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Diseases » Bronchitis » Diagnosis

Diagnosis of Bronchitis

Bronchitis Diagnosis: Book Excerpts

Diagnosis of Bronchitis: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Bronchitis:

Diagnostic Tests for Bronchitis: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Bronchitis.

COUGH: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

Is it acute or chronic? Acute onset of a cough would suggest an acute URI, viral pneumonia, or bronchopneumonia. A chronic cough is more suggestive of pneumoconiosis, chronic bronchitis, emphysema, bronchiectasis, tuberculosis, carcinoma of the lung, or bronchial asthma.
Is there exposure to toxic fumes? The most common toxic fume is cigarette smoke. However, if one asks the patient's occupation one might find that he is a miner and therefore pneumoconiosis comes to mind. One might find that he is an aircraft maker or shipbuilder, in which case berylliosis and asbestosis would come to mind, or that he is a farmer and, therefore, farmer's lung would come to mind.
Is there significant sputum production? If so, what is the nature of the sputum? Purulent sputum would suggest a pneumonia, abscess, tuberculosis, or bronchiectasis; bloody sputum would suggest carcinoma of the lung, tuberculosis, and bronchiectasis; mucoid sputum would suggest asthma. If the sputum is foamy, one would consider congestive heart failure, mitral stenosis, and inhalation of poison gas.
Is there fever? If there is fever associated with the cough, obviously one would suspect an infectious process to be present. This could be viral or bacterial. Most likely the patient has bronchopneumonia, but the possibility of an abscess or pulmonary infarct would still have to be entertained.
What other symptoms and signs are associated with the cough? The first thing to be considered would be dyspnea. In acute cases dyspnea would be a sign of congestive heart failure, pulmonary embolism and, of course, advancing pneumonia. In chronic cases dyspnea would be a sign of emphysema, chronic pulmonary fibrosis, and chronic congestive heart failure. Wheezing would be a sign of asthma or congestive heart failure, but of course it is also found in pulmonary emphysema. Cardiomegaly would suggest congestive heart failure and if there is an associated murmur, that makes congestive heart failure even more likely. If there is hepatosplenomegaly, one would suspect a systemic disease involving the lungs such as periarteritis nodosa or other collagen diseases.
Is the patient taking drugs? Angiotensin-converting enzyme (ACE) inhibitors such as captopril are well known to cause cough.

DIAGNOSTIC WORKUP

If there is nasal stuffiness and a postnasal drip, a trial of antihistamines or decongestants is indicated before starting an expensive workup. All patients require a CBC and differential count, a sedimentation rate, and a chemistry panel. A sputum for routine smear and culture should be done, and in chronic cases a sputum for AFB culture and smear must be done. One should keep a high index of suspicion for Mycoplasma pneumoniae and Legionnaire's disease. Also, sputum for fungi culture should be done on chronic cases.

Asthma can be further elucidated and confirmed by doing a sputum for eosinophils. Carcinoma of the lung can be confirmed with a sputum for Pap smear. If there is fever, blood cultures may be useful and febrile agglutinins should also be done. An x-ray of the chest with anteroposterior, lateral, and apical lordotic views should be done, and when a tumor is suspected, tomography should be done or a CT scan. In cases of chronic cough, skin testing for coccidioidomycosis, cystoplasmosis, tuberculosis, and blastomycosis should be done. A Kveim test to rule out sarcoidosis may be necessary. When these tests fail to make a diagnosis, bronchoscopy and possibly bronchograms to look for a bronchiectasis should be done. Lung biopsy may be necessary also. Pulmonary function tests should be done in suspected cases of emphysema and asthma. Allergy skin testing is extremely valuable in cases of asthma. Look for alpha 1-antitrypsin deficiency in difficult cases. If congestive heart failure is suspected, an arm-to-tongue circulation time would be valuable. A trial of diuretics may also assist in the diagnosis. If reflux esophagitis is suspected, prolonged monitoring of esophageal pH may be diagnostic. A trial of therapy with an H₂ antagonist may also be diagnostic.

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

STRIDOR: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

Is the patient an adult or a child? If the patient is a child, acute epiglottitis, acute laryngotracheitis, foreign body, congenital laryngeal stridor, laryngismus stridulus, and a retropharyngeal abscess should be considered. Diphtheria is rarely found nowadays. If the patient is an adult, myasthenia gravis, bulbar and pseudobulbar palsy, recurrent laryngeal palsy, pharyngitis, laryngotracheitis, carcinoma of the larynx or trachea, angioneurotic edema, foreign bodies, thyroid disorders, and disorders of the mediastinum should be considered.
Is it acute or gradual onset? The presence of stridor of acute onset would suggest acute epiglottitis, acute pharyngitis, laryngotracheitis, angioneurotic edema, retropharyngeal abscess, laryngismus stridulus, and foreign body.
Is there fever? The presence of fever would suggest acute laryngotracheitis, diphtheria, subacute thyroiditis, retropharyngeal abscess, and mediastinitis.
Are there abnormalities on the ear, nose, and throat examination? On ear, nose, and throat examination, the clinician may find pharyngitis, acute epiglottitis, a foreign body, tenderness of the thyroid suggesting thyroiditis, and thyroid masses.
Are there neurologic abnormalities on examination? Neurologic abnormalities may be found in myasthenia gravis, bulbar and pseudobulbar palsy, bilateral recurrent laryngeal nerve palsy, and comatose states.

DIAGNOSTIC WORKUP

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

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

The CBC, sedimentation rate, chest x-ray, EKG, sputum analysis and culture, and pulmonary function testing will usually assist with the clinical diagnosis. Bronchoscopy may be needed also, especially when there is hemoptysis .

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Stridor & Wheezing: Differential Diagnosis
(In a Page: Signs and Symptoms)

Stridor (inspiratory)

Croup (laryngotracheobronchitis)
–Viral infection with tracheal narrowing due to airway edema
–“Bark-like” cough, hoarseness

Epiglottitis
–Airway emergency most commonly due to Haemophilus influenzae or group A streptococcus infection
–Abrupt onset of high fevers, sore throat, hoarseness, dysphagia, respiratory distress

Foreign body lodged in the upper airway

Allergic reaction/anaphylaxis
–May have urticaria and angioedema (subcutaneous or mucosal swelling, often of the lips)

Trauma
Postendotracheal intubation
Psychogenic (e.g., paroxysmal vocal cord dyskinesia)
Stridor (expiratory)
COPD (expiratory vocalization to prolong time to airway closure and avoid air trapping)
Cardiac failure (expiratory vocalization to prolong increased intrathoracic pressure and unload left ventricle)

Wheezing

Asthma
–Triad of chronic cough, dyspnea, wheezing
–Wheezing may be absent in cases of severe obstruction (insufficient air movement)

Pulmonary edema
–Leakage of fluid into the interstitium and alveoli due to elevated capillary pressure (cardiogenic) or abnormal capillary permeability (noncardiogenic)

COPD

GERD

Respiratory infection
–Upper respiratory infection
–Bronchiolitis
–“Atypical” pneumonia

Aspirated foreign body
–Abrupt onset of unilateral wheezing or stridor (if lodged in the upper airway), cough, and decreased breath sounds

Allergic reaction/anaphylaxis
–Urticaria, throat swelling (angioedema), and lip/tongue edema may be present

Workup and Diagnosis

History and physical examination
Initial labs may include CBC with differential, pulse oximetry, electrolytes, BUN/creatinine, calcium, and glucose
Consider blood and/or sputum cultures if infectious cause is suspected
Chest X-ray helps to differentiate respiratory infection from pulmonary edema, diagnose radiopaque foreign bodies, and shows “steeple sign” in cases of croup
Lateral neck X-ray may reveal swelling of the epiglottis in cases of epiglottitis or abscess
Chest CT with contrast provides excellent views of the lung parenchyma and helps to identify tumors and bronchiectasis
Bronchoscopy may be diagnostic and therapeutic in cases of obstruction due to foreign body
Lung biopsy or bronchoalveolar lavage can be performed in cases of suspected malignancy
Echocardiogram may be indicated to evaluate for structural heart disease, valve disease, and left ventricular function

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Cough - Productive: Differential Diagnosis
(In a Page: Signs and Symptoms)

Postnasal drip (e.g., chronic sinusitis, allergic rhinitis)
–Most common cause of chronic cough in nonsmokers
Acute bronchitis
–Most commonly caused by viruses (e.g., influenza, adenovirus, rhinovirus, RSV)
–Bacteria are much less common (e.g., Streptococcus pneumoniae, Mycoplasma, Haemophilus influenzae)
Pneumonia
–May be community-acquired, hospital-acquired, or due to aspiration
–“Typical” pneumonia (e.g., S. pneumoniae, H. influenzae, influenza virus) has acute or subacute onset of fever, dyspnea, fatigue, pleuritic chest pain, and productive cough
–“Atypical” pneumonia (e.g., Mycoplasma, Legionella, Chlamydia, Pneumocystis carinii) has more gradual onset, dry cough, headache, fatigue
Smoker's cough

Lung cancer
–90% of cases due to smoking (other risk factors include radon, asbestos, pollutants)
Asthma with secondary infection
COPD (chronic bronchitis component)
Congestive heart failure
–Associated with “frothy” sputum
Tuberculosis

Workup and Diagnosis

Complete history and physical examination
–Note acute (<3 weeks) versus chronic or recurrent
Initial tests may include CBC, pulse oximetry, ESR, peak flow measurements, PPD, chest X-ray, blood cultures, sputum Gram stain and culture, and acid-fast stain for tuberculosis
Pulmonary function tests with or without methacholine challenge
Chest CT and/or sputum cytology if patient has concerning symptoms (e.g., weight loss, hemoptysis, fever)
Initial empiric treatment for postnasal drip (antihistamine, decongestant, nasal steroids)
Consider CT of sinuses or nasolaryngoscopy to evaluate for sinusitis
Consider bronchoscopy with possible bronchoalveolar lavage and/or biopsy

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Cough - Nonproductive: Differential Diagnosis
(In a Page: Signs and Symptoms)

Smoker's cough
Postnasal drip (e.g., chronic sinusitis, allergic rhinitis)
–Most common cause of chronic cough in nonsmokers

GERD
–Second most common cause of chronic cough in nonsmokers

Asthma/reactive airway disease
–Classic triad of chronic cough, dyspnea, and wheezing

ACE inhibitor use

Acute bronchitis
–Most commonly caused by viruses (e.g., influenza, adenovirus, rhinovirus, RSV)
–Postviral bronchitis may last beyond 6 weeks

Pneumonia
–“Typical” pneumonia (e.g., Streptococcus pneumoniae, Haemophilus influenzae, or influenza/parainfluenza viruses) is characterized by acute or subacute onset of fever, dyspnea, fatigue, pleuritic chest pain, and cough
–“Atypical” pneumonia (e.g., Mycoplasma, Legionella, Chlamydia) is characterized by more gradual onset, dry cough, headache, fatigue, and minimal lung signs

Aspirated foreign body
–Abrupt onset of unilateral wheezing or stridor, cough, decreased breath sounds
–Leading cause of home accidental death in children younger than 6 (boys >girls)

Lung cancer
–90% of cases due to smoking (other risk factors include radon, asbestos, pollutants)

COPD (emphysematous variant)

Sarcoidosis

Cryptogenic organizing pneumonia
–Most commonly occurs following viral infection or exposure

Congestive heart failure

Filarial disease

Aspiration

Workup and Diagnosis

Complete history and physical examination
–Note acute (<3 weeks) versus chronic or recurrent
Initial tests may include CBC, pulse oximetery, ESR, peak flow measurements, PPD, and eosinophil count
Chest X-ray and/or CT if patient has concerning symptoms (e.g., weight loss, hemoptysis, fever)
Consider blood and sputum cultures
Initial empiric treatment of postnasal drip (antihistamine, decongestant, nasal steroids), asthma (trial of bronchodilators or a methacholine challenge test), and/or GERD (proton pump inhibitor) may be advisable
If imaging is normal and empiric treatment for GERD does not resolve symptoms, proceed with upper GI endoscopy or esophageal pH monitoring
Consider CT of sinuses or nasolaryngoscopy to evaluate for sinusitis
Consider bronchoscopy to identify subtle pulmonary causes
Consider cardiac workup if pulmonary and GI evaluations are negative

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Stridor: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Nasal cavity and nasopharynx

Congenital
–Piriform aperture stenosis
–Choanal atresia
–Lacrimal duct cyst
–Craniofacial anomaly
–Nasopharyngeal mass (teratoma)

Inflammatory/infectious
–Rhinosinusitis
–Adenoid hypertrophy

Oral cavity, oropharynx, and hypopharynx

Congenital
–Macroglossia
–Glossoptosis
–Vallecular cyst
Inflammatory/infectious
–Tonsillar hypertrophy
Tumors
–Lingual thyroid
–Dermoid
–Lymphovascular malformation
Foreign body

Laryngeal

Congenital
–Laryngomalacia (#1 cause in infants); usual onset is in the first 2 weeks of life, typically positional; most resolve spontaneously by age 1
–Saccular cyst
–Webs
–Clefts
–Vocal cord paralysis

