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Diagnosis of Obstructive sleep apnea

Obstructive sleep apnea Diagnosis: Book Excerpts

Diagnosis of Obstructive sleep apnea: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Obstructive sleep apnea:

Diagnostic Tests for Obstructive sleep apnea: Online Medical Books

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


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

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

  1. Is there excessive snoring? Excessive snoring would indicate obstructive sleep apnea from large tonsils, deviated nasal septum, cleft palate, other abnormalities, and obesity.
  2. Is there obesity? More than 60% of patients with sleep apnea have obesity, and pickwickian syndrome should be considered in these patients, as well as idiopathic obesity.
  3. Are there abnormalities of the neurologic examination? The presence of neurologic abnormalities should make one think of poliomyelitis, Shy-Drager syndrome, brain stem tumors, and other neurologic disorders.

DIAGNOSTIC WORKUP

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

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Paroxysmal Nocturnal Dyspnea: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • CHF is the most common cause
    –Etiologies include uncontrolled HTN, pulmonary embolus, endocarditis, hyperthyroidism, pericardial disease, endocardial disease (e.g., valvular stenosis, insufficiency, rupture, endocarditis), and myocardial disease (e.g., MI, ischemia, arrhythmias)
  • Mitral stenosis
    –Almost always secondary to rheumatic heart disease (after 15–40 years)
    –Advanced cases result in pulmonary hypertension and right heart failure
    –Dyspnea is the most significant symptom
    –Classic triad: Diastolic rumble, opening snap, and loud first heart sound
  • Aortic regurgitation
    –Most commonly due to rheumatic fever
  • Cardiomyopathies
    –Abnormal myocardium, resulting in impaired cardiac output and CHF
  • Aortic stenosis
    –Due to senile valve degeneration, rheumatic disease, or congenital
    –Associated with angina, syncope, and CHF
  • Congenital heart disease
    –May see failure to thrive, progressive CHF symptoms, cyanosis, and/or murmur
    • “Cardiac asthma”
      –Bronchospasm secondary to pulmonary congestion and interstitial edema that compresses small airways
      –Standing decreases lung congestion
    • Anxiety
    • Severe COPD and emphysema
    • Asthma
    • Obstructive sleep apnea
    • Obesity/hypoventilation
    • Tropical pulmonary eosinophilia (filariasis)

    Workup and Diagnosis

    • Complete history and physical exam with special attention to cardiac and respiratory systems
    • Initial laboratory studies may include CBC, pulse oximetry, electrolytes, BUN/creatinine, glucose, and calcium
    • Chest X-ray to evaluate for effusion and heart size
    • Echocardiogram may be used to evaluate valves, chamber size, and ventricular function
    • ECG
    • Consider cardiology consult
    • Cardiac catheterization may be indicated for valvular disease, cardiomyopathies, and congenital heart disease

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

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

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

      • Much apnea is physiologic and normal
        –Post-sigh apnea is normal
        –Newborns, especially premature babies, may have irregular breathing as their respiratory control center matures
        –Periodic breathing at high altitude
    • Prolonged apnea is respiratory arrest, and inadequate ventilation is respiratory failure, and both require immediate intervention
    • Apnea may be divided into central, obstructive, and mixed apnea; etiologies vary by age
    • Central apnea in infants
      –Apnea of prematurity
      –Congenital central hypoventilation syndrome (CCHS, or Ondine curse)
      –CNS depression (sepsis, shock, drug effect, RSV, seizure or postictal state)
      –Respiratory muscle failure (e.g., myotonia, infantile botulism)
      • Obstructive apnea in infants
        –Upper airway obstruction (severe laryngomalacia, choanal atresia, macroglossia, micrognathia, subglottic stenosis or web, laryngospasm)
        –Lower airway: Rarely causes obstructive apnea (tracheal stenosis, rings, slings)
      • Central apnea in children
        –CNS (drug-induced CNS depression, CCHS, abnormal CNS brainstem anatomy and function, sepsis/septic shock)
        –Respiratory muscle failure (muscular dystrophy, myotonia, myasthenia gravis)
      • Obstructive apnea in children
        –Upper airway obstruction, obstructive sleep apnea syndrome (OSAS), tonsillar and adenoidal hypertrophy, macroglossia, micrognathia, subglottic stenosis, laryngospasm
      • Mixed apnea
        –CNS depression and decreased upper airway tone
        –Gastroesophageal reflux leading to increased parasympathetic activity and/or laryngospasm
        –Respiratory muscle failure and adenoidal hypertrophy
      • Apparent life-threatening events (ALTE)
      • Trauma may cause apnea at any age

