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Diagnosis of Respiratory conditions

Respiratory conditions Diagnosis: Book Excerpts

Diagnosis of Respiratory conditions: medical news summaries:

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

Diagnostic Tests for Respiratory conditions: Online Medical Books

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


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

  1. Are there exudates? This is a key question when evaluating a sore throat. Most cases of sore throat with exudates will be found to have streptococcal pharyngitis. Without exudates, one could still have a streptococcal sore throat, but it is less likely.
  2. Is there a temperature elevation? A significant elevation of the temperature, with or without exudates, is also characteristic of streptococcal pharyngitis.
  3. Are there enlarged lymph nodes? If the lymph nodes are enlarged in the peritonsillar area, this is often a sign of streptococcal sore throat, but it certainly is not diagnostic. Interestingly enough, 90% of patients with infectious mononucleosis have posterior cervical adenopathy.
  4. Are there systemic symptoms and signs? Patients who present with exudative tonsillitis and splenomegaly certainly should be considered to have infectious mononucleosis until proven otherwise. Also, an exudative tonsillitis along with a fever and heart murmur should make one consider rheumatic fever. Systemic symptoms such as dry cough, runny nose, and generalized malaise or fatigue should make one think of a viral URI.

DIAGNOSTIC WORKUP

In a sore throat with typical exudates very suggestive of streptococcal pharyngitis, a throat culture may be all one needs before starting definitive antibiotic therapy. In the more difficult cases, screening for streptococcal antigens (streptozyme test and ASO titer) might be indicated. An ASO titer is particularly important when one suspects rheumatic fever. If the patient's streptococcal sore throat persists, a Monospot test and a culture for gonorrhea should be done. Although there are hardly any false-negative Monospot tests, there are 10% false positives, and that should be kept in mind. A blood smear for atypical lymphocytes may be helpful, as well as a heterophile antibody titer in those cases.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Sore Throat: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Viral pharyngitis/laryngitis
    –Most common cause of sore throat
    –Associated with cough, low-grade fever, nasal congestion, and sneezing
    –Influenza occasionally causes sore throat with high fever, cough, severe myalgias
    –Rhino-, adeno-, coxsackie-, and herpesvirus
    –Acute HIV infection
  • Mononucleosis
    –Associated with fever, headache, and excessive fatigue
    –Most common in teen and college ages
    –May have associated lymphadenopathy, splenomegaly, hepatitis, or encephalitis
  • Streptococcal pharyngitis
    –May be associated with scarlatiniform rash, fever >101°F (>38.3°C), exudative pharyngitis, tender cervical lymphadenopathy, and absence of cough
    –More common in winter months, ages 5–10, and with history of group A Streptococcus exposure
  • Allergic pharyngitis
  • Gonococcal pharyngitis
  • Fungal pharyngitis (e.g., Candida)
    • Foreign body in throat
      –Most often occurs in smaller children
      –Associated with sudden onset of audible wheezing, stridor, drooling
    • GERD
    • Sore throat secondary to postnasal drip
    • Irritation secondary to inhalants (e.g., cigarette smoke), chemicals (e.g., alcohol), hot foods
    • Voice abuse (e.g., excessive screaming)
    • Deep neck space infections (e.g., retropharyngeal abscess, peritonsillar abscess, Ludwig's angina)
      • Epiglottitis/bacterial tracheitis
        –Occurs in children ages 2–7 and increasingly in adults
      • Diphtheria
      • Trauma
      • Lymphadenitis (cervical)
      • Cancer (e.g., tonsillar, tongue, laryngeal, esophageal)
      • Caustic ingestions
      • Thyroiditis
      • Angina/acute coronary syndrome

