What is Pediatric Bronchospasm?
Bronchospasm is a condition that causes the small airways in the lungs to tighten. This often results in a symptom called wheezing, which is a high-pitched whistling sound made while breathing. Kids are more likely to get bronchospasm and have complications from it because their bodies are still growing and their lung structure is different.
Babies, in particular, use different lung muscles compared to older children, which makes them more likely to have wheezing symptoms. How easy or hard it is for air to move through the lungs depends on the size of the airways and flexibility of the lungs and chest wall.
According to Poiseuille’s Law, which is a principle in physics, the amount of airflow resistance in a tube, like an airway, is opposite to the tube’s radius to the power of four. This means minor decreases in the size of the airway can cause significant hurdles for airflow due to high resistance.
What Causes Pediatric Bronchospasm?
Several health issues can cause spasms in the bronchial tubes, the small airways in your lungs, in children. This document discusses some of them in detail, particularly, severe asthma attacks, bronchiolitis from a virus, and severe allergic reactions (anaphylaxis). It also briefly mentions blockage from a foreign body and abnormal blood vessel structures (vascular ring).
Asthma is a lung disease where the airways swell, muscles tighten, and more mucus is produced, causing blockage and trapping air. Certain triggers in the environment like viral infections of the respiratory system, exposure to tobacco, changes in weather, strong smells, air pollution, and other irritants can cause these airways to constrict excessively, a state known as airway hyperresponsiveness. This leads to a severe asthma attack.
Bronchiolitis is a viral infection affecting the lower respiratory tract, commonly seen in children under two years. This infection causes inflammation, swelling, and death of cells in the bronchioles, leading to spasms. It also causes more mucus to be produced, which causes further blockage of the airways.
Anaphylaxis is a sudden and severe allergic reaction that can also cause bronchospasms. This reaction is usually triggered by Immunoglobulin E, a special class of antibodies produced by the body to fight against allergens.
Risk Factors and Frequency for Pediatric Bronchospasm
Asthma, particularly in children, can be influenced by factors like where they live, the level of development in their community, and even the climate. In the U.S., it’s found that 6.2 million kids from birth to 17 years old have asthma. Kids in this age group tend to have a higher rate of asthma, and they typically visit doctors and emergency departments more often than adults. However, they have a lower rate of asthma-related death. Notably, racial disparities do exist, with African American children often having a higher prevalence and more severe outcomes of asthma, like more hospital visits and higher death rates.
- Bronchiolitis, a respiratory illness, is more commonly observed in the winter season because of exposure to various viral pathogens, with the Respiratory syncytial virus being a common culprit.
- It tends to be more common in males, non-breastfed infants, and children who live in crowded conditions.
- In the U.S., over 130,000 children under two years old are hospitalized each year due to bronchiolitis, which incurs healthcare costs close to $1.73 billion annually.
- This illness accounts for about 16% of all hospitalizations in this age group.
- Severe disease is more likely for children under 12 weeks old, those who were born prematurely, have heart or lung disease, or have compromised immune systems.
Concerning anaphylaxis, a severe allergic reaction, estimates suggest a lifetime prevalence of between 0.5% to 2% in developed countries. Specific to the U.S., the lifetime prevalence is believed to be more than 1.6%. Diagnosis rates of the condition have been increasing over the years, with emergency department visits nearly doubling from 2009 to 2013.
Signs and Symptoms of Pediatric Bronchospasm
Bronchospasm is a condition that causes wheezing upon physical examination. Additional signs include chest tightness, shortness of breath and coughing, which may lead healthcare practitioners to suspect this condition in a child. Sometimes, parents notice their child’s “noisy breathing”. Other indications could be the use of accessory muscles for breathing, nasal flaring, fast-paced breathing, and extended expiratory phase. Children who have had allergic conditions, such as allergic rhinitis or atopic dermatitis, are more prone to developing asthma.
With bronchiolitis, children also show signs of viral infections, which include nasal congestion, runny nose and occasionally, fever. Anaphylaxis involves numerous signs such as wheezing due to bronchospasm, tightness in the throat, stridor, skin hives, face and skin flushing, swollen and/or itchy lips and tongue, nauseous feeling, vomiting, abdominal discomfort, light-headedness, fainting, rapid heart beat, low blood pressure, anxiety, and swelling around the eyes. These symptoms usually occur within seconds to minutes after exposure to a trigger.
There are certain medical conditions related to bronchospasm or wheezing which have unique presentations. For instance, foreign body aspiration happens typically in late infancy or toddlerhood when children put various objects into their mouths. This may cause sudden respiratory distress, with symptoms dependant on the location of the foreign object. Symptoms include stridor, unilateral wheezes, coughing, and choking. If a patient has persistent symptoms, such as difficulty in swallowing, “noisy breathing”, stridor, wheezing, and high-pitched cough without any viral symptoms associated, a vascular ring which can compress the trachea and/or esophagus might be suspected.
Testing for Pediatric Bronchospasm
When trying to figure out if a child has bronchospasm, or tightening of the airways, doctors will look at information they have about the suspected cause.