Inflammatory/infectious
–Epiglottitis
–Laryngotracheitis (croup)
–Gastroesophageal reflux
Tumors
–Papillomas
–Hemangiomas

Trauma
–Subglottic stenosis
–Foreign bodies
–Laryngeal fracture
–Caustic ingestion
Tracheobronchial
Congenital
–Tracheomalacia
–Vascular rings
–Tracheoesophageal fistula
Inflammatory

Workup and Diagnosis

History
–Duration, onset, severity, character, progression
–Failure to thrive, feeding problems, cyanosis, apnea
–Reflux history: Frequent spit-ups, vomiting, heartburn, chest pain, hoarseness
–Birth, neonatal, and past medical history: Complicated labor, respiratory distress at delivery
–Prior intubations, neurologic problems, prior episodes of croup, prior neck surgery, foreign body ingestion
–Immunization history

Physical exam
–Fever, respiratory rate, heart rate, level of consciousness, cyanosis
–Auscultation: Chest, nose, mouth, neck (phase of stridor: inspiratory, expiratory, biphasic)
–Nose: Nasal obstruction
–Mouth: Tonsillar hypertrophy
–Neck: Retractions, compressive mass, thyroid
- Studies
  –Flexible nasolaryngoscopy: Check for choanal patency, adenoid size, laryngomalacia, vocal cord mobility
  –Direct laryngoscopy and bronchoscopy (DLB): Controversial whether all children with stridor need DLB
  –MRI: Vascular compression or external mediastinal mass
  –Modified barium swallow or esophagram in children with history of swallowing difficulties

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Wheezing: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Lower airway (expiratory, polyphonic)

Extraluminal compression of airways
–Parenchymal: Pneumonia, pulmonary edema, bronchogenic cyst
–Vascular: Ring, sling, “cardiac wheeze”
–Lymphatics: Enlarged lymph nodes (TB, sarcoidosis, malignancy)
–Structural: CLE, scoliosis, or chest wall deformity with airway “kinking”
Transluminal change in airway
–Asthma: Inflammation, edema, hyperemia, mucus gland hypertrophy and proliferation, smooth muscle bronchospasm
–Bronchiectasis/bronchitis
–Cystic fibrosis
–Ciliary disease: Primary ciliary dyskinesia, dysfunction due to ETS or hyperoxia
–Anatomic: Hemangioma, polyps, TEF, bronchial atresia, BALT, bronchiolitis obliterans, tracheobronchomalacia
–Immunologic disorders (e.g., IgA deficiency)

Intraluminal change in airway
–Mucus (increased production or decreased clearance), pus (infected sputum), blood
–Foreign body
–Aspirated food or stomach contents secondary to gastroesophageal reflux
Upper airway (usually inspiratory and monophonic)

Nasal (congestion, choanal atresia, FB)
Oropharyngeal (tonsils, adenoids, macroglossia, foreign body, decreased tone, retropharyngeal abscess)

Laryngeal (laryngomalacia, vocal cord dysfunction or paralysis, laryngeal web or polyp, subglottic stenosis)

Central nervous system

Structural disease (e.g., Arnold-Chiari malformation leading to vocal cord paralysis)
Functional (e.g., vocal cord dysfunction, chronic aspiration)

Workup and Diagnosis

History
–Triggers: Viral disease, irritants, and allergic disease
–Improvement with β -agonists or steroids suggests asthma
–Worsening with ETS suggests asthma or bronchitis; with exercise, EIA or VCD; with β-agonists, bronchomalacia
–Delayed onset with exercise suggests EIA; rapid onset with exercise suggests VCD (teens) or bronchomalacia (babies)
–Age of onset: First month, structural problems (e.g., bronchomalacia); first year, RSV bronchiolitis, GER, or aspiration; early childhood, asthma, possible FB aspiration; adolescence, asthma and VCD
–Other symptoms: Hemoptysis, chronic cough, weight loss (CF, TB, bronchiectasis, malignancy, recurrent infection, or immunodeficiency); weakness, hypotonia (neuromotor disease, Down syndrome, aspiration); choking on feeds (upper airway disease, TEF, chronic aspiration)

Exam findings
–High pitch indicates smaller airways; low pitch, larger airway(s); inspiratory, extrathoracic airway; expiratory, intrathoracic airways; biphasic, fixed obstruction or two sites; expiratory prolongation, small airways or severe larger airways

Diagnostic tests: CXR may show hyperinflation, peribronchial cuffing, congenital lesions; CT, tissue density abnormalities, airway lesions; MRI, airway, blood vessel interface; MRA defines vascular anatomy; nuclear med, reflux and V/Q studies; PFT, volume and air flow; bronchoscopy, lavage and visualize
Blood gas; disease-specific studies (e.g., sweat test)

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Cough – Acute: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Upper airway disease
–URI or common cold accounts for much pediatric coughing (influenza, parainfluenza, rhinovirus)
–Chronic sinusitis, tonsillitis, laryngitis, and croup are other common infections
–Allergic disease
–Vocal cord dysfunction (VCD)

Lower airway disease
–Asthma is inflammatory triad of edema, mucus, and bronchospasm, characterized by reversibility with asthma drugs (the most common triggers for asthma are viral disease, irritants such as ETS, allergic disease, and gastroesophageal reflux)
–Infectious diseases: Bronchiolitis, caused by RSV in babies, causes cough from inflammatory changes and debris; bronchitis is more common in older children and may be secondary to smoking or ETS exposure; other viral lower airway diseases include adenovirus, influenza, and parainfluenza
–Foreign body aspiration
–Chronic diseases (e.g., cystic fibrosis and bronchiectasis) and structural abnormalities (e.g., PCD, TEF, or cleft, rings, and slings) may present with intermittent rather than chronic cough

Parenchymal and pleural disease
–Infectious diseases account almost exclusively for all parenchymal and pleural causes of cough (i.e., pneumonia and empyema)
–Usual infectious agents include bacterial disease (e.g., streptococcal, staphylococcal) and atypical pneumonias (e.g., Mycoplasma pneumoniae), TB
–Irritation of a branch of cranial nerve ten in the external auditory canal can trigger cough

Workup and Diagnosis

History
–What started it? History (e.g., infection or FB aspiration) may suggest a mechanism
–What makes it worse? Activity leading to cough may suggest asthma or structural disease; seasonal onset suggests allergic disease; night cough suggests GER
–Is the cough productive? Infection is the primary cause of sputum production; also consider asthma, bronchiectasis, smoking, or CF

Physical exam
–Loud, “brassy,” vibrato, honking quality suggests tracheomalacia
–High-pitched stridor suggests a fixed tracheal obstruction (ring, sling, FB, subglottic stenosis)
–Violent paroxysms with an inspiratory whoop suggests pertussis syndrome
–A productive, “wet” cough suggests bronchitis or pneumonia
–A wheezy, “tight” cough suggests asthma

Studies
–CXR may demonstrate an atypical pneumonia
–Pulmonary function tests to diagnose asthma or large airway obstruction
–Bronchoscopy and lavage to diagnose malacia, infection, FB, VCD
–V/Q scan may diagnose a pulmonary embolus (rare)

Exercise testing may provoke symptoms of exercise-induced asthma or VCD

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Cough – Chronic: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Lower airway disease
–Asthma
–Inflammatory triad of edema, mucus, and bronchospasm, characterized by reversibility with asthma drugs
–The most common triggers for asthma are viral disease, irritants (e.g., ETS), allergic disease, and GER
–Airway infections: Bronchiolitis, caused by RSV in babies, may cause chronic cough from persistent inflammatory change and debris; bronchitis is more common in older children and may be secondary to smoking or ETS exposure
–Foreign body: Associated with endobronchial infection and damage
–Cystic fibrosis: The most common life-threatening inherited illness of whites, is associated with production of chronically infected sputum
–Bronchiectasis: Chronic infection and damage to the airway; may be secondary to another disease (e.g., TB or CF)
–Structural abnormalities: PCD, TEF, or cleft, rings, slings

Upper airway disease
–Infectious diseases: Chronic sinusitis, tonsillitis, laryngitis, including that secondary to GER (although acute disorders, the inflammation from URI may be associated with a chronic cough if frequent enough)

Parenchymal and pleural disease
–Infectious disease accounts almost exclusively for all parenchymal and pleural causes of cough (e.g., pneumonia and empyema)
- CNS causes
  –CNS causes of cough include “habit cough” (or psychogenic cough), Tourette disease associated “cough tic” or throat clearing, VCD
  –Irritation of a branch of cranial nerve ten in the external auditory canal can trigger chronic cough
Workup and Diagnosis
- History
  –Cough lasting longer than 2–6 weeks suggests either a predisposing factor (e.g., bronchomalacia) or an ongoing trigger (e.g., asthma)
  –An acute lung or airway injury (i.e., infection or FB) suggests a mechanism for chronic cough
  –An insidious onset is more consistent with a chronic underlying condition (i.e., CF, TB, GER)
  –Seasonal change suggests allergic disease
  –Night cough suggests GER
  –A positive response to asthma therapy suggests asthma
  –Antibiotic responsiveness suggests chronic infection (i.e., CF, bronchiectasis, sinusitis)
  –Distractability suggests habit cough, as may a lack of coughing while asleep
  –Is the cough productive? Culture sputum and consider asthma, bronchiectasis, smoking, or CF
- Physical exam: Loud, “brassy,” vibrato, honking quality suggests tracheomalacia; high-pitched stridor suggests a fixed tracheal obstruction (ring, sling, FB, subglottic stenosis); violent paroxysms with an inspiratory whoop suggest pertussis syndrome
- Studies: Chest films often not diagnostic; PFT to diagnose asthma or large airway obstruction; bronchoscopy and lavage to diagnose malacia, infection, FB, VCD
- Exercise testing may provoke symptoms of EIA or VCD

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

COUGH: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Clinically, exposure to dust, smoke, and various gases should be looked for in the patient presenting with a cough. An allergic history (e.g., hay fever) is important. Careful exclusion of cardiovascular disease should be done, especially when sputum is negative for routine cultures, tuberculosis, fungi, and Papanicolaou smears and chest x-rays, bronchoscopy, and bronchography are normal. Hysterical cough should be considered, however, as well as reflux esophagitis and hiatal hernia. A sputum and nasal smear for eosinophils should be done to rule out asthma. A trial of therapy may be indicated.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

STRIDOR AND SNORING: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The approach to the diagnosis involves a careful examination of the air passage with the laryngoscope and bronchoscope (if necessary, under anesthesia). If these have negative findings, a thorough neurologic examination should be performed and a Tensilon test may be indicated. Laryngismus stridulus in children may be terminated by putting the child in a steam bath; this helps establish that diagnosis. Skin testing for allergies may be necessary. A sleep study is often necessary to rule out neurogenic or obstructive sleep apnea.

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Source: Differential Diagnosis in Primary Care, 2007

Cough, barking: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the child's parents when the barking cough began and what other signs and symptoms accompanied it. When did the child first appear to be ill? Has he had previous episodes of croup syndrome? Did his condition improve upon exposure to cold air?

Spasmodic croup and epiglottiditis typically occur in the middle of the night. The child with spasmodic croup has no fever, but the child with epiglottiditis has a sudden high fever. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.

» READ BOOK EXCERPT ONLINE »

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

Cough, productive: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

When the patient's condition permits, ask when the cough began, and find out how much sputum he's coughing up each day. (The normal tracheobronchial tree can produce up to 3 oz [89 ml] of sputum per day.) At what time of day does he cough up the most sputum? Does his sputum production have any relationship to what or when he eats or to his activities or environment? Ask him if he has noticed an increase in sputum production since his coughing began. This may result from external stimuli or from such internal causes as chronic bronchial infection or a lung abscess. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or a tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or a lung abscess.

How does the cough sound? A hacking cough results from laryngeal involvement, whereas a “brassy” cough indicates major airway involvement. Does the patient feel pain associated with his productive cough? If so, ask about its location and severity and whether it radiates to other areas. Does coughing, changing body position, or inspiration increase or help relieve his pain?

Next, ask the patient about his cigarette, drug, and alcohol use and whether his weight or appetite has changed. Find out if he has a history of asthma, allergies, or respiratory disorders, and ask about recent illnesses, surgery, or trauma. What medications is he taking? Does he work around chemicals or respiratory irritants such as silicone?

Examine the patient's mouth and nose for congestion, drainage, or inflammation. Note his breath odor; halitosis can be a sign of pulmonary infection. Inspect his neck for distended veins, and palpate for tenderness and masses or enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss for dullness, tympany, or flatness. Finally, auscultate for a pleural friction rub and abnormal breath sounds — rhonchi, crackles, or wheezes. (See Productive cough: Common causes and associated findings, page 168.)

» 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

Cough, nonproductive: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the patient when his cough began and whether body position, the time of day, or a specific activity affects it. How does the cough sound — harsh, brassy, dry, or hacking? Try to determine if the cough is related to smoking or a chemical irritant. If the patient smokes or has smoked, note the number of packs smoked daily multiplied by years (“pack-years”). Next, ask about the frequency and intensity of the coughing. If he has pain associated with coughing, breathing, or activity, when did it begin? Where is it located?

