Children with suspected reactive airway disease need thorough inspection and chest examination for affect (playful vs ill-appearing), posture (relaxed vs upward straining to expand the chest), nasal flaring/obstruction, breath sounds (wheezing with prolonged expiration vs stridor with prolonged inspiration, presence of rales and rhonchi, overall intensity with alertness for silent areas dull to percussion), and respiratory distress (suprasternal, intercostal, and subcostal retractions). Monitor objective data, such as respiration rate and capillary oxygen saturation, as a function of therapy; obtain chest radiographs when warranted by the child’s age, ill appearance, degree of distress/tachypnea, or accessory findings and history (prior rapid progression/recurrence, RSV positivity, poor therapy response). Radiographic findings, including hyperinflation (flattened diaphragms, increased anteroposterior chest diameter, decreased density), peribronchial cuffing, and/or atelectasis, will attest to the bronchiolar involvement of obstructive airway disease and show infiltrates that may suggest coexisting bacterial pneumonia.
However, even with the help that radiographic evidence and other test results can provide, diagnosing the cause of wheezing in children younger than 3 years remains “one of the last true art forms in medicine”3—one that requires broad thinking, the ability to gain the trust and respect of families, and persistence in ruling out possible diagnoses.3
Both of these patients have onset of wheezing at an early age, and their histories could indicate intermittent or mild to moderate persistent asthma at presentation. Additional follow-up is needed to determine whether wheezing episodes persist up to age 6 years to justify the diagnosis of asthma. Parental diaries are useful to document recurrent wheezing episodes, along with their severity and response to therapy regimens.
ACUTE TREATMENT AND OUTCOME
Case 1. Acute therapy in this 6-month-old boy involved intramuscular ceftriaxone (75 mg/kg) and home nebulizer treatments with albuterol (1.25 mg every 4 hours). The next day, he presented with minimal respiratory distress. A second injection of ceftriaxone was administered; the parents were instructed to continue oral therapy with cefdinir (250 mg/d) and albuterol treatments for 2 days and to bring the child back if symptoms of fever, wheezing, or respiratory distress developed.
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