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Diseases » Asphyxia » Tests
 

Diagnostic Tests for Asphyxia

Contents
  1. Asphyxia: Introduction
  2. Symptoms of Asphyxia
  3. Diagnosis
  4. Complications

Asphyxia Tests: Book Excerpts

Asphyxia Diagnosis: Book Excerpts

Diagnostic Tests for Asphyxia: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the diagnostic tests for Asphyxia.

DYSPNEA: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

The basic workup of acute onset dyspnea should include a CBC to exclude anemia; a chest x-ray and arterial blood gases to exclude pneumothorax, pneumonia, and other pulmonic diseases; and an EKG and serial cardiac enzymes to exclude myocardial infarction and some of the causes of congestive heart failure. A sputum smear and culture should always be done when there is adequate sputum. Eosinophils should be sought. It is important to make sure that you have an adequate specimen and, therefore, leukocytes should be reported on the smear.

If there is chest pain accompanied by hemoptysis, arterial blood gases and a ventilation-perfusion scan should be done to rule out pulmonary embolism. Even without chest pain and hemoptysis, a pulmonary embolism may need to be excluded. If the ventilation-perfusion scan is inconclusive, a pulmonary angiography may still need to be done in difficult cases. If routine smears and cultures are negative, cultures for AFB and fungi may need to be done, especially when there is continuing purulent sputum. The clinician should also consider doing skin testing for these diseases.

If congestive heart failure is suspected, an arm-to-tongue circulation time and pulmonary function testing should also be done. Echocardiography may also be diagnostic. A therapeutic trial of a diuretic may be valuable. When there is significant wheezing, a trial of sublingual isoproterenol hydrochloride (IsuprelŪ) or epinephrine 0.3 cc subcutaneously may clear up the confusion.

In chronic dyspnea the chest x-ray and EKG should be complemented by pulmonary function testing, exercise testing, and arterial blood gases. Pulmonary function testing will be very useful in diagnosing asthma and distinguishing pulmonary emphysema from pulmonary fibrosis. A diagnosis of pulmonary fibrosis is substantiated by a reduction in a single-breath carbon monoxide-diffusing capacity. The advice of a pulmonologist should be sought when extensive pulmonary function testing, such as compliance and diffusing capacity, need to be determined. Bronchoscopy may need to be done to exclude a foreign body, neoplasm, or bronchiectasis. Cardiac catheterization and pulmonary angiography may be needed to identify chronic recurrent pulmonary embolism, intracardiac shunts, and pulmonary hypertension. Dyspnea without objective findings on physical examination should prompt a referral to a psychiatrist.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

STRIDOR: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

Routine tests may include a CBC; sedimentation rate; smear and culture of material from the nose, throat, and sputum; x-ray of the chest and sinuses; and, in adults, an EKG. In adults also it might be wise to order a chemistry panel, thyroid profile, and VDRL test, depending on the clinical picture. Direct laryngoscopy can now be done in the office with the fiberoptic laryngoscope. In addition, fiberoptic bronchoscopy may be valuable. A Tensilon test may need to be done. An ear, nose, and throat specialist should be consulted before ordering expensive diagnostic tests. If there are neurologic signs, a neurologist should be consulted.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

SLEEP APNEA: DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)

The most important diagnostic test is an all-night polygraphic recording (polysomnography). This will differentiate between obstructive and nonobstructive sleep apnea. If obstructive sleep apnea is suspected, a referral should be made to an ear, nose, and throat specialist. If there are abnormalities on the neurologic examination, a neurologic consultation should be sought. If idiopathic nonobstructive sleep apnea is suspected, the patient should be referred to a pulmonologist. A therapeutic trial of continuous positive airway pressure may be done. Some cases should have evaluation for a pituitary tumor, a thyroid profile, and a trial of tricyclic drugs and progesterone.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Apnea: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

When the patient’s respiratory and cardiac status is stable, investigate the underlying cause of apnea. Ask him (or, if he’s unable to answer, anyone who witnessed the episode) about the onset of apnea and events immediately preceding it. The cause may become readily apparent, as in trauma.

Take a patient history, noting especially reports of headache, chest pain, muscle weakness, sore throat, or dyspnea. Ask about a history of respiratory, cardiac, or neurologic disease and about allergies and drug use.

