Episode 37: The pediatric wheezing Podcast feat. dr. dana libov and dr. anand swaminathan
Learning Points:
Age Matters (e.g. wheezing may mean something different in a 6 month old vs. a 6 year old)
Bronchiolitis primarily affects infants under 2
Croup classically effects 6 months - 6 years
Reactive Airway Disease/Asthma Exacerbation: no defined age minimum, but generally >7 months though there are certain age factors that make you think of reactive airway disease vs. the other etiologies
What not to do is just as important as what to do
Don’t reflexively give albuterol to every wheezing baby
If confident it is croup or RAD, asthma - don't delay steroids
Xrays are not diagnostic for any of these diseases. They should be reserved for:
Severe symptoms or poor responders
Significant hypoxemia
Markedly asymmetric lung exam
Croup
Pathophysiology: Upper airway obstruction due to subglottic/parapharyngeal edema
Age: classically 6mo-6years
Classic Presentation: 1-3 days of URI symptoms with progress to barky cough, stridor +/- respiratory distress
Etiology: Many viruses can cause croup (e.g. influenza, covid) though classically parainfluenza (important for in-service)
History Pearls:
Often presents or worsens overnight due to airway positioning and dependent edema
Parents will often describe stridor as "wheezing" (in a child who has never wheezed before). Stridor often resolve en route due to cold air.
Treatment:
Steroids: Dexamethasone 0.6 mg/kg IV for oral use (more concentrated)
Racemic Epinephrine:
Indicated ONLY for stridor at rest
Provides temporary improvement while steroids take effect
Monitor for 2 hours after racemic epi to monitor for recurrence of stridor.
May administer up to three doses of racemic epinephrine every 2 hours prior to admission, as needed
Bronchiolitis
Pathophysiology: It is named poorly, it really is an –itis from nose to lungs, though classically affecting the bronchioles
Age: <2 years old
Classic Presentation: URI symptoms, worst on day 3-5 with increased work of breathing and fine crackles or wheezing on exam. It is classically the snotty kid with snot dripping down their nose
Etiology: Can be caused by any virus but RSV has a higher admission rate
History Pearls:
Again think of the child less than 2 years old with snot running down their nose and difficulty breathing
Treatment:
If there is a strong personal or family history of atopic diseases and the child is greater than 6 months a trial with Albuterol may be worth a try. If no improvement, then it's likely bronchiolitis and supportive care is the only treatment.
Supportive care:
Suctioning before feeds and when kids are in respiratory distress can make a big difference. Good nasal suctioning can really improve how well they feed and ease their work of breathing.
If in significant distress, NIPPV (preferably HFNC but if in significant distress, consider CPAP/BIPAP. Think of these like your adults with interstitial disease that benefit from HFNC over BIPAP.
RAD/Asthma:
Pathophysiology: bronchospasm and airway inflammation
Age: older than 6 months old
Classic Presentation: URI symptoms + respiratory distress with wheezing
Etiology: most commonly precipitated by viral illness
History Pearls:
Start to consider at 6mo with atopic history such as eczema or food allergies
If you're clinically unsure between bronchiolitis vs. RAD, trial of albuterol can help steer diagnostic momentum
Remember same pathophysiology as your COPD exacerbations which you can treat with your eyes closed!
Treatment:
Steroids: Dexamethasone 0.6 mg/kg IV for oral use (more concentrated)
Used both to decrease airway inflammation and because it affects the beta-receptors to make albuterol more effective upon presumed discharge
Ideally administered within 1 hour of presentation to the ED.
NNT 5-8 to prevent admission
Bronchodilators:
<30 kg: 2.5 mg albuterol + 500 mcg every 20 minutes for moderate/severe disease
> 30 kg: 5 mg albuterol + 500 mcg every 20 minute or moderate/severe disease
Adjunts as needed:
IM epi
Magnesium
NIPPV
