ajnelson Posted May 21, 2017 Share Posted May 21, 2017 So, I had somewhat of an interesting peds case the other night. I'm still waiting on some follow up, so, I'm not sure of all of the answers yet. 3 month old, family said 'breathing funny' A few times over the past month or so, child has has been noted to breath 'deep'. Its noted after he gets upset about something and when he's laid down to sleep. These are brief episdoes and resolved spontaneously. He was brought in to the ED because he was doing it more and it wouldn't resolve this time on its own and family thought it was much worse when he was sleeping. Healthy 3mo old. Full term, vaginal delivery, breast fed. Had some jaundice which required close follow up, but no medical intervention (no bili lights, etc). Immunizations UTD. Afebrile. Feeding, peeing, stooling normally. Diapers wet. BMs normal. On exam, he is breathing normally with occasional gasping/deep breaths. No accessory muscle use, no retractions, no cyanosis, oxygen sats never drop below 99%. Mom feeds him, falls asleep, the breathing pattern is ONLY these weird deep/gasping breaths. Lungs are clear. Remainder of exam unremarkable. Do any of you smart people have any thoughts? Link to comment Share on other sites More sharing options...
NYCPAC Posted May 21, 2017 Share Posted May 21, 2017 Stridorous sounding when it happens? Consider perhaps a degree of subglottic stenosis which may only become pronounced enough to notice when asleep due to positioning Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
NYCPAC Posted May 21, 2017 Share Posted May 21, 2017 Or reflux? Is the baby tugging when they're making the sound? Unlikely it's OSA without a desat but worst case the pedi could always order a psg Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
ajnelson Posted May 21, 2017 Author Share Posted May 21, 2017 No stridor. Baby looked perfect. He had the gasping when awake, sitting up, but had normal respirations between. When asleep it was just those gasping respirations. When I chatted with peds, he thought reflux or just normal infant breathing (because of immature resp center). Waiting to hear on what peds decided on their exam... Link to comment Share on other sites More sharing options...
ajnelson Posted May 21, 2017 Author Share Posted May 21, 2017 It was very odd. I've been in medicine for close to 20 years...Not saying I've seen everything. But, it's something I've definitely not come across before, at least not this obvious. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted May 21, 2017 Administrator Share Posted May 21, 2017 Not Kussmaul, right? I assume basic labs were run and normal? Link to comment Share on other sites More sharing options...
JDayBFL Posted May 21, 2017 Share Posted May 21, 2017 Tracheomalacia. Highest on my ddx based on presentation. Will resolve before the age of two. If parents worried send to pulm for a dynamic bronchoscopy. (I work in Peds surgery) Link to comment Share on other sites More sharing options...
Boatswain2PA Posted May 22, 2017 Share Posted May 22, 2017 I'm with Rev. R/o Kussmaul's with basic BMP (especially sugar) and send home. Kids are just learning to breath, along with everything else. Of course, since I said that you will present with some sort of extinct hippopotamus (instead of the horse) that nobody was thinking of..... Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted May 22, 2017 Share Posted May 22, 2017 My wife would argue that I'm still learning to breath nocturnally. Don't tell her, but I think she is as well at times. Link to comment Share on other sites More sharing options...
ajnelson Posted May 23, 2017 Author Share Posted May 23, 2017 I'm with Rev. R/o Kussmaul's with basic BMP (especially sugar) and send home. Kids are just learning to breath, along with everything else. Of course, since I said that you will present with some sort of extinct hippopotamus (instead of the horse) that nobody was thinking of..... I'm still waiting for the peds note to see what they are thinking. This was a weird case for me... I'm stumped, so was curious what all you smart people thought. All labs (CBC, BMP, CRP) were within normal limits. RSV negative. CXR negative. Outpatient upper GI was negative (ordered by peds). I'm hoping I'll see the peds follow up note soon! Link to comment Share on other sites More sharing options...
DizzyJ Posted May 23, 2017 Share Posted May 23, 2017 Interesting and good case to re-familiarize with BRUE criteria. He is over 60 days, but has had more then one episode of brief abnormal breathing. So, doesn't fall into the low-risk category. My mind jumped to reflux as well, but I feel like the reflux diagnosis is used more often then reflux is actually present. Link to comment Share on other sites More sharing options...
ajnelson Posted May 24, 2017 Author Share Posted May 24, 2017 I hadn't heard of BRUE yet...So looked it up. This looks like a good synopsis. http://pedemmorsels.com/brue/ While his breathing was weird, everything else looked great. The system I'm currently working for is really good with close follow up. And had I asked, the pediatrician would have come in that night and evaluate him. This kid truly looked great. The breathing was a little weird awake and more concerning asleep, but he was never in any distress, and he wasn't having any actual apnea. Link to comment Share on other sites More sharing options...
Guest JMPA Posted May 24, 2017 Share Posted May 24, 2017 eye exam? neuro? i would consider brain mri? Link to comment Share on other sites More sharing options...
medic25 Posted May 24, 2017 Share Posted May 24, 2017 I hadn't heard of BRUE yet...So looked it up. This looks like a good synopsis. http://pedemmorsels.com/brue/ I'm sure you have, just by a different name. It was ALTE until last year; the AAP just recently changed the name to BRUE. Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
ajnelson Posted May 24, 2017 Author Share Posted May 24, 2017 eye exam? neuro? i would consider brain mri? Pupils equal and reactive. Follows as well as a 3 month old would. Moves all extremities. No depressed mental status. Interacting appropriately for age. Looks like they are referring to pulmonology. I still don't see the peds note finalized, so I can't read it..But I'll update along the way [emoji846] Link to comment Share on other sites More sharing options...
bob_inski Posted May 26, 2017 Share Posted May 26, 2017 You must not carry a stethoscope with you. Lung sounds would not be normal. @jdaybfl Link to comment Share on other sites More sharing options...
JDayBFL Posted May 28, 2017 Share Posted May 28, 2017 You must not carry a stethoscope with you. Lung sounds would not be normal. @jdaybfl I appreciate your concern about what type of medical equipment is available to me. Any other helpful hints you can give me? Actually, the OP was the one looking for suggestions so don't let my poor judgement get in the way of you providing your help. Aside from that... Lung sounds absolutely can be normal in mild tracheomalacia/laryngomalacia which is an isolated, intermittent upper airway inspiratory sound. Not a stridor. Not a wheeze. Link to comment Share on other sites More sharing options...
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