Consider the broad-differential diagnosis for respiratory distress in children
Consider the broad-differential diagnosis for respiratory distress in children: Excerpt from Avoiding Common Pediatric Errors
Author:
Sarika Joshi, MD
What to Do - Gather Appropriate Data
It is important for pediatricians to recognize the signs and symptoms of
respiratory distress, as it is a common presenting complaint for children.
With a careful history and physical exam, it is possible to narrow down the
broad differential for respiratory distress so that appropriate treatment may
be started. Respiratory distress is characterized by increased work of breathing (i.e., tachypnea, flaring, retractions) often in association with pulmonary
exam findings such as stridor, wheezing, and rales.
Important elements of the history for a child with respiratory distress
include trauma, voice changes (i.e., muffled, hoarse), and associated symptoms, such as fever. Prior episodes of respiratory distress or any chronic
medical conditions are also significant parts of the history. Physical exam
should start with vital signs, especially respiratory rate and oxygen saturation. The World Health Organization defines tachypnea (in breaths per
minute) based on age: >60 for age <2 months, >50 for ages 2 months to 1
year, >40 for ages 1 to 5 years, >20 for age >5 years. Remember that for
febrile children, each degree Celsius increase may cause an increase of up to
10 breaths per minute. In additionto the respiratory rate,pay attention tothe
respiratory pattern. For instance, Kussmaul breathing and Cheyne-Stokes
breathing occur with metabolic acidosis and central nervous system (CNS)
processes, respectively.
Prior to auscultation, careful observation of the child in respiratory distress may provide important clues to the diagnosis. Mental status changes,
such as combativeness or somnolence, may indicate severe hypoxia or hypercarbia. Cyanosis is a late sign in the hypoxic child. The child will assume
a position that decreases work of breathing. For example, a child with upper
airway obstruction may assume the "sniffing position." Observe whether
there is nasal flaring, head bobbing, retractions (supraclavicular, intercostal,
substernal), or grunting, all of which signify respiratory distress. If there is
cough, listen to the quality: hoarse or barky (suggests upper airway problem), tight and persistent (suggests lower airway obstruction), or loose and
productive (suggests infection). On auscultation, particularly note stridor,
wheezing, rales,anddecreasedbreathsounds.Stridor is generally aninspiratory noise from upper airway obstruction. Wheezing is usually an expiratory
noise from lower airway obstruction. Rales are typically an inspiratory noise
from lower airway reinflation, which occurs in pneumonia and pulmonary
edema. Decreased breath sounds may indicate local areas of collapse, consolidation, or fluid.
Armed with your history and physical exam findings, it is then conceptually helpful to categorize the child with respiratory distress as follows: (a)
upper airway obstruction; (b) asymmetric breath sounds, no upper airway
obstruction;(c)symmetricbreathsounds,noupperairwayobstruction.Childrenwithupperairwayobstructionwillhavesymptomssuchasstridor,voice
changes, and dysphagia. Some causes of afebrile upper airway obstruction in
children are foreign body, neck trauma, and upper airway burns. Causes of
febrile upperairway obstruction includecroup,retropharyngeal abscess, and
epiglottitis. Asymmetric breath sounds indicate a focal pulmonary process.
An important cause of afebrile asymmetric breath sounds, often with a history of trauma, is pneumothorax. Atelectasis can produce this picture, with
or without fever. Lobar pneumonia is a cause of febrile asymmetric breath
sounds, typically associated with rales. Symmetric breath sounds suggest a
diffusepulmonaryprocessoranonpulmonaryprocess.Pulmonaryprocesses
that present in this manner include viral or atypical pneumonia (usually with
fever and rales), asthma (generally with wheezing), and bronchiolitis (typically with fever, rales, and wheezing). Significant nonpulmonary etiologies
to consider are myocarditis, metabolic acidosis, and CNS processes.
In summary, the differential diagnosis of respiratory distress in children
is broad and necessitates a careful history and physical exam. Important
features include recognition of the signs of increased work of breathing and
auscultation of symptoms such as stridor, rales, wheezing, and differential
breath sounds.
Suggested Readings
Margolis P, Gadomski A. The rational clinical examination. Does this infant have pneumonia?
JAMA. 1998;279:308–313.
Zaritsky AL, Nadkarni VM, Hickey RW, et al., eds. Pediatric Advanced Life Support Provider
Manual. Dallas, TX: American Heart Association; 2002.
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Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
More About Neonatal Respiratory Distress Syndrome
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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