Wheezing and Respiratory Distress in a 7-Week Old
Radiology Cases in Pediatric Emergency Medicine
Volume 2, Case 6
Collin S. Goto, M.D.
Children's Medical Center of Dallas
University of Texas Southwestern School of Medicine
This is a 7 week old term female infant who
presented in mid-November with wheezing, coughing,
and two episodes of non-bilious emesis. She was seen
by her pediatrician, who suspected that she had
bronchiolitis, and she was treated with oral albuterol
syrup. An RSV (Respiratory Syncytial Virus) nasal prep
was done, and this was negative; however, the patient's
condition worsened, and she was brought to the
Emergency Department later that evening.
Exam: VS T37.2R, P168, R70, BP126/86, oxygen
saturation 96% on room air. The infant was fussy,
though consolable, with moderate respiratory distress.
She was non-toxic in appearance. The anterior
fontanelle was soft and flat. The pupils were equal and
reactive and the mucus membranes were moist. The
neck was supple. The lungs had diffuse wheezes and
crackles bilaterally with intercostal retractions. Heart
sounds were difficult to auscultate due to the noisy
breathing, but no obvious loud pathologic murmur was
heard. The abdomen was soft and nontender with
active bowel sounds. The liver edge was palpated 3-4
cm below the right costal margin. Capillary refill time in
the extremities was 3 seconds.
The patient was placed on supplemental oxygen and
a CXR was obtained.
View CXR image.
The CXR showed cardiomegaly and possibly
increased pulmonary vascular markings consistent with
congestive heart failure (CHF). The femoral pulses
were difficult to palpate. Measurement of blood
pressures in the four extremities showed 126/86 (left
arm), 132/92 (right arm), 69/41 (left leg), and 63/59
(right leg). An EKG was done.
It is not easy to see the tracing of some of the
precordial leads because they are very large. R2 (R
wave of V2) extends into the tracing of V1. R4 is off the
scale. Suffice it to say that all the R and S waves in
V1-V6 are large. The axis of QRS is 90 degrees
(roughly isoelectric in I and positive in AVF). This is a
rightward axis. The large QRS's in V1-V6 meet voltage
criteria for both LVH and RVH. This EKG shows
The patient was treated with furosemide, 1 mg/kg
IV, and dobutamine, 5 mcg/kg/min as a continuous
infusion, with marked improvement in respiratory status.
The infant was admitted to the Pediatric Intensive
Care Unit, and a cardiology consultation was obtained.
An echocardiogram showed severe coarctation of the
aorta, with a tight posterior shelf distal to the left
subclavian artery. The left ventricle was dilated with
markedly decreased function. The patient subsequently
underwent operative repair of the coarctation, with an
uneventful postoperative course.
1. Wheezing and respiratory distress are a common
presentation of CHF in infants. Tachypnea alone may
be the earliest sign. Even in the midst of the busy
winter bronchiolitis season, the clinician must be careful
to consider that the infant with wheezing and tachypnea
may be a presentation of CHF, rather than bronchiolitis.
Physical exam findings of hepatomegaly or a gallop
rhythm may aid in making the proper diagnosis.
Parents may also give a history of poor feeding, slow
weight gain, and increased sweating. A CXR showing
cardiomegaly and increased pulmonary vascular
markings will help to confirm the diagnosis.
2. Coarctation of the aorta may present at an early
age, as in this case, with progressive CHF. More than
80% of infants with preductal COA develop CHF by 3
months of age. Coarctation of the aorta may also
present in the first one or two weeks of life with a
sudden state of shock with CHF and cardiovascular
collapse when the ductus arteriosus closes
(duct-dependent lesion). This is also the typical
presentation of the hypoplastic left heart syndrome.
Other types of congenital heart disease which may
present early in infancy with CHF include large
ventricular septal defects, a large patent ductus
arteriosus, anomalous left coronary artery, and critical
aortic or pulmonary stenosis. Acquired causes of CHF
in young infants include viral myocarditis and
3. COA can range in severity from very slight with
minimal physiologic consequence to severe aortic
coarctation or hypoplasia. More severe COA tends to
present in infancy while less severe COA may present
in later childhood or adolescence. The CXR of the
young infant presenting with severe COA typically
demonstrates cardiomegaly and increased pulmonary
vascular markings (CHF). This is in contrast to the
CXR of COA presenting later in childhood, which
typically shows a normal or only slightly enlarged heart,
and normal pulmonary vascular markings. Rib
notching, although pathognomonic for COA, is rarely
seen in children younger than 9 years of age. The
aorta may develop dilation pre and post coarctation
resembling a "3" (3 sign) when viewing the right side of
the aorta on an overpenetrated film. If a barium
swallow is performed the pre and post coarctation
dilation of the aorta impinges upon the esophagus
to it giving an "E" appearance to this area of the
esophagus (E sign). These signs are not generally
seen on routine views that would be ordered in the E.D.
4. Treatment of CHF in infancy requires attention to
the cardinal ABCs of emergency medicine (Airway,
Breathing, Circulation). Administration of supplemental
oxygen should be considered as a first-line therapy. If
the patient is unstable, intubation with positive-pressure
ventilation may be required. To improve cardiac
contractility, inotropes such as digoxin or dobutamine
may be needed. Dobutamine also has the advantage
of decreasing afterload. Diuretics such as furosemide
aid by decreasing preload. In severe cases, other
vasoactive or inotropic agents such as sodium
nitroprusside and amrinone may be considered. These
agents should be used in the intensive care unit, using
invasive hemodynamic monitoring. If a duct-dependent
lesion is suspected, prostaglandin E1 should be started
as a continuous infusion at 0.1 mcg/kg/min.
1. Li MM, Klassen TP, and Watters LK.
Cardiovascular Disorders. In Barkin RM ed. Pediatric
Emergency Medicine Concepts and Clinical Practice.
St. Louis, Mosby-Year Book Inc., 1992, pp. 576-586.
2. Park MK. The Pediatric Cardiology Handbook.
St. Louis, Mosby-Year Book Inc., 1991, pp. 83-86 and
3. Rosenthal BW. Wheezing. In Fleisher GR,
Ludwig S, eds. Textbook of Pediatric Emergency
Medicine, Third Edition. Baltimore, Williams and
Wilkins, 1993, pp. 518-525.
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