze

Initial Vitals: HR 160

RR 60

BP 88/50

Temp 38

O2sat on RA 89%


You do your pediatric triage

Appearance Crying, distressed, looking

around, moving all 4 limbs

Breathing (work of) Laboured, chest caving in,


Circulation Colour OK, N cap refill


What would you like to do now?

Oxygen by mask applied, IV attempt started and

pt now on cardiac monitor

Airway No stridor audible, no obvious secretions

Breathing +++ wheeze with little air entry bilat

(inspiratory AND expiratory)

Circulation Warm extrem, PPP, cap refill 2 secs


What would you like to do now?


Salbutamol nebulizer

IV Access established – orders?

CXR done / pending

ABG report

Venous Gas pH 7.35

pCO2 38

pO2 125

Normal ABG values are: pO2 of 80-100 mmHg; pCO2 of 35-45 mmHg; pH of 7.35-7.45; and SaO2 of 95-100%



  • Has had a “cold” for almost 2 days now
  • (mild fever, decreased energy / appetite with cough
  • and runny nose)
  • Started getting wheezy this morning
  • No history of exposure to allergens, inhalants
  • or FB aspiration

Family History of Asthma / no smokers / no pets

Otherwise healthy with no known allergies


Continuous Salbutamol nebulizer

  • for 15 mins has little effect
      • Still indrawing
      • RR 65
      • Still alert and looking around, crying

Additional treatment?

IV steroids Methylprednisolone 1 mg/kg IV / IM

Continue Salbutamol

Consider racemic Epinephrine (0.5 mls)


Repeat Venous Gas about 30 mins later

pH 7.15

pCO2 55

pO2 120

Normal ABG values are: pO2 of 80-100 mmHg; pCO2 of 35-45 mmHg; pH of 7.35-7.45; and SaO2 of 95-100%

Eyes rolling back, little crying now …

What do you want to do?

Drugs? Tube Size?

Ketamine 1-2 mg/kg IV

Atropine 0.01 mg/kg IV (min 0.1 mg)

Succinyl 1 mg/kg IV

4 – 4.5 tube


Other Options

  • IV Magnesium 25 mg/kg (max 2 gm)
  • IV Epinephrine
  • IV Salbutamol
  • Inhalational Anesthetics
  • Methylxanthines
  • Heli - Ox

Differential Diagnosis of Wheezing

H + N Vocal cord dysfunction

Chest Asthma


Foreign Body Aspiration

CVS Congestive Heart Failure

Vascular Rings


Pediatric Asthma Guidelines

  • MILD
  • Nocturnal cough
  • Exertional SOB
  • Increased Salbutamol use
  • Good response to Salbutamol
  • O2 sat > 95%
  • PEF > 75% (predicted / personal best)
  • ± O2
  • Salbutamol
  • Consider po Steroids


Pre - Treat



Pediatric Asthma Guidelines

  • Normal mental status
  • Abbreviated speech
  • SOB at rest
  • Partial relief with Salbutamol and required > than q 4h
  • O2 sat 92%-95%
  • PEF 50-75% (predicted / personal best)
  • O2 100%
  • Salbutamol
  • Systemic corticosteroids
  • Consider anticholinergic


Pre - Treat



Asthma Guidelines

  • Altered mental status
  • Difficulty speaking
  • Laboured respirations
  • Persistant tachycardia
  • No prehospital relief with usual dose Salbutamol
  • O2 saturation <92%
  • PEF, FEV1 <50%
  • 100% O2
  • Continuous or frequent b-agonists
  • Systemic corticosteroids & magnesium sulfate
  • Consider anticholinergic & / or methylxanthines


Pre - Treat



Asthma Guidelines

  • Exhausted , Confused
  • Diaphoretic
  • Cyanotic, Decreased respiratory effort, APNEA
  • Falling heart rate
  • O2 saturation <80%
  • (spirometry not indicated)
  • As above PLUS
  • IV Salbutamol
  • Inhalational anesthetic, aminophylline
  • Epinephrine


Pre - Treat




18 mo Girl with 24 hr Hx of coughing with drooling

Hx: Has had an URTI for about a week and was

getting mildly better until yesterday. She

developed a fever and the cough got harsher.

