Respiratory distress in children is caused
by either upper or lower airway diseases. Upper airway obstruction is recognized by
the presence of stridor, a high pitch sound often audible without a stethoscope, mainly
on inspiration but can also be heard on expiration. Aspiration of a foreign body, especially frequent
in the 1-3 age group, must be ruled out. A history of aspiration may be offered by the
patient or family. Remember to get imaging – while the foreign body may be lucent,
look for signs of hyperinflation. Another serious cause of upper airway obstruction
is viral laryngotracheobronchitis or croup. Patients with croup have a stridor and usually
have a cough that sounds like a seal barking. A dose of systemic corticosteroid will alleviate
the obstruction for the course of the illness, but nebulized epinephrine may sometimes be
necessary to reduce the edema quickly to relieve the acute respiratory distress. A rare but
severe complication of croup is bacterial tracheitis. Lower airway obstruction presents with shortness
of breath, a prolonged expiratory phase, wheezing and accessory muscle use. In children over two years old, viral induced
asthma is the most common cause for this presentation. Inhaled bronchodilators are used for symptomatic
relief, but corticosteroids are essential to settle the lower airway inflammation.
Bronchiolitis is caused by a viral infection in infants less than 12 months of age and
while it may present very similarly to asthma, it does not respond to bronchodilators or
corticosteroids. Recommended management include supportive care such as intravenous hydration
(if the infant is too distressed to feed) oxygen supplementation (if the oxygen saturation
is below 90%) and ventilatory support (for impending respiratory failure).
Pediatric pneumonia often presents after symptoms of viral upper respiratory infections, but
with fast breathing and lung crackles. Lung radiography confirms the diagnosis and the
pattern of infiltrate or consolidation may guide antibiotic selection.