      Workup and Diagnosis

      • History and physical exam often make the diagnosis
        –Consider exposure history, age, associated symptoms, past medical history (e.g. immunocompromise), use of inhaled steroids (e.g. with Candida pharyngitis), allergy history)
        –Focus on head and neck, lung, and abdominal examinations
      • Streptococcal pharyngitis is often a clinical diagnosis
        –Presence of three out of four of the following criteria suggests the diagnosis: Exudative pharyngitis (not just a red throat); tender anterior lymphadenopathy; presence or history of fever; and absence of a cough; whereas if none or one of the criteria exists, group A β-hemolytic streptococcus is unlikely
        –Streptococcal culture is the gold standard (inexpensive; identifies group A and others; 1–2 days for results)
        –Rapid strep testing is more expensive and identifies only group A strep, but gives immediate results; very specific (95%) but less sensitive (60–70%), so consider culture if negative
      • Monospot or CBC showing atypical lymphocytes is diagnostic for mononucleosis
      • X-ray for foreign body; laryngoscopy if unable to verify
      • Lateral neck X-ray may diagnose epiglottitis and retropharyngeal abscess
      • Gonococcal and diphtheria cultures if necessary
      • Barium swallow, upper GI series, or EGD for GERD

» 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

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

  • Infectious
    –Viral
         –Adenovirus
         –Rhinovirus
         –Parainfluenza
         –Influenza
         –Coronavirus
         –Others: EBV RSV, CMV, HSV
    –Bacterial
         –Streptococcus
         –Haemophilus
         –Moraxella
         –Staphylococcus
         –Corynebacterium
    –Fungal
         –Candida
    • Inflammatory
      –Allergy
      –Gastroesophageal reflux disease
      –Sinusitis resulting in postnasal drainage
      • Tumors
        –Leukemia
        –Rhabdosarcomas
        –Squamous cell carcinoma secondary to oral ulcerations
      • Trauma
        –Foreign body ingestion
        –Caustic ingestion
        –Soft tissue injury from accidental and nonaccidental trauma
    • Systemic/rheumatologic disorders
      –Kawasaki disease: Mucocutaneous lymph node syndrome may have sore throat at presentation (other oral findings include strawberry tongue, fissured lips, mucosal erythema, fever, and lymphadenopathy)
      –Behçet syndrome
      –Reiter syndrome
      • Others
        –Cigarette smoke
        –Environmental pollutants
        –Pharyngeal drying: Mouth and pharynx can be dry from mouth breathing, more common in the winter months

    Workup and Diagnosis

  • History
    –Duration, onset, severity, frequency, odynophagia, dysphagia, daycare, sick contacts, fever, malaise, headache
    –Foreign body and caustic ingestion
    –Days of school or work missed
    –Immunization history
    –Medical history: Systemic disease, connective tissue disorder
      • Physical exam
        –Nasal exam: Evidence of rhinosinusitis
        –Mouth: Ulcerations, masses, tonsil size, erythema, exudates
        –Neck: Lymphadenopathy
        –Skin: Rash
        –Chest: Wheezes, asymmetry
    • Studies
      –For pharyngitis: A major goal is to differentiate streptococcal pharyngitis from viral etiologies
      –Throat culture: 92% sensitive; 100% specific; requires 24–48 hours
      –Rapid strep test: 72–85% sensitive; 88–100% specific
      –CBC with differential for suspected mononucleosis
      –Chest X-ray (inspiratory and expiratory) for suspected foreign body
      –CT neck: When complication of infection is suspected such as abscess

    » READ BOOK EXCERPT ONLINE »

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

    SORE THROAT: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    In diagnosing the cause of sore throat, it has been traditional to do a throat culture and possibly a CBC and differential and start the patient on penicillin until the culture comes back. Now Abbott Laboratories (Abbott Park, IL, U.S.A.) has developed a rapid Streptococcus agglutination test on a throat swab. In resistant cases, repeated cultures (especially for diphtheria, gonorrhea, and Listeria organisms) and a monospot test will be useful. Because the titer for infectious mononucleosis may not be high initially, the differential test (Paul–Bunnell) or a repeated monospot test 1 to 3 weeks later may be necessary. Remember that subacute thyroiditis may present as a sore throat.

    » READ BOOK EXCERPT ONLINE »

    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

    Acute respiratory failure in COPD: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    Progressive deterioration in ABG levels and pH, when compared with the patient’s “normal” values, strongly suggests ARF in COPD. (In patients with essentially normal lung tissue, pH below 7.35 usually indicates ARF, but patients with COPD display an even greater deviation from this normal value, as they do with PaCO2 and PaO2.)