Still drinking but not interested in solids

Vomited once last night

Started drooling this morning


Physical Exam

T39.1 degrees rectally, P170, R28, BP 100/66

Appearance alert, awake, not toxic, in no acute distress

Did not appear to prefer upright or a forward leaning position

EENT Moist MM, slight erythema of oropharynx,

nasal crusting, N TMs, no rash / petechiae,

no drooling

Supple neck

Chest Clear when resting

Mild inspiratory stridor with crying

Rest of the exam N



  • Croup
  • Epiglottitis
  • Bacterial
  • tracheitis
  • RetroPharygeal
  • abcess
  • Foreign Body
  • aspiration

Other things on DDx of

Inspiratory Stridor

Laryngeal Web



Airway thermal injury

Subglottic stenosis

Peritonsillar abcess


Esophageal FB

Laryngeal fracture

Laryngeal cyst



Soft tissue lateral

neck radiograph


Retropharyngeal Abscess

  • Lymph nodes between the posterior pharyngeal wall
  • and the prevertebral fascia
    • gone by 3 – 4 yrs of life
    • drain portions of the nasopharynx and the posterior
    • nasal passages
    • may become infected and progress to breakdown
    • of the nodes and to suppuration


  • Complication of bacterial pharyngitis
  • Less frequently
  • - extension of infection from vertebral osteomyelitis
  • Group A hemolytic streptococci, oral anaerobes,
  • and S. aureus

Typically …

  • Recent or current history of an acute URTI
  • Abrupt onset:
      • High fever with difficulty in swallowing
      • Refusal of feeding
      • Severe distress with throat pain
      • Hyperextension of the head
      • Noisy, often gurgling respirations
      • Drooling

On Exam …

Nasopharynx Bulging forward of the soft palate and

nasal obstruction

Oropharynx Bulging of posterior phyaryngeal wall


Not visualized

Soft Tissue Neck Film

Patient position – MILD EXTENSION

Positive Film - Retropharyngeal soft tissue > ½ the width

of the adjacent vertebral body

- may see air in the retropharynx



Abscess rupture - aspiration of pus.

Lateral extension - present externally on the side of the neck

Dissection along fascial planes into the mediastinum

Death may occur with aspiration, airway obstruction,

erosion into major blood vessels, or mediastinitis.



  • Ceftriaxone 75mg/kg/day/divided Q 12 hrly
  • Clindamycin 20-30 mg/kg/day divided Q8H

(if pre-fluctuant phase)

  • Decadron 0.6 mg/kg
  • Airway management
  • Surgical decompression


17 month old male with a one-hour history

of noisy and abnormal breathing

Normal now but at the time, parents thought he was

quite distressed.

Now, he is able to speak and drink fluids without difficulty


VS T36.8, P200 (crying), R28 (crying), O2 sat 99%

Alert with no signs of respiratory distress

Able to speak, had no cyanosis, no drooling,

no dyspnea

H+N No obvious swelling, bleeding, FB seen

Chest Mild wheezing with ? mild inspiratory stridor

What would you like to do now???


Soft Tissue

Neck View






Inspiratory View

Expiratory View






Foreign Body Aspiration

  • More common with food than toys
  • Highest risk between 1 and 3 years old

(immature dentition – no molars, poor food control)

  • Common foods = peanuts, grapes, hard candies
  • Some foods swell with prolonged aspiration
  • (may even sprout)

Clinical Manifestations

Typically …

Acute respiratory distress (now resolved or ongoing)

