Prehospital Incident Profile
All That Wheezes Is Not Asthma
By Paul Werfel, NREMT-P

Presentation
One spring evening dispatch sends you and your partner to a high-rise apartment building for a child with difficulty breathing. As you head to the address, you prepare for a problem that could be anything from a chest cold to an airway obstruction.

On arrival you find a 10-month-old infant, actively wheezing. The child's heartbeat is strong, and he seems alert. He doesn't present with a fever. All other sections of the physical exam fall within normal limits.

The parents tell you the baby woke up wheezing, and they called you right away. They report their son has no history of asthma or anything else and takes no medications. Your partner places a pediatric non-rebreather on the patient, and you prepare an albuterol inhaler.

You move the child to the ambulance and prepare for the 25-minute ride to the hospital. The patient's wheezes improve only slightly after the first trial of the medication. Your protocol allows you to treat a pediatric patient with wheezing refractory to the albuterol with a subcutaneous injection of epinephrine. You administer the epinephrine, but observe no improvement in the patient's condition.

You try to dial medical control on the cell phone and realize the battery is dead. Puzzled by the patient's non-responsiveness to the drugs, you decide to continue oxygen and expedite your transport to the hospital. The rest of the ride proves uneventful, and you present the patient to the ED staff.

Discussion
After you complete your paperwork, you seek out the physician treating the patient. He tells you the patient has bronchiolitis -- not asthma. That's why the patient responded only minimally to the medications.

The doctor tells you that bronchiolitis results from a respiratory synctal virus (RSV) infection of the lower airways, usually occurring in the winter or spring in children younger than 18 months old. Symptoms include inflammation of the distal airways with wheezing that's frequently unresponsive to medication aimed at relieving bronchospasm.

This condition is usually self-limiting but can progress to life-threatening hypoxemia. The younger the patient, the higher the risk of respiratory failure. This is due to the small bronchiole diameter of younger infants.

The preferred prehospital treatment is ventilatory support with humidified oxygen and rapid transport. Although usually ineffective at completely reversing the bronchospasm, nebulized medications (albuterol or metaproterenol) may afford some relief.

Once again the streets give up another secret to you. All that wheezes is not asthma. You decide whoever coined that phrase was pretty wise.

About the Author
Paul Werfel, NREMT-P, paramedic program director for the University Medical Center at State University of New York, Stony Brook, may be reached via e-mail at pwerfel@epo.hsc.sunysb.edu.