Ask the patient about recent illness (especially a cardiovascular or pulmonary disorder), surgery, or trauma. Also ask about hypersensitivity to drugs, foods, pets, dust, or pollen. Find out which medications the patient takes, if any, and ask about recent changes in schedule or dosages. Also, ask about recent changes in his appetite, weight, exercise tolerance, or energy level and recent exposure to irritating fumes, chemicals, or smoke.

As you're taking his history, observe the patient's general appearance and manner: Is he agitated, restless, or lethargic; pale, diaphoretic, or flushed; anxious, confused, or nervous? Also, note whether he's cyanotic or has clubbed fingers or peripheral edema.

CULTURAL CUE: Because of the fear of being known as someone with tuberculosis (TB), the patient may be reluctant to provide information about his signs and symptoms such as a cough. Ask the patient at risk for TB — one born in another country, in contact with acute TB, or with high-risk behaviors — about potential TB exposure.

Next, perform a physical examination. Start by taking the patient's vital signs. Check the depth and rhythm of his respirations, and note if wheezing or “crowing” noises occur with breathing. Feel the patient's skin: Is it cold or warm; clammy or dry? Check his nose and mouth for congestion, inflammation, drainage, or signs of infection. Inspect his neck for distended jugular veins and tracheal deviation, and palpate for masses or enlarged lymph nodes.

Examine his chest, observing its configuration and looking for abnormal chest wall motion. Do you note any retractions or use of accessory muscles? Percuss for dullness, tympany, or flatness. Auscultate for wheezing, crackles, rhonchi, pleural friction rubs, and decreased or absent breath sounds. Finally, examine his abdomen for distention, tenderness, masses, or abnormal bowel sounds.

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

Wheezing [Sibilant rhonchi]: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient isn’t in respiratory distress, obtain a history. What provokes his wheezing? Does he have asthma or allergies? Does he smoke or have a history of a pulmonary, cardiac, or circulatory disorder? Does he have cancer? Ask about recent surgery, illness, or trauma or changes in appetite, weight, exercise tolerance, or sleep patterns. Obtain a drug history. Ask about exposure to toxic fumes or any respiratory irritants. If he has a cough, ask how it sounds, when it starts, and how often it occurs. Does he have paroxysms of coughing? Is his cough dry, sputum producing, or bloody?

Ask the patient about chest pain. If he reports pain, determine its quality, onset, duration, intensity, and radiation. Does it increase with breathing, coughing, or certain positions?

Examine the patient’s nose and mouth for congestion, drainage, or signs of infection, such as halitosis. If he produces sputum, obtain a sample for examination. Check for cyanosis, pallor, clamminess, masses, tenderness, swelling, distended jugular veins, and enlarged lymph nodes. Inspect his chest for abnormal configuration and asymmetrical motion, and determine if the trachea is midline. (See Detecting slight tracheal deviation, page 599.) Percuss for dullness or hyperresonance, and auscultate for crackles, rhonchi, or pleural friction rubs. Note absent or hypoactive breath sounds, abnormal heart sounds, gallops, or murmurs. Also note arrhythmias, bradycardia, or tachycardia. (See Evaluating breath sounds.)

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

Whooping cough: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Classic clinical findings, especially during the paroxysmal stage, suggest this diagnosis; laboratory studies will confirm it. Nasopharyngeal swabs and sputum cultures show B. pertussis only in the early stages of this disease; fluorescent antibody screening of nasopharyngeal smears provides quicker results than cultures but is less reliable. In addition, the white blood cell (WBC) count is usually increased, especially in children older than age 6 months and early in the paroxysmal stage. Sometimes, the WBC count may reach 175,000 to 200,000/µl, with 60% to 90% lymphocytes.

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Source: Professional Guide to Diseases (Eighth Edition), 2005

Cough, barking: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the child’s parents when the barking cough began and what other signs and symptoms accompanied it. When did the child first appear to be ill? Has he had previous episodes of croup syndrome? Did his condition improve upon exposure to cold air?

Spasmodic croup and epiglottiditis typically occur in the middle of the night. The child with spasmodic croup has no fever, but the child with epiglottiditis has a high fever of sudden onset. An upper respiratory tract infection typically is followed by laryngotracheobronchitis.

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

Cough, productive: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

When the patient’s condition permits, ask when the cough began and how much sputum he’s coughing up each day. (The normal tracheobronchial tree can produce up to 3 oz [89 ml] of sputum per day.) At what time of day does he cough up the most sputum? Is his sputum production affected by what or when he eats, his activities, or his environment? Ask him if he has noticed an increase in sputum production since his coughing began. This may result from external stimuli or from such internal causes as chronic bronchial infection or a lung abscess. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or a tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or a lung abscess.

How does the cough sound? A hacking cough results from laryngeal involvement, whereas a “brassy” cough indicates major airway involvement. Does the patient feel any pain associated with his productive cough? If so, ask about its location and severity and whether it radiates to other areas. Does coughing, changing body position, or inspiration increase or help relieve his pain?

Examine the patient’s mouth and nose for congestion, drainage, or inflammation. Note his breath odor: Halitosis can be a sign of pulmonary infection. Inspect his neck for distended veins, and palpate it for tenderness, masses, and enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss it for dullness, tympany, or flatness. Finally, auscultate for pleural friction rub and abnormal breath sounds, including rhonchi, crackles, or wheezing. (See Productive cough: Causes and associated findings, pages 206 and 207.)

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

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

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.

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

Cough, nonproductive: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the patient when his cough began and whether any body position, time of day, or specific activity affects it. How does the cough sound—harsh, brassy, dry, or hacking? Try to determine if the cough is related to smoking or a chemical irritant. If the patient smokes or has smoked, note the number of packs smoked daily multiplied by years (“pack-years”). Next, ask about the frequency and intensity of the coughing. If he has any pain associated with coughing, breathing, or activity, when did it begin and where is it located?

Ask the patient about recent illness (especially a cardiovascular or pulmonary disorder), surgery, or trauma. Also ask about hypersensitivity to drugs, foods, pets, dust, or pollen. Find out which medications the patient takes, if any, and ask about recent changes in schedule or dosages. Also ask about recent changes in his appetite, weight, exercise tolerance, or energy level; recent exposure to irritating fumes, chemicals, or smoke; and recent travel to foreign countries.

As you’re taking his history, observe the patient’s general appearance and manner: Is he agitated, restless, or lethargic; pale, diaphoretic, or flushed; anxious, confused, or nervous? Also, note whether he’s cyanotic or has clubbed fingers or peripheral edema.

Cultural Cue: Because of the fear of being known as someone with tuberculosis (TB), the patient may be reluctant to provide information about his signs and symptoms such as cough. Ask the patient at risk for TB—those born in another country, those in contact with acute TB, and those with high-risk behaviors—about potential TB exposure.

Next, perform a physical examination. Start by taking the patient’s vital signs. Check the depth and rhythm of his respirations, and note wheezing or “crowing” noises that occur with breathing. Feel the patient’s skin: Is it cold or warm; clammy or dry? Check his nose and mouth for congestion, inflammation, drainage, or signs of infection. Inspect his neck for distended veins and tracheal deviation, and palpate for masses or enlarged lymph nodes.

Examine his chest, observing its configuration and looking for abnormal chest wall motion. Do you note any retractions or use of accessory muscles? Percuss for dullness, tympany, or flatness. Auscultate for wheezing, crackles, rhonchi, pleural friction rub, and decreased or absent breath sounds. Finally, examine his abdomen for distention, tenderness, or masses, and auscultate it for abnormal bowel sounds.

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

Wheezing [Sibilant rhonchi]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient isn’t in respiratory distress, obtain a history. What provokes his wheezing? Does he have asthma or allergies? Does he smoke or have a history of a pulmonary, cardiac, or circulatory disorder? Does he have cancer? Ask about recent surgery, illness, or trauma and recent changes in appetite, weight, exercise tolerance, or sleep patterns. Obtain a drug history. Ask about exposure to toxic fumes or any respiratory irritants. If he has a cough, ask how it sounds, when it starts, and how often it occurs. Does he have paroxysms of coughing? Is his cough dry, sputum producing, or bloody?

Ask the patient about chest pain. If he reports pain, determine its quality, onset, duration, intensity, and radiation. Does it increase with breathing, coughing, or certain positions?

Examine the patient’s nose and mouth for congestion, drainage, or signs of infection such as halitosis. If he produces sputum, obtain a specimen for examination. Check for cyanosis, pallor, clamminess, masses, tenderness, swelling, distended jugular veins, and enlarged lymph nodes. Inspect his chest for abnormal configuration and asymmetrical motion, and determine if the trachea is midline. (See Detecting slight tracheal deviation, page 766.) Percuss for dullness or hyperresonance, and auscultate for crackles, rhonchi, or pleural friction rub. Note absent or hypoactive breath sounds, abnormal heart sounds, gallops, or murmurs. Also note arrhythmias, bradycardia, or tachycardia. (See Evaluating breath sounds. See also Differential diagnosis: Wheezing, pages 826 and 827.)

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

Cough: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Characteristics of the cough. What is the type of cough (barking, brassy, wheezy, nocturnal, paroxysmal)? What are the duration, timing, and triggers? Are there associated symptoms of fever, sputum production, dypsnea, hemoptysis, and weight loss? Are there clear relieving factors? Ask specifically about postnasal drip as patients often do not volunteer this information. A good history is the key to diagnosis.

1. Upper respiratory causes most commonly relate to postnasal drip. In adults, sinusitis, pharyngitis, and allergic rhinitis should be considered. In children, concomitant otitis media should be excluded.

2. Lower respiratory causes include lung (bronchitis, asthma, pneumonia, bronchiectasis, and in children, foreign body aspiration) and cardiac [congestive heart failure (CHF) and mitral stenosis].

3. Nonrespiratory causes include GERD, drug effects [e.g., angiotensin converting enzyme (ACE)-inhibitors], and psychogenic.

B. Smoking patients should be identified early as bronchitis and lung cancer are possibilities. Passive smoking is also a risk factor, especially in children. Office visits for cough represent teachable moments for smoking cessation education. Smoking cessation has been shown to reduce respiratory symptoms by 50%.

C. Psychosocial impact of the cough reflects severity and the need for further workup. Has the patient missed school or work? Is the sleeping partner disturbed? Is there avoidance of exercise because it triggers cough? In chronic, episodic cough, a correct diagnosis of asthma can considerably improve quality of life. A psychogenic cause for cough and behavioral problems in children may be unmasked here.

D. Other information. Associated chest pain should direct the history toward pleurisy or rib fracture secondary to chronic cough. Occupational exposures (toxic fumes, chemicals, birds and animals), systemic diseases [rheumatoid arthritis, breast and prostate cancer metastases, human immunodeficiency virus disease (HIV)] and drug exposure (ACE-inhibitors, cyclophosphamide, and methotrexate) are important factors to consider in the cause. Cough with significant weight loss should trigger a workup for TB, HIV, or lung cancer in the smoker.

Physical examination

A. Focused physical examination (PE) should include vital signs (temperature, pulse, respiratory rate, and blood pressure), ear, nose, sinuses, throat (ENST), and a full lung examination with the chest uncovered. Normal lung examination often excludes pneumonia but not asthma, bronchitis, COPD, GERD, or lung cancer. It is more effective to examine the lung before the ENST in young children because the ENST examination is more traumatic and can induce crying. In the older patient, especially the postmenopausal woman, rib palpation may be included to isolate fracture secondary to osteoporosis.

B. Additional PE. The cardiovascular examination is directed at a diagnosis of CHF. Associated lymphadenopathy suggests infection or neoplasm. Wasting can be ominous (cancer or HIV). Abdominal examination may reveal a tender enlarged liver in CHF, or epigastric tenderness in GERD (Chapters 7.5 and 9.6).

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

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

A. Characteristics of stridor. When confronted with stridor, check the age of the patient and the duration of the symptoms.

1. A child aged less than 6 months with stridor of a few weeks to months has a congenital cause of stridor.

2. Patients aged more than 6 months with stridor lasting hours to days usually have an acquired cause of stridor, most commonly viral croup, epiglottitis, or aspiration of a foreign body.

3. A typical history is a child aged less than 6 years with a 2- to 3-day history of upper respiratory infection (URI) and gradually worsening cough, especially at night. A barking cough with the inspiratory stridor heralds the diagnosis of croup, which accounts for 90% of all cases of stridor. This condition will classically improve with moist air (1,3).

4. A history of choking, coughing, or gagging points to aspiration or ingestion of a foreign body.

5. In older children and adults, a concomitant sore throat and fever may indicate acute supraglottitis, which constitutes an emergency.

B. Other information

1. Whether stridor is acute, recurrent, or chronic.

2. Personal or family history of atopy, would suggest spasmodic croup, which presents with stridor at night, not necessarily associated with a URI.

Physical examination

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)

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

Wheezing: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Onset. Is this the first episode? If so, were there problems with wheezing or asthma in childhood?

