Hot Seat Case #106: 16 month old male with respiratory distress
Posted on: January 31, 2018, by : Sarah Isbey
Sarah Isbey, MD Children’s National Medical Center
with Emily Willner, MD Children’s National Medical Center
16 mo old male who presented with cough and congestion for 3 days. The caretaker noted that he had a runny nose, tactile fevers, and cough for 3 days, worse at night, with decreased PO of solids but drinking well and normal wet/dirty diapers. She brought him in because of his history of getting “really sick with colds,” including a previous hospitalization for bronchiolitis requiring ECMO, complicated by a DVT (currently on anticoagulation therapy).
PMHx: full term, no NICU stay; admission as above
Fam Hx: no history of asthma or other respiratory issues
Soc Hx: lives at home with MOC, FOC, and BOC
Meds: Lovenox BID
Allergies: None
ROS: notable for cough, congestion, tactile fevers. No vomiting, diarrhea, abdominal pain, ear pain, syncope, or seizure-like activity.
Vital signs: Febrile 38.6, P 130, R 55, BP 90/74, 95% on RA
General: Tired but calm in parents’ arms
Skin: Warm. intact.
Head: Normocephalic. atraumatic.
Neck: No lymphadenopathy
Eye: PERRLA, EOMI, Clear conjunctiva
Ears, nose, mouth and throat: Oral mucosa moist. Crusted clear rhinorrhea
Cardiovascular: Regular rate and rhythm. No murmur.
Respiratory: Subcostal and intercostal retractions, mild belly breathing. Coarse throughout with intermittent fine crackles on R side.
Gastrointestinal: Soft. Nontender. Non distended. No organomegaly.
Neurological: Alert. Pushes examiner away
You decide to suction the patient and give Tylenol. 45 minutes later, he remains tachypneic to 50 with belly breathing despite these interventions; sats are in low 90s.
The mother mentioned that on the patients last CXR before discharge his right lung wasn’t as well inflated as the left and asks you what you think of his exam. Repeat clinical exam with coarse crackles throughout and transmitted upper airway noises. You place him on LFNC for work of breathing.
You order a CXR that shows mild hyperinflation but not evidence of lung collapse or pneumonia. Upon further review, it appears the patient is up to date with all his vaccinations except the flu.
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With flu/bronchiolitis season raining down on us this case comes at no surprise. I think its quite clear this patient has such and sounds like between the borderline hypoxemia and work of breathing, the child needs some more help. If we were keeping it to EBM then my response to the first question would be to ignore the first two choices for sure and start with a normal saline bolus as well as supplemental oxygen for “comfort/work of breathing”. Sounds like the infant does not quite meet the hypoxemia threshold to justify supplemental oxygen otherwise. I tend to, however, have a low threshold for HFNC if my previous decisions have made little improvement.
What makes this child stand out from others is clearly their prior history and current medication regimen. I think this childs history and presentation still very much fit the typical illness script for bronchiolitis and not a PE. Therefore in my mind the CT is not a priority at this time and would probably hold on the cxr as well. My impression is that this child is getting admitted anyways and so if the course worsens, those things can be done later.
As far as the last question, this child meets high risk criteria according to the CDC and with the massive influenza wave we are seeing, I would preemptively treat with tamiflu and forgo testing.
This case touches on a lot of what we think about when we see a child with mild-moderate brochiolitis in the ED: who is likely to get much sicker than they look now, and who looks like they have bronchiolitis, but are trying to fool us and it’s really something else (pneumonia, myocarditis, etc).
Looking at the literature of which infants with bronchiolitis worsen after an ED visit or admission to a regular inpatient unit, there are recurring themes across the ED and hospitalist studies: historical factors predictive of clinical worsening include male sex, previous hospitalization, birth weight <5lbs, gestational age <37 wk, age 70, and poor PO intake. This bears out what we intuitively know- little babies, premature infants, and those who are “sick” on presentation are more likely to get sicker.
This case falls way outside the normal healthy bronchiolitis baby, though, and I’d definitely consider him high-risk since even if he did not have CLD before his ECMO stint, he certainly has chronic lung changes now. I’d start with a suction/bronchodilator trial, but have a low threshold to escalate to other respiratory support if he worsens. With his history and asymmetric lung findings, I’d also get a CXR as was in this case.
Despite his hx of DVT, PE would remain fairly low on my ddx. If the DVT was catheter-associated, in the setting of critical illness/ECMO, and he is currently on therapeutic anticoagulation, my level of concern would be quite low. At admission, I would make a point of mentioning to the admitting team to consider further evaluation of this if his clinical course is not progressing as expected. PE aside, and especially if he has had past lower respiratory issues aside from his severe respiratory failure, he needs workup for other chronic lung conditions such as CF or primary ciliary dyskinesia. This can also be done by the inpatient or outpatient teams following him.
Finally, assuming that this case takes place in our current Epoch of The Flu, I personally would empirically treat with Tamiflu rather than testing.
I’d have a lower threshold for admission in this child- he’d need to look pretty awesome (medical terminology) to be able to go home, given his history of recent severe respiratory failure/ECMO (eek). If he appears to have adequate sats and improved RR and WOB on LFNC, he can go to the floor on his LFNC and with a PIV in place.
Re: treating with Tamiflu empirically, I find myself treating empirically only if the patient is high risk and presenting within 48hrs of symptoms onset. The side effects of Tamiflu can be significant, and I wouldn’t want to subject the already-sick baby to nausea, vomiting, and diarrhea with neither proof of influenza infection nor evidence that the medication will make a significant difference in his clinical course given the timeline of symptoms.
I chose to send the full pathogen PCR panel mostly due to “systems” practice – it sounds like he’s headed for HFNC, which means he’s headed for the PICU, which means that he’ll ultimately get a respiratory pathogen panel sent (this appears to be standard PICU practice). Therefore, if I send it earlier, they can have answers earlier (and maybe start Tamiflu in the PICU). I’m not sure that I would’ve sent it in a baby that’s improving with interventions and floor-or-home bound.
Finally, would LOVE to hear everyone’s thoughts on LFNC or “oxygen for comfort”. I’ve had hospitalists reject my suggestion that WOB improved with supplemental oxygen and suggest that oxygen should only be utilized as a treatment for true hypoxemia (i.e. low pulse ox). I would argue that increased WOB can be a compensatory mechanism for hypoxia (i.e. the supply of oxygen is not sufficient to support life functions), and supplemental oxygen is thus an appropriate treatment. I’ve also heard the concern that supplemental oxygen may mask hypercarbia and developing respiratory failure.
Thoughts?