Hot Seat Case #90: 7 yo F in respiratory distress
Posted on: March 13, 2017, by : Evan Sherman
Evan Sherman MD, Children’s National Medical Center
With Emily Willner MD, Children’s National Medical Center
The Case
A 7yo F is brought in by EMS for respiratory distress. The patient was in school when she complained that she felt “wheezy.” She has a history of asthma, but did not have an albuterol pump at school, so EMS was called. On arrival, the EMT found the patient to be short of breath with diffuse wheezing on respiratory exam. SaO2 at that time was 88%. The patient was given 5mg albuterol and 500mg ipratropium via nebulizer, after which her respiratory distress and O2 saturation improved. She was then brought to our ED, with her mother on the way. As you review her history in the hospital EMR, you note three ED visits for asthma over the past year, but no prior admissions. The patient reports absolutely no symptoms at this time, and denies having felt unwell in the past few days.
PE:
VS T 99.2F HR 116 RR 16 BP 100/70 S 96% RA
Gen: Well appearing, no distress
HEENT: Mild rhinorrhea, OP clear, TMs clear, no cervical LAD
Cardiac: RRR, NS1S2, no m/r/g. Well perfused.
Respiratory: No retractions, good aeration, clear lungs, no focality
Question #1:
Before you are able to make this decision or give any medications, the mother arrives. She is obviously annoyed, and states, “I wish the school had just called me. She doesn’t need to be here.” The mother does endorse that her daughter has had clear rhinorrhea over the past 2 days, but otherwise no symptoms and no recent albuterol use. She confirms the history as follows:
PMH: asthma, no controller meds, no admissions
Vaccines: UTD
Meds: None
The mother asks to be discharged. She states that her daughter “looks even better than she usually does” and that she “can handle this at home.” It has now been 60 minutes since the patient received albuterol from EMS.
Question #2:
Before you are able to implement your plan, the patient develops subcostal retractions and diffuse expiratory wheezing. You explain to the mother that the patient will require additional treatment, and she reluctantly agrees. You treat the patient as per the ED’s “asthma pathway” with 15mg albuterol, 1000mcg ipratropium, and oral steroids. After the treatment, the patient’s repeat exam is as follows:
VS HR 128 RR 16 S 94% RA
Gen: Well appearing, no distress, well perfused, reading a book
Respiratory: No retractions, good aeration, clear lungs, no focality
Question #3:
You explain your rationale to the mother, who reluctantly agrees.
The patient’s exam remains unchanged until 2 hours after albuterol, at which point she again develops wheezing and mild subcostal retractions. You give another hour-long albuterol treatment. Despite your explanations, the patient’s mother becomes increasingly adversarial. She states that she “doesn’t have time for this,” and that “I can do this at home.” After the treatment, the patient is again comfortable with clear lungs. You explain to the mother that you will again need to observe the patient to make sure she does not need additional treatment. She does not respond and instead looks off into the distance. After an hour of observation, the mother comes out to the nursing station and says to you, “Come listen to her, because we’re leaving.” On exam, she remains comfortable with clear lungs.
Question #4:
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Since a few folks have already seen it and voted but not commented, I have to say that a couple pieces that I would want to do along the way….
1) Seriously consider an airway foreign body causing these recurrent seemingly severe symptoms that may be functioning in some kind of ball-valve process. This happened at school “all of a sudden” ish.
2) Really sit down and talk to mom and see what the real problem is as to why she’s in a rush to get out of here. Some of my stock language is “We don’t want you to be here any longer than necessary either,” “We are just looking out to make sure your child is safe to be able to be at home.” In this case, personally I would throw in, “I’m not sure if this is really just asthma that’s the problem. Sometimes our treatments for asthma can temporarily relieve the symptoms actually caused by something else.” Often time, as Jennifer reminds me constantly, it could be kids at school, time off from work, pick-up/drop off, sick family member that is really distracting her, and in those stressful times, it’s hard to think clearly.
Let’s see what plays out….
I, respectfully, disagree with Pavan here. It’s hard to believe that an airway foreign body in this 7 yo could be causing such reproducible improvement with simple beta-agonist therapy. This smells, tastes, and sounds like asthma to me, and I’m pretty sure I’d not be barking up another tree.