B. Exposures. Are there any precipitating factors? Have there been any recent exposures? Is there an exposure to cigarette smoke? What is the patient’s occupation?

1. Cigarette smoke is one of the most potent and ubiquitous avoidable allergens.

2. Occupational exposures can frequently be identified, especially among agricultural and industrial workers.

3. Family or household exposure to tuberculosis or pertussis can indicate an infectious cause.

C. Concurrent illnesses. Has the patient recently suffered an upper respiratory infection or sinusitis? Is there a history of gastroesophageal reflux disease?

D. Family history. A history of asthma, allergies, or atopic disease in family members can support the diagnosis of asthma.

E. Past history. A childhood history of atopic disease or allergies suggests adult onset asthma. Past history of exercise-induced wheezing also supports this diagnosis.

F. Psychosocial aspects. Emotional stress can lead to exacerbation of chronic asthma. Psychogenic wheezing is a conversion disorder, which can coexist with other psychopathology.

Physical examination

A. Vital signs. A full set of vital signs is essential to the assessment of the wheezing patient. The respiratory rate and the pulse are a more objective, and often more accurate, assessment of the severity of wheezing than the auditory volume of the wheezing itself. Fever suggests a concurrent respiratory infection. Hypotension is an ominous sign that points to a decompensating patient.

B. Lung examination. During auscultation, note the location, intensity, and duration of wheezing. Wheezing caused by asthma, chronic obstructive pulmonary disease (COPD), or interstitial disease should be diffuse and symmetric and present during expiration. The expiratory phase will be prolonged. Focal obstruction (e.g., tumors and foreign bodies) can give asymmetric findings and inspiratory wheezing. Mucus plugging will change with cough. Rhonchi and crackles suggest a concurrent infectious process. Percussion and egophony can be present with consolidation.

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

Wheezing: Differential Overview
(Field Guide to Bedside Diagnosis)

Wheezing

❑ Asthma

❑ Reactive airways disease

❑ Pulmonary edema

❑ Pulmonary embolism

❑ Emphysema

❑ Gastroesophageal reflux

❑ Drug/toxin reaction

❑ Vocal cord dysfunction

❑ Foreign body aspiration

❑ Mediastinal mass

❑ Carcinoid syndrome

Stridor

❑ Mucus plug

❑ Laryngeal trauma

❑ Angioedema

❑ Acute epiglottitis

❑ Retropharyngeal abscess

Diagnostic Approach

A wheeze is a continuous musical sound produced by vibration of airway walls when they are near closure. A wheeze consisting of a single musical note indicates small airways disease, usually asthma. Polyphonic wheezes (multiple musical notes) are produced by dynamic compression of large central airways.

Stridor signifies central airway obstruction, and is an ominous portent of impending complete airway closure. Causes such as an aspirated foreign body or bronchogenic cancer should be suspected when the onset of wheezing is sudden and focal, allergic markers and specific triggers are absent, and response to bronchodilator is poor. A history of aspiration, or smoking and clubbing are also helpful.

Nocturnal wheezing could be the result of congestive heart failure (paroxysmal nocturnal dyspnea) or gastric aspiration with reflux.

Dyspnea on exertion correlates with an FEV1 below 50% predicted, and dyspnea at rest with FEV1 below 25% predicted. Forced expiratory time (FET) is measured by ausculting over the trachea, and timing until airflow is no longer heard. FET of 9 seconds predicts an FEV1/FVC ratio of 70%. Stridor indicates that the airway diameter is less than 5 mm.

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Source: Field Guide to Bedside Diagnosis, 2007

Acute Cough: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Viral upper respiratory infection

❑ Asthma

❑ Sinusitis

❑ Mycoplasma bronchitis

❑ Pneumonia

❑ Gastroesophageal reflux

❑ Congestive heart failure

❑ ACE inhibitor

❑ Aspiration

❑ Cough in HIV

❑ Thermal

❑ Fume inhalation

❑ Pertussis

❑ Lung abscess

Diagnostic Approach

The main issue in diagnosis is differentiating respiratory viruses, which cause most cases, from bacterial infection such as pneumonia, which would benefit from treatment with antibiotics, and from influenza, for which antivirals are effective. The classic presentation of bacterial pneumonia is acute onset with a progressive course marked by cough productive of yellow or green sputum, fever to 100˚ to 104˚F with chills or rigors, and pleuritic chest pain. The patient often appears “toxic.” The affected lung will often have coarse rales and bronchial breath sounds, and there may be localized percussive dullness. Viral pneumonia is associated with upper respiratory signs such as nasal congestion and sore throat, and by a nonproductive cough. Use of the Pneumonia diagnosis rule is helpful: Temperature .37.8˚C (100˚F); pulse .100; rales; decreased breath sounds; and no asthma each score 1.

Detection of induced bronchial hyperreactivity (reactive airways disease), which benefits from bronchodilator or corticosteroid treatment, is also important. Wheezing, shortness of breath, and a predisposition (atopy or smoker) are helpful clinical clues.

A cough appearing mostly at night suggests congestive heart failure or reflux. Confusion and absence of fever are common presenting findings in older adults.

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Source: Field Guide to Bedside Diagnosis, 2007

Chronic Cough: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Upper respiratory infection

❑ Allergy

❑ Asthma

❑ Chronic bronchitis

❑ Chronic sinusitis

❑ Gastroesophageal reflux

❑ ACE inhibitor

❑ Pollutants

❑ Psychogenic

❑ Foreign body

❑ Congestive heart failure

❑ Lung cancer

❑ Tuberculosis

❑ Mediastinal mass

❑ Bronchiectasis

❑ Pulmonary fibrosis

❑ Cystic fibrosis

❑ Aspergillosis

Diagnostic Approach

Chronic cough persists 3 weeks or longer. During vigorous coughing intrathoracic pressure of 300 mm Hg and expiratory velocity of 500 miles per hour develop, which over time are responsible for the secondary effects of exhaustion, insomnia, chest wall pain, dizziness, syncope, and urinary incontinence. Postnasal drip, asthma, and gastroesophageal reflux are responsible for 99.4% of cases in patients with the characteristics: nonsmoker, no use of ACE inhibitor, and normal or stable chest x-ray.

Green color in the sputum may be caused by either polymorphonuclear leukocytes or eosinophils. Hoarseness suggests tumor with involvement of the vocal cords or recurrent laryngeal nerve, or it may suggest chronic esophageal reflux.

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Source: Field Guide to Bedside Diagnosis, 2007

Cough, barking: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Determine when the barking cough began and other associated signs and symptoms. Determine when the child first appeared to be ill and ask if there have been previous episodes of croup syndrome.

Physical examination

Assess the respiratory system, noting rate and pattern of respirations. Assess the patient for signs of hypoxia. Stay alert for signs of airway obstruction (nasal flaring, sternal retraction, stridor).

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Cough, productive: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Determine the onset of the cough and amount of daily sputum production. (The normal tracheobronchial tree can produce up to 3 oz [89 ml] of sputum per day.) Determine the time of day that the most sputum is produced and relationship of food to sputum production. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or lung abscess.

Determine cough characteristics. A hacking cough results from laryngeal involvement, whereas a “brassy” cough indicates major airway involvement. Ask the patient about cigarette, drug, and alcohol use and if there has been weight or appetite changes. Find out if he has a history of asthma, allergies, or respiratory disorders, and ask about recent illnesses, surgery, or trauma. Determine a medication history, including over-the-counter medications. Ask the patient if his work involves chemicals or respiratory irritants.

Physical examination

Examine the patient’s mouth and nose for congestion, drainage, or inflammation. Note breath odor: Halitosis can be a sign of pulmonary infection. Inspect his neck for jugular vein distention, and palpate for tenderness and masses or enlarged lymph nodes. Observe his chest for accessory muscle use, retractions, and uneven chest expansion, and percuss for dullness, tympany, or flatness. Finally, auscultate for pleural friction rub and abnormal breath sounds — rhonchi, crackles, or wheezes.

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Stridor: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

When the patient’s condition permits, obtain his medical history. 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?

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Wheezing: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If the patient isn’t in respiratory distress, obtain his medical history. What provokes his wheezing? Does he have asthma or allergies? Does he smoke or have a history of a pulmonary, cardiac, or circulatory disorder? Does he have cancer? Ask about recent surgery, illness, or trauma or changes in appetite, weight, exercise tolerance, or sleep patterns. Obtain a drug history. Ask about exposure to toxic fumes or respiratory irritants. If he has a cough, ask how it sounds, when it starts, and how often it occurs. Does he have paroxysms of coughing? Is his cough dry, sputum producing, or bloody?

Ask the patient about chest pain. If he reports pain, determine its quality, onset, duration, intensity, and radiation. Does it increase with breathing, coughing, or certain positions?

Physical examination

Examine the patient’s nose and mouth for congestion, drainage, or signs of infection such as halitosis. If he produces sputum, obtain a sample for examination. Check for cyanosis, pallor, clamminess, masses, tenderness, swelling, jugular vein distention, and enlarged lymph nodes. Inspect his chest for abnormal configuration and asymmetrical motion, and determine if the trachea is midline. (See Detecting slight tracheal deviation, page 299.) Percuss for dullness or hyperresonance, and auscultate for crackles, rhonchi, or a pleural friction rub. Note absent or hypoactive breath sounds, abnormal heart sounds, gallops, or murmurs. (See Evaluating breath sounds.) Also note arrhythmias, bradycardia, or tachycardia. (See Wheezing: Causes and associated findings, pages 318 and 319.)

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Cough, barking: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

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

Cough, productive: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

When the patient’s condition permits, ask when the cough began, and find out how much sputum he’s coughing up each day. (The normal tracheobronchial tree can produce up to 3 oz [88.7 ml] of sputum per day.) At what time of day does he cough up the most sputum? Does his sputum production have any relationship to what or when he eats, or to his activities or environment? Ask him if he has noticed an increase in sputum production since his coughing began. This may result from external stimuli or from such internal causes as chronic bronchial infection or a lung abscess. Also ask about the color, odor, and consistency of the sputum. Blood-tinged or rust-colored sputum may result from trauma due to coughing or from an underlying condition, such as a pulmonary infection or a tumor. Foul-smelling sputum may result from an anaerobic infection, such as bronchitis or lung abscess.

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

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

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

Wheezing: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask the patient about chest pain. If he reports pain, determine its quality, onset, duration, intensity, and radiation. Does it increase with breathing, coughing, or certain positions?

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

Cough, nonproductive: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask the patient when his cough began and whether body position, time of day, or specific activity affects it. How does the cough sound — harsh, brassy, dry, or hacking? Try to determine if the cough is related to smoking or a chemical irritant. If the patient smokes or has smoked, note the number of packs smoked daily multiplied by years (“pack years”). Next, ask about the frequency and intensity of the coughing. If he has pain associated with coughing, breathing, or activity, when did it begin? Where is it located?

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

Cough: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Infection/Inflammation

Upper Respiratory Tract Infection

URI (commoncold) is acute viral infection.

Common pathogens include rhinoviruses,parainfluenza viruses, respiratory syncytial virus (RSV), and coronaviruses.Other viruses that occasionally cause common cold are adenoviruses,enteroviruses, influenza viruses, and reoviruses.

Usual clinical findings are watery,mucoid, or purulent discharge; dry, hacking cough; and inflamednasal mucosa.

Diagnosis is clinical.

Sinusitis

Usuallypresents with history of purulent nasal discharge and persistentcough of >10 days' duration. Less common presentationis combination of fever, headache, and facial pain or sinus tenderness.

Usually clinical diagnosis.

CT should be performed when orbitalabscess or intracranial complication is suspected.

Laryngitis

Most frequentcause is viral URI.

Hoarseness and dry, hacking cough,which may last up to 1 wk, are usual clinical findings.

Usually clinical diagnosis.

Croup

Characterizedby a barking cough and stridor ± fever.

See Chap.63, Stertor, Stridor, and Airway Obstruction.

Tracheitis

Often crouplikeillness with cough and stridor precedes sudden onset of respiratory distressand high fever.

Clinical picture suggests bacterialtracheitis.

See Chap.63, Stertor, Stridor, and Airway Obstruction.

Bronchitis

Inflammatoryprocess affecting trachea and bronchi. Most episodes are causedby viruses (e.g., RSV, parainfluenza viruses, influenza viruses,rhinoviruses, and adenoviruses).

Hacking cough appears several daysafter onset of typical URI. Rhonchi may be heard, but crackles areinfrequent. Presence of wheezing usually indicates presence of reactiveairways disease.

Usually clinical diagnosis.

Pertussis

B. pertussisinfection begins with nasal discharge, which is followed by paroxysmal coughthat often has staccato quality. Whoop may follow paroxysm.

Fever may or may not occur.

There is usually leukocytosis withpredominance of lymphocytes.

Apnea is serious complication, especiallyin young infants.

Duration of illness may be as longas 6–10 wks.

Chest radiograph may be normal or showperihilar infiltrates.

Positive direct immunofluorescent assayof nasopharyngeal secretions suggests diagnosis, but false-positiveand false-negative results occur.