Inspect the head, face, neck, and trunk for soft-tissue injury, hemorrhage, or skeletal deformity. Don’t overlook obvious clues, such as oral and nasal secretions reflecting fluid-filled airways and alveoli or facial soot and singed nasal hair suggesting thermal injury to the tracheobronchial tree.

Auscultate over all lung lobes for adventitious breath sounds, particularly crackles and rhonchi, and percuss the lung fields for increased dullness or hyperresonance. Move on to the heart, auscultating for murmurs, pericardial friction rub, and arrhythmia. Check for cyanosis, pallor, jugular vein distention, and edema. If appropriate, perform a neurologic assessment. Evaluate the patient’s level of consciousness (LOC), orientation, and mental status; test cranial nerve function and motor function, sensation, and reflexes in all extremities.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Bradypnea: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Obtain a brief history from the patient, if possible. Alternatively, obtain this information from whoever accompanied him to your facility. Ask if he's experiencing a drug overdose and, if so, try to determine what drugs he took, how much, when, and by what route. Check his arms for needle marks, indicating possible drug abuse. You may need to administer I.V. naloxone, a opioid antagonist.

If you rule out a drug overdose, ask about chronic illnesses, such as diabetes and renal failure. Check for a medical identification bracelet or an I.D. card that identifies an underlying condition. Also, ask whether the patient has a history of head trauma, brain tumor, neurologic infection, or stroke.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Hyperpnea: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If you observe hyperpnea in a patient whose other signs and symptoms signal a life-threatening emergency, you must intervene quickly and effectively. (See Managing hyperpnea, page 348.) However, if the patient’s condition isn’t grave, first determine his level of consciousness (LOC). If he’s alert (and if his hyperpnea isn’t interfering with speaking), ask about recent illnesses or infections, ingestion of aspirin, and ingestion or inhalation of other drugs or chemicals. Find out if the patient has diabetes mellitus, renal disease, or pulmonary condition. Is he excessively thirsty or hungry? Has he recently had severe diarrhea or an upper respiratory tract infection?

Next, observe the patient for clues to his abnormal breathing pattern. Can he speak, or does he speak only in brief, choppy phrases? Is his breathing abnormally rapid? Examine the patient for cyanosis (especially of the mouth, lips, mucous membranes, and earlobes), restlessness, and anxiety — all signs of decreased tissue oxygenation, as occurs in shock. In addition, observe the patient for intercostal and abdominal retractions, use of accessory muscles, and diaphoresis, all of which may indicate deep breathing related to an insufficient oxygen supply. Next, inspect for draining wounds or signs of infection, and ask about nausea and vomiting. Take the patient’s vital signs, including oxygen saturation, noting a fever, and examine his skin and mucous membranes for turgor, possibly indicating dehydration. Auscultate the patient’s heart and lungs.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Orthopnea: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Begin by asking about a history of cardiopulmonary disorders, such as myocardial infarction, rheumatic heart disease, valvular disease, asthma, emphysema, or chronic bronchitis. Does the patient smoke? If so, how much? Explore associated symptoms, noting especially complaints of coughing, nocturnal or exertional dyspnea, fatigue, weakness, loss of appetite, or chest pain. Does the patient use alcohol or have a history of heavy alcohol use?

When examining the patient, check for other signs of increased respiratory effort, such as accessory muscle use, shallow respirations, and tachypnea. Also note barrel chest. Inspect the patient’s skin for pallor or cyanosis and the fingers for clubbing. Observe and palpate for edema, and check for jugular vein distention. Auscultate the lungs for crackles, rhonchi, or wheezing. Also auscultate the heart. Monitor the patient’s oxygen saturation.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Stridor: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

When the patient’s condition permits, obtain a patient history from him or a family member. First, find out when the stridor began. Has he had it before? Does he have an upper respiratory tract infection? If so, how long has he had it?

Ask about a history of allergies, tumors, and respiratory and vascular disorders. Note recent exposure to smoke or noxious fumes or gases. Next, explore associated signs and symptoms. Does stridor occur with pain or a cough?

