Case #3 - Acute Respiratory Distress in a 3-Year-Old at Daycare

Wesley C. Crowell, MD; Sheryl A. Falkos, MD; Karen D. Crissinger, MD

Disclosures

February 10, 2003

Introduction

A 3-year-old white male developed stridor and respiratory distress while eating lunch at his daycare facility. Upon admission to the emergency room, direct laryngoscopy revealed a food bolus at the level of the posterior pharynx that was easily removed with a rigid suction catheter. The patient's stridor initially improved, but symptoms returned and transport to a tertiary care facility was initiated. On arrival, the child was in severe respiratory distress with signs of respiratory failure. According to his mother, the child was developmentally normal and had been in good health recently.

The child had a tracheoesophageal fistula repaired when he was 2 days old and underwent esophageal dilation and Nissen fundoplication secondary to severe gastroesophageal reflux disease at the age of 9 months. Because of a history of failure to thrive, a gastrostomy tube was also placed at this time to allow continuous night feedings.

The child had a history of 2 previous hospitalizations, which included: (1) treatment for pneumonia at 10 months of age, and (2) an admission following "choking on food" 8 months ago. The child has a ventriculoseptal defect that is nonsymptomatic.

Vital signs were as follows: rectal temperature 98.6° F, pulse 149, respiratory rate 28/min, blood pressure 125/58 mm Hg, peripheral oxygen saturation on high-flow oxygen by face mask 100%, weight 12 kg.

The patient was in severe respiratory distress prior to intubation. Substernal and subcostal retractions and inspiratory stridor were present.

On auscultation, there was poor air movement bilaterally. Heart rate was regular with III/VI systolic murmur; otherwise, patient exhibited cardiovascular stability. A clean, dry, intact gastrostomy button was placed at the left abdomen. The remainder of the physical exam was within normal limits.

Peripheral blood examination showed a total white cell count of 15,700/mm3 with 74% polymorphonuclear leukocytes, 2% band forms, 19% lymphocytes, 4% monocytes, hemoglobin 11.0 g/dL, and a platelet count of 266,000/mm3. A chemistry panel showed no electrolyte abnormalities.

A chest x-ray revealed a mild right middle lobe infiltrate. No other acute process was noted.

The patient's respiratory status continued to deteriorate. He was sedated, paralyzed, and mechanically ventilated. A bronchoscopy was performed.

An esophagogastroduodenoscopy (EGD) was performed.

A bronchoscopy was also performed.

Results revealed questionable tracheomalacia, but no foreign body.

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