    Other supporting findings include:

    ❑ Bicarbonate — Increased levels indicate metabolic alkalosis or reflect metabolic compensation for chronic respiratory acidosis.

    ❑ Hematocrit (HCT) and Hb — Abnormally low levels may be due to blood loss, indicating decreased oxygen-carrying capacity. Elevated levels may occur with chronic hypoxemia.

    ❑ Serum electrolytes — Hypokalemia and hypochloremia may result from diuretic and corticosteroid therapies used to treat ARF.

    ❑ White blood cell count — Count is elevated if ARF is due to bacterial infection; Gram stain and sputum culture can identify pathogens.

    ❑ Chest X-ray — findings identify pulmonary pathologic conditions, such as emphysema, atelectasis, lesions, pneumothorax, infiltrates, or effusions.

    ❑ Electrocardiogram — Arrhythmias commonly suggest cor pulmonale and myocardial hypoxia.

    » READ BOOK EXCERPT ONLINE »

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

    Infant respiratory distress syndrome: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    CONFIRMING DIAGNOSIS Although signs of respiratory distress in a premature neonate during the first few hours of life strongly suggest IRDS, a chest X-ray and arterial blood gas (ABG) analysis are necessary to confirm the diagnosis.

    ❑ Chest X-ray may be normal for the first 6 to 12 hours (in 50% of neonates with IRDS), but 24 hours after birth it will show the characteristic ground-glass appearance and air bronchograms.

    ❑ ABG analysis shows decreased partial pressure of arterial oxygen; normal, decreased, or increased partial pressure of arterial carbon dioxide; and decreased pH (from respiratory or metabolic acidosis or both).

    ❑ Chest auscultation reveals normal or diminished air entry and crackles (rare in early stages).

    When a cesarean delivery is necessary before 36 weeks’ gestation, amniocentesis enables the determination of the lecithin/sphingomyelin (L/S) ratio and the presence of phosphatidylglycerol. An L/S ratio of more than 2:1 and the presence of phosphatidylglycerol decrease the likelihood of IRDS.

    » READ BOOK EXCERPT ONLINE »

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

    Respiratory syncytial virus infection: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    Diagnosis is usually based on clinical findings and epidemiologic information.

    ❑Many facilities can perform rapid tests for the virus using fluid obtained from the nose.

    ❑Cultures of nasal and pharyngeal secretions may show RSV; however, the virus is labile, so cultures aren't always reliable.

    ❑Chest X-rays help detect pneumonia.

    » READ BOOK EXCERPT ONLINE »

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

    Introduction: Respiratory Disorders: Diagnostic tests
    (Professional Guide to Diseases (Eighth Edition))

    Diagnostic tests evaluate physiologic characteristics and pathologic states within the respiratory tract.

    Noninvasive tests include:

    ❑  Chest X-ray shows such conditions as atelectasis, pleural effusion, infiltrates, pneumothorax, lesions, mediastinal shifts, pulmonary edema, and chronic obstructive pulmonary disease (COPD).

    ❑ Computed tomography scan provides a three-dimensional picture that’s 100 times more sensitive than a chest X-ray.

    ❑ Magnetic resonance imaging identifies obstructed arteries and tissue perfusion, but movement of the heart and lungs reduces the image’s clarity.

    ❑ Sputum specimen analysis assesses sputum quantity, color, viscosity, and odor; microbiological stains and culture of sputum can identify infectious organisms; and cytologic preparations can detect respiratory tract neoplasms. Sensitivity tests determine antibiotic sensitivity and resistance.

    ❑ Pulmonary function tests measure lung volume, flow rates, and compliance. Normal values, individualized by body stature and age, are reported in percentage of the normal predicted value. Static measurements are volume measurements that include tidal volume, volume of air contained in a normal breath; functional residual capacity, volume of air remaining in the lungs after normal expiration; vital capacity, volume of air that can be exhaled after maximal inspiration; residual volume, air remaining in the lungs after maximal expiration; and total lung capacity (TLC), volume of air in the lungs after maximal inspiration. Dynamic measurements characterize the movement of air into and out of the lungs and show changes in lung mechanics. They include measurement of forced expiratory volume in 1 second, maximum volume of air that can be expired in 1 second from total lung capacity; maximal voluntary ventilation, volume of air that can be expired in 1 minute with the patient’s maximum voluntary effort; and forced vital capacity, maximal volume of air that the patient can exhale from TLC. (Peak flow rate, which can be obtained at the bedside, is also a dynamic measurement of pulmonary function.)