Then examine the patient’s mouth for excessive secretions, foreign matter, inflammation, and swelling. Assess his neck for swelling, masses, subcutaneous crepitation, and scars. Observe the patient’s chest for delayed, decreased, or asymmetrical chest expansion. Auscultate for wheezes, rhonchi, crackles, rubs, and other abnormal breath sounds. Percuss for dullness, tympany, or flatness. Finally, note burns or signs of trauma, such as ecchymoses and lacerations.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Paroxysmal nocturnal dyspnea: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Begin by exploring the patient’s complaint of dyspnea. Does he have dyspneic attacks only at night or at other times as well, such as after exertion or while sitting down? If so, what type of activity triggers the attack? Does he experience coughing, wheezing, fatigue, or weakness during an attack? Find out if he has a history of lower extremity edema or jugular vein distention. Ask if he sleeps with his head elevated and, if so, on how many pillows or if he sleeps in a reclining chair. Obtain a cardiopulmonary history. Does the patient or a family member have a history of a myocardial infarction, coronary artery disease, or hypertension or of chronic bronchitis, emphysema, or asthma? Has the patient had cardiac surgery?

Next perform a physical examination. Begin by taking the patient’s vital signs and forming an overall impression of his appearance. Is he noticeably cyanotic or edematous? Auscultate the lungs for crackles and wheezing and the heart for gallops and arrhythmias.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Apnea: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

When the patient’s respiratory and cardiac status is stable, investigate the underlying cause of apnea. Ask him (or, if he’s unable to answer, anyone who witnessed the
episode) about the onset of apnea and events immediately preceding it. The cause may become readily apparent, as in trauma.

Take a patient history, especially noting reports of headache, chest pain, muscle weakness, sore throat, or dyspnea. Ask about a history of respiratory, cardiac, or neurologic disease and about allergies and drug use.

Inspect the head, face, neck, and trunk for soft-tissue injury, hemorrhage, or skeletal deformity. Don’t overlook obvious clues, such as oral and nasal secretions (reflecting fluid-filled airways and alveoli) or facial soot and singed nasal hair (suggesting thermal injury to the tracheobronchial tree).

Auscultate over all lung lobes for adventitious breath sounds, particularly crackles and rhonchi, and percuss the lung fields for increased dullness or hyperresonance. Move on to the heart, auscultating for murmurs, pericardial friction rub, and arrhythmias. Check for cyanosis, pallor, jugular vein distention, and edema. If appropriate, perform a neurologic assessment. Evaluate level of consciousness (LOC), orientation, and mental status; test cranial nerve and motor function, sensation, and reflexes in all extremities.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Bradypnea: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Obtain a brief history from the patient, if possible, or from whoever accompanied him to your facility. Ask if he’s experiencing a drug overdose and, if so, try to determine which drugs he took, how much, when, and by what route. Check his arms for needle marks, indicating possible drug abuse. You may need to administer I.V. naloxone, an opioid antagonist.

If you rule out a drug overdose, ask about chronic illnesses, such as diabetes and renal failure. Check for a medical identification bracelet or card that identifies an underlying condition. Also ask whether the patient has a history of head trauma, brain tumor, neurologic infection, or stroke.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Dyspnea: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient can answer questions without increasing his distress, take a complete history. (See Differential diagnosis: Dyspnea, pages 276 and 277.) Ask if the shortness of breath began suddenly or gradually. Is it constant or intermittent? Does it occur during activity or while at rest? If the patient has had dyspneic attacks before, ask if they’re increasing in severity. Can he identify what aggravates or alleviates these attacks? Does he have a productive or nonproductive cough or chest pain? Ask about recent trauma, and note a history of upper respiratory tract infection, deep vein phlebitis, or other disorders. Ask the patient if he smokes or is exposed to toxic fumes or irritants on the job. Find out if he also has orthopnea, paroxysmal nocturnal dyspnea, or progressive fatigue.

Cultural Cue: Because dyspnea is subjective and is exacerbated by anxiety, patients from cultures that are highly emotional may complain of shortness of breath sooner than those who are more stoic about symptoms of illness.

During the physical examination, look for signs of chronic dyspnea such as accessory muscle hypertrophy (especially in the shoulders and neck). Also look for pursed-lip exhalation, clubbing, peripheral edema, barrel chest, diaphoresis, and jugular vein distention.

Check blood pressure and auscultate the lungs for crackles, abnormal heart sounds or rhythms, egophony, bronchophony, and whispered pectoriloquy. Finally, palpate the abdomen for hepatomegaly, and assess the patient for edema.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Hyperpnea: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If you observe hyperpnea in a patient whose other signs and symptoms signal a life-threatening emergency, you must intervene quickly and effectively. (See Managing hyperpnea, page 442.) However, if the patient’s condition isn’t grave, first determine his level of consciousness (LOC). If he’s alert (and if his hyperpnea isn’t interfering with speaking), ask about recent illnesses or infections; ingestion of aspirin or other drugs or chemicals; or inhalation of drugs or chemicals. Find out if the patient has diabetes mellitus, renal disease, or any pulmonary conditions. Is he excessively thirsty or hungry? Has he recently had severe diarrhea or an upper respiratory tract infection?