Witnessed choking period

Uncommonly …

Cyanosis and resp arrest

Symptoms: cough, gag, stridor, wheeze, drool,

muffled voice



  • Xrays
    • Lateral neck
    • Chest – inspiratory, expiratory, decubitus views
  • Expiratory views
  • Overinflation (partial obstruction with inspiratory flow)
  • Volume loss with mediastinal shift towards obstructed
  • side (partial obstruction with expiratory flow)
  • Atelectasis (complete obstruction)

Decubitus views

Normal Smaller volumes and elevated diaphragm

on side down

Abnormal Hyperinflation or “normal” volumes in

decub position

If suspected …

Need a bronchoscope to rule out or

remove Foreign Body



2 yo Boy with Barky Cough for 2 days

  • Runny nose, decreased appetite
  • Not himself
  • No PMHx / FHx of significance
  • Shots UTD
  • Other sibs with similar URTIs

On Exam …

Temp 38.9

HR 140

O2 sat 98% (drops to 90% when he crys)

RR 40 (mild indrawing)

Irritable, crying, good colour

H & N sl erythema of throat, no pus

N TMs, small cervical nodes

Chest Barky cough, inspiratory stridor

No wheeze noted



Racemic Epinephrine 0.5 ml dose

? Dexamethasone now or later

Re – Assess in 30 minutes

No improvement with 1st dose of epinephrine

What would you like to do now?


Re – Examine

Ongoing Inspiratory Stridor

Cries when trachea is examined

IV Ceftriaxone PLUS Cloxacillin

Consult Pediatric ICU / Pulmonary

for Bronch / Intubation


Bacterial tracheitis

  • An acute bacterial infection of the upper airway capable

of causing life-threatening airway obstruction

  • Staph aureus most commonly

(parainfluenza, Moraxella catarrhalis, H. influenzae, anearobes)

  • Most pts less than 3 years old
  • Usually follows an URTI (esp laryngotracheitis)
  • Mucosal swelling at the level of the cricoid cartilage,
  • complicated by copious thick, purulent secretions


Brassy cough

High fever

“Toxicity" with respiratory distress

(may occur immediately or after a few days of

apparent improvement)

Failed response to CROUP TREATMENT

(mist, intravenous fluid, racemic epinephrine)



Antibiotics (good Staph coverage)

Intubation or tracheostomy is usually necessary

? Decadron


Pediatric Pneumonia

Neonate Bacteria more frequent

E. coli, Grp B strep, Listeria, Kleb

1 – 3 mo Chlamydia trachomatis (unique)

Commonly viral (RSV, etc.)

B. Pertussis

1 – 24 mo S. pneumonia, Chlamydia pneum

Mycoplasma pneumonia

2 – 5 yrs RSV

Strep pneumonia, Mycoplasma, Chlam


Severe Pneumonia:

Staph aureus

Strep pneumonia

Grp. A strep


Mycoplasma pneumonia

Pseudomonas if recently hospitalized



Infants < 3 months Tachypnea, cough, retractions,

grunting, isolated fever or

hypothermia, vomiting, poor

feeding, irritability, or lethargy

As age increases, symptoms are more specific

Fever and chills, headache

Cough or wheezing

Chest pain, abdominal distress,

neck pain and stiffness


Physical Exam

Tachypnea is the best single indicator of pneumonia

Age in monthsUpper limit of Normal RR

< 2 60

2-12 50

> 12 40



Neonates Ampicillin + Gentamycin / Cefotaxime

1 – 3 mo Erythromycin 10 mg/kg IV Q6H

1 – 24 mo Cefuroxime 50 mg/kg IV Q8H (not ICU)

Ceftriaxone 50-75 mg/kg IV Q24H

and Cloxacillin 50 mg/kg IV Q6H (ICU)

3 mo – 5 yrs Ceftriaxone / Erythro

Clarithro / Azithro (outpt Tx)

respiratory failure where is the defect
Respiratory failure: where is the defect?




Abnormal oxygen carrying capacity

failure of cellular oxygen uptake

types of respiratory failure
Type I failure, also known as normocapnic or non-ventilatory failure, is indicated by hypoxemia (low pO2 ) with a normal or low pCO2.