    ❑ Exercise stress test evaluates the ability to transport O2 and remove CO2 with increasing metabolic demands.

    ❑ Polysomnography can diagnose sleep disorders.

    ❑ Lung scan (ventilation-perfusion or scintiphotography scan) demonstrates ventilation and perfusion patterns. It’s used primarily to evaluate pulmonary embolus.

    ❑ Arterial blood gas (ABG) analysis assesses gas exchange. Decreased PaO2 may indicate hypoventilation, ventilation-perfusion mismatch, or shunting of blood away from gas exchange sites. Increased partial pressure of arterial carbon dioxide (PaCO2) reflects marked ventilation-perfusion mismatch or hypoventilation; decreased PaCO2 reflects increased alveolar ventilation. Changes in pH may reflect metabolic or respiratory dysfunction.

    ❑ Pulse oximetry is a noninvasive assessment of arterial oxygen saturation.

    ❑ Capnography may be used either transcutaneously or in ventilator circuit to determine PaCO2 trends.

    Invasive tests include:

    ❑ Bronchoscopy permits direct visualization of the trachea and mainstem, lobar, segmental, and subsegmental bronchi. It may be used to localize the site of lung hemorrhage, visualize masses in these airways, and collect respiratory tract secretions. Brush biopsy may be used to obtain specimens from the lungs for microbiological stains, culture, and cytology. Lesion biopsies may be performed by using small forceps under direct visualization (when present in the proximal airways) or with the aid of fluoroscopy (when present distal to regions of direct visualization). Bronchoscopy can also be used to clear secretions and remove foreign bodies.

    ❑ Thoracentesis permits removal of pleural fluid for analysis.

    ❑ Pleural biopsy obtains pleural tissue for histologic examination and culture.

    ❑ Pulmonary artery angiography, the injection of dye into the pulmonary artery, can locate pulmonary embolism. This is considered the gold standard for diagnosing pulmonary emboli.

    ❑ Positron emission tomography scan uses a short-life radionuclide. Increased uptake of the substance is seen in malignant cells.

    » READ BOOK EXCERPT ONLINE »

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

    Severe acute respiratory syndrome: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    Diagnosis of severe respiratory illness is made when the patient has a fever greater than 100.4° F (38° C) or upon clinical findings of lower respiratory illness and a chest X-ray demonstrating pneumonia or acute respiratory distress syndrome.

    Laboratory validation for the virus includes cell culture of SARS-CoV, detection of SARS-CoV ribonucleic acid by the reverse transcription polymerase chain reaction (PCR) test, or detection of serum antibodies to SARS-CoV. Detectable levels of antibodies may not be present until 21 days after the onset of illness, but some individuals develop antibodies within 14 days. A negative PCR, antibody test, or cell culture doesn’t rule out the diagnosis.

    » READ BOOK EXCERPT ONLINE »

    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.

    » READ BOOK EXCERPT ONLINE »

    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?

    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 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.)

    » READ BOOK EXCERPT ONLINE »

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

    Sore Throat: Differential Overview
    (Field Guide to Bedside Diagnosis)

    ❑ Rhinovirus

    ❑ Group A streptococci

    ❑ Ebstein-Barr virus

    ❑ Adenovirus

    ❑ Influenza

    ❑ Candida/thrush

    ❑ Herpes simplex virus

    ❑ Peritonsillar abscess

    ❑ Mycoplasma pneumoniae

    ❑ Coxsackievirus

    ❑ Primary HIV

    ❑ Neisseria gonorrhea

    ❑ Epiglottitis

    ❑ Corynebacterium diphtheriae

    ❑ Leukemia

    Diagnostic Approach

    The most important consideration is whether the patient has a group A strep infection because prompt treatment prevents rheumatic fever. The findings of fever, tender anterior cervical adenopathy, and tonsillar exudate can be combined to make the diagnosis more or less likely. Rapid antigen tests have a sensitivity of 80% to 90% and specificity of 95% to 100%, so give a reasonably accurate diagnosis. Because of limitations in sensitivity however, patients with a high suspicion on clinical grounds should have a backup culture taken.