Next, observe the patient for clues to his abnormal breathing pattern. Is he unable to speak, or does he speak only in brief, choppy phrases? Is his breathing abnormally rapid? Examine the patient for cyanosis (especially of the mouth, lips, mucous membranes, and earlobes), anxiety, and restlessness—all signs of decreased tissue oxygenation, as occurs in shock. In addition, observe the patient for intercostal and abdominal retractions, use of accessory muscles, and diaphoresis, all of which may indicate deep breathing related to an insufficient supply of oxygen. Next, inspect for draining wounds or signs of infection, and ask about nausea and vomiting. Take the patient’s vital signs, including oxygen saturation, noting fever. Also, examine his skin and mucous membranes for turgor, possibly indicating dehydration. Auscultate the patient’s heart and lungs.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Orthopnea: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Begin by asking about a history of cardiopulmonary disorders, such as myocardial infarction, rheumatic heart disease, valvular disease, asthma, emphysema, or chronic bronchitis. Does the patient smoke? If so, how much? Explore associated symptoms, noting especially complaints of cough, nocturnal or exertional dyspnea, fatigue, weakness, loss of appetite, or chest pain. Does the patient use alcohol or have a history of heavy alcohol use?

When examining the patient, check for other signs of increased respiratory effort, such as accessory muscle use, shallow respirations, and tachypnea. Also note barrel chest. Inspect the patient’s skin for pallor or cyanosis, and the fingers for clubbing. Observe and palpate for edema, and check for neck vein distention. Auscultate the lungs and heart. Monitor the patient’s oxygen saturation.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Stridor: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

When the patient’s condition permits, obtain a patient history from him or a family member. First, find out when the stridor began. Has he had it before? Does he have an upper respiratory tract infection? If so, how long has he had it?

Ask about a history of allergies, tumors, and respiratory and vascular disorders. Note recent exposure to smoke or noxious fumes or gases. Next, explore associated signs and symptoms. Does stridor occur with pain or a cough?

Then examine the patient’s mouth for excessive secretions, foreign matter, inflammation, and swelling. Assess his neck for swelling, masses, subcutaneous crepitation, and scars. Observe the patient’s chest for delayed, decreased, or asymmetrical chest expansion. Auscultate for wheezes, rhonchi, crackles, rubs, and other abnormal breath sounds. Percuss for dullness, tympany, or flatness. Finally, note any burns or signs of trauma, such as ecchymoses and lacerations.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Paroxysmal nocturnal dyspnea: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Begin by exploring the patient’s complaint of dyspnea. Does he have dyspneic attacks only at night or at other times as well, such as after exertion or while sitting down? If so, what type of activity triggers the attack? Does he experience coughing, wheezing, fatigue, or weakness during an attack? Find out if he has a history of lower extremity edema or jugular vein distention. Ask if he sleeps with his head elevated and, if so, on how many pillows or if he sleeps in a reclining chair. Obtain a cardiopulmonary history. Does the patient or a family member have a history of a myocardial infarction, coronary artery disease, or hypertension, or of chronic bronchitis, emphysema, or asthma? Has the patient had cardiac surgery?

Next perform a physical examination. Begin by taking the patient’s vital signs and forming an overall impression of his appearance. Is he noticeably cyanotic or edematous? Auscultate the lungs for crackles and wheezing and the heart for gallops and arrhythmias.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Stridor: Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Focused physical examination (PE)

1. The PE should include vital signs, notably temperature and respiratory rate, and pulse, with emphasis on general appearance and examination of the head and neck, including ears, nose, and throat.

2. Signs of respiratory distress may be present, including dyspnea, tachypnea, chest retractions, nasal flaring, and stridor. If cyanosis is present, this is an ominous sign (2,4) (Chapter 8.2).

