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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). t

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. t
    • 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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