I’ll go out on a limb (to carry that tree analogy a little farther!) and state that it’s OK to discharge asthmatics who are wheezing and might even have mild retractions from the ED. Asthmatics wheeze — that’s what they do. If you want clear lungs from an asthmatic in the midst of an exacerbation (from an URI), you’ll be keeping a lot more kids than you need to — and driving up healthcare costs. I often have to re-teach trainees that as Asthma Score of 3 (out of 10) is OK to be D/C-ed home from the ED, and the child will likely still be wheezing for a few more days! FYI, diffuse expiratory wheezing and subcostal retractions is still only an AS of 2/10 — OK to be d/c-ed home safely in my opinion.
Just my 2 cents,
Dewesh
I agree with Dewesh. Also, in situations like this, I call the PMD and sometimes engage in a three way convo over the phone so we are all on the same page. It has helped in situations where the family has a good relationship with PMD. You dont have to be perfectly clear on lung auscultation to be d/c’d by me (especially if parents are insisting on leaving) — but you have to have comfortable respirations. If I want to convince myself and mom that things are good – I’ll even make you walk with me around the unit briskly to ensure you don’t end up in a wheezing fit with exertion. If you pass that test –you’re good to go and I am documenting the heck out of the chart about all the d/c criteria met and the family education provided.
There are 2 parts of this case to consider: medical and social.
Medically, I agree with Dewesh that this really sounds like asthma, especially with the rapid and complete response described to albuterol. However, there are a few things that don’t quite fit. The rapidity and completeness of the response, without any symptoms or findings, followed by the sudden onset of symptoms again is a little atypical. Most kids don’t go from totally clear/no distress to wheezing/wheezing working in 10 min while sitting in the ER (emotional upset, physical activity, or irritant exposure could bring this on, though). I’d entertain a few other possibilities, if that’s really what happened.
In school age and older kid who have sudden onset, intermittent difficulty breathing which rapidly resolves, consider paradoxical vocal ford motion (aka vocal cord dysfunction). These kids can be really hard to differentiate from asthma as they have diminished air entry and apparent I/E wheezing on exam. Some appear to respond to albuterol becuase an episode of abnormal vocal cord motion resolves concurrent with albuterol treatment. They can have sudden and apparently severe return of symptoms. The thing about this case that does NOT fit is the documented hypoxia (88% with EMS, 94% after her round). If you were concerned about vocal cord dysfunction, flexible laryngoscopy by ENT while symptomatic is diagnostic.
While not likley, I agree with Pavan that I’d at least consider an airway foreign body with a ball-valve. The resolution of her sx with albuterol each time makes this unlikely, but the suddenness with which they return is weird. If she had any focality, or if my sense was that this was not acting like a typical asthma exacerbation, I’d do a CXR with inspiratory and expiratory views (better than decubs if able to comply). External compression of the trachea or bronchi by a mass or a vascular anomaly is possible, but the albuterol responsiveness makes this less plausible. These conditions may have positional “wheezing”, or appear worse with exertion, which doesn’t seem to be the case here.
Anaphylaxis can present with albuterol-responsive wheezing, and is something to consider, but no other sx or findings doesn’t meet criteria.
I have to admit, that as this case is written, if the kid had gotten 2 duo-nebs by EMS, and was totally fine on arrival without any resp findings and with normal VS, I’d probably give her oral steroids in ED and for home, watch her for an hour or so, and send her out with mom if no parental concerns and assurance of followup.
Socially, I feel like I encounter similar situations not infrequently, especially with respiratory patients. I have started pre-emptively telling families exactly how long to expect. My script is approximately “We are going to give a treatment that lasts 1 hour, and after that is done we will check to see if he needs more. If he does not, we will watch for 2 hours after that to make sure the breathing difficulty does not return. If it comes back before the 2 hours, we will need to give more and we will need to watch for longer. Expect to be here for at least 3-4 hours from now, possibly longer. Let us know if there is anything we can do to make your time here better.”
If someone is really worked up and wanting to leave, I agree with taking a moment to hear the parent’s concern (most often they have another child to pick up or care for). I also explain (again) my reasoning for watching. I try to point out concrete data the parent can see (in this case, I’d reference the low sat with EMS, and the 94% sat post round).
As Dewesh and Joelle said, clear lungs are not a requirement for DC, but I don’t like to send patients out diminished, or with retractions (unless a well-appearing bronchiolitic). That said, if I felt quite certain that this patient had asthma and didn’t need further workup, I’d talk with mom, try to convince her to stay longer- ideally at least until I spoke with the PCP. I’d make absolutely sure she understood the importance of scheduled albuterol, PCP followup, and returning to ED promptly if worsening. But especially with an older child with no complaints or findings and totally normal VS an hour after a round, I would document well, and discharge home.