Diagnosis of Wheezing
Wheezing Diagnosis: Book Excerpts
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Diagnostic Tests for Wheezing: Online Medical Books
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for more information about diagnostis of Wheezing.
STRIDOR:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is the patient an adult or a child? If the patient is a child, acute epiglottitis, acute laryngotracheitis, foreign body, congenital laryngeal stridor, laryngismus stridulus, and a retropharyngeal abscess should be considered. Diphtheria is rarely found nowadays. If the patient is an adult, myasthenia gravis, bulbar and pseudobulbar palsy, recurrent laryngeal palsy, pharyngitis, laryngotracheitis, carcinoma of the larynx or trachea, angioneurotic edema, foreign bodies, thyroid disorders, and disorders of the mediastinum should be considered.
- Is it acute or gradual onset? The presence of stridor of acute onset would suggest acute epiglottitis, acute pharyngitis, laryngotracheitis, angioneurotic edema, retropharyngeal abscess, laryngismus stridulus, and foreign body.
- Is there fever? The presence of fever would suggest acute laryngotracheitis, diphtheria, subacute thyroiditis, retropharyngeal abscess, and mediastinitis.
- Are there abnormalities on the ear, nose, and throat examination? On ear, nose, and throat examination, the clinician may find pharyngitis, acute epiglottitis, a foreign body, tenderness of the thyroid suggesting thyroiditis, and thyroid masses.
- Are there neurologic abnormalities on examination? Neurologic abnormalities may be found in myasthenia gravis, bulbar and pseudobulbar palsy, bilateral recurrent laryngeal nerve palsy, and comatose states.
DIAGNOSTIC WORKUP
Routine tests may include a CBC; sedimentation rate; smear and culture of material from the nose, throat, and sputum; x-ray of the chest and sinuses; and, in adults, an EKG. In adults also it might be wise to order a chemistry panel, thyroid profile, and VDRL test, depending on the clinical picture. Direct laryngoscopy can now be done in the office with the fiberoptic laryngoscope. In addition, fiberoptic bronchoscopy may be valuable. A Tensilon test may need to be done. An ear, nose, and throat specialist should be consulted before ordering expensive diagnostic tests. If there are neurologic signs, a neurologist should be consulted.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
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
.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
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
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Source: In a Page: Signs and Symptoms, 2004
Stridor:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
Nasal cavity and nasopharynx
-
Congenital
–Piriform aperture stenosis
–Choanal atresia
–Lacrimal duct cyst
–Craniofacial anomaly
–Nasopharyngeal mass (teratoma)
-
Inflammatory/infectious
–Rhinosinusitis
–Adenoid hypertrophy
Oral cavity, oropharynx, and hypopharynx
-
Congenital
–Macroglossia
–Glossoptosis
–Vallecular cyst
-
Inflammatory/infectious
–Tonsillar hypertrophy
-
Tumors
–Lingual thyroid
–Dermoid
–Lymphovascular malformation
-
Foreign body
Laryngeal
- Congenital
–Laryngomalacia (#1 cause in infants); usual onset is in the first 2 weeks of life, typically positional; most resolve spontaneously by age 1
–Saccular cyst
–Webs
–Clefts
–Vocal cord paralysis
-
Inflammatory/infectious
–Epiglottitis
–Laryngotracheitis (croup)
–Gastroesophageal reflux
-
Tumors
–Papillomas
–Hemangiomas
-
Trauma
–Subglottic stenosis
–Foreign bodies
–Laryngeal fracture
–Caustic ingestion
Tracheobronchial
-
Congenital
–Tracheomalacia
–Vascular rings
–Tracheoesophageal fistula
-
Inflammatory
Workup and Diagnosis
-
History
–Duration, onset, severity, character, progression
–Failure to thrive, feeding problems, cyanosis, apnea
–Reflux history: Frequent spit-ups, vomiting, heartburn, chest pain, hoarseness
–Birth, neonatal, and past medical history: Complicated labor, respiratory distress at delivery
–Prior intubations, neurologic problems, prior episodes of croup, prior neck surgery, foreign body ingestion
–Immunization history
-
Physical exam
–Fever, respiratory rate, heart rate, level of consciousness, cyanosis
–Auscultation: Chest, nose, mouth, neck (phase of
stridor: inspiratory, expiratory, biphasic)
–Nose: Nasal obstruction
–Mouth: Tonsillar hypertrophy
–Neck: Retractions, compressive mass, thyroid
- Studies
–Flexible nasolaryngoscopy: Check for choanal patency, adenoid size, laryngomalacia, vocal cord mobility
–Direct laryngoscopy and bronchoscopy (DLB): Controversial whether all children with stridor need DLB
–MRI: Vascular compression or external mediastinal mass
–Modified barium swallow or esophagram in children with history of swallowing difficulties
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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)
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Source: In A Page: Pediatric Signs and Symptoms, 2007
STRIDOR AND SNORING:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The approach to the diagnosis involves a careful examination of the air passage with the laryngoscope and bronchoscope (if necessary, under anesthesia). If these have negative findings, a thorough neurologic examination should be performed and a Tensilon test may be indicated. Laryngismus stridulus in children may be terminated by putting the child in a steam bath; this helps establish that diagnosis. Skin testing for allergies may be necessary. A sleep study is often necessary to rule out neurogenic or obstructive sleep apnea.