B. Additional physical examination may reveal:

1. A toxic-appearing child with high fever, drooling, severe respiratory distress, and preference for a sitting and forward-leaning position (1,4)

2. Varying degrees of anxiety, which will increase during examination, cause a worsening of stridor (1,4)

Testing

A. The best test is a lateral neck x-ray study to assist with a diagnosis that is mostly made on clinical grounds. Films of the larynx and trachea in anteroposterior and lateral neck views may show narrowing of the trachea or extrinsic pressure on the tracheobronchial airway. Acutely, lateral neck radiographs showing the classic swollen glottis described by some as a thumbprint, assist with the diagnosis of acute supraglottitis and eminent respiratory collapse. Chest x-ray studies are of little value. Films showing hyperinflation or bronchial thickening may help to make a diagnosis of asthma rather than stridor. Additionally, foreign body aspiration or mass will be elucidated in x-ray studies (2).

B. Tomograms or computed tomography (CT) of the neck may provide additional information, especially in chronic stridor (2).

C. Blood tests (e.g., complete blood count) can be useful in the acutely ill patient, especially if viral or bacterial infection is suspected.

D. With suspicion that the stridor is a result of a laryngomalacia or laryngeal lesions such as papilloma, direct laryngoscopy is the test of choice for accurate diagnosis. Direct observation via fiberoptic bronchoscope positioned in the pharynx would provide diagnostic views of the larynx (2,4).

Diagnostic assessment

In making the diagnosis of stridor, two key elements exist: acute onset in a toxic-appearing patient, versus chronic stridor in a relatively stable patient.

A. Acute stridor

 1. The most likely cause of acute stridor in the febrile child with the additional features of barking cough and antecedent coryza is laryngotracheobronchitis or croup. Acute stridor is a non–life-threatening condition accounting for 90% of stridor cases. Classically, it improves with exposure to moist air. It has a viral cause, usually from one of the following: respiratory syncytial virus, rhinovirus, adenovirus, parainfluenza virus, and influenza virus. Generally, this diagnosis is made on clinical grounds (1). The child is less ill and, although often febrile, not toxic appearing. The entire illness usually abates in 5 days. Hospitalization, unlike with epiglottitis, is rarely needed (2).

2. In the toxic patient with fever, respiratory distress, sore throat, or drooling, especially in the younger age group, consider epiglottitis—a medical emergency. As use of the Haemophilus influenzae vaccine has increased in recent years, acute epiglottis is becoming increasingly rare. H. influenzae is the most common bacterial cause of stridor, although streptococcus, staphylococcus and viral agents are also possible causes.

 3. The patient with a history of suspected foreign body aspiration will have similar symptoms without fever. Foreign body aspiration is common in the 1- to 2-year age groups, although it does occur in adults. It can be a cause of chronic stridor (3).

 4. Additionally, an acute allergic reaction can cause stridor. The history should herald a possible offending agent and, although respiratory collapse may be eminent, the patient will not be toxic, as no infectious agent is involved.

 5. Trauma can also cause laryngeal damage; however, the history will assist with this diagnosis.

 B. Chronic stridor. For the most part, these causes of stridor occur in early childhood. With the exception of laryngeal papillomas, tumors, and subglottic stenosis after instrumentation as in intubation (there is a congenital form also), foreign body aspiration with partial obstruction and hysterical stridor can occur at any age. Laryngomalacia and laryngeal lesions are caused by webs, hemangiomas, and cysts; they are usually identified early in life (1–3).


References

1. Pryor MP. Noisy breathing in children. Postgrad Med 1997;101:103–112.

2. Behrman RE, Kliegman RM, Arvin AM. Nelson textbook of pediatrics. Philadelphia: WB Saunders, 1996:241, 1173, 1198, 1238.

3. Behrman RE, Vaughan VC. Nelson textbook of pediatrics. Philadelphia: WB Saunders, 1983:1031–1032, 1076–1077.

4. Tintinalli JE, Ruiz E, Krome RL. Emergency medicine: a comprehensive study guide. New York: McGraw-Hill, 1996:247–251.

5. Campbell AGM, MacIntosh N. Textbook of pediatrics. London: Pearson Ltd., 1998:
508–513, 563.

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Acute Dyspnea: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

Dyspnea is a sensation of inability to take in enough air, which causes anxiety and discomfort. Being caused by factors including tissue hypoxia, reduced lung compliance, and activation of J receptors, it may not correlate reliably with arterial oxygen saturation.

Paroxysmal nocturnal dyspnea occurs in congestive heart failure (CHF) when the patient awakens with a sense of suffocation. A patient with chronic bronchitis may also awaken with shortness of breath and wheezing caused by mucous plugging; this clears with a cough. Orthopnea is seen in CHF, asthma, and bilateral diaphragmatic paralysis. Sudden onset suggests pneumothorax, pulmonary embolism, or “flash” pulmonary edema.