Positive nasopharyngeal culture confirmsdiagnosis.

Bronchiolitis

Usuallycaused by RSV and occasionally by parainfluenza viruses, influenzaviruses, and adenoviruses.

Occurs during winter months, oftenin epidemics.

Rhinorrhea usually precedes cough,which may be persistent and harsh. Expiratory wheezing is prominentfinding.

See Chap.75, Wheezing.

Pneumonia

Definedas inflammation of lung parenchyma that may be caused by infection.

Frequently presents with fever, cough,and respiratory distress. Crackles and wheezes may be heard on exam.Decreased breath sounds and dullness to percussion indicate areaof lung consolidation.

Presence of pneumonia usually can beconfirmed by chest radiography, although early in illness radiographcan appear normal.

Specific cause requires further investigation.

Viral

Accountsfor most cases of pneumonia in infancy and childhood.

Most common viruses causing pneumoniainclude RSV, parainfluenza viruses, adenoviruses, and influenzaviruses. Less common causes are rhinoviruses and coronaviruses.

Cytomegalovirus and herpes simplexvirus may cause pneumonia in newborn or in immunocompromised individuals.

May also be caused by measles, varicella,and Hantavirus infection.

Chest radiograph frequently shows involvementof both lungs, with peribronchial thickening, perihilar linear densities,and patchy infiltrates. Segmental or lobar consolidation, hilaradenopathy, and pleural effusions are unusual.

Nasal wash cultures or polymerase chainreaction (PCR) of nasal secretions may sometimes diagnose specificviral infection.

RSV antigen may be detected by enzymeimmunoassay or immunofluorescent techniques.

Bacterial

Pathogenscausing bacterial pneumonia vary with age of child.

Most common causes of bacterial pneumoniain neonates are group B Streptococcus and gram-negative entericbacteria (E. coli, K. pneumoniae, P. aeruginosa).

In infancy, childhood, and adolescence,S. pneumoniae is most common, whereas S. aureus and group A Streptococcusare much less common.

H. influenzae type b has become unusualcause of pneumonia, since advent of H. influenzae vaccine.

M. tuberculosis can cause infectionat any age.

Clinical findings with bacterial pneumoniausually include fever, cough that may be productive of sputum inolder child, and some degree of respiratory distress.

Leukocytosis with predominance of polymorphonuclearleukocytes is common finding.

Pleural effusions and pneumatocelesare more frequent with bacterial pneumonia than with viral pneumonia.

Chest radiograph usually shows segmentalor lobar infiltrate.

Diagnosis of bacterial pneumonia canbe confirmed by positive blood, pleural fluid, or lung biopsy cultures.McCarthy et al. (1999) demonstrated that PCR may be used to diagnosepneumonia caused by S. pneumoniae using sample of pleural fluid.

Pharyngeal or sputum culture that haslarge numbers of single organism is suggestive but not diagnostic.

Counterimmune electrophoresis and latexagglutination tests have successfully detected bacterial antigensof S. pneumoniae, group B Streptococcus, and H. influenzae typeb in urine, so these tests may be diagnostic.

Tuberculosis

Usual modeof transmission of M. tuberculosis infection is by inhalation.

Positive skin test with PPD may beobserved 2–12 wks after exposure.

Children with disease usually haveprimary pulmonary TB with cough and fever.

In most cases of TB infection, individualis asymptomatic, primary complex of infection is not seen on chestradiograph, and disease does not progress.

In TB disease, individual has clinicalor radiographic findings and disease may be pulmonary or nonpulmonary.

Chest radiograph shows involvementof segment or lobe, usually with enlarged regional lymph nodes.With progression, cavitary lesions or miliary disease can occur.

Acid-fast bacilli smears and culturesshould be performed in anyone with suspected TB. In young child,especially if cough is nonproductive, best culture material is fromearly morning gastric aspirate. Otherwise, isolation of tuberclebacilli by culture of sputum, urine, pleural fluid, cerebrospinalfluid, other body fluids, or biopsy material confirms diagnosis.

Negative PPD never excludes infectionor disease with TB. Anergy may be due to young age, viral infections,immunosuppression, and severe disseminated TB.

Chlamydia

Pneumoniadue to C. trachomatis usually occurs in infants 1–3 mosof age.

Clinical findings include conjunctivitisor history of conjunctivitis, staccato cough, tachypnea, crackles,and mild peripheral eosinophilia. Fever is variable finding.

Chest radiograph usually shows hyperinflationand bilateral interstitial infiltrates.

Positive nasopharyngeal or eye cultureconfirms diagnosis.

Legionella

Legionnaire'sdisease is transmitted by inhalation of aerosolized water contaminated withLegionella species.

Most common cause of Legionella infectionin U.S. is L. pneumophila serogroup 1.

Frequent findings include fever, nonproductivecough, headache, and myalgia.

Chest radiograph usually shows infiltrate.Pulmonary nodules ± cavitation also may occur.

Diagnosis can be confirmed in a numberof ways:

positiveculture of sputum or lung tissue

detection of organisms on smears ofrespiratory tract secretions by direct immunofluorescent assay usingmonoclonal or polyclonal antibodies

DNA probes

serologic testing using indirect immunofluorescenceantibody assay

Increase in antibody titer to ≥1:128is also considered diagnostic.

Nocardia

Nocardiaspecies are funguslike bacteria that live in soil.

Lung is probable portal of entry aswell as most frequent site of infection.

Most common agent in U.S. is N. asteroides.

Clinical findings include fever, cough,chest pain, night sweats, malaise, and weight loss.

Chest radiography shows scattered infiltrates.

Stained smears of sputum, spinal fluid,or pus may reveal gram-positive rods that are variably acid fast.

Positive culture confirms diagnosis.

Mycoplasma

M. pneumoniaeis common cause of pneumonia in school-aged children and adolescents.

Infection with this organism is uncommonin patients <5 yrs of age.

Persistent nonproductive cough andfever are usual presenting features. Other findings include headache,myalgia, sore throat, and macular or papular rash. Crackles andwheezes may be heard on lung exam.

Typically, chest radiograph shows patchy,unilateral, segmental, or subsegmental consolidation, but diffuse,bilateral, interstitial infiltrates may be seen.

Cold agglutinin titer of ≥1:64 issuggestive of diagnosis, although other viral infections (adenoviruses,Epstein-Barr virus) also can produce elevated titer. Complementfixation test is most widely available serologic test, and titerof ≥1:32 during an acute respiratory illness is suggestive ofinfection.

Fungal

Histoplasmosis

Endemicin eastern and midwestern U.S., especially in Mississippi and OhioRiver valleys.

Infection occurs by inhalation of H.capsulatum spores, which are present in soil or dust in barnyardsor other areas that contain bird and bat droppings.

>95% of infectionsare asymptomatic. Common presentation is acute influenza-like illness withpulmonary infiltrates and hilar adenopathy. Disseminated diseasewith fever, cough, pulmonary infiltrates, hepatosplenomegaly, andpancytopenia occurs most frequently in immunocompromised hosts.

Culture of sputum, blood, or bone marrowconfirms diagnosis, as does demonstration of intracellular yeastsin smears of bone marrow or biopsy material from infected tissues.

Detection of H. capsulatum antigenin urine or serum also can be used to diagnose disseminated disease.Single titer of ≥1:32 or 4-fold increase in yeast phase titersis presumptive evidence of active infection. H bands found in immunodiffusionantibody assay also suggest active infection.

Coccidioidomycosis

Endemicin southwestern U.S. Transmission occurs by inhalation of dust-borne sporesof C. immitis.

Primary infection is often asymptomatic,whereas symptomatic infection usually presents with fever and cough.

Chest radiograph may show hilar adenopathyand calcification of healing primary lesion. Granulomatous lesionscan occur in lungs, lymph nodes, bones, joints, skin, and meninges.

Typical clinical and radiologic findingsand positive skin test or ≥1:32 complement fixation antibodytiter are diagnostic. Spherules seen in tracheal aspirates, sputum,urine, or spinal fluid; biopsies of skin lesions or organs; or positivecultures from any of these sources are also diagnostic.

Aspergillosis

Aspergillusspecies grow in soil and in decaying vegetation. Transmission isby inhalation of airborne spores.

Different clinical presentations mayoccur:

Allergicbronchopulmonary aspergillosis with low-grade fever, productivecough, episodic wheezing, transient pulmonary infiltrates, and eosinophilia

Aspergillomas that do not invade lungtissue

Invasive pulmonary disease with feverand productive cough

Disseminated disease with involvementof skin (cutaneous papules and abscesses), heart (endocarditis),bone (osteomyelitis), sinuses (sinusitis), or brain (abscess).

Chest radiograph may show patchy ornodular infiltrates or consolidation ± cavitation.

Branching and septate hyphae in sputumsuggest diagnosis.

Positive sputum or lung biopsy cultureconfirms diagnosis.

Blastomycosis

Infectionwith B. dermatitidis is endemic in southeastern U.S. and in midwestern statesbordering the Great Lakes.

Pulmonary, cutaneous, and disseminatedforms of disease can occur, but pulmonary disease is most commonin children.

Clinical findings of pulmonary diseaseinclude cough, fever, malaise, chest pain, weight loss, and hemoptysis.

Chest radiograph may show infiltrates,cavities, or nodular densities.

Primary cutaneous blastomycosis maypresent with ≥1 subcutaneous nodules that eventually ulcerate.

Disseminated disease produces granulomatouslesions, which may involve liver, spleen, bone, skin, and brain.

Thick-walled single budding yeast formsmay be seen with 10% KOH preparations from sputum, spinalfluid, urine, or skin lesions.

Positive immunodiffusion test on serathat shows precipitin bands (A and B) is evidence for active infection;however, bronchoalveolar lavage or lung biopsy may be necessaryto establish diagnosis in children with pneumonia.

Serologic assays are not reliable fordiagnosis.

Protozoa

P. cariniiinfection occurs almost exclusively in immunocompromised childrenand is common in those affected with HIV.

Clinical findings include nonproductivecough and fever.

Chest radiograph shows bilateral interstitialor air-space disease.

Diagnosis is confirmed by demonstrationof organism in lower respiratory tract secretions or lung tissue.

Induction of sputum in older childrenand adolescents, bronchoscopy with bronchoalveolar lavage, or lungbiopsy can be performed.

Methenamine silver nitrate and toluidineblue O are most useful stains to identify thick-walled cysts.

Chemical Pneumonia

Gasoline,kerosene, and charcoal lighter fluid are hydrocarbons with low surfacetension and viscosity. Because of these properties, aspiration intotracheobronchial tree can easily occur after ingestion.

Acute onset of cough and respiratorydistress and history of ingestion are diagnostic. Within severalhours of ingestion, chest radiograph may show evidence of pneumonia,with infiltrates commonly in right middle and lower lobes.

Aspiration Pneumonia

Interferencewith normal swallowing predisposes to aspiration of oral and gastricsecretions as well as food. Children with gastroesophageal reflux,tracheoesophageal fistula, or neurologic disorders with swallowingdysfunction are more prone to develop aspiration pneumonia.

Onset of respiratory distress afterchoking, gagging, coughing, or vomiting episodes should lead oneto suspect aspiration pneumonia.

Cystic Fibrosis

Common causeof chronic lung disease in children but also affects other organsystems with epithelial surfaces, especially intestine, pancreas,liver, and sweat glands. Mutations in CFTR gene located on chromosome7 result in abnormal ion transport across epithelial surfaces. Genetictransmission is autosomal recessive.

Age of onset and clinical presentationvary widely. Earliest clinical manifestation is meconium ileus innewborn. Most common manifestation of respiratory disease is coughthat may be dry or productive. Other clinical findings include wheezing;nasal polyps; frequent large, foul-smelling stools; digital clubbing;recurrent rectal prolapse; and poor growth.

Chest radiograph usually shows hyperinflation,irregular aeration with areas of patchy atelectasis, and accentuatedperibronchial markings.

Bacterial organisms that commonly colonizerespiratory tract in this disease are S. aureus, H. influenzae,and gram-negative enteric bacteria, including P. aeruginosa.

Sweat chloride level >60 mEq/Lis diagnostic.

DNA mutation analysis is definitive.

Bronchiectasis

Infectionor chronic inflammation of airways can cause bronchiectasis.

May be focal (foreign body, local infection)or generalized (cystic fibrosis, chronic aspiration).

Chronic productive cough with cracklesand rhonchi on lung exam are usual findings.

Chest radiography may show persistentatelectasis or infiltrates that fail to resolve.

Diagnosis may be confirmed by chestCT, which shows dilated bronchi that do not taper peripherally.

Lung Abscess

May occur ± pneumonia.

Most common organisms found in lungabscesses are Staphylococcus species and group A Streptococcus.Anaerobes also may play role in individuals with aspiration pneumonia.

Persistent fever and cough are usualclinical features.

Abscess (density with air-fluid level)may be seen on chest radiography, with confirmation by chest CT.

Needle aspirate may reveal specificpathogen.

