Harvey's Garden

Acute Respiratory Distress in Children

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A key differentiator is that upper airway obstruction typically causes stridor (an inspiratory sound), while lower airway disease is characterized by wheezing (an expiratory sound).

Upper Airway Diseases

The primary sign of upper airway obstruction is stridor, a high-pitched sound caused by turbulent airflow through a narrowed larynx or trachea.

  • Croup (Laryngotracheobronchitis)
    • Site: Larynx, trachea (subglottic region).
    • Etiology: Parainfluenza virus.
    • Presentation: Age 6mo-3yr. Barking seal-like cough, inspiratory stridor.
    • Dx: Clinical. X-ray: Steeple sign.
    • Tx: Corticosteroids (dexamethasone). Nebulized epinephrine if severe.
  • Epiglottitis
    • Site: Epiglottis and supraglottic structures.
    • Etiology: Hib (less common post-vaccine).
    • Presentation: Age 2-7yr. Acute high fever, drooling, tripod position. Medical emergency.
    • Dx: Lateral neck X-ray: Thumbprint sign. Do NOT examine throat.
    • Tx: Secure airway in OR. Ceftriaxone.
  • Foreign Body Aspiration
    • Site: Right mainstem bronchus is most common. Can be anywhere in tracheobronchial tree.
    • Presentation: Toddler (1-3yr). Sudden choking. Unilateral wheezing or diminished breath sounds.
    • Dx/Tx: Rigid bronchoscopy.

Lower Airway Diseases

Lower airway diseases involve the bronchi and bronchioles, typically presenting with wheezing, tachypnea, and increased work of breathing.

  • Bronchiolitis
    • Site: Small airways (bronchioles).
    • Etiology: RSV.
    • Presentation: <2 yr old. URI sx followed by tachypnea, diffuse wheezing/crackles.
    • Tx: Supportive: nasal suctioning, O2, hydration.
    • Prophylaxis: Palivizumab for high-risk infants.
  • Asthma
    • Site: Bronchi (reversible bronchoconstriction).
    • Presentation: Recurrent wheezing, cough (worse at night).
    • Tx: Acute: Albuterol (SABA). Chronic: Inhaled corticosteroids (ICS).

Parenchymal Disease

  • Pneumonia
    • Site: Lung parenchyma (alveoli).
    • Etiology: Viral (RSV) or bacterial (S. pneumoniae).
    • Presentation: Fever, cough, tachypnea. Exam shows crackles or focal decreased breath sounds.
    • Tx: Viral is supportive. Bacterial is Amoxicillin.
  • ARDS
    • Site: Alveolar-capillary membrane.
    • Etiology: Sepsis, pneumonia → diffuse alveolar damage.
    • Presentation: Severe, refractory hypoxemia (PaO2/FiO2 < 300).
    • Dx: CXR: Bilateral pulmonary infiltrates (“white-out”).
    • Tx: Low tidal volume ventilation + PEEP.

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