Tachypnea can occur without dyspnea in conditions such as metabolic acidosis.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Chronic Dyspnea: Diagnostic Approach
(Field Guide to Bedside Diagnosis)

Nonproductive cough may be a “dyspnea equivalent.” Nocturnal coughing to clear the airway of excess secretions can be confused with paroxysmal nocturnal dyspnea.

Trepopnea, dyspnea lying on one side but not the other, occurs with cardiomegaly, unilateral parenchymal lung disease, and mediastinal or endobronchial tumors.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Bradypnea: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Determine the patient’s respiratory rate and assess his other vital signs. Then proceed to a complete physical assessment, paying particular attention to the cardiopulmonary assessment.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Dyspnea: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

During the physical examination, look for signs of chronic dyspnea, such as accessory muscle hypertrophy (especially in the shoulders and neck). Also look for pursed-lip exhalation, clubbing, peripheral edema, barrel chest, diaphoresis, and jugular vein distention. Check blood pressure and auscultate for crackles, abnormal heart sounds or rhythms, egophony, bronchophony, and whispered pectoriloquy. Finally, palpate the abdomen for hepatomegaly, and assess the patient for edema.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Hyperpnea: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Observe the patient for clues to his abnormal breathing pattern. Is he unable to speak, or does he speak only in brief, choppy phrases? Is his breathing abnormally rapid? Examine the patient for cyanosis (especially of the mouth, lips, mucous membranes, and earlobes), restlessness, and anxiety — all signs of decreased tissue oxygenation, as occurs in shock. In addition, observe the patient for intercostal and abdominal retractions, use of accessory muscles, and diaphoresis, all of which may indicate deep breathing related to an insufficient supply of oxygen. Next, inspect for draining wounds or signs of infection, and ask about nausea and vomiting. Take the patient’s vital signs, including oxygen saturation, noting fever, and examine his skin and mucous membranes for turgor, possibly indicating dehydration. Auscultate the patient’s heart and lungs.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Orthopnea: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

When examining the patient, check for other signs of increased respiratory effort, such as accessory muscle use, shallow respirations, and tachypnea. Also note barrel chest. Inspect the patient’s skin for pallor or cyanosis, and the fingers for clubbing. Observe and palpate for edema, and check for jugular vein distention. Auscultate the lungs and heart. Monitor the patient’s oxygen saturation.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Stridor: Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Examine the patient’s mouth for excessive secretions, foreign matter, inflammation, and swelling. Assess his neck for swelling, masses, subcutaneous crepitation, and scars. Observe the patient’s chest for delayed, decreased, or asymmetrical chest expansion. Auscultate for wheezes, rhonchi, crackles, rubs, and other abnormal breath sounds. Percuss for dullness, tympany, or flatness. Finally, note any burns or signs of trauma, such as ecchymoses and lacerations.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Respiratory Distress and Apnea: Diagnostic Approach: Respiratory Distress
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  • In preterminfants, most common cause of respiratory distress is respiratorydistress syndrome. In term infants, transient tachypnea, meconiumaspiration, pneumonia, and pneumothorax are most common lower respiratorytract disorders causing respiratory distress. Other nonpulmonarycauses of respiratory distress in neonates are congenital heartdisease, persistent fetal circulation, and septicemia. In infancyand childhood, most common causes of respiratory distress are bronchiolitis,croup, asthma, pneumonia, foreign body aspiration, and congenitalor acquired heart disease with cardiac failure.
  • History and physical exam suggest mostlikely cause for respiratory distress. Oxygen saturation in roomair indicates degree of hypoxemia. Certain tests should be considereddepending on clinical circumstances:

  • Airway radiography or endoscopy for upperairway obstruction
  • Chest radiography for lower respiratorydisorders or cardiac disease
  • CBC for anemia
  • Serum electrolytes and creatinine;blood urea nitrogen; and venous/capillary pH for metabolicacidosis
  • ECG and 2-D echocardiography for cardiacfailure
  • Chest CT for any airway, lung, or mediastinal mass

    • » READ BOOK EXCERPT ONLINE »

    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Stertor, Stridor, and Airway Obstruction: Diagnostic Approach
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  • Stertorand stridor are signs of upper airway obstruction. With seriousairway obstruction, establishing control of the airway and maintainingventilation are the most important immediate priorities. In absenceof life-threatening airway obstruction, prompt but thorough investigationis essential.
  • Age of onset is useful in diagnosis.Onset of stridor at birth or during neonatal period suggests laryngomalacia,laryngeal web, vocal cord paralysis, or vascular ring. In infancyand childhood, onset of acute stridor suggests croup, supraglottitis,or foreign body. Most common cause of persistent stertor in children2–8 yrs of age is adenoid or tonsillar hypertrophy.
  • Phase of respiration in which stridoroccurs, pitch of the sound, character of voice or cry, and changein position help in assessing degree of obstruction and its localization.