     Prior probability in an adult population with sore throat is 5% to 10%, and in a pediatric population 20% to 25%. A prominent sore throat out of proportion to the degree of pharyngeal inflammation should raise the possibility of acute epiglottitis and acutely impending airway compromise. Persistent unilateral tonsillar enlargement in a young adult without sore throat should raise the suspicion of lymphoma.

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Acute respiratory failure in COPD: Diagnosis
    (Handbook of Diseases)

    Progressive deterioration in ABG levels and pH, when compared with the patient’s baseline values, strongly suggests ARF in COPD patients. (In patients with essentially normal lung tissue, a pH less than 7.35 usually indicates ARF, but COPD patients display an even greater deviation from this normal value, as they do with blood Paco2 and Pao2.) The following findings further support the diagnosis:

  • Bicarbonate levels are increased, indicating metabolic alkalosis or metabolic compensation for chronic respiratory acidosis.
  • Hb levels and hematocrit are abnormally low, which may be due to blood loss, indicating decreased oxygen-carrying capacity.
  • Serum electrolyte levels may indicate hypokalemia, which may result from compensatory hyperventilation — an attempt to correct alkalosis; hypochloremia is common with metabolic alkalosis.
  • White blood cell count is elevated if ARF is due to bacterial infection; in certain cases of profound septicemia, the leukocyte count may be decreased. Gram stain and sputum culture can identify pathogens.
  • Chest X-rays reveal pulmonary pathology, such as emphysema, atelectasis, lesions, pneumothorax, infiltrates, or effusions.
  • Electrocardiogram reveals arrhythmias, which commonly suggest cor pulmonale and myocardial hypoxia. Large P waves (“p pulmonale”) may indicate a history of right-sided heart failure.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

    Respiratory acidosis: Diagnosis
    (Handbook of Diseases)

    ❑ The following arterial blood gas (ABG) levels confirm respiratory acidosis: a Paco2 exceeding the normal level of 45 mm Hg, pH usually below the normal range of 7.35 to 7.45, and a bicarbonate level that’s normal in the acute stage but elevated in the chronic stage.

    ❑ Chest X-ray, computed tomography scan, or pulmonary function test may help diagnose lung disease.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

    Respiratory alkalosis: Diagnosis
    (Handbook of Diseases)

    Arterial blood gas (ABG) analysis confirms respiratory alkalosis and rules out respiratory compensation for metabolic acidosis. Findings include a Paco2 below 35 mm Hg, a pH that’s elevated in proportion to the fall in Paco2 in the acute stage but that drops toward normal in the chronic stage, and a bicarbonate level that’s normal in the acute stage but below normal in the chronic stage.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

    Respiratory distress syndrome: Diagnosis
    (Handbook of Diseases)

    Although signs of respiratory distress in a premature neonate during the first few hours of life strongly suggest respiratory distress syndrome, the following tests are necessary to confirm the diagnosis:

    ❑ Chest X-ray may be normal for the first 6 to 12 hours (in 50% of neonates with respiratory distress syndrome) but later shows a fine reticulonodular pattern.

    ❑ Arterial blood gas (ABG) analysis shows decreased partial pressure of arterial oxygen (Pao2); normal, decreased, or increased partial pressure of arterial carbon dioxide; and decreased pH (from respiratory or metabolic acidosis or both).

    ❑ Pulmonary function studies may be necessary.

    When a cesarean section is necessary before the 36th week of gestation, amniocentesis allows determination of the lecithin-sphingomyelin ratio, which helps to assess prenatal lung development and the risk of respiratory distress syndrome.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

    Respiratory syncytial virus infection: Diagnosis
    (Handbook of Diseases)

    The following clinical findings and epidemiologic information aid in the diagnosis:

    ❑ Cultures of nasal and pharyngeal secretions may show RSV.

    ❑ Serum antibody titers may be elevated, but before age 6 months, maternal antibodies may impair test results.