      Workup and Diagnosis

      • Acute or prolonged apnea must be treated immediately with life-support protocols
      • History may determine if apnea is central or obstructive
        –Snoring, stridor, gasps are consistent with obstructive apnea
        –Pauses are consistent with central apnea
        –Ingestion of raw honey can cause infantile botulism
        –Apnea/ALTE may occur in a familial pattern, but such a history should provoke a search for intentional injury
        • Apnea is most often associated with sleep and/or change in stage of sleep, so obtaining data during sleep may be needed to diagnose the cause of the apnea
        • CCHS may be associated with hypoventilation while awake, but is primarily a sleep-related disorder
        • Neuromuscular disease may be accompanied by structural disease (e.g., arthrogryposis, scoliosis)
        • Obstructive disease may have an obvious etiology (e.g., micrognathia), but consider central or CNS disease
        • Radiographic studies not as helpful as physiologic studies; fluoroscopy may diagnose malacia
        • A pneumogram examines heart rate, respiratory rate, chest wall movement, and oxygen saturation, but may miss obstructive disease
        • Preferred test is polysomnography, which adds measures of sleep stage and body movement, EEG, pH, and CO2
        • Covert videotaping in hospital may be needed for suspected abuse

    » 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

    DECREASED RESPIRATIONS, APNEA, AND CHEYNE–STOKES BREATHING: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Obviously, the association of other signs and symptoms will determine the workup in most cases. The most important things to do are to order a BUN level, electrolytes, FBS, and arterial blood gases, and a drug screen and to check for increased intracranial pressure by examining the eye grounds. If the history or physical findings suggest increased intracranial pressure, and other metabolic studies (e.g., BUN) are normal, a mannitol or urea drip is begun while awaiting the results of other investigations such as CT scan, EEG, and echoencephalogram. A neurosurgeon should be consulted immediately.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    SLEEP APNEA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    A thorough examination of the upper respiratory system is essential: It may be wise to get an otolaryngologist to do this. A CBC to rule out anemia and arterial blood gases to rule out anoxia and hypercarbia may be helpful. Spirometry, chest x-ray, ECG, and arm-to-tongue circulation time will help rule out pulmonary and cardiovascular disorders. Ultimately, overnight polysomnography will be required to secure the diagnosis. A pulmonologist or otolaryngologist ought to be consulted before ordering this expensive test.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

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

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

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

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

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

    » READ BOOK EXCERPT ONLINE »

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

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

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

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

    » READ BOOK EXCERPT ONLINE »

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

    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.)  

    » READ BOOK EXCERPT ONLINE »

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

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

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

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

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

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

    » READ BOOK EXCERPT ONLINE »

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

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

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

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

    » READ BOOK EXCERPT ONLINE »

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

    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.)

    » READ BOOK EXCERPT ONLINE »

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

    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.

    » READ BOOK EXCERPT ONLINE »

    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.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

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

    When the patient is stabilized, obtain a history from the family. Determine the onset and events immediately preceding the event. Determine if there were related events, such as headache, chest pain, muscle weakness, sore throat, or dyspnea. Ask about a history of respiratory, cardiac, or neurologic disease and about allergies and drug use.