It is commonly due to ventilation/perfusion (V/Q) abnormalities. Other causes include: impaired diffusion across the alveolar-capillary membrane (as occurs with pulmonary fibrosis and shunting)

Types of Respiratory Failure
Type II failure:

An elevated pCO2 is the hallmark , also known as ventilatory or hypercapnic failure.

It is generally the result of alveolar hypoventilation, increased dead space ventilation, or increased CO2 production. Other causes are factors that impair the central ventilatory drive in the brainstem, restrict ventilation, or increase CO2 production.

causes of type i failure
V/Q abnormaltities

Pneumonia, meconium aspiraton, Pulmonary oedema.

Cyanotic heart disease

Diffusion abnormalities

Interstitial fibrosis

Inadequate systemic blood flow


Inadequate oxygen carrying capacity

Severe anemia, methhemoglobinemia

Inadequate cellular uptake:

Cyanide poisioning

Causes of Type I Failure
type ii failure alveolar hypoventialtion

CNS disease, GB Syndrome.

Respiratory muscle disorders

Muscular dystrophy

Chest wall / pleura:

Pliable chest, pneumothorax, pleural effusion

Airway disorders:


Pulmonary disease

Bronchiolitis, pneumonia, asthma

Increased CO2 production:

Sepsis, fever, burn

Type II Failure: alveolar hypoventialtion
In children, respiratory failure most often is due to diseases of the lungs.
  • CNS disorders that lead to respiratory failure are:

Control abnormalities that cause Type II (hypercapnic) respiratory failure and usually present without signs and symptoms of respiratory distress (such as dyspnea, retractions, or tachypnea


A 16-year-old female arrives in the ED after the SLC result. No other history is available because the friends who brought him to the ED left.

The vital signs are:

  • Temperature (T) = 96°F;
  • Pulse (P) = 90 beats/min;
  • Respiratory rate (R)= 6 breaths/min;
  • Blood pressure (BP) =120/80 mmHg; and
  • Pulse oxygen saturation is 76% on room air.
normal abg values are po2 of 80 100 mmhg pco2 of 35 45 mmhg ph of 7 35 7 45 and sao2 of 95 100
Arterial blood gas (ABG) is: pH = 7.13; pO2 = 52; pCO2 = 81; HCO3 = 26; and oxygen saturation = 75% on room air.

Glasgow coma scale: 4.

Shallow respiration.

Pinpoint pupil.

Lungs and heart are normal

Normal ABG values are: pO2 of 80-100 mmHg; pCO2 of 35-45 mmHg; pH of 7.35-7.45; and SaO2 of 95-100%
  • This patient has hypercapnia and hypoxia.
  • Of the physiologic events in respiration, diffusion, transport, and the tissue/cellular uptake of oxygen are normal, but ventilation is impaired.
  • Pin point pupil points to the poisoning probably narcotic drug.
an 8 year old male muscular dystrophy
Eamination reveals rhinorrhea and excessive secretions in the oropharynx.

There are scattered rhonchi in the lungs bilaterally. There is no cyanosis.

The neurologic exam is consistent with his diagnosis of muscular dystrophy with muscle weakness

His vital signs are:

T = 100.2°F;

P = 120 beats/min;

R = 12 breaths/min; and

BP = 100/70 mmHg; and

Weight = 20 kg.

An 8-year-old male muscular dystrophy
normal abg values are po2 of 80 100 mmhg pco2 of 35 45 mmhg ph of 7 35 7 45 and sao2 of 95 10062
The ABG is: pH = 7.17; pO2 = 46; pCO2 = 78; HCO3 = 32; and O2 saturation = 71% on room air.

This patient has Type II hypercapnic respiratory failure secondary to failure of the respiratory muscles from a primary muscle disorder.

