Hot Seat #49: 8 y/o bounceback for respiratory distress and wheezing
Posted on: January 15, 2015, by : Fareed Saleh MD
by Fareed Saleh, Children’s National
with Karen O’Connell, Children’s National
The Case
8 y/o girl returns to the ED for respiratory distress and wheezing after being discharged from the ED 1 day prior to this visit. During her initial visit she was evaluated to be in stable condition with a discharge diagnosis of LUL pneumonia (confirmed by CXR, below) and asthma exacerbation.
She was discharged with amoxicillin, albuterol and steroids but returned to the ED due to persistent respiratory distress. Associated symptoms of fever, nasal congestion and cough. Mother also noticed some cheek swelling after taking the amoxicillin. No other rashes or hives, denies N/V/D. Decreased PO intake, +UOP.
PMH: Wheezing (one episode ‘years ago’ per mother; never formally diagnosed with asthma)
PE: VS: T38.2 / HR 156 / RR 46 / BP 128/77 / 91% on RA (VS taken with albuterol last given 2 hours prior to this ED visit)
Gen: Alert, appropriate for age
Skin: Warm, dry, no rashes
HEENT: PERRL, EOMI, normal conjunctiva w/no discharge. TMs clear. Mildly tender, indurated swelling of LT cheek w/o skin discoloration and no dental caries
CVS: Tachycardia, regular rhythm, normal perfusion, no murmurs/rubs/gallops
Resp: Breath sounds diminished with wheezing (I/E) b/l, mild retractions
GI: Soft, nontender, nondistended, no HSM
Initial management given with albuterol, atrovent, steroids. Despite this, she continued to be tachypneic, with increased WOB, wheezing and poor air entry bilaterally. She now complains of chest pain as well. HR 166, RR 54, 90% RA.
You order the above, but given her exam you also give magnesium, 0.3 IM epinephrine, and IV bolus. She has minimal improvements.
Questions for you:
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
So, I always say that you are surrounded by assassins in the ED — trust no one! I am worried that the radiologist missed a potentially life-threatening diagnosis on the initial read of the CXR, and I’d like to get another CXR to reassess for the possibility of pneumomediastinum and air-leak syndrome tracking up into the fascial planes of the neck (and maybe into the cheek!) — based on what I might be seeing on the CXR depicted above with irregularities within the soft tissues of the right neck and the weird appearance of the mediastinum. I also think that it’s mighty convenient that there is no “neck” exam listed in the physical examination above. If there truly is pneumomediastinum on the CXR, then we would need to do everything possible to make it easier for this kid to breath and stop coughing — throw the book at them! Just my 2 cents, but certainly I could be over-reading the CXR.
Consider thinking of this case as what are the child’s Xray and exam telling me that I haven’t heard?
The framework of how I think of this child is to ask is it asthma or not? If so, is it a complication of asthma or just bad asthma. And if not, what else is it.
Is it asthma? A continued exacerbation of asthma is being appropriately addressed with the current treatment. Since the child is worsening, think through what else may need to be done: CO2 monitoring, watching for fatigue, next steps to support ventilation (such as BiPap).
Is it a complication of asthma? In thinking about air leaks, the worsening exam and new chest pain would fit with this. Any child with a worsening exam with asthma needs an Xray to look for dissection of air.
If it is not asthma, then I need to revisit my original diagnosis. If purely infections, then common causes include viral, atypical and bacterial pneumonia. There is no reason to consider the child to be immunocompromised given her overall normal appearance and lack of significant PMH. So would not worry about PJP or fungal infections. If this is not infectious, then what causes wheezing and respiratory distress? In my mind, I would go through CHF (not supported by film or exam), foreign body (diffuse and not localized wheezing, so less likely but still possible if tracheal foreign body), chest mass (not seen on film), lung disease such as LIP, and others.
What I would do now:
– talk to the Radiologist to review the first film along with a new film. It is helpful to ask the Radiologist what else the film looks like if it is not asthma or pneumonia.