  • The phaseof respiration associated with different levels of airway obstructionhas already been described.
  • Variation in pitch depends on leveland degree of obstruction. Coarse low-pitched snoring sounds (stertor)localize lesion to nose, nasopharynx, or oropharynx. Harsh inspiratorystridor may occur with supraglottic, glottic, or subglottic lesions.Stridor associated with deep barking cough signifies subglotticor tracheal obstruction, whereas stridor associated with hoarsenessor change in character of voice or cry signifies glottic lesion.
  • When infants with laryngomalacia orinnominate artery compression are placed in prone position withneck extended, stridor decreases.
  • After history and physical exam, othertests may be useful depending on suspected diagnosis. These includeneck and chest radiography and flexible laryngoscopy. If resultsof these tests are normal, upper GI radiographic series with attentionto the pharynx and esophagus should be considered. With suspectedobstruction below glottis, bronchoscopy is necessary. Usefulnessof esophagoscopy, CT, and MRI depends on suspected diagnosis.
  • Histologic diagnosis is necessary forany suspected neoplasm except perhaps hemangioma, which can usuallybe recognized clinically.

    • » READ BOOK EXCERPT ONLINE »

    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Apnea: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    When the patient's respiratory and cardiac status is stable, investigate the underlying cause of apnea. Ask him (or, if he's unable to answer, anyone who witnessed the episode) about the onset of apnea and events immediately preceding it. The cause may be readily apparent, as in trauma.

    Take a patient history, noting reports of headache, chest pain, muscle weakness, sore throat, or dyspnea. Ask about a history of respiratory, cardiac, or neurologic disease and about allergies and drug use.

    Inspect the head, face, neck, and trunk for soft-tissue injury, hemorrhage, or skeletal deformity. Don't overlook obvious clues, such as oral and nasal secretions reflecting fluid-filled airways and alveoli or facial soot and singed nasal hair suggesting thermal injury to the tracheobronchial tree.

    Auscultate all lung fields for adventitious breath sounds, particularly crackles and rhonchi, then percuss for increased dullness or hyperresonance. Next, auscultate the heart for murmurs, pericardial friction rub, and arrhythmias. Check for cyanosis, pallor, jugular vein distention, and edema. If appropriate, perform a neurologic assessment. Evaluate the patient's level of consciousness (LOC), orientation, and mental status; test cranial nerve function and motor function, sensation, and reflexes in all extremities.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Bradypnea: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Obtain a brief history from the patient if possible. Alternatively, obtain this information from whoever accompanied him to the facility. Ask if he's experiencing a drug overdose and, if so, try to determine what drugs he took, how much, when, and by what route. Check his arms for needle marks, indicating possible drug abuse. You may need to administer I.V. naloxone, an opioid antagonist.

    If you rule out a drug overdose, ask about chronic illnesses, such as diabetes and renal failure. Check for a medical identification bracelet or an I.D. card that identifies an underlying condition. Ask whether the patient has a history of head trauma, brain tumor, neurologic infection, or stroke.

    Perform a complete physical examination, especially noting abnormalities of the respiratory system.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Dyspnea: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If the patient can answer questions without increasing his distress, take a complete history. Ask if the shortness of breath began suddenly or gradually. Is it constant or intermittent? Does it occur during activity or while at rest? If the patient has had dyspneic attacks before, ask if they're increasing in severity. Can he identify what aggravates or alleviates these attacks? Does he have a productive or nonproductive cough or chest pain? Ask about recent trauma, and note a history of upper respiratory tract infection, deep vein phlebitis, or other disorders. Ask the patient if he smokes or is exposed to toxic fumes or irritants on the job. Find out if he also has orthopnea, paroxysmal nocturnal dyspnea, or progressive fatigue.

