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Pediatric Medicine

Answer 1
  1. Diminished symmetric breath sounds without wheezing on lung examination. This patient is experiencing a severe asthma exacerbation. Although the patient has been managed appropriately, her symptoms have progressed, which indicates that her clinical status is worsening.1 Notably, the patient is alert, but she appears uncomfortable. Other warning signs of impending respiratory failure include use of accessory muscles with severe retractions, presence of cyanosis, or inability to speak in full sentences.2 The use of accessory muscles is a signal that the normal respiratory muscles are unable to provide adequate mechanical force to generate airflow. Severe retractions indicate that the chest wall muscles are working to produce adequate airflow, but the muscles will likely fatigue, leading to respiratory failure. Cyanosis in severe asthma exacerbations occurs when ventilation is no longer sufficient to deliver an appropriate amount of oxygen to tissues. Inability to speak in full sentences suggests that oxygenation and ventilation are poor and unable to sustain normal speech patterns. Fine basilar crackles that improve with coughing are not a sign of impending respiratory failure. The development of diminished breath sounds without the presence of wheezing is concerning for impending respiratory failure because it indicates that the patient is no longer able to generate a sufficient amount of high-velocity airflow to produce wheezing.

    Keogh KA, Macarthur C, Parkin PC, et al. Predictors of hospitalization in children with acute asthma. J Pediatr 2001;139:273-7.

    2. Roy S, Milgrom H. Management of the acute exacerbation of asthma. J Asthma 2003;40:593-604.

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