Alright! Now we are getting somewhere...
This kid is sick, but really not too terribly bad.
RSV is the picture I was trying to paint. Temperature slightly elevated, cruddy looking, fussy, lower than normal SPO2, and most importantly-
COPIOUS NASAL SECRETIONS.
For those that want to apply oxygen first, nice try, but it will not likely get you anywhere. This is not a failure to oxygenate, but more a difficulty with ventilation. Because of the obligate nose breathing infants have, anytime they have a large amount of nasal secretion it effects their ability to ventilate. They get irritable, start crying, and begin mouth breathing.
The caving of the chest is not necessarily accessory muscle use or intercostal retractions, but actually the chest pulling inward as the infant pulls negative pressure to breathe. The air cannot move in fast enough due to the secretions blocking the majority of the nasal passage.
Applying oxygen will only dry out and thicken these secretions.
For those who said suction, that is spot on. You suction these kids, and then you will likely suction some more, and then most likely prepare to suction some more. Performing a nasal lavage with normal saline and a 10 or 12 fr soft catheter will really make these kids pissed off, and probably scare the parents, but afterwards, the improvement will be remarkable. They will very literally be breathing like normal. Beware though, within about 30 minutes or so, the secretions will build back up, and they will need suctioning again.
After suctioning, some blow by oxygen isn't a bad thing, but probably not necessary. These kids will most likely need a 20 cc/kg isotonic crystalloid bolus, possibly followed by a repeat. The increased respiration and decreased PO intake will have them dehydrated.
Antipyretic treatment for low grade fever is acceptable, however, if you do not have a documented temp above 100.4 then I don't think it is justifiable. So either obtain a true temp, or allow the fever to persist. Fever is not a bad thing. Malignant fever with persistent high temps is a bad thing, but low grade fevers are part of the body's initial immune response.
Usually we try not to completely abolish the fever. As you mentioned earlier, our criteria is 100.4 and greater (38 C) if the child looks miserable. If they appear to be tolerating it well, we will hold off. Acetaminophen q 4 hrs or Ibuprofen q 6 hours. Try to stick with one or the other, unless you absolutely can not get the temperature down with only one.
Try to keep mom and dad from holding the child too much or keeping them covered up. This is some sort of natural parenting instinct that kicks in. When there is a fever, parents put more clothes on and keep the kids bundled up for whatever reason. One light layer (onesie or shirt and diaper) in an average temperature room is good. Educate them that the body needs to be allowed to regulate its own temperature, and covering the child up could lead to malignant hyperthermia. Also be careful of reducing the temperature too quickly, or covering the child up and allowing the fever to "spike." Some of the literature identifies this as a possible cause of febrile seizures.
Antibiotics in the field? Please don't. RSV is a virus, they will not do anything. Even if this was bacterial, antibiotics in the field do nothing to treat symptoms, and administration of antibiotics prior to drawing cultures is highly frowned upon (at least where I come from.) The hospital may administer antibiotics in this case, only as prophylaxis from secondary bacterial infection while the kid is fighting off the virus.
Care at the hospital will include: monitor, suction, IV, o2 PRN, lab work, fluid bolus PRN, and supportive care. Most of what they do will center around relieving symptoms, while the body naturally clears the virus. As I mentioned earlier, they may provide antibiotics to prevent secondary infection, that is provider choice. This will only be done after cultures are obtained.
I think I covered it all.
A few pro tips:
Auscultating lung sounds of the crying infant can be difficult. Listen during inspiration if possible to try and identify lower airway abnormalities.
Croup has a high pitch barking cough, inspiratory stridor, and fever. It usually strikes in the middle of the night after the child has been put down for bed. Heavy nasal secretions are not usually present. Don't irritate these kids. Cool air, racemic epi if you have it, humidified o2 or nebulised saline if you don't. When these kids get angry, their airway can become extremely tenuous. Steeple sign on X ray...
Epiglottitis will present with trouble swallowing, not necessarily trouble breathing. What I am trying to say is that the swelling usually will not cause the inspiratory stridor that you hear in the croup patient. These kids posture forward and drool a lot. The croup patients typically do not drool as much, as they have the ability to swallow without much discomfort. Thumb sign on X ray...
Pneumonia will typically have the same symptoms of asthma, along with a fever. You will hear lower airway wheezes, and there should be no abnormality in the upper airway. Consolidation on X ray...
Asthma/Bronchiolitis will typically present without a fever (except in the case of secondary infection exacerbating current condition.) These patient have trouble exhaling, not trouble inhaling. The constriction of the lower airways makes it difficult to exchange gas. The constriction of the lower airways may also lead to an absence of wheezes until they have had one or two treatments, at which time they will sound much worse then when you started. They should be able to begin to produce the thick secretions that have been accumulating in the lower airways. Hyperinflation and possible atelectasis on X ray...sometimes, but not always...
FBO is a wildcard. Acute onset, no history of worsening condition (i.e. child was looking sickly earlier and now appears to be worse.) Possible high pitch whistling, trouble swallowing, etc. An actual aspiration will typically cause much worse symptoms, and the patient will likely be in extremis. Silhouette of toy car or coin on X ray....consider possibility of radiotranslucent aspiration, which will barely/not be visible.
Ok, I am getting tired. I think that covers a lot. Please add in your own experience or comments. This is not meant to be all encompassing by any means, just a general presentation for you to consider in your practice.