    Physical examination

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

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

    » READ BOOK EXCERPT ONLINE »

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

    Respirations, stertorous: History
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    Ask the patient about signs of sleep deprivation, such as personality changes, headaches, daytime somnolence, or decreased mental acuity. When possible, ask a family member whether the patient snores. If so, does his snoring awaken others? Does the snoring improve if he sleeps with the window open? Does the patient talk in his sleep or sleepwalk? 

    Physical examination

    Perform a complete respiratory assessment. Examine the head, nose, and throat. If you detect stertorous respirations while the patient is sleeping, observe his breathing pattern for 3 to 4 minutes. Do noisy respirations cease when he turns on his side and recur when he assumes a supine position? Watch carefully for periods of apnea and note their length. Monitor the patient’s level of oxygenation.

    » READ BOOK EXCERPT ONLINE »

    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.)

    » READ BOOK EXCERPT ONLINE »

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

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

    When possible, question the patient’s partner about his snoring habits. Is the partner frequently awakened by the patient’s snoring? Does the snoring improve if the patient sleeps with the window open? Has the partner also observed the patient talk in his sleep or sleepwalk? Ask about signs of sleep deprivation, such as personality changes, headaches, daytime somnolence, or decreased mental acuity.

    » READ BOOK EXCERPT ONLINE »

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

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

    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?

    » READ BOOK EXCERPT ONLINE »

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

    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.

    • » READ BOOK EXCERPT ONLINE »

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

    Respiratory Distress and Apnea: Clinical Features and Diagnosis: Respiratory Distress (Neonatal)
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    Upper Respiratory Tract Obstruction

    Disorders that cause upper respiratory tractobstruction are discussed in Chap.63, Stertor, Stridor, and Airway Obstruction.

    Lower Respiratory Tract Disorders

    Transient Tachypnea of the Newborn

  • Delayedresorption of lung fluid or mild immaturity of surfactant systemare most probable explanations for this disorder, which usuallyoccurs in term infants soon after birth.
  • Respiratory rate is commonly 60–80breaths/min but sometimes is >100 breaths/min.Mild intercostal retractions and expiratory grunting also may occur.
  • Characteristic chest radiographic findingsare prominent perihilar markings, hyperaeration, widening of interlobarfissures, and evidence of interstitial and pleural fluid.
  • Most infants require <40% supplementaloxygen. Tachypnea usually resolves in 3 or 4 days.

    • Respiratory Distress Syndrome (Hyaline Membrane Disease)

  • Respiratorydistress syndrome, which is most common cause of respiratory distress inpreterm infants, is due to inadequate amount of surfactant. Someinfants experience intrapartum asphyxia and fail to expand theirlungs at birth, whereas others develop tachypnea and expiratorygrunting within first 1–2 hrs of life.
  • Spectrum of disease varies from mild(tachypnea and minimal oxygen requirement) to severe (apnea andrespiratory failure). Crackles may be heard on chest exam.
  • Characteristic chest radiograph showsdiffuse reticulogranular infiltrates, atelectasis, and air bronchograms.
  • Diagnosis is clinical and radiographic.

    • Meconium Aspiration and Other Aspiration Syndromes

  • Neonateswho aspirate meconium are usually those who have had intrapartumasphyxia.
  • Thick meconium in upper airway andmeconium staining of skin and nails are usual findings. Airway obstruction,pneumonia, and respiratory failure can occur.
  • Chest radiography shows irregular distributionof coarse, patchy infiltrates and hyperaeration.
  • Clinical and radiologic findings arediagnostic.
  • Aspiration of feedings sometimes occursin normal infants but is more frequent in those with sucking andswallowing disorders (see Chap.65, Sucking and Swallowing Difficulty).