Normal ABG values are: pO2 of 80-100 mmHg; pCO2 of 35-45 mmHg; pH of 7.35-7.45; and SaO2 of 95-100%
a 4 month old female with breathing difficulties
Her vital signs are:

T = 103.5° F;

P = 190 beats/min;

R = 64 breaths/min;

BP = 80/50 mmHg; and

Pulse oxygen saturation = 82% in room air

Prematurity (30 weeks), respiratory distress syndrome requiring a ventilator. She also had a congenital gastrointestinal problem requiring surgery at 6 weeks of age and has continued to have gastrointestinal problems. She has bronchopulmonary dysplasia

A 4-month-old female with breathing difficulties.
normal abg values are po2 of 80 100 mmhg pco2 of 35 45 mmhg ph of 7 35 7 45 and sao2 of 95 10064
Small for her age. Respiratory distress with retractions, grunting, flaring, head nodding. Skin is pale, sweaty, and cyanotic with delayed capillary fill. There are rales in both lung fields. The chest roentgenogram shows diffuse bilateral infiltrates.

The ABG on room air is: pH = 7.61; pO2 = 56; pCO2 = 24; HCO3 = 27; and oxygen saturation is 78%.

Normal ABG values are: pO2 of 80-100 mmHg; pCO2 of 35-45 mmHg; pH of 7.35-7.45; and SaO2 of 95-100%
a 2 month old is brought to the ed with a chief complaint of not eating for several days
Vital signs are:

T = 36.8°C (R);

P = 180 beats/min;

R = 58 breaths/min

BP = 55/30 mmHg; and

Pulse oxygen saturation is 78% on room air.

O/E tachypnea, retractions, and cyanosis. The lungs are clear. The heart is tachycardic with no murmurs. The liver edge is down 2 cm. The abdomen is non-tender. There is no edema and no rash.

A 2-month-old is brought to the ED with a chief complaint of not eating for several days.
normal abg values are po2 of 80 100 mmhg pco2 of 35 45 mmhg ph of 7 35 7 45 and sao2 of 95 10066
ABG drawn on 100% FiO2 shows essentially no change from the room air blood gas: pH = 7.48; pO2 = 64; pCO2 = 35; HCO3 = 23; and O2 saturation is 79%.

An initial ABG reveals: pH = 7.48; pO2 = 62; pCO2 = 34; and HCO3 = 23.

Normal ABG values are: pO2 of 80-100 mmHg; pCO2 of 35-45 mmHg; pH of 7.35-7.45; and SaO2 of 95-100%
a 5 year old male is seen for a cough of several days duration that is not improving
O/E: sitting up and leaning forward. wheezing bilaterally. Tachypnic with intercostal retractions. Three continuous salbutamol aerosols were given by nebuliser.

Vital signs are:

T = 96.8°F (O);

P = 170 beats/min;

R = 44 breaths/min; and

Pulse oximetry is 94% on room air.

A 5-year-old male is seen for a cough of several days duration that is not improving
His lungs are clear, no wheeze or rales, and no retractions. He has dry mucous membranes and pale skin with tenting.

Vital signs are now:

T = 96.8°F (O);

P = 102 beats/min;

R = 16 breaths/min;

BP = 65/40 mmHg; and

Pulse oxygen saturation = 86% on room air.

First ABG ; pH = 7.52; pO2 = 58; pCO2 = 24; HCO3 = 14; and oxygen saturation = 88% on room air.

The second ABG shows: pH = 7.12; pO2 = 68; pCO2 = 70; HCO3 = 14; and oxygen saturation is 90% on 100% FiO2.

Normal ABG values are: pO2 of 80-100 mmHg; pCO2 of 35-45 mmHg; pH of 7.35-7.45; and SaO2 of 95-100%

treatment acute respiratory failure
Treatment: Acute Respiratory Failure

Hypoxemia is more dangerous than hypercarbia.

  • Administration of supplemental oxygen
  • Ventilatory support
  • Extracorporial Membrane Oxygenation (ECMO)

Never use bicarbonates unless lung can exhale