Pneumonia incidence varies inversely with age, whereas the

etiology changes based on the season and age of the patient.

Important secondary causes of respiratory distress

include congenital heart disease, cardiac tamponade,

myocarditis/pericarditis, tension pneumothorax, central

nervous system infection, toxic ingestion, peripheral nervous system disease (eg, Guillain-Barre syndrome, myasthenia gravis, botulism), metabolic disorders ( eg, diabetic

ketoacidosis), hyperammonemia, and anemia.

CLINICAL PRESENTATION

..,._ History

Initial treatment may be required for stabilization before a

complete history and physical examination can be performed.

Ask for a description of respiratory problems, including

onset, duration, and progression of symptoms. Keep in

mind that respiratory distress can present as difficulty with

feedings in infants and decreased activity or feeding in toddlers. Inquire about precipitating or exacerbating factors.

Ask if there was any recent history of choking, as this may

be the only clue for a foreign body aspiration. Inquire if

they have ever had a similar presentation in the past.

Review all prior medications (chronic and acute) and note

time of administration. For example, how many times

albuterol was given per day in the past several days and the

last time given before coming to the ED. Ask if immunizations are up to date, as failure to do so could put the child

at risk for rare diseases (ie, epiglottitis, pertussis). Review

in detail all past medical history. Infants born prematurely

may have bronchopulmonary dysplasia (BPD), making

reactive airway disease, respiratory infections, hypoxia, and

hypercarbia more likely. When treating children with

asthma, ask about frequency of exacerbations, if they ever

required intubation or positive pressure ventilation, previous admissions (ED, general floor, intensive care unit) and

the last time they were on steroids. A history of chronic

cough or multiple previous episodes of pneumonias may

be suggestive of a congenital condition, undiagnosed reactive airway disease, or foreign body aspiration.

..,._ Physical Examination

The assessment should be conducted in a calm, efficient

manner, with assistance from parents. Agitating a child can

worsen symptoms and even precipitate acute decompensation, especially in suspected upper airway obstruction.

Allow the child to assume a position of comfort. Take extra

caution if the patient is presenting in the sniffing position

(head and chin are positioned slightly forward), as this may

indicate severe upper airway obstruction. Likewise, if the

patient is presenting in the tripod position (leaning forward

and supporting the upper body with their hands), this indicates severe lower airway obstruction, and this position will

optimize their accessory muscle use. Respiratory rate varies

in relation to age: newborn (30-60); 1-6 months (30-40);

6-12 months (25-30); 1-6 years (20-30); > 6 years (15-20).

Heart rate also varies with age: newborn ( 140-1 60),

6 months (120-160), 1 year (100-140), 2 years (90-140),

4 years (80-l lO), 6-14 years (75-100), > 14 years (60-90).

Keep in mind that tachycardia is typical with albuterol

treatment.

Skin exam can show diaphoresis, cyanosis (peripheral

or central), rash (eg, hives), bruising, or trauma and can be

a clue to the cause of respiratory distress. Make sure to fully

unclothe the patient, taking care not to worsen distress.

Stridor indicates upper airway obstruction, and the

phase of the respiratory cycle in which it occurs is a clue to

the location of obstruction. Inspiratory stridor is seen with

subglottic/glottis obstruction above the larynx ( eg, epiglottitis). Nasal flaring, dysphonia, and hoarseness also suggest

upper airway obstruction. Expiratory stridor is consistent

with obstruction below the larynx, in the bronchi or lower

trachea. Croup is the most common cause, but also consider foreign body, epiglottitis, anaphylaxis, angioedema,

peritonsillar abscess, retropharyngeal abscess, tracheomalacia, laryngomalacia, or obstructing mass.

Inspect the chest for depth, rhythm, and symmetry of

respirations. Retractions indicate accessory muscle use.

As the involved muscle groups move more superiorly (subcostal, intercostal, suprasternal, supraclavicular), airway

obstruction is more severe. Also examine the chest and

neck for any crepitus.

Lung exam is particularly important. Pneumothorax is

suggested by unilateral decreased or absent breath sounds,

but this finding is not always present. Wheezing and a prolonged expiratory phase indicate lower airway obstruction.

It is important to note that in patients with very severe

lower airway obstruction, wheezing may be absent as a

CHAPTER 49

result of poor aeration. Crackles, rhonchi, and decreased or

asymmetric breath sounds are found with alveolar disease.

Grunting prevents alveolar collapse and preserves func ­

tional residual capacity (FRC). Its presence implies severe

respiratory compromise.