Allergic Disorders

Allergic Rhinitis

Althoughusual clinical findings with allergic rhinitis are persistent orrecurrent rhinorrhea, sneezing, and itchy tearing eyes, nonproductivecough also occurs.

See Chap.41, Nasal Discharge.

Asthma

Definedas inflammatory disorder of smaller airways, which is characterizedby recurrent wheezing that is reversible with bronchodilator therapyor spontaneously. Another common manifestation is recurrent cough, ± wheezing,especially after exercise or at night.

See Chap.75, Wheezing.

Mechanical or Chemical Irritation

Environmental Irritants

Smoke, chemicalfumes, particulate matter from fire, and other environmental pollutantsand toxins may stimulate cough production.

History of exposure is diagnostic.

Foreign Body Aspiration

Aspirationof foreign body into bronchus commonly produces choking or gagging followedby persistent coughing or wheezing.

Some common foreign bodies are food(nuts, seeds, meat), pins, tacks, and plastic tops.

Chest radiography may show segmentalor lobar collapse or unilateral hyperinflation. Chest radiographstaken in inspiration/expiration or in right and left lateraldecubitus positions as well as fluoroscopy may demonstrate unilateralair trapping and movement of mediastinum away from affected side duringexpiration. In some cases, bronchoscopy is necessary to confirmdiagnosis.

Bronchopulmonary Dysplasia

A form ofchronic lung disease that often follows neonatal respiratory distresssyndrome treated with endotracheal intubation, mechanical ventilation,and high concentrations of inspired oxygen.

During course of disease, respiratorydistress waxes and wanes with intermittent cough.

Crackles and rhonchi may be heard onlung exam.

Hypoxemia and hypercapnia occur, andapnea may develop.

Chest radiograph shows combinationof hyperinflation, prominent perihilar markings, and streaky densitiesthat may persist for many months.

Congenital Anomalies

Congenitalanomalies that may produce cough include laryngomalacia, tracheomalacia,tracheoesophageal fistula, pulmonary sequestration, bronchogeniccyst, cystic adenomatoid malformation, and vascular rings and slings.

See Chap.56, Respiratory Distress and Apnea, Chap. 63, Stertor, Stridor, and Airway Obstruction,and Chap. 65, Sucking and SwallowingDifficulty.

Cardiac Failure

Pulmonaryvenous congestion occurring as manifestation of cardiac failuremay cause airway edema leading to cough. Other findings includerespiratory distress, tachycardia, hepatomegaly, and cardiomegaly.

See Chap.7, Cardiac Failure.

Gastroesophageal Reflux

Aspirationof stomach contents into lung may produce airway obstruction andpneumonia with coughing and wheezing. Another proposed mechanismfor cough and respiratory distress is the stimulation of esophagealvagal afferents by gastric contents to produce laryngospasm andbronchospasm.

See Chap.55, Regurgitation and Vomiting.

Swallowing Dysfunction

Disordersthat cause difficulty in swallowing may produce gagging, choking,and recurrent coughing.

See Chap.65, Sucking and Swallowing Difficulty.

Immotile Cilia Syndrome

Autosomal-recessivedisorder characterized by defects in ultrastructure of cilia that impairciliary motion and clearance of mucus from respiratory tract.

1 form of this syndrome has been mappedto chromosome 9p21-p13, whereas another has been mapped to chromosome5p.

Structural defects include absenceof dynein arms and radial spokes.

Onset is in infancy or early childhoodwith chronic cough that is usually productive of sputum. Other manifestationsinclude chronic rhinitis, sinusitis, otitis media, bronchitis, andpneumonia.

Chest radiograph may show hyperinflation,bronchial wall thickening, segmental atelectasis or consolidation,situs inversus, and bronchiectasis.

Electron microscopy of cilia obtainedby nasal or bronchial biopsy brushing techniques demonstrates structuraldefects.

Neoplasm

Chroniccough may occur with airway tumors (hemangioma, papilloma), mediastinal masses,and lung tumors, including metastatic lesions.

See Chap.56, Respiratory Distress and Apnea.

Reflex Cough

In somechildren, foreign body or cerumen in ear canal causes transientreflex cough.

Persistent cough also has been attributedto hair lodged against tympanic membrane.

Otoscopic exam is diagnostic.

Psychogenic/Habitual Cough

Occasionallychild has persistent or recurrent cough with no evidence of underlying respiratorytract disease. Usually occurs in school-aged child after URI, andcough lasts for weeks.

Cough is usually loud, harsh, and foghorn-like,disappearing during sleep and often decreasing when alone or onweekends.

Otherwise, child is well and physicalexam and chest radiograph are normal.

Often secondary gain can be identified.Some of these children may have emotional problems that requirefurther evaluation.

Diagnostic Approach

In manycases history and physical exam are diagnostic.

Age of child, duration of cough, qualityand characteristic features of cough, and associated findings narrowdiagnostic possibilities.

Age of Child and Duration of Cough

In infantsand preschool children, most common causes of acute cough are viralURI, pneumonia (viral, bacterial, aspiration), laryngotracheobronchitis(croup), bronchiolitis, and foreign body aspiration.

In school-aged children and adolescents,most common causes of acute cough are viral URI, bronchitis, andpneumonia (viral, bacterial, M. pneumoniae).

Chronic cough lasts >3–4wks, although many coughs induced by acute viral URIs may persistfor a number of weeks after onset of infection.

Most common causes of persistent coughin early infancy are pertussis, pneumonia (infection, aspiration),and cystic fibrosis.

In later infancy and early childhood,recurrent viral URIs and asthma are most common causes of recurrentcough.

Most common causes of recurrent orchronic cough in adolescents are asthma, smoking, cystic fibrosis,and psychologic problems.

Periodicity and Quality of Cough

Asthma,pneumonia, cystic fibrosis, bronchiectasis, TB, and focal lesionscausing local irritation or infection cause persistent coughs.

Recurrent viral URIs and asthma causeepisodic coughing.

Paroxysmal cough suggests pertussisbut can also occur with Chlamydia and Mycoplasma infection.

Dry, barking or brassy cough with voicechanges signifies laryngotracheal pathology.

Loud, honking cough in older childthat disappears with sleep suggests habit or psychogenic cough.

Neuromuscular disorders produce a weakand feeble cough.

Loose rattling cough means that excesssecretions or exudate exist in airways. Moist cough with sputumproduction is hallmark of suppurative lung disease.

Timing of Cough

If coughdisappears while asleep, it usually has psychologic basis.

Recurrent episodes of nocturnal coughor after exertion suggest cough-variant asthma.

Productive cough with morning awakeningis common with bronchitis secondary to smoking or cystic fibrosis.

Nature of Sputum Production

Few infants or young children expectorate.Cough productive of purulent sputum is usually associated with bacterialpneumonia, cystic fibrosis, bronchiectasis, or lung abscess. Occasionally,the sputum is blood streaked.

Associated Findings

Presenceof fever suggests infectious process such as viral URI, pneumonia,croup, pertussis or TB.

Hemoptysis suggests bronchitis, foreignbody, bronchiectasis, cystic fibrosis, TB, pulmonary hemosiderosis,or lung abscess.

Cough associated with stridor indicatesairway obstruction.

Evaluation

Etiologyof cough can usually be determined or at least suspected from historyand physical exam.

Chest radiography shows pattern andextent of disease and is confirmatory in many instances.

With suspected bacterial pneumonia,CBC and differential, blood culture, and sputum culture (older child)should be performed.

If TB is suspected, intermediate-strengthPPD should be placed.

Thoracentesis should be performed ifthere is significant pleural effusion because Gram and acid-faststains, cultures (viral, bacterial, fungal), PCR, and cytology mayprovide specific diagnosis.

With segmental or lobar collapse unresponsiveto therapy, bronchoscopy should be performed to define obstructivelesion and to obtain cultures.

Another useful test is sweat test inchildren with recurrent or chronic cough.

With suspected pulmonary infectionin immunocompromised host, nasal wash cultures for viruses, andsputum and blood cultures for bacteria and fungi, should be performed.Empiric therapy may be started for gram-positive and gram-negativebacteria and for P. carinii infection, but bronchoscopy with bronchoalveolarlavage should be considered at early stage. If this is nondiagnostic,lung biopsy is next step.

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

Wheezing: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Asthma

Inflammatorydisorder of smaller airways produces recurrent wheezing, which isreversible with bronchodilator therapy or spontaneously. Wheezingis heard on expiration and often on inspiration.

Cough, tachypnea, and dyspnea are commonfindings.

Episodes may be triggered by viralinfections, allergens (pollens, molds, house dust mite, dog or catdander), exercise, cold air, emotional stress, noxious irritants(tobacco smoke, chemical fumes), and drugs (aspirin, propranolol).

Clinical or family history of atopicdisease is common.

Chest radiography often shows hyperinflationand peribronchial thickening. Peripheral eosinophilia may occurin some cases.

Clinical findings and positive responseto bronchodilators confirm diagnosis.

Bronchiolitis

Inflammationof bronchioles that is usually caused by respiratory syncytial virus (RSV)and occasionally by parainfluenza viruses, influenza viruses, andadenoviruses. Peak incidence is in infants 2–18 mos ofage during winter months.

Usual presentation is rhinorrhea andcough for 1–2 days followed by tachypnea and expiratorywheezing. Fever and crackles are variable findings.

Chest radiography usually shows hyperinflationand peribronchial thickening.

Detection of RSV antigen can be accomplishedby enzyme immunoassay using secretions from nasal wash. Other virusesmay be detected by polymerase chain reaction or by nasal wash culture.

Pneumonia

Is an inflammationor infection of lung parenchyma.

Clinical findings include fever, cough,some degree of respiratory distress, and occasionally expiratorywheezing. Crackles and decreased breath sounds may be heard overinvolved lung field.

Chest radiography confirms presenceof lung infiltrate but not the specific cause.

See further discussion of pneumoniain Chap. 10, Cough.

Foreign Body

Aspiration of foreign body in airway mayproduce choking, gagging, coughing, and wheezing (see Chap. 10, Cough).

Bronchopulmonary Dysplasia

Wheezing is frequent finding in this disorder,which can occur following prolonged mechanical ventilation for treatmentof neonatal respiratory distress syndrome (see Chap. 10, Cough, and Chap. 56, Respiratory Distress and Apnea).

Cystic Fibrosis

Most common manifestation of respiratorydisease in cystic fibrosis is cough that is intermittent and oftenproductive. Wheezing also may occur, especially with acute pulmonaryexacerbations. This disorder is discussed in Chap. 10, Cough.

Cardiac Failure

Severe cardiac failure may cause pulmonaryedema and wheezing (see Chap.7, Cardiac Failure).

Bronchial Obstruction

Intrinsicor extrinsic tracheal or bronchial obstruction may cause wheezing.

Intrinsic lesions include tracheomalacia,tracheal or bronchial stenosis, and endobronchial tumors.

Extrinsic lesions include enlargedlymph nodes (tuberculosis, histoplasmosis), cardiovascular disorders(enlarged pulmonary arteries from large left-to-right shunt lesionsor enlarged left atrium of any cause), and mediastinal masses.

In evaluation, chest radiography, bronchoscopy,chest CT, and MRI are useful diagnostic tools.

Anaphylaxis

Can produceacute onset of urticaria, wheezing, and hypotension. There is usually historyof exposure to specific allergen (foods, drugs, hymenoptera stings).

History and physical exam are usuallydiagnostic.

Gastroesophageal Reflux

Gastroesophagealreflux disease may cause respiratory disturbances including wheezingand apnea. Often there is history of persistent regurgitation andpoor weight gain.

Esophageal pH monitoring for 24 hrscan confirm presence of pathologic reflux.

Allergic Bronchopulmonary Aspergillosis

Rare butcan be complication of asthma.

Usual pathogen is A. fumigatus.

Inhalation of spores and shedding ofantigens into respiratory tract lead to inflammatory response ofairways.

Almost all affected individuals haverecurrent wheezing and dyspnea. Less frequent are chronic cough,fever, and pleuritic chest pain. Crackles may be heard over involvedlung segments.

Chest radiography usually shows patchydensities or consolidation that usually occurs in upper lobes. Peripheralblood eosinophilia is usual feature.

Serum immunoglobulin E level may beas high as 2,500 mg/dL. There is immunologic evidence ofexposure allergy to Aspergillus antigens (immediate skin reactivityor serum precipitins to these antigens). Sputum culture may revealA. fumigatus organisms.

Most serious complication is saccularbronchiectasis, which usually begins centrally. Can be demonstratedby chest CT.

Psychogenic

Normally,vocal cords abduct during inspiration and adduct slightly, if atall, during expiration.

In vocal cord dysfunction, cords adductduring inspiration, narrowing airway. Throat tightness, wheezing,and dyspnea, especially on exertion, can occur.

Direct visualization of cords throughfiberoptic laryngoscope, when patient is symptomatic, establishesdiagnosis. History of psychologic disturbance (e.g., anxiety ordepression) may be found in some cases.

Diagnostic Approach

History,physical exam, and chest radiograph are diagnostic in most casesof wheezing.