    ❑ Serology for RSV is positive.

    ❑ Chest X-rays help detect pneumonia or bronchiolitis.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Diseases, 2003

    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.

    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.

    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).

    » READ BOOK EXCERPT ONLINE »

    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.

    » READ BOOK EXCERPT ONLINE »

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

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

    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.

    » READ BOOK EXCERPT ONLINE »

    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.

    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?

    » READ BOOK EXCERPT ONLINE »

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

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

    Infection

    Pharyngitis/Tonsillitis

    Viral

  • Severalviruses may cause pharyngitis/tonsillitis, including parainfluenzaviruses, influenza viruses, rhinoviruses, coronaviruses, and respiratorysyncytial virus. Coryza and cough predominate, whereas fever isvariable finding. Nasal wash cultures are diagnostic but usuallyunnecessary for management.
  • Enteroviruses also may cause sore throatand fever, especially in summer months, but tonsillar exudate isunusual.

  • Herpanginais characterized by fever and painful vesicular lesions on pharynxand tonsils.
  • Coxsackie A16 is major cause of hand-foot-mouthdisease, which is characterized by vesicular lesions in the mouthand on hands and feet.
  • Herpes simplex virus produces acutegingivostomatitis with fever and painful vesicles usually confinedto anterior mouth. However, lesions may extend to anterior tonsillarpillars.
  • Epstein-Barr virus is common causeof sore throat in adolescents. Other characteristic findings ofinfectious mononucleosis include fever, malaise, fatigue, cervicalor generalized lymphadenopathy, and hepatosplenomegaly. >10% atypicallymphocytes are usually seen on blood smear. Positive mono spottest, which identifies immunoglobulin M (IgM) heterophile antibody,is diagnostic. When this test is negative, IgG and IgM antibodyagainst viral capsid antigen (VCA) should be determined. Presenceof IgM-VCA is associated with recent or current illness and confirmsdiagnosis, whereas IgG-VCA is present continuously after acute infection.
  • Adenovirus may cause pharyngoconjunctivalfever. Follicular hyperplasia of tonsils and exudate may be seen.

    • Bacterial

    Group A Streptococcus

  • Most commonbacterial cause of pharyngitis/tonsillitis is group A Streptococcus.
  • Classic clinical presentation is school-agedchild with acute onset of fever and sore throat. Headache, abdominalpain, and vomiting also may occur. Rhinorrhea, cough, conjunctivitis,hoarseness, and diarrhea are unusual. Tonsils are enlarged and inflamed,with patches of exudate. Petechiae may sometimes be seen on palate.
  • Anterior cervical lymph nodes may beenlarged on 1 or both sides and are often tender.
  • Usual clinical dilemma is to distinguishbetween viral infection or group A streptococcal infection. Difficultto distinguish them clinically, except when typical erythematoussandpaper-like rash of scarlet fever occurs, which signifies infectionwith group A Streptococcus.
  • Rapid techniques are now availablefor detection of streptococcal antigen. Either rapid antigen testor throat culture should be performed if streptococcal pharyngitisis suspected. If antigen assay is negative, throat culture shouldbe obtained.

    • Other Bacteria

  • Pharyngitiscaused by group C or G Streptococcus is indistinguishable from that causedby group A Streptococcus.
  • A. hemolyticum produces illness similarto group A Streptococcus. Scarlet fever–like rash occursmost often in adolescents, but strawberry tongue and palatal petechiaehave not been described.
  • N. gonorrhoeae pharyngitis can occurin sexually active adolescents as consequence of oral-genital contact.Ulceration of pharynx and tonsils along with exudate may be seen.Its presence in younger children suggests sexual abuse.
  • M. pneumoniae is uncommon cause ofpharyngitis, whereas C. diphtheriae is rare cause of pharyngitis.With the latter infection, acute onset of fever and sore throatis followed in 1–2 days by grayish membrane over pharynxand tonsils, which may extend into larynx and trachea.
  • Positive throat culture confirms diagnosisof these pathogens.