    • Pneumonia

  • Pneumoniamay be caused by infections acquired transplacentally, during birthprocess, and postnatally. Viral infections transmitted by transplacentalroute include enteroviruses, adenoviruses, influenza viruses, rubellavirus, varicella-zoster virus, herpes simplex virus, cytomegalovirus,and HIV. Transplacental bacterial infections caused by L. monocytogenes,M. tuberculosis, or T. pallidum are less common than viral infections.
  • Neonatal pneumonia is most commonlyacquired during birth process. Group B Streptococcus is most commonpathogen; other pathogens (e.g., gram-negative enteric bacteria)are less common. Most common viral agents acquired during birthprocess are herpes simplex virus and cytomegalovirus. C. trachomatisis also acquired during delivery and usually presents at 2–8wks of age with staccato cough and wheezing. History of conjunctivalinfection may or may not exist.
  • Inadequate hand washing and exposureto respiratory equipment or humidified incubators may contributeto infection, especially with S. aureus and gram-negative entericbacteria.
  • Other causes of postnatal infectionsinclude respiratory syncytial virus, parainfluenza viruses, influenzaviruses, herpes simplex virus, cytomegalovirus, and fungi (C. albicans).
  • Infants with pneumonia present withrespiratory distress. Chest radiography shows interstitial or alveolarinfiltrates or consolidation. With suspected bacterial pneumoniain newborns, blood and spinal fluid cultures should be performed,and treatment begun immediately while awaiting culture results.
  • Diagnosis of viral infections is discussedin other chapters.

    • Pulmonary Air Leaks

  • Extrapulmonaryair can accumulate in interstitial spaces of lung (pulmonary interstitialemphysema), mediastinum (pneumomediastinum), pleural space (pneumothorax),and pericardium (pneumopericardium).

  • Common cause of pulmonary interstitial emphysemais positive-pressure mechanical ventilation.
  • Pneumomediastinum results from dissectionof air from interstitial space into mediastinum.
  • Pneumothorax results from mediastinalair rupture into pleural space or rupture of air blebs on surfaceof lung. Most common causes of pneumothorax are respiratory distresssyndrome, meconium aspiration, and high-pressure mechanical ventilation.
  • Pneumopericardium is produced fromdissection of mediastinal air into pericardium.
  • Clinical presentation depends on sizeand location of air leak. Significant unilateral pneumothorax collapsesipsilateral lung and shifts heart and mediastinum to opposite sidewith diminished breath sounds on affected side. Significant pneumopericardiummay compromise cardiac filling and cause diminished cardiac output.
  • Chest radiography is diagnostic ofdifferent types of air leak.

    • Pulmonary Hemorrhage

  • Predisposingfactors in neonatal period include perinatal asphyxia, septicemia,and mechanical ventilation, especially in those with respiratorydistress syndrome.
  • Accompanying respiratory distress isbloody fluid, which oozes from nose, mouth, or endotracheal tube.
  • Depending on how severe bleeding is,chest radiography may show spectrum of findings ranging from patchyinfiltrates to opacification of lungs.

    • Bronchopulmonary Dysplasia

    This form of chronic lung disease developsin neonates treated with prolonged oxygen therapy and positive-pressureventilation for primary lung disorders. Most infants improve duringfirst 1–2 yrs of life, and with time chest radiograph becomesnormal. However, some of these children continue to have abnormalpulmonary function in childhood. Others with severe disease developcor pulmonale and succumb to their illness.

    Congenital Malformations of Lungs, Bronchi, Diaphragm, andRib Cage

    Lung Agenesis and Aplasia

  • Lung agenesisis complete absence of lung or lobe and its branches, whereas lung aplasiais complete absence of lung tissue except for presence of smalllobar bronchus.
  • Respiratory distress often occurs atbirth with decreased breath sounds on affected side.
  • Chest radiography shows opaque hemithoraxwith displacement of mediastinum and normal lung toward involvedside.
  • Bronchoscopy shows absence of mainbronchus in agenesis and presence of small bronchus in aplasia.