In the case of pediatric asthma, doctors typically diagnose based on symptoms and signs that suggest the child’s airways are narrowing and becoming inflamed in reaction to something in their environment. When kids are around six years old or older, they can usually do a test called spirometry – essentially, they blow into a tube to measure how well air is moving through their lungs. This can help doctors confirm an asthma diagnosis. It’s good to do this test when the child is feeling well, to get a baseline measurement. Doctors may then have the child do this test once a year to check that their asthma continues to be well-managed or to see if their asthma medicine needs to be adjusted. During an asthma attack, the doctor will listen carefully to the child’s symptoms and do a physical exam to come up with a treatment plan. If the child’s asthma attack is very severe (a condition known as status asthmaticus), or growth of pulmonary microorganisms or if the child seems to be getting worse from a respiratory perspective or if their mental state seems altered, the doctor might get a blood sample from an artery to check how well the child’s lungs are exchanging gases. They might also order a chest X-ray to check for a collapsed lung, lung collapse due to blockage, or pneumonia.
Acute viral bronchiolitis, a common lung infection in young children, is usually diagnosed based on the child’s symptoms and the doctor’s physical exam. Tests and X-rays aren’t usually needed. But if the child’s symptoms don’t clearly point to bronchiolitis, or if it’s not winter (when bronchiolitis is most common), or if the child’s exam findings don’t entirely fit with bronchiolitis, or if the child is at greater risk for severe disease, the doctor might decide to order lab tests or a chest X-ray.
Anaphylaxis, a serious allergic reaction, can be hard to identify because it can affect many different parts of the body. It’s diagnosed based on certain criteria. Anaphylaxis is likely if: 1) the skin or mucous membranes are involved and the child has either breathing issues or shock; 2) the child has been exposed to something they’re likely allergic to and have two or more of the following: involvement of the skin or mucous membranes, breathing issues, low blood pressure, or problems with the digestive system; and 3) the child has low blood pressure after being exposed to something they’re known to be allergic to. A higher level of a blood protein called tryptase can support the diagnosis of anaphylaxis, even though it’s not needed to make the diagnosis.
If doctors think an older child may have breathed in a foreign body, they can do chest X-rays when the child breathes in and out. They can determine which side of the airway is obstructed by looking at the X-rays and seeing which side days more air. Infants and toddlers don’t understand directions well enough to do this type of imaging. So in young ones, doctors take pictures with the child lying on their side (lateral decubitus films) from both sides. The side of the airway with the foreign body is determined by looking to see which lung doesn’t deflate (because it’s blocked) when it’s in a lower position. If the X-rays don’t show what doctors expect but they still think the child may have a foreign body obstruction, they can do more detailed imaging such as CT scan of the chest, or more invasive tests such as using a tube, bronchoscopy, to look into the airways – which could also remove the obstruction.
Treatment Options for Pediatric Bronchospasm
When someone suffers from a severe asthma attack, the main goal of treatment is to address the key issues causing symptoms. These include inflammation in the airways, muscle tightness, swelling, and excess mucus. The initial therapy typically involves oxygen, intermittent use of quick-response respiratory medications, and steroids.
If the asthma worsens, a dose of a medicine called magnesium sulfate can be administered as a last resort. Magnesium sulfate relaxes the muscles by limiting the absorption of calcium, which can help open up the airways. It also hinders the release certain inflammatory substances, reducing inflammation and swelling.
If a child experiences what’s called ‘status asthmaticus’, which is a severe, potentially life-threatening asthma attack that doesn’t respond to normal treatments, they will need to be admitted to the pediatric intensive care unit. Here, they will receive continuous medication via a nebulizer to help relax and open up the airways. At the same time, they will be monitored for potential side effects of the medication, like restlessness, rapid heartbeat, nausea, low potassium levels, high blood sugar, and tremors.
If the situation continues to deteriorate. there are a few additional treatment options. A medication called terbutaline can be administered, which acts like the body’s own substances that relax the airways and ease breathing. Other medications such as ketamine, which has pain relieving properties and can also help open the airways, can be used. Ultimately, in the most severe cases, the patient may need to be put on a ventilator to help them breathe.
When treating bronchiolitis, a condition that causes inflammation and congestion in the small airways of the lungs, the main focus is on supportive care. This includes providing supplemental oxygen, maintaining hydration, and clearing the airways of mucus. Some children may require more intensive respiratory support.
It’s worth noting that bronchodilatory drugs – those that relax the muscles around the airways – are not typically recommended for treating bronchiolitis. Hypertonic saline, a solution that can draw out fluid and reduce swelling, may be used in some cases, but is not typically first-line treatment.
Anaphylaxis, a severe allergic reaction, requires early recognition and immediate treatment with a medication called epinephrine to prevent life-threatening respiratory and heart-related complications. If anaphylaxis is suspected, it’s important to thoroughly assess the child’s airway, breathing, and circulation, and to administer epinephrine as soon as possible. In addition to epinephrine, other treatments may include antihistamines, bronchodilators, and glucocorticoids.
What else can Pediatric Bronchospasm be?
