Breath with fruity odor
Breath with fruity odor: Excerpt from Handbook of Signs & Symptoms (Third Edition)
Fruity breath odor results from respiratory elimination of excess acetone. This sign characteristically occurs with ketoacidosis — a potentially life-threatening condition that requires immediate treatment to prevent severe dehydration, irreversible coma, and death.
Ketoacidosis results from the excessive catabolism of fats for cellular energy in the absence of usable carbohydrates. This process begins when insulin levels are insufficient to transport glucose into the cells, as in diabetes mellitus, or when glucose is unavailable and hepatic glycogen stores are depleted, as in low-carbohydrate diets and malnutrition. Lacking glucose, the cells burn fat faster than enzymes can handle the ketones, the acidic end products. As a result, the ketones (acetone, beta-hydroxybutyric acid, and acetoacetic acid) accumulate in the blood and urine. To compensate for increased acidity, Kussmaul's respirations expel carbon dioxide with enough acetone to flavor the breath. Eventually, this compensatory mechanism fails, producing ketoacidosis.
Emergency interventions
When you detect fruity breath odor, check for Kussmaul's respirations and examine the patient's level of consciousness (LOC). Take his vital signs and check skin turgor. Be alert for fruity breath odor that accompanies rapid, deep respirations; stupor; and poor skin turgor. Try to obtain a brief history, noting especially diabetes mellitus, nutritional problems such as anorexia nervosa, and fad diets with little or no carbohydrates. Obtain venous and arterial blood samples for glucose, complete blood count, and electrolyte, acetone, and arterial blood gas (ABG) levels. Also obtain a urine specimen to test for glucose and acetone. Administer I.V. fluids and electrolytes to maintain hydration and electrolyte balance and, in the patient with diabetic ketoacidosis, give regular insulin to reduce blood glucose levels.
If the patient is obtunded, you'll need to insert endotracheal and nasogastric (NG) tubes. Suction as needed. Insert an indwelling urinary catheter, and monitor intake and output. Insert central venous pressure and arterial lines to monitor the patient's fluid status and blood pressure. Place the patient on a cardiac monitor, monitor his vital signs and neurologic status, and draw blood hourly to check glucose, electrolyte, acetone, and ABG levels.
History and physical examination
If the patient isn't in severe distress, obtain a thorough history. Ask about the onset and duration of fruity breath odor. Find out about changes in breathing pattern. Ask about increased thirst, frequent urination, weight loss, fatigue, and abdominal pain. Ask the female patient if she has had candidal vaginitis or vaginal secretions with itching. If the patient has a history of diabetes mellitus, ask about stress, infections, and noncompliance with therapy — the most common causes of ketoacidosis in known diabetics. If the patient is suspected of having anorexia nervosa, obtain a dietary and weight history.
Medical causes
❑ Anorexia nervosa. Severe weight loss associated with anorexia nervosa may produce fruity breath, usually with nausea, constipation, and cold intolerance as well as dental enamel erosion and scars or calluses in the dorsum of the hand, both related to induced vomiting.
❑ Ketoacidosis. Fruity breath odor accompanies alcoholic ketoacidosis, which is usually seen in poorly nourished alcoholics with vomiting, abdominal pain, and only minimal food intake over several days. Kussmaul's respirations begin abruptly and accompany dehydration, abdominal pain and distention, and absent bowel sounds. Blood glucose levels are normal or slightly decreased.
With diabetic ketoacidosis, fruity breath odor commonly occurs as ketoacidosis develops over 1 to 2 days. Other findings include polydipsia, polyuria, nocturia, a weak and rapid pulse, hunger, weight loss, weakness, fatigue, nausea, vomiting, and abdominal pain. Eventually, Kussmaul's respirations, orthostatic hypotension, dehydration, tachycardia, confusion, and stupor occur. Signs and symptoms may lead to coma.
Starvation ketoacidosis is a potentially life-threatening disorder that has a gradual onset. Besides fruity breath odor, typical findings include signs of cachexia and dehydration, a decreased LOC, bradycardia, and a history of severely limited food intake (anorexia nervosa).
Other causes
❑ Drugs. Any drug known to cause metabolic acidosis, such as nitroprusside and salicylates, can result in fruity breath odor.
❑ Low-carbohydrate diets. These diets, which encourage little or no carbohydrate intake, may cause ketoacidosis and the resulting fruity breath odor.
Special considerations
Provide emotional support for the patient and his family. Explain tests and treatments clearly. When the patient is more alert and his condition stabilizes, remove the NG tube and start him on an appropriate diet. Switch his insulin from the I.V. to the subcutaneous route.
Pediatric pointers
Fruity breath odor in an infant or child usually stems from uncontrolled diabetes mellitus. Ketoacidosis develops rapidly in this age-group because of low glycogen reserves. As a result, prompt administration of insulin and correction of fluid and electrolyte imbalance are necessary to prevent shock and death.
Geriatric pointers
The elderly patient may have poor oral hygiene, increased dental caries, decreased salivary function with dryness, and poor dietary intake. In addition, he may take multiple drugs. Consider all of these factors when evaluating an elderly patient with mouth odor.
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
More About Diabetic Ketoacidosis
More Medical Textbooks Online about Diabetic Ketoacidosis
Review other book chapters online related to Diabetic Ketoacidosis:
Medical Books Excerpts
- Diabetes Mellitus
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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