    • Pulmonary Hypoplasia

  • Pulmonaryhypoplasia refers to smaller than normal lungs. Can be isolatedmalformation or occur in association with space-occupying lesionsof thorax (congenital diaphragmatic hernia, cystic adenomatoid malformation,large pleural effusion), oligohydramnios (renal agenesis, polycystickidney disease), and thoracic and abdominal wall abnormalities (asphyxiatingthoracic dystrophy, large omphalocele).
  • Respiratory distress, chronic cough,and recurrent infection may occur with unilateral hypoplasia. Thoraxis asymmetric because of underdevelopment of 1 side.
  • Chest radiography shows small hemithoraxwith displacement of mediastinum toward affected side. When bilateralhypoplasia occurs as isolated malformation, respiratory distressoccurs at birth and chest radiography shows small but clear lungfields.

    • Pulmonary Sequestration

  • Mass ofnonfunctioning pulmonary tissue that receives its blood supply fromsystemic circulation.
  • May occur within or outside a lobe.Intralobar sequestration usually occurs in lower lobe of eitherlung, whereas extralobar sequestration usually occurs just aboveor below diaphragm on left side. Whereas intralobar sequestrationis usually isolated malformation, extralobar sequestration is commonly associatedwith other malformations (e.g., diaphragmatic hernia and pulmonaryhypoplasia).
  • Clinical findings include respiratorydistress, hemoptysis, and recurrent pneumonia.
  • Chest radiography shows mass lesion.
  • Chest CT or MRI is usually diagnostic.

    • Lobar Emphysema

  • Overdistensionof lobe of lung (usually upper lobe). Usually congenital but alsomay be acquired secondary to extrinsic or intrinsic airway obstruction.
  • Respiratory distress occurs with decreasedbreath sounds and hyperresonance on involved side.
  • Chest radiography shows large distendedlobe or lobes with displacement of mediastinum to opposite sideand compression of contralateral lung. Extension of pulmonary vesselsto periphery of hyperexpanded lung almost always distinguishes lobaremphysema from lung cyst or pneumothorax.

    • Cystic Lung Lesions

    Bronchogenic Cyst

  • Abnormalbudding or branching of tracheobronchial tree produces bronchogenic cysts,which are found incidentally or because they are infected. Locationcan be above or at carina or adjacent to 1 of main lobar bronchi.
  • They usually do not communicate withtracheobronchial tree and are usually fluid-filled, but if theycommunicate with airway or esophagus, they may contain air. Airwayor lung compression can cause respiratory distress.
  • CT or MRI is usually diagnostic.

    • Congenital Cystic Adenomatoid Malformation

  • Usuallyconsists of multiple cysts, frequently within 1 lobe of lung.
  • Size of lesion determines age of presentationand degree of respiratory distress.
  • Chest CT is usually diagnostic.

    • Intrapulmonary Cysts

  • Can be singleor multiple and involve ≥1 lobes of lung.
  • Respiratory distress may occur duringneonatal period. Older children may develop chronic cough or persistentinfiltrate.
  • Chest radiography usually shows ovalor round translucent area or areas within pulmonary parenchyma containingair or combination of fluid and air.
  • Chest CT usually confirms diagnosis.

    • Congenital Pulmonary Lymphangiectasia

  • Is the dilatationof lung lymphatics. Can occur as isolated defect, with congenital heartlesions that cause obstruction of pulmonary venous drainage, orwith generalized lymphangiectasia.
  • Respiratory distress usually beginsat birth.
  • Chest radiography shows reticular appearanceof lungs with nodular infiltrates and hyperinflation.
  • Localized form of this disorder, whichis less common, may only involve 1 or 2 lobes of lung and presentlater in life with mild respiratory distress or abnormal chest radiograph.
  • Lung biopsy confirms diagnosis.

    • Chylothorax

  • Presenceof chylous fluid in the thorax. Usually attributed to trauma fromdelivery or congenital abnormalities of thoracic duct system.
  • Lymph does not become chylous untilingestion of formula or breast milk. If large amount of chyle accumulates,respiratory distress occurs, with decreased breath sounds over affectedthorax.
  • Chest radiography shows large fluidcollection and shift of mediastinum.
  • Thoracentesis reveals chyle, whichappears milky and has high protein and fat content.