Age of child; timing and duration ofwheezing; presence of fever, stridor, or cough; and family historyof asthma or other atopic disorders help distinguish various causesof wheezing.

Asthma, bronchiolitis, and pneumoniaare most frequent causes of acute wheezing, whereas asthma is mostcommon cause of recurrent or persistent wheezing.

Other useful tests in children withhistory of wheezing are sweat test (cystic fibrosis), pH probe andendoscopy (gastroesophageal reflux disease), video swallowing study(swallowing disorders with aspiration), bronchoscopy (foreign bodyaspiration, tracheal or bronchial stenosis, tracheomalacia), andflexible laryngoscopy (vocal cord dysfunction). Further investigationsdepend on suspected diagnosis.

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

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

Nose and Nasopharynx

Congenital

Choanal Atresia

Causes obstructionof nasopharynx that may be unilateral or bilateral.

Respiratory distress occurs with bilateraldisease unless the mouth is open because neonates are obligate nosebreathers.

Best diagnostic test is flexible endoscopy.CT is used to delineate anatomy prior to surgery.

Craniofacial Anomalies

2 autosomal-dominantdisorders, Apert syndrome and Crouzon syndrome, are caused by mutationsin gene encoding fibroblast growth factor receptor-2 on chromosome10q26. In both disorders, midface hypoplasia and shape of palatecontribute to airway obstruction.

Apert syndrome is characterized byacrobrachycephaly, coronal craniosynostosis, shallow orbits, proptosis,hypertelorism, cutaneous and osseous syndactyly, broad distal phalanxof thumb and hallux of big toe, and variable mental retardation.

Characteristic features of Crouzonsyndrome include craniosynostosis (especially of coronal, sagittal,and lambdoid sutures), shallow orbits, proptosis, hypertelorism,parrot-beaked nose, and variable mental retardation.

Midline Masses

Nasal dermoidcyst may be suspected when pit or swelling is seen on dorsum ofnose in midline.

Encephalocele is herniation of meningesand brain tissue into nasal area producing mass or swelling.

CT demonstrates location and extentof these lesions. Biopsy is never performed if there is suspicionof intracranial communication.

Infection/Inflammation

Rhinitis

Infectious or allergic rhinitis may causeinflammation and edema of nasal mucosa, causing upper airway obstruction(see Chap. 41, Nasal Discharge).

Adenoid Hypertrophy

Recurrentviral URIs and allergic rhinitis contribute to adenoid hypertrophy.

Persistent snoring is common finding,and sleep apnea also may occur.

History, physical exam, and lateralneck radiograph confirm diagnosis.

Polyps

Nasal polyps can be visualized on nasal examas gray, smooth, soft, mobile masses. Predisposing causes are allergicrhinitis and cystic fibrosis.

Trauma

Trauma tonose and nasopharynx may produce significant swelling and bleeding, whichcause airway obstruction.

Plain radiographs and CT provide valuablediagnostic information.

Neoplasm

In childhood,most common benign tumors of nasal cavity are hemangioma and lymphangioma.In adolescence, most frequent benign tumor is juvenile angiofibroma.Malignant tumors include rhabdomyosarcoma, carcinoma, and lymphoma.

Common presenting feature of thesetumors is nasal obstruction.

Nasal speculum can be used to examinenasal cavity, while flexible nasopharyngoscopy permits visualizationof nasopharynx.

CT of nasal cavity, nasopharynx, andsinuses locates mass and defines its extent. Histologic diagnosisis definitive.

Oropharynx and Hypopharynx

Congenital

Micrognathia and Other Skull Base Abnormalities

Althoughmicrognathia can occur as isolated lesion, also can occur as partof Pierre Robin syndrome, which includes glossoptosis and cleftpalate.

Another disorder with significant micrognathiais autosomal-dominant Treacher-Collins-Franceschetti syndrome, whosegene locus has been mapped to chromosome 5q32-33.1. Other characteristicfindings include downward slanting palpebral fissures, colobomaof lower lid, malar hypoplasia, and malformations of external ear(commonly microtia).

Macroglossia

Can be associated with congenital hypothyroidism,Beckwith-Wiedemann syndrome, Hurler syndrome, and glycogen storagedisease type II. Diagnosis may be suspected from history and physicalexam. These disorders are discussed in other chapters.

Decreased Pharyngeal Muscle Tone

Decreased tone of pharyngeal musculaturemay contribute to noisy breathing, especially with cerebral palsyand trisomy 21.

Infection/Inflammation

Tonsillar Hypertrophy

Hypertrophy of tonsils may be seen with recurrentviral URI or allergic rhinitis. Tonsils are enlarged and may causeupper airway obstruction.

Abscess

Peritonsillar, retropharyngeal, or lateralpharyngeal abscess may cause fever, difficulty swallowing, drooling,neck pain, and respiratory distress, including stridor (see Chap. 61, Sore Throat).

Foreign Body

Foreignbody in pharynx may cause acute onset of choking and airway obstruction.

History and physical exam can be diagnostic;however, in some cases neck radiographs and nasopharyngoscopy maybe needed to locate the foreign body.

Trauma

Any facialor neck injury can cause edema or hematoma formation that compromises airway.

History, physical exam, radiographsof face and neck, and nasopharyngoscopy are usually diagnostic.

Laryngoscopy and bronchoscopy alsomay be necessary depending on extent of injury. Early tracheostomyshould be considered.

Inhalation injury from fire may causesevere edema of mouth, pharynx, and larynx, producing combinationof cough, hoarseness, and stridor. Visualization of larynx may beaccomplished by endoscopy.

Neoplasm

Benign tumorsof tongue include hemangioma and lymphangioma. Most common malignanttumor of tongue is rhabdomyosarcoma.

Hemangioma can usually be diagnosedclinically.

CT or MRI defines extent of mass. Histologicdiagnosis is definitive.

Supraglottic

Congenital

Laryngomalacia

Most commoncongenital anomaly affecting larynx.

Inward collapse of aryepiglottic foldsis usual mechanism of stridor, which may occur at birth or may bedelayed for a few weeks.

Respiratory distress and feeding difficultiesoccasionally occur. Stridor often improves with placement in proneposition, whereas agitation makes it worse.

Flexible endoscopy is diagnostic procedureof choice.

Resolution usually occurs in firstyear of life when these tissues become firmer. Only in extreme casesis tracheostomy required.

Laryngeal Cyst and Laryngocele

Unusuallesions that are thought to arise from saccule of laryngeal ventricle.

Fluid-filled mass is called cyst andair-filled mass is called laryngocele.

Cyst usually causes airway obstructionat birth, whereas laryngocele usually causes airway problems laterin infancy.

Lateral neck radiography shows massthat may be seen by flexible laryngoscopy. CT and MRI are usefulin determination of location and extent of mass.

Infection/Inflammation

Supraglottitis

Infectionof supraglottic tissues that includes epiglottis.

Generally caused by infection of encapsulatedorganisms.

Usual age range is 1–5 yrs.

Since introduction of H. influenzaetype b vaccine, occurrence of epiglottitis has markedly decreased.Now organisms usually cultured are S. pneumoniae, S. aureus, nontypeableH. influenzae, and group A Streptococcus.

Onset is acute, with fever, inspiratorystridor, pain with swallowing, and drooling.

Laryngoscopy should be performed toconfirm diagnosis but should be done with utmost caution and withanesthesiologist or otolaryngologist present.

Gastroesophageal Reflux

Can be associatedwith coughing, gagging, and choking.

Persistent stridor may occur as consequenceof severe gastroesophageal reflux, and laryngoscopic visualizationof upper airway may reveal inflammatory changes (see Chap. 55, Regurgitation and Vomiting).

Hereditary Angioedema

Laryngeal edema can occur in this autosomal-dominantdisorder in which serum levels of C1 inhibitor are low or its functionis defective (see Chap. 17, Edema).

Trauma

Supraglottic stenosis may be due to traumaor may result from surgical procedures involving the airway.

Neoplasm

Laryngealpapillomas are caused by human papilloma viruses, which can be transmittedduring birth from infected mother to newborn.

They may occur anywhere in airway,but most common location is larynx.

Flexible laryngoscopy reveals mass,and histologic diagnosis is confirmatory.

Glottic

Congenital

Laryngeal Web

Incomplete canalization of laryngeal airwayresults in formation of laryngeal web. This lesion usually occursat glottic level and produces aphonia or weak or husky voice. Stridoralso may occur, and laryngoscopy is diagnostic.

Laryngeal Cleft

Cleft inlarynx is produced by failure of rostral development of tracheoesophageal septum.

Stridor is often heard, and attemptsat feeding produce choking and coughing. Recurrent aspiration mayresult in pneumonia.

Esophagraphy shows spillage of contrastinto trachea with swallowing. Endoscopy is confirmatory.

Vocal Cord Paralysis

Vagus nerveby means of recurrent laryngeal nerve helps control vocal cord movement.Any lesion that affects these nerves may cause unilateral or bilateralvocal cord paralysis, which may be congenital or acquired.

When 1 vocal cord is involved, airwaycompromise is usually minimal and weak or hoarse cry occurs. Onlywith periods of agitation or stress does stridor appear. Causesof unilateral vocal cord paralysis include recurrent laryngeal nervecompression or injury secondary to neck or mediastinal mass, enlargedleft atrium or pulmonary artery, and surgery, particularly cardiovascularor neck surgery.

Stridor is characteristic of bilateralvocal cord paralysis. Cause is usually CNS lesion (e.g., hydrocephalus,intracranial hemorrhage, or Chiari malformation).

Diagnosis of vocal cord paralysis canbe made by flexible laryngoscopy. Vocal cord(s) fails to abducton inspiration. Further investigation depends on suspected cause.

Infection/Inflammation

Laryngitis

Usually associated with hoarseness and notwith stridor, unless inflammation is so severe that airway obstructionoccurs (see Chap. 31, Hoarseness).

Laryngeal Spasm

May be caused by repeated attempts at intubation,allergic reactions, and hypocalcemia. Manifestations of allergicreaction include urticaria, wheezing, and hypotension. Carpopedalspasm suggests tetany, in which case serum calcium should be measuredand intravenous calcium given immediately.

Foreign Body

Foreign body in glottic area may cause acuteonset of choking and coughing. Persistent stridor may be only manifestationof retained foreign body. Diagnosis may be suspected from historyand confirmed by neck radiography or laryngoscopy.

Trauma

Granuloma formation may occur secondary toendotracheal intubation. Obstruction can be minimal or severe.

Neoplasm

Laryngeal papillomas are discussed in thesection Supraglottic: Neoplasm.

Subglottic

Congenital

Subglottic Stenosis

Biphasicstridor usually occurs with congenital subglottic stenosis, yetvoice remains normal.

Neck radiography may demonstrate subglotticnarrowing.

Diagnosis is confirmed by rigid endoscopyunder general anesthesia.

Cysts

Subglottic cysts can be congenital or occursecondary to airway intubation. Rigid endoscopy under general anesthesiais diagnostic.

Infection/Inflammation

Croup

In viralcroup subglottic edema produces airway obstruction and stridor.Most common cause is parainfluenza viral infection. Influenza viruses,rhinoviruses, respiratory syncytial virus, adenoviruses, and enterovirusesalso can cause croup. Age range is usually 6–36 mos.

Symptoms of upper respiratory infectionare followed in 12–24 hrs by barky cough and stridor. Feveris variable finding. This is usually self-limited illness lasting3–7 days.

Neck radiography may be performed ifpresentation is unusual or puzzling and diagnosis is uncertain. "Steeplesign" indicates airway obstruction and is consistent withdiagnosis of croup.

Except for signs of infection, spasmodiccroup cannot be distinguished from viral croup. Onset is sudden,and episodes usually occur during night. Although pathogenesis remainsuncertain, episodes usually resolve during day and subside in afew days. Diagnosis is clinical.

Bacterial Tracheitis

Usuallyfollows preexisting viral infection.

Usual pathogens are S. aureus, S. pneumoniae,M. catarrhalis, and nontypeable H. influenzae.

Average age of onset is 5 yrs.

Clinical presentation is similar tothat of viral croup except these children appear more toxic. Theyhave worsening stridor with purulent tracheal secretions and areless responsive to racemic epinephrine. In most cases, trachealintubation is required because of severe airway obstruction.

Radiography shows subglottic edemaand irregular tracheal densities. Flexible nasopharyngoscopy canidentify purulent secretions in airway, and rigid endoscopy shouldbe performed for debridement. This diagnosis should be consideredin older child with unusually severe croup.

Trauma

Acquiredsubglottic stenosis is usually complication of prolonged endotrachealintubation and is generally more severe than congenital subglotticstenosis.

Although airway films may be diagnostic,flexible endoscopy should be performed to visualize larynx and otherstructures above vocal cords. Occasionally, view of subglottis ispossible. Rigid endoscopy confirms diagnosis.

Neoplasm

Subglottichemangioma is benign tumor that usually becomes symptomatic by 3–6 mosof age.

Stridor may be inspiratory or biphasic.Barky cough and hoarseness also may occur.

Neck radiography may show asymmetricsubglottic narrowing. CT or MRI is used to determine extent of thelesion.