    • Peritonsillar, Retropharyngeal, and Lateral Pharyngeal Abscesses

  • Generallydue to spread of infection from local sites.
  • Most common pathogens are aerobes (groupA Streptococcus, S. aureus, H. influenzae) and anaerobes (Peptostreptococcus,Fusobacterium, Prevotella, Porphyromonas species), although manyinfections are polymicrobial.
  • Peritonsillar abscess generally occursas complication of acute bacterial tonsillitis in older childrenand adolescents. Sore throat, fever, pain on swallowing, drooling,and trismus characterize this infection. Ipsilateral otalgia alsomay occur. Swollen inflamed tonsil has fluctuant quality and oftenpushes uvula across midline of oral cavity. Diagnosis is clinical,although specific pathogen can be cultured from infected tonsilor abscess drainage.
  • Although retropharyngeal abscess/cellulitisis uncommon cause of sore throat, it usually occurs in children <4yrs. Most children appear toxic and are in respiratory distress,but some complain of sore throat and painful swallowing early incourse. Often direct visualization is impossible and lateral neck radiographyshows bulge of posterior pharyngeal wall. If diagnosis is uncertain,CT can be performed.
  • Lateral pharyngeal abscess usuallypresents with fever and trismus as well as swelling and tendernessbelow mandible. CT is helpful in determining extent of abscess.

    • Irritants

  • Upon awakeningin morning, otherwise well child may have scratchy sore throat, whichusually improves over several hours. This sensation is usually dueto dryness of pharynx and frequently occurs with rhinitis, especiallyduring winter months when humidity is low and mouth breathing islikely because of nasal congestion.
  • Exposure to dust or smoke also maycause irritation of pharynx.
  • Postnasal drip secondary to allergicrhinitis or sinusitis also may cause pharyngeal irritation and mildsore throat.

    • Trauma

  • Excessiveuse of voice due to prolonged shouting or singing may cause sore throat.
  • Burn secondary to exposure of hot gasesor liquid also may cause pharyngeal pain.

    • Foreign Body

  • Foreignbody lodged in pharynx causes acute onset of choking, dysphagia,and sometimes upper airway obstruction.
  • Commonly, fish bone or chicken bonecan be seen in pharynx. Otherwise, neck radiography may be diagnostic.
  • Only symptom of retained foreign bodyin upper airway may be persistent stridor. In this circumstance,laryngoscopy is usually diagnostic.

    • Caustic Substances

  • Ingestionof caustic substances may cause inflammation of pharynx.
  • History and physical exam are diagnostic.
  • For suspected esophageal injury, esophagoscopyshould be performed.

    • Psychogenic

    Sometimes there does not seem to be explanationfor sore throat after history, physical exam, negative throat culture,and normal neck radiographs. In this case, psychosocial historyis most valuable clinical tool.

    Diagnostic Approach

  • Historyand physical exam provide important clues for proper diagnosis ofsore throat.
  • Most common clinical dilemma in childwith pharyngitis is whether pathogen is virus or group A Streptococcus.Tests to detect streptococcal antigen may be diagnostic, but ifresults of such tests are negative, throat culture should be performed.
  • Because many cases of pharyngitis aredue to viruses, antibiotic use should be guided by antigen detectiontests or culture. Presence of conjunctivitis, cough, rhinitis, andhoarseness suggests viral etiology. Infectious mononucleosis isalso a consideration, especially in older children and adolescents.
  • Neck radiography, flexible laryngoscopy,and CT are useful with suspected foreign body or retropharyngeal/lateralpharyngeal abscess.
    • >

    » 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

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

    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: Nursing: Interpreting Signs and Symptoms, 2007

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

    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.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    SORE THROAT: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    In diagnosing the cause of sore throat, it has been traditional to do a throat culture and possibly a CBC and differential and to start the patient on penicillin until the culture comes back. Now Abbott Laboratories (Abbott Park, IL) has developed a rapid Streptococcus agglutination test on a throat swab. In resistant cases, repeated cultures (especially for diphtheria, gonorrhea, and Listeria organisms) and a monospot test will be useful. Because the titer for infectious mononucleosis may not be high initially, the differential test (Paul–Bunnell) or a repeated monospot test 1 to 3 weeks later may be necessary. Remember that subacute thyroiditis may present as a sore throat.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007


     » Next page: Signs of Respiratory conditions

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