    • Bronchial Malformations

  • Bronchialstenosis usually involves main bronchus with narrowing just distalto carina. Narrowing of lobar bronchus usually results in recurrentinfection or atelectasis of involved lobe. Usual presenting featuresare respiratory distress and recurrent lung infection.
  • Chest radiography may show hyperinflationof involved lung and evidence of recurrent infection or atelectasis.
  • Chest CT or bronchoscopy is usuallydiagnostic.

    • Diaphragm Lesions

    Congenital Diaphragmatic Hernia

  • Congenitaldefect in diaphragm allows herniation of abdominal organs into hemithorax,producing varying degrees of lung hypoplasia. Nearly 90% areon left side.
  • Severe respiratory distress beginsat birth.
  • Diagnostic chest radiograph shows air-filledloops of bowel and occasionally liver in thoracic cavity.

    • Diaphragmatic Eventration

  • Abnormalhigh position of diaphragm or portion of diaphragm, which is dueto congenital defect of muscularization of diaphragm.
  • Most children are asymptomatic, butmild respiratory distress can occur.
  • Diagnosis is usually made by chestradiography or fluoroscopy.

    • Diaphragmatic Paralysis or Paresis

  • Occurrenceis usually due to phrenic nerve injury from thoracic surgery.
  • Respiratory distress and asymmetricchest movement can occur.
  • Fluoroscopy or U/S that showsparadoxic movement of affected hemidiaphragm during respirationis diagnostic.

    • Rib Cage Anomalies

  • Thoracicrib cage anomalies that reduce amount of intrathoracic volume maycause respiratory distress. These include asphyxiating thoracicdystrophy, thanatophoric dysplasia, achondrogenesis, and chondroectodermaldysplasia.
  • Structural anomalies of rib cage andthorax usually are obvious on physical exam.
  • Physical exam, chest radiograph, andskeletal survey are usually diagnostic of specific disorder.

    • Persistent Fetal Circulation

  • Is the persistenceof high pulmonary vascular resistance after birth with resultinghypoxemia and cyanosis. Affected infants are usually near term,and many have history of perinatal asphyxia.
  • Soon after birth, respiratory distressoccurs. Hyperoxia test with exposure to 100% oxygen for5–10 mins shows small, if any, increase in partial pressureof arterial oxygen (PaO2)(<20 mm Hg). Simultaneous preductal-postductal measurementsof PaO2 inright arm and umbilical artery reveal PaO2 inright arm that is >15 mm Hg higher than in umbilical artery,which is consistent of right-to-left shunt across patent ductusarteriosus
  • 2-D echocardiogram with Doppler methodsshould be performed to rule out any form of structural cardiac disease.

    • Cardiac Disorders

    Disorders that cause cardiac failure or cyanosismay produce respiratory distress. See Chap.7, Cardiac Failure, and Chap. 12, Cyanosis.

    Hematologic Disorders

    Anemia

    Severe acute or chronic anemia may causerespiratory distress. Pallor usually is evident. Low Hct or Hgbconfirms presence of anemia. Diagnostic approach to anemia is discussedin Chap. 45, Pallor (Anemia).

    Polycythemia

    Common occurrence in infants who have haddelayed clamping of umbilical cord or in infants of diabetic mothers.Venous Hct is greater than 65%, and mild respiratory distressmay occur.

    Metabolic Disorders

    Hypothermia

    May occur in preterm low-birth-weight infantswho are otherwise normal, or in ill newborns who have bacterialmeningitis, septicemia, or intracranial hemorrhage. Oxygen consumptionis significantly increased, and hypoxemia as well as metabolic acidosismay occur.

    Hypoglycemia

  • Irregularrespirations, apnea, seizures, and alteration of consciousness mayoccur in infants with hypoglycemia.
  • Low blood glucose is diagnostic (see Chap. 59, Seizures).

    • Metabolic Acidosis

    Increase in minute ventilation is compensatoryresponse to metabolic acidosis and lowered blood pH. Normal aniongap with reduced bicarbonate may occur with diarrhea or renal tubularacidosis. Increased anion gap with accumulation of fixed acid occurswith lactic acidosis (lactate), diabetic ketoacidosis (beta-hydroxybutyrate,acetoacetate), and organic acidemias (organic acids).

    Neurologic and Muscle Disorders

    Brain Disorders

    Respiratory distress and apnea may occurwith intracranial hemorrhage or cerebral edema as consequence ofperinatal asphyxia or birth trauma. Other causes of depressed respirationand apnea include cerebral malformations (Chiari, Dandy-Walker),bacterial meningitis, viral encephalitis, and brain tumors.

    Spinal Cord Injury

  • Injury tospinal cord in neonates may occur with vaginal breech delivery orshoulder dystocia.
  • Fractures of vertebrae with transectionof the cord may result in irregular respirations and apnea, as wellas absence of spontaneous movements.
  • Neurologic findings depend on locationand severity of lesion.

    • Neuromuscular Disorders

    Disorders affecting neuromuscular system(spinal muscular atrophy, myasthenia gravis, congenital myopathies)may produce slow and shallow respirations with hypoventilation andrespiratory failure (see Chap.33, Hypotonia and Weakness).

    Drugs

    Drugs (e.g., magnesium sulfate, morphine,and meperidine) that are given to some mothers during labor cancause neonatal respiratory depression. Neonatal drug withdrawalsyndrome may produce tachypnea as 1 of its manifestations. >>

    » READ BOOK EXCERPT ONLINE »

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

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

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

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

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

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

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

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

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

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

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Respirations, stertorous: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If you detect stertorous respirations while the patient is sleeping, observe his breathing pattern for 3 to 4 minutes. Do noisy respirations cease when he turns on his side and recur when he assumes a supine position? Watch carefully for periods of apnea and note their length.

    If the patient isn't in severe respiratory distress, begin with the history. Question the patient about his snoring habits. Is his partner frequently awakened by his snoring? Does the snoring improve if the patient sleeps with the window open? Does he talk in his sleep or sleepwalk? Ask about signs of sleep deprivation, such as personality changes, headaches, daytime somnolence, or decreased mental acuity.

    Perform the physical examination by first assessing the patient's level of consciousness and his orientation to time, place, and person. Observe spontaneous movements, and test muscle strength and deep tendon reflexes. Next, inspect the chest for deformities or abnormal movements such as intercostal retractions. Inspect the extremities for cyanosis and digital clubbing.

    Now, palpate for expansion and diaphragmatic tactile fremitus, and percuss for hyperresonance or dullness. Auscultate for diminished, absent, or adventitious breath sounds and for abnormal or distant heart sounds. Do you note peripheral edema? Finally, examine the abdomen for distention, tenderness, or masses.

    » 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

    DECREASED RESPIRATIONS, APNEA, AND CHEYNE–STOKES BREATHING: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    Obviously, the association of other signs and symptoms will determine the workup in most cases. The most important things to do are to order a blood urea nitrogen (BUN) level, electrolytes, fasting blood sugar (FBS), arterial blood gases, and a drug screen and to check for increased intracranial pressure by examining the eye grounds. If the history or physical findings suggest increased intracranial pressure, and other metabolic studies (e.g., BUN) are normal, a mannitol or urea drip is begun while awaiting the results of other investigations such as computed tomography (CT) scan, electroencephalogram (EEG), and echoencephalogram. A neurosurgeon should be consulted immediately.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    SLEEP APNEA: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    A thorough examination of the upper respiratory system is essential: It may be wise to get an otolaryngologist to do this. A CBC to rule out anemia and arterial blood gases to rule out anoxia and hypercarbia may be helpful. Spirometry, chest x-ray, echocardiogram (ECG), and arm-to-tongue circulation time will help to rule out pulmonary and cardiovascular disorders. Ultimately, overnight polysomnography will be required to secure the diagnosis. A pulmonologist or otolaryngologist ought to be consulted before ordering this expensive test.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007


     » Next page: Signs of Obstructive sleep apnea

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