– broaden antibiotic coverage: Vanco +/- azithromycin
– keep thinking a step ahead: if this is an air leak and if the child is worsening, what will be next steps to support breathing- 100% O2, NIV but may need to place chest tube, Heliox
Hmmm..so even though I am in the early years of my career – I think I can count how many times I have seen a left upper lobe pneumonia on my fingers. It is not that common. Deviation from the norm always makes me look at a patient twice or three times to be sure I am not missing something ominous. Given lack of improvement for a wheezing child with the appropriate initial regimen of bronchodilators and steroids, I would definitely go back to square one in reviewing the history and data collected so far. I agree with Dewesh – I would like a neck exam, a good lymph node exam and I would discuss with radiologist. Given symptom progression, I think it is reasonable to get a repeat x-ray to assess disease progression as well (per rads input). I would love a lateral view. Alternatively, It would be helpful to place an US on the chest to eval lungs for effusion and take a look at the heart (given this onset of chest pain) while you’re at it. The US can also be used to eval swelling of the cheek. Is that the parotid?
“All that wheezes is not asthma” – The title of a talk I give to residents of cases I’ve had over the years that include pericardial effusions, oncologic processes and “bad things” compressing the trachea or parts of the bronchial tree (rings, slings, foreign bodies, tumors). She is only 91% on RA and has been on bronchodilators for some time and worsening. The direction she is heading is not a good one so my money is on more imaging to figure out what’s going on in that chest.
(shorter version as my first submit looks like it didn’t post!)
Kid sick and circling the drain.
1. Call med alert and shared mental model on arrival of your working dx – asthmatic with pneumomedistinum and impending resp failure (hard signs: air under heart seen with the continuous diaphragm, subcut air above clavicles, mess of air borders around trachea, air in cheek).
2. Full court press on asthma: continuous albuterol with 100% o2, IV steroids, mag, terb bolus and infusion, ketamine 0.25 mg/kg boluses, SC Epi.
3. Avoid bipap/cpap if possible given increased intraluminal air pressure and continued air leak; prep intubation tray but avoid for the same reason.
4. Call PICU to get bed ready.
5. Then order ekg, repeat portable cxr, labs. Doing these first, esp if in the room, would kill valuable time. I think you have 15-60 minutes to improve this kid before she tires out and these tests could easily take that long without providing any therapeutic improvement.
This 8 yr pt with resp distress, wheezing, recent dx of LUL pneumonia and asthma exac, now with worsening symptoms and new cheek swelling. Her vitals and presentation are concerning: tachycardic outside normal post 2hr alb neb response for 8 yr old, tachypneic, hypoxic and in distress.
ED care to present was appropriate with escalating her RAD care (one prior episode with RAD components with viral process) – IM Epi, mag, ivf
However, little improvement of symptoms necessitates a hard ‘reflection’ on the part of the providers. First – avoid diagnostic bias: revisit the HPI, CC, etc.. and broaden your differential.
Is this just plain bad RAD/asthma/viral or bacterial pneumonia? Has she developed a complication for the above issues: ptx, pneumomediastinum, pleural effusion, development of ARDS?
While your brain is working through the ddx and best approach, your physical body is at her bedside watching for responses to your interventions.
Every re-eval should be shared with team – group think is really the best. This is where you discover lapses in care, lapses in response, development of sense of urgency.
My approach – review xray from day prior and repeat to see progression of illness.
Dewesh’s 2 cents are always worth something! She clearly has subcutaneous emphysema extending up bilateral cervical planes and down into supraclavicular regions. She has patchy interstitial infiltrates and a LUL infiltrate. I would personally review the xray with the radiologist and discuss the patient’s current state. Working through the ddx with the radiologist is very helpful: eg. primary pulm infectious vs reactive; cardiogenic with pulm edema; FB with reactive component; systemic inflammatory/rheum such as sarcoidosis; malignancy/chest mass.
Rx options: I would increase her RAD therapies; broaden her infectious coverage for atypical pneumonia; but most importantly, seek means of supporting her symptoms/preventing deterioration. Here is where the repeat xray is key. Does she need more positive pressure? Less positive pressure? 100% FiO2? Drainage of aberrant air or fluid collections? (IF these are causing CV/resp compromise, put a tube in it!)