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Source: Differential Diagnosis in Primary Care, 2007
Stridor:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
When the patient’s condition permits, obtain a patient history from him or a family member. First, find out when the stridor began. Has he had it before? Does he have an upper respiratory tract infection? If so, how long has he had it?
Ask about a history of allergies, tumors, and respiratory and vascular disorders. Note recent exposure to smoke or noxious fumes or gases. Next, explore associated signs and symptoms. Does stridor occur with pain or a cough?
Then examine the patient’s mouth for excessive secretions, foreign matter, inflammation, and swelling. Assess his neck for swelling, masses, subcutaneous crepitation, and scars. Observe the patient’s chest for delayed, decreased, or asymmetrical chest expansion. Auscultate for wheezes, rhonchi, crackles, rubs, and other abnormal breath sounds. Percuss for dullness, tympany, or flatness. Finally, note burns or signs of trauma, such as ecchymoses and lacerations.
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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.)
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Stridor:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
When the patient’s condition permits, obtain a patient history from him or a family member. First, find out when the stridor began. Has he had it before? Does he have an upper respiratory tract infection? If so, how long has he had it?
Ask about a history of allergies, tumors, and respiratory and vascular disorders. Note recent exposure to smoke or noxious fumes or gases. Next, explore associated signs and symptoms. Does stridor occur with pain or a cough?
Then examine the patient’s mouth for excessive secretions, foreign matter, inflammation, and swelling. Assess his neck for swelling, masses, subcutaneous crepitation, and scars. Observe the patient’s chest for delayed, decreased, or asymmetrical chest expansion. Auscultate for wheezes, rhonchi, crackles, rubs, and other abnormal breath sounds. Percuss for dullness, tympany, or flatness. Finally, note any burns or signs of trauma, such as ecchymoses and lacerations.
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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.)
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Stridor:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Characteristics of stridor. When confronted with stridor, check the age of the patient and the duration of the symptoms.
1. A child aged less than 6 months with stridor of a few weeks to months has a congenital cause of stridor.
2. Patients aged more than 6 months with stridor lasting hours to days usually have an acquired cause of stridor, most commonly viral croup, epiglottitis, or aspiration of a foreign body.
3. A typical history is a child aged less than 6 years with a 2- to 3-day history of upper respiratory infection (URI) and gradually worsening cough, especially at night. A barking cough with the inspiratory stridor heralds the diagnosis of croup, which accounts for 90% of all cases of stridor. This condition will classically improve with moist air (1,3).
4. A history of choking, coughing, or gagging points to aspiration or ingestion of a foreign body.
5. In older children and adults, a concomitant sore throat and fever may indicate acute supraglottitis, which constitutes an emergency.
B. Other information
1. Whether stridor is acute, recurrent, or chronic.
2. Personal or family history of atopy, would suggest spasmodic croup, which presents with stridor at night, not necessarily associated with a URI.
Physical examination
A. Focused physical examination (PE)
1. The PE should include vital signs, notably temperature and respiratory rate, and pulse, with emphasis on general appearance and examination of the head and neck, including ears, nose, and throat.
2. Signs of respiratory distress may be present, including dyspnea, tachypnea, chest retractions, nasal flaring, and stridor. If cyanosis is present, this is an ominous sign (2,4) (Chapter 8.2).
B. Additional physical examination may reveal:
1. A toxic-appearing child with high fever, drooling, severe respiratory distress, and preference for a sitting and forward-leaning position (1,4)
2. Varying degrees of anxiety, which will increase during examination, cause a worsening of stridor (1,4)
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
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.
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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.
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Source: Field Guide to Bedside Diagnosis, 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.
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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Stridor:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
When the patient’s condition permits, obtain his medical history. First, find out when the stridor began. Has he had it before? Does he have an upper respiratory tract infection? If so, how long has he had it?
Ask about a history of allergies, tumors, and respiratory and vascular disorders. