The Pediatric Wheezing Podcast
An original Only in Staten podcast. Dr. Dana Libov returns to discuss pediatric wheezing with Dr. Anand Swaminathan.
Why it matters
Wheezing is one of the most common presentations in the pediatric ED. It can mean very different things in a 6-month-old and a 6-year-old.
General principles
Age matters
Bronchiolitis mainly affects infants under 2 years.
Croup classically affects children from 6 months to 6 years.
Reactive airway disease (RAD)/asthma exacerbation: no defined minimum age, but generally over 6–7 months. Certain age-related factors point toward RAD rather than other causes.
What not to do matters as much as what to do
Do not reflexively give albuterol to every wheezing baby.
If you are confident the diagnosis is croup or RAD/asthma, do not delay steroids.
Chest X-rays are not diagnostic for any of these diseases. Reserve them for:
severe symptoms or poor response to treatment
significant hypoxemia
a markedly asymmetric lung exam
Croup
Pathophysiology: upper airway obstruction from subglottic edema.
Age: classically 6 months to 6 years.
Presentation: 1–3 days of URI symptoms progressing to a barky cough and stridor, with or without respiratory distress.
Etiology: many viruses (for example, influenza, COVID-19). The classic cause, important for the in-service exam, is parainfluenza.
History pearls:
Symptoms often start or worsen overnight, because of positioning and dependent airway edema.
Parents often describe stridor as "wheezing" in a child who has never wheezed before.
Stridor often resolves on the way to the ED because of cold air.
Treatment:
Dexamethasone 0.6 mg/kg PO (max 16 mg). The IV formulation can be given orally, because it is more concentrated.
Racemic epinephrine: indicated only for stridor at rest. It provides temporary improvement while the steroid takes effect.
Observe for 2 hours after racemic epinephrine for recurrent stridor.
Per the episode, up to three doses of racemic epinephrine may be given, every 2 hours as needed, before admission.
Bronchiolitis
Pathophysiology: a poorly named "-itis" that really runs from the nose to the lungs, classically affecting the bronchioles.
Age: under 2 years.
Presentation: URI symptoms that peak around days 3–5, with increased work of breathing and fine crackles or wheezing. Classically, the infant with snot running down the nose and trouble breathing.
Etiology: any virus. RSV has a higher admission rate.
Treatment:
If there is a strong personal or family history of atopy and the child is over 6 months old, an albuterol trial may be worthwhile. If there is no improvement, it is likely bronchiolitis, and supportive care is the only treatment.
Suctioning before feeds and during respiratory distress makes a big difference. Good nasal suctioning improves feeding and eases work of breathing.
If the infant is in significant distress, escalate respiratory support. HFNC is preferred; consider CPAP/BiPAP for significant distress. Much like adults with interstitial disease, these patients tend to do better on HFNC than on BiPAP.
Reactive airway disease/asthma
Pathophysiology: bronchospasm and airway inflammation.
Age: older than about 6 months.
Presentation: URI symptoms plus respiratory distress with wheezing.
Etiology: most commonly triggered by a viral illness.
History pearls:
Start considering RAD from 6 months of age in a child with atopic history, such as eczema or food allergy.
If you cannot tell bronchiolitis from RAD, a trial of albuterol can help steer the diagnosis.
The pathophysiology is the same as the COPD exacerbations you already treat confidently.
Treatment:
Dexamethasone 0.6 mg/kg PO (max 16 mg) (IV formulation given orally). It reduces airway inflammation and also acts on β-receptors to make albuterol more effective after discharge.
Ideally give it within 1 hour of ED arrival. NNT 5–8 to prevent admission. (Max dose per Connecticut Children's ED asthma pathway.)
Bronchodilators for moderate/severe disease, every 20 minutes:
< 30 kg: albuterol 2.5 mg + ipratropium 500 mcg
> 30 kg: albuterol 5 mg + ipratropium 500 mcg
Adjuncts as needed: IM epinephrine, magnesium, non-invasive ventilation.
Clinical pearls
Croup is stridor; bronchiolitis is snot; asthma responds to albuterol. Use age and history to tell them apart.
Steroids early for croup and asthma; supportive care and suctioning for bronchiolitis.
Save chest X-rays for the sick, the hypoxemic, and the asymmetric.