    During the physical examination, look for signs of chronic dyspnea such as accessory muscle hypertrophy (especially in the shoulders and neck). Also look for pursed-lip exhalation, clubbing, peripheral edema, barrel chest, diaphoresis, and jugular vein distention.

    Check blood pressure and auscultate for crackles, abnormal heart sounds or rhythms, egophony, bronchophony, and whispered pectoriloquy. Finally, palpate the abdomen for hepatomegaly, and assess the patient for edema.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Hyperpnea: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If you observe hyperpnea in a patient whose other signs and symptoms signal a life-threatening emergency, you must intervene quickly and effectively. (See Managing hyperpnea, page 334.) However, if the patient's condition isn't grave, first determine his level of consciousness (LOC). If he's alert (and if his hyperpnea isn't interfering with speaking), ask about recent illnesses or infections, ingestion of aspirin, and ingestion or inhalation of other drugs or chemicals. Find out if the patient has diabetes mellitus, renal disease, or pulmonary condition. Is he excessively thirsty or hungry? Has he recently had severe diarrhea or an upper respiratory tract infection?

    Next, observe the patient for clues to his abnormal breathing pattern. Can he speak, or does he speak only in brief, choppy phrases? Is his breathing abnormally rapid? Examine the patient for cyanosis (especially of the mouth, lips, mucous membranes, and earlobes), restlessness, and anxiety—all signs of decreased tissue oxygenation, as occurs in shock. In addition, observe the patient for intercostal and abdominal retractions, use of accessory muscles, and diaphoresis, all of which may indicate deep breathing related to an insufficient oxygen supply. Next, inspect for draining wounds or signs of infection, and ask about nausea and vomiting. Take the patient's vital signs, including oxygen saturation, noting a fever, and examine his skin and mucous membranes for turgor, possibly indicating dehydration. Auscultate the patient's heart and lungs.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Orthopnea: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Begin by asking about a history of cardiopulmonary disorders, such as myocardial infarction, rheumatic heart disease, valvular disease, asthma, emphysema, or chronic bronchitis. Does the patient smoke? If so, how much? Explore associated symptoms, noting especially complaints of coughing, nocturnal or exertional dyspnea, fatigue, weakness, loss of appetite, or chest pain. Does the patient use alcohol or have a history of heavy alcohol use?

    When examining the patient, check for other signs of increased respiratory effort, such as accessory muscle use, shallow respirations, and tachypnea. Also note barrel chest. Inspect the patient's skin for pallor or cyanosis and the fingers for clubbing. Observe and palpate for edema, and check for jugular vein distention. Auscultate the lungs for crackles, rhonchi, or wheezing. Also auscultate the heart. Monitor the patient's oxygen saturation.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Stridor: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    When the patient's condition permits, obtain a patient history from him or a family member. First, find out when the stridor began. Has he had it before? Does he have an upper respiratory tract infection? If so, how long has he had it?

    Ask about a history of allergies, tumors, and respiratory and vascular disorders. Note recent exposure to smoke or noxious fumes or gases. Next, explore associated signs and symptoms. Does stridor occur with pain or cough?

    Then examine the patient's mouth for excessive secretions, foreign matter, inflammation, andswelling. Assess his neck for swelling, masses, subcutaneous crepitation, and scars. Observe the patient's chest for delayed, decreased, or asymmetrical chest expansion. Auscultate for wheezes, rhonchi, crackles, rubs, and other abnormal breath sounds. Percuss for dullness, tympany, or flatness. Finally, note burns or signs of trauma, such as ecchymoses and lacerations.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Paroxysmal nocturnal dyspnea: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    Begin by exploring the patient's complaint of dyspnea. Does he have dyspneic attacks only at night or at other times as well, such as after exertion or while sitting down? If so, what type of activity triggers the attack? Does he experience coughing, wheezing, fatigue, or weakness during an attack? Find out if he has a history of lower extremity edema or jugular vein distention. Ask if he sleeps with his head elevated and, if so, on how many pillows or if he sleeps in a reclining chair. Obtain a cardiopulmonary history. Does the patient or a family member have a history of a myocardial infarction, coronary artery disease, or hypertension or of chronic bronchitis, emphysema, or asthma? Has the patient had cardiac surgery?

    Next perform a physical examination. Begin by taking the patient's vital signs and forming an overall impression of his appearance. Is he noticeably cyanotic or edematous? Auscultate the lungs for crackles and wheezing and the heart for gallops and arrhythmias.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007


     » Next page: Diagnosis of Asphyxia

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