Some of the most common causes of bronchospasm, which usually presents as a tightening in the chest in children, include severe asthma attacks, bronchiolitis, and anaphylaxis (severe allergic reactions). There are many other conditions that can cause bronchospasm and lead to wheezing, and there are some conditions that can resemble bronchospasm. Here is a list of conditions that might be considered when diagnosing bronchospasm:
- Foreign body aspiration (something stuck in the airway)
- Vascular ring (an abnormal formation of the aorta)
- Tracheobronchomalacia (an abnormal softening of the windpipe and bronchi)
- Reactive airway disease (commonly known as asthma)
- Gastroesophageal reflux disease (acid reflux)
- Oropharyngeal dysphagia with aspiration (difficulty swallowing, leading to food or drink entering the lungs)
- Bronchopulmonary dysplasia (a chronic lung disease, usually seen in premature babies
- Exercise-induced bronchospasm (wheezing, chest tightness, or trouble breathing due to exercise)
- Cystic fibrosis (a genetic disorder that affects the lungs)
- Vocal cord dysfunction (improper functioning of the vocal cords)
- Disorders of cilia motility (genetic disorders that affect the tiny hair-like structures, cilia, in the lungs)
- Tracheoesophageal fistula (an abnormal connection between the esophagus and the windpipe)
- Cardiac disease with pulmonary overflow or venous congestion (heart disease with affected blood flow to the lungs)
- Mediastinal mass (a tumor in the area between the lungs)
- Primary immunodeficiencies (a weak immune system caused by a genetic defect)
- Bronchiectasis (permanent widening of the bronchi)
- Bronchiolitis obliterans (inflammation and scarring in the bronchioles, the smallest airways in the lungs)
It’s important to remember that health professionals will consider these possibilities and other relevant conditions to diagnose the underlying cause accurately.
What to expect with Pediatric Bronchospasm
Wheezing, or the production of a high-pitched whistling sound when breathing, is a common symptom among children in their preschool years. Nevertheless, only a few of these children will continue to have long-term asthma, a condition that affects the airways of the lungs. If a child has one or more incidents of bronchiolitis – an inflammation of the small airways in the lungs – the chances of developing asthma in early childhood can be two to three times higher.
Children who needed to be hospitalized because of bronchiolitis are more likely to suffer from asthma-related health issues in their early childhood. To predict these outcomes, a system called the Asthma Predictive Index was developed. This tool is accurate in identifying asthma in children under three years old. According to this tool, a child has a high risk of developing asthma if they have experienced three or more episodes of wheezing in a year and meet either one significant factor (parent having asthma, a skin condition known as atopic dermatitis, or sensitivity to airborne allergens) or two minor factors (food allergies, wheezing not associated with common cold, or a high level of white blood cells known as eosinophils).
With a positive Asthma Predictive Index, a child is thought to be at a significantly higher risk for developing asthma later in life. In fact, up to 76% of children with a positive index may show signs of active asthma by the time they reach school age.
When it comes to anaphylaxis, a severe allergic reaction that can lead to difficulty breathing or even heart failure, early recognition and prompt treatment with a medicine called epinephrine can stop the progression of the reaction and prevent it from becoming fatal.
Possible Complications When Diagnosed with Pediatric Bronchospasm
In the event of a severe asthma attack, the blockage caused by narrowed airways can trap air in the lungs. This can potentially lead to air leaks in the lungs or the middle portion of your chest. In extreme cases, where this narrowing causes a sudden inability to breathe that results in dangerously low levels of oxygen or abnormally high levels of carbon dioxide in the body, life-support equipment might be required.
Possible Risks:
- Air trapped in the lungs due to blocked airways
- Leakage of air in the lungs or in the center of the chest
- Sudden inability to breathe leading to low oxygen levels
- High carbon dioxide levels
- Potential need for life-support equipment
Preventing Pediatric Bronchospasm
Smoking has been linked to triggering asthma, as well as damaging a child’s lungs. It’s important to limit or remove a child’s exposure to smoke for their overall health. If your child has asthma, their doctor will usually prescribe an inhaler (like albuterol) instead of regular over-the-counter cough medication. If a child with asthma is coughing, it usually means they are wheezing, signaling that their asthma needs treatment. This treatment typically requires using their inhaler, not just cough syrup.
Bronchiolitis is a chest infection caused by a virus that usually occurs in children under the age of two. Since it’s caused by a virus, antibiotics are ineffective. Symptoms of this condition include a runny and congested nose, mouth secretions, a cough, and sometimes a fever. Because young children might not be able to blow their noses effectively and their small airways can get congested, they often need help clearing mucus and secretions. You can do this easily with a bulb suctioning device, sometimes along with over-the-counter saline drops. It sometimes needs to be done frequently. In some cases, children may need oxygen, fluids given through an IV, and even a hospital stay to recover fully from this condition.
Allergic reactions should never be ignored, as some can lead to a dangerous and potentially life-threatening reaction known as anaphylaxis. Anaphylaxis can include symptoms such as hives, an itchy throat, a hoarse voice, shortness of breath, wheezing, and throwing up. If you think a child might be dealing with anaphylaxis, it’s crucial to immediately call for emergency medical help and take the child to the emergency room right away. At the hospital, they may need to be given a medicine called epinephrine, which can save their life.