Diagnosis is confirmed by endoscopicexam under general anesthesia.

Tracheobronchial

Congenital

Tracheomalacia

Presenceof misshapen or deficient tracheal cartilage rings contributes toabnormal collapse of trachea, called tracheomalacia.

Onset is insidious and often episodic.Crying, coughing or feeding may lead to acute exacerbation. Stridoris typically expiratory. Cartilage becomes firmer with growth, andstridor usually resolves by 12–18 mos of age.

Diagnosis can be confirmed by fluoroscopyor bronchoscopy, which demonstrates inspiratory collapse of extrathoracictrachea and expiratory collapse of intrathoracic trachea.

Tracheal Web

Local narrowing of trachea produced by fibroustissue, and bronchoscopy is diagnostic.

Tracheal Cysts

Usuallyasymptomatic, but large or infected ones may produce stridor and cough.

Chest radiography usually shows cysticmediastinal structure adjacent to trachea.

Other useful diagnostic tests includeesophagraphy, CT, and bronchoscopy.

Tracheal Stenosis

Fibrousstrictures that narrow airway may occur anywhere in trachea, andbronchoscopy is diagnostic.

Tracheal ring involves individual trachealrings or segmental areas of trachea that may not increase in sizewith growth. Rings resemble cartilage and lack membranous posteriorsegment.

Chest radiography may show narrow orfunnel-shaped trachea. Bronchoscopy confirms diagnosis.

Vascular Anomalies

Double aorticarch can compress trachea and esophagus and cause stridor, dysphagia, andapnea. Esophagraphy shows characteristic indentations of esophagus,with higher and larger indentation caused by right aortic arch andlower indentation caused by left aortic arch. MRI is confirmatory.

Anomalous innominate artery originatesmore distally from aortic arch than normal and compresses rightanterior aspect of trachea just above carina. Stridor, persistentcough, and apnea may occur. Chest radiography shows anterior indentationof trachea. Demonstration of anterior compression of distal tracheaby pulsatile vessel at bronchoscopy is diagnostic.

In pulmonary artery sling, left pulmonaryartery arises as branch of right pulmonary artery, courses betweentrachea and esophagus to reach left lung, and compresses right mainbronchus and esophagus. Chest radiograph shows anterior bowing ofright main bronchus, deviation of lower trachea to the left, unequalaeration of lungs, and mediastinal density between trachea and esophagus.Esophagraphy may show anterior indentation of esophagus just abovelevel of carina. MRI or cardiac catheterization with pulmonary angiographyis diagnostic.

Infection/Inflammation

Retroesophagealabscess may cause fever and stridor due to compression of trachea.

Chest radiography, esophagraphy, andCT are useful in diagnosis. Confirmation of diagnosis may only bepossible at surgery.

Foreign Body

Trachealforeign bodies may produce choking and gagging followed by persistent coughingand stridor. Radiopaque foreign body may be recognized on chestradiograph; otherwise, bronchoscopy is confirmatory.

Esophageal foreign body may compresstrachea and cause stridor, cough, and respiratory distress, sometimeswithout any esophageal symptoms (e.g., drooling, dysphagia, or pain).

Chest radiography may show its location,whereas esophagraphy usually shows filling defect.

Esophagoscopy is confirmatory.

Trauma

Tracheal stenosis may occur from complicationsof intubation or, less commonly, tracheostomy. Bronchoscopy is diagnostic.

Neoplasm

Tracheal

Rare inpediatric population.

Benign tumors include squamous papilloma,chondroma, and hemangioma, whereas malignant tumors include varioussarcomas and carcinomas.

Presenting symptoms include persistentcough, expiratory stridor, and hemoptysis.

Chest and airway radiography may identifymass lesion. Combination of tests that includes bronchoscopy, CT,and MRI can locate site and extent of lesion.

Histologic diagnosis is definitive.

Thyroid

Thyroid neoplasm may compress trachea andcause stridor. CT can demonstrate compression. See further discussionof thyroid neoplasms in Chap.42, Neck Masses.

Mediastinal Masses

Some mediastinalmasses including teratoma, lymphangioma, and lymphoma may compresstrachea and cause stridor.

Combination of tests, including chestCT and MRI as well as bronchoscopy, can locate and determine extentof lesion.

Histologic diagnosis is definitive.

Psychogenic

In pediatricpopulation, this type of stridor is most common in adolescent girls.Often history of psychologic stress exists.

Stridor may be heard in inspiration,expiration or both. Associated findings include cough, hoarseness,and dyspnea.

In some cases, flexible laryngoscopymay reveal paradoxic vocal cord motion, in which vocal cords adductrather than abduct in inspiration.

Diagnostic Approach

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

Cough, barking: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Cough, productive: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

» 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?

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

Cough, nonproductive: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Ask the patient when his cough began and whether body position, the time of day, or a specific activity affects it. How does the cough sound—harsh, brassy, dry, or hacking? Try to determine if the cough is related to smoking or a chemical irritant. If the patient smokes or has smoked, note the number of packs smoked daily multiplied by years (“pack-years”). Next, ask about the frequency and intensity of the coughing. If he has pain associated with coughing, breathing, or activity, when did it begin? Where is it located?

Ask the patient about recent illness (especially a cardiovascular or pulmonary disorder), surgery, or trauma. Also ask about hypersensitivity to drugs, foods, pets, dust, or pollen. Find out which medications the patient takes, if any, and ask about recent changes in schedule or dosages. Ask about recent changes in his appetite, weight, exercise tolerance, or energy level and recent exposure to irritating fumes, chemicals, or smoke.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Wheezing [Sibilant rhonchi]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient isn't in respiratory distress, obtain a history. What provokes his wheezing? Does he have asthma or allergies? Does he smoke or have a history of a pulmonary, cardiac, or circulatory disorder? Does he have cancer? Ask about recent surgery, illness, or trauma or changes in appetite, weight, exercise tolerance, or sleep patterns. Obtain a drug history. Ask about exposure to toxic fumes or respiratory irritants. If he has a cough, ask how it sounds, when it starts, and how often it occurs. Does he have paroxysms of coughing? Is his cough dry, sputum producing, or bloody?

Ask the patient about chest pain. If he reports pain, determine its quality, onset, duration, intensity, and radiation. Does it increase with breathing, coughing, or certain positions?

Examine the patient's nose and mouth for congestion, drainage, or signs of infection, such as halitosis. If he produces sputum, obtain a sample for examination. Check for cyanosis, pallor, clamminess, masses, tenderness, swelling, distended jugular veins, and enlarged lymph nodes. Inspect the patient's chest for abnormal configuration and asymmetrical motion, and determine if the trachea is midline. (See Detecting slight tracheal deviation, page 597.) Percuss for dullness or hyperresonance, and auscultate for crackles, rhonchi, or pleural friction rubs. Note absent or hypoactive breath sounds, abnormal heart sounds, gallops, or murmurs. Also note arrhythmias, bradycardia, or tachycardia. (See Evaluating breath sounds, pages 650 and 651.)

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

COUGH: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Clinically, exposure to dust, smoke, and various gases should be looked for in the patient presenting with a cough. Postnasal drip from chronic sinusitis should be ruled out. An allergic history (e.g., hay fever) is important. Cardiovascular disease should be carefully excluded, especially when sputum is negative for routine cultures, tuberculosis, fungi, and Papanicolaou smears and chest x-rays, bronchoscopy, and bronchography are normal. Hysterical cough should be considered, however, as well as reflux esophagitis and hiatal hernia. A sputum and nasal smear for eosinophils should be done to rule out asthma. A trial of therapy may be indicated.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

STRIDOR AND SNORING: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The approach to the diagnosis involves a careful examination of the air passage with the laryngoscope and bronchoscope (if necessary, under anesthesia). If these have negative findings, a thorough neurologic examination should be performed and a Tensilon test may be indicated. Laryngismus stridulus in children may be terminated by putting the child in a steam bath; this helps to establish that diagnosis. Skin testing for allergies may be necessary. A sleep study is often necessary to rule out neurogenic or obstructive sleep apnea.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

» Next page: Signs of Bronchitis

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TREATMENTS & RESEARCH

Dr. Huntley's Diagnosis Checklist

Diagnosis of Bronchitis

Bronchitis Diagnosis: Book Excerpts

Diagnosis of Bronchitis: medical news summaries:

Diagnostic Tests for Bronchitis: Online Medical Books

COUGH: Ask the following questions: (Algorithmic Diagnosis of Symptoms and Signs)

DIAGNOSTIC WORKUP

STRIDOR: Ask the Following Questions: (Algorithmic Diagnosis of Symptoms and Signs)

DIAGNOSTIC WORKUP

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

Stridor & Wheezing: Differential Diagnosis (In a Page: Signs and Symptoms)

Workup and Diagnosis

Cough - Productive: Differential Diagnosis (In a Page: Signs and Symptoms)

Workup and Diagnosis

Cough - Nonproductive: Differential Diagnosis (In a Page: Signs and Symptoms)

Workup and Diagnosis

Stridor: Differential Diagnosis (In A Page: Pediatric Signs and Symptoms)

Workup and Diagnosis

Wheezing: Differential Diagnosis (In A Page: Pediatric Signs and Symptoms)

Workup and Diagnosis

Cough – Acute: Differential Diagnosis (In A Page: Pediatric Signs and Symptoms)

Workup and Diagnosis

Cough – Chronic: Differential Diagnosis (In A Page: Pediatric Signs and Symptoms)

Workup and Diagnosis

COUGH: Approach to the Diagnosis (Differential Diagnosis in Primary Care)

STRIDOR AND SNORING: Approach to the Diagnosis (Differential Diagnosis in Primary Care)

Cough, barking: History and physical examination (Handbook of Signs & Symptoms (Third Edition))

Cough, productive: History and physical examination (Handbook of Signs & Symptoms (Third Edition))

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

Cough, nonproductive: History and physical examination (Handbook of Signs & Symptoms (Third Edition))

Wheezing [Sibilant rhonchi]: History and physical examination (Handbook of Signs & Symptoms (Third Edition))

Whooping cough: Diagnosis (Professional Guide to Diseases (Eighth Edition))

Cough, barking: History and physical examination (Professional Guide to Signs & Symptoms (Fifth Edition))

Cough, productive: History and physical examination (Professional Guide to Signs & Symptoms (Fifth Edition))

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

Cough, nonproductive: History and physical examination (Professional Guide to Signs & Symptoms (Fifth Edition))

Wheezing [Sibilant rhonchi]: History and physical examination (Professional Guide to Signs & Symptoms (Fifth Edition))

Cough: History (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

Physical examination

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

Physical examination

Wheezing: History (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

Physical examination

Wheezing: Differential Overview (Field Guide to Bedside Diagnosis)

Diagnostic Approach

Acute Cough: Differential Overview (Field Guide to Bedside Diagnosis)

Diagnostic Approach

Chronic Cough: Differential Overview (Field Guide to Bedside Diagnosis)

Diagnostic Approach

Cough, barking: History (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Physical examination

Cough, productive: History (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Physical examination

Stridor: History (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Wheezing: History (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Physical examination

Cough, barking: History (Signs & Symptoms: A 2-in-1 Reference for Nurses)

Cough, productive: History (Signs & Symptoms: A 2-in-1 Reference for Nurses)

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

Wheezing: History (Signs & Symptoms: A 2-in-1 Reference for Nurses)

Cough, nonproductive: History (Signs & Symptoms: A 2-in-1 Reference for Nurses)

Cough: Clinical Features and Diagnosis (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Infection/Inflammation

Upper Respiratory Tract Infection

Sinusitis

Laryngitis

Croup

Tracheitis

Bronchitis

Pertussis

Bronchiolitis

Pneumonia

Viral

Bacterial

Tuberculosis

Chlamydia

Legionella

Nocardia

Mycoplasma

TREATMENTS &
RESEARCH

Dr. Huntley's
Diagnosis
Checklist

COUGH: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

STRIDOR: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

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

Stridor & Wheezing: Differential Diagnosis
(In a Page: Signs and Symptoms)

Cough - Productive: Differential Diagnosis
(In a Page: Signs and Symptoms)

Cough - Nonproductive: Differential Diagnosis
(In a Page: Signs and Symptoms)

Stridor: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Wheezing: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Cough – Acute: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

Cough – Chronic: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

COUGH: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

STRIDOR AND SNORING: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Cough, barking: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Cough, productive: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

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

Cough, nonproductive: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Wheezing [Sibilant rhonchi]: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Whooping cough: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Cough, barking: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Cough, productive: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

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

Cough, nonproductive: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Wheezing [Sibilant rhonchi]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Cough: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

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

Wheezing: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

Wheezing: Differential Overview
(Field Guide to Bedside Diagnosis)

Acute Cough: Differential Overview
(Field Guide to Bedside Diagnosis)

Chronic Cough: Differential Overview
(Field Guide to Bedside Diagnosis)

Cough, barking: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Cough, productive: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Stridor: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Wheezing: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Cough, barking: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Cough, productive: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

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

Wheezing: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Cough, nonproductive: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Cough: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Wheezing: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

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