Cyanosis

Cyanosis is due to arterial hypoxemia and may not easily be seen during physical exam. Examine soft tissue with high blood flow, such as the gums or tongue, for cyanosis. Cyanosis elsewhere (e.g., fingertips or lips) may be due to reduced blood flow. If possible, use pulse oximetry to measure oxyhemoglobin saturation.

Differential Diagnosis

• Recall the pathway for oxygen, from the air to the tissue; etiology is often multifactorial
• Reduced O2 availability: High altitude (>6,000 feet), e.g., air travel, ski resort, mountain travel
• Reduced O2 transport to alveoli: Respiratory failure/arrest, air flow obstruction (usually compensate for large obstruction unless complete); restrictive chest wall disease (e.g., kyphosis, weakness, or obesity)
• Abnormal gas exchange or V/Q mismatch: Most common physiologic pulmonary cause of hypoxia

• Abnormal ventilation
  –Alveolar diseases: Pneumonia, pulmonary edema, diffuse alveolar damage, alveolar proteinosis
  –Conducting airway diseases: Asthma, bronchiolitis
  –Combined pathology: ARDS, bronchopulmonary dysplasia, HMD

• Abnormal perfusion
  –Pulmonary hypertension, pulmonary embolus, abnormal anatomy (e.g., pulmonary sequestration)
• Shunt
  –Intrapulmonary shunt (or “total” V/Q mismatch), e.g., AV malformations
  –Extrapulmonary shunt, e.g., TOF, TAPVR, TGA
• Abnormal transport to tissue
  –Abnormal hemoglobin: β-thalassemia, sickle cell disease, CO poisoning
  –Decreased hemoglobin: Anemia, blood loss
  –Decreased blood flow: Dysrhythmia, bradycardia, cardiac arrest, hypotension
  • Abnormal O2 delivery at tissue
    –Abnormal hemoglobin affinity for O2
    –End-organ failure (e.g., mitochondrial disease, cyanide poisoning)
  • Chronic cyanosis starting at birth suggests either congenital lesion or neonatal injury (e.g., meconium aspiration, group B streptococcus sepsis, HMD)

  Workup and Diagnosis

  • History
    –Birth history
    –Past medical history including respiratory, cardiac and hematologic disorders, acute or chronic onset, and accompanying features
  • Physical exam
    –Patency of the airway, adequate air movement, distribution of air flow, symmetry of breath sounds, crackles, dullness to percussion, chest wall movement
    –Auscultate heart, feel all pulses, obtain BP, seek signs of chronicity (e.g., clubbing of nail beds)
    –Examine well-perfused soft tissue (e.g., gums) to assess for cyanosis, not fingertips
  • Oximetry is useful but may not help during shock or hemoglobinopathies; may not be accurate with dark skin
  • If O2 does not help, consider shunt (cardiac disease is more common than intrapulmonary shunt)
  • Arterial blood gases
    –Disparate PaO2 and SaO2 suggests possibility of abnormal hemoglobin affinity for O2
  • Chest film and CT for parenchymal disease
  • MRI/MRAfor vascular anatomy
  • V/Q scan
  • ECG, Echo, or catheterization for cardiac disease
  • PFT for obstructive or restrictive disease
  • Sleep studies, EEG for CNS causes
  • Muscle biopsy for tissue or mitochondrial diseases

  Treatment

  • Immediately treat cyanosis with O2, monitor the patient, then determine cause
  • Treat underlying causes
    –High altitude: Descend
    –Central or obstructive causes of respiratory failure: Treat with mechanical ventilation and search for cause
    –V/Q mismatch: Treat cause(s)
    –Shunt: Treatment may be surgical
    –Hemoglobinopathies: May need transfusion, exchange transfusion, or electrophoresis
    –Decreased hemoglobin: May need whole blood or packed red blood cells
    –Decreased delivery: May need blood pressure support, cardiac stimulants, manual chest compression, or cardiac massage
    –Abnormal tissue delivery: Target specific disease

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Blue skin

• Back to symptom: Blue skin: Introduction (review 385 causes)
• Next Book Extract About Blue skin: CYANOSIS (Differential Diagnosis in Primary Care)
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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: CYANOSIS (Differential Diagnosis in Primary Care)

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