Asthma Uncertainty

[fetch, BSN, RN]

Here's a time when I wish I had another nurse here at my side, but I'll ask ya'll's opinion instead.

Asthma kid, about 8 years old - lungs sound okay (some wheezes, but about the level that an inhaler can usually take care of) but sitting across the room from the kid, you can hear audible breaths. They sound HORRIBLE. Sounds like gasping for breath, shallow breath, musical breath -- but only from the mouth/nose. Lung sounds clear lower lobes, slight insp wheezes upper lobes. Kid had 2 inhaler puffs at school, back to class for a few hours, then back in the clinic with the same issues. Lungs sound totally fine, then slight wheezes. Whole time, color is WNL and no sternal retractions. (Child is now with mom on the way to the MD - even though I was unsure, I sent them out.)

My biggest hangup is that what I was hearing when they sat across the room was SO DIFFERENT from what I was hearing in the lungs. I haven't encountered that before. And having had behavior issues with this kid in the past, my first instinct was that the kid was intentionally making wheeze noises in mouth/throat area. But they really seemed to be miserable.

Writing it all out has helped me evaluate it a little: I think next time I'd check mouth/throat area for obstruction (very obvious in retrospect but at the time I was just focused on lungs). Force the child to verbalize what they're feeling (this one only said "the weasels are back" - not an autocorrect, they actually said "weasels";)). Take the kid's pulse (they were in the clinic about 45 minutes all together, I had plenty of time to take a pulse but I forgot). I also want to get a pulse ox for the clinic so I can have some more data in times like this.

Any other advice? Do you see a really obvious thing that I missed (because I'm sure there's something)?

[NutmeggeRN, BSN]

I love having a pulse ox...it really is a very useful assessment tool. Just another piece of the puzzle!

[OldDude]

Sounds like stridor for sure; little old for croup but it happens. It will help in identifying the origin if you hold your stethoscope right on the larynx. If the noise is originating from there the sound will blow your ears out. In cases like this, lungs will be clear, pulse ox will be normal, pulse may be a little elevate if they have stridor at rest and are working a little harder to breathe. Stridor at rest is a concern so you did the right thing by sending them on for further eval.

[schooldistrictnurse]

Pls let us know if you learn anything about their evaluation.

[Spidey's mom, ADN, BSN, RN]

Sounds like stridor for sure; little old for croup but it happens. It will help in identifying the origin if you hold your stethoscope right on the larynx. If the noise is originating from there the sound will blow your ears out. In cases like this, lungs will be clear, pulse ox will be normal, pulse may be a little elevate if they have stridor at rest and are working a little harder to breathe. Stridor at rest is a concern so you did the right thing by sending them on for further eval.

Exactly right.

Our policy states, if there is no improvement (from those audible sounds) within 5 minutes after using their inhaler, then we call 911. It can go so fast . . . .

I had a kiddo whose VS including 02 Sat were all normal and lung sounds were clear but he said "it feels like I can't breath" and "I have pressure on my chest".

I don't rely on VS . ... . I look and listen to the patient.

What to look for:

Shortness of breath. Coughing or wheezing. Chest tightness. Difficulty walking, talking, or breathing.

Use quick relief medication as indicated in Asthma Action Plan or med authorization form.

No improvement after 5 minutes call 911.

Call 911 immediately if:

Lips and/or nails are blue

Skin is pulled tightly around neck or chest

Child cannot walk or talk

Yes, please let us know what happened.

[fetch, BSN, RN]

I called the mom on Friday - admitted to a local children's hospital from the doctor's office and kept overnight Thursday and Friday on contact precautions for suspected Enterovirus D68. She said the student was bouncing off the walls (didn't have their ADHD meds!) and acting like their normal self. Follow-up MD appt today, anticipated return to school tomorrow.

Thank you all for your advice. I really appreciate it! So far I've been pretty lucky, and have followed the rules of "send 'em out" if I don't iron-clad know what's going on, and then try to figure it out later. Had a few ***** moms but I can deal with that.

(Spidey's mom - no coughing, no change in skin or nail color, no sternal retractions. Skin around throat pulled tight I'll keep in mind to look for in the future.)

[Spidey's mom, ADN, BSN, RN]

Thanks for the update. Yes, EV-D68 is dangerous for kids with asthma. Well, any respiratory illness is dangerous to them for that matter.

Last year, 96 kids died from influenza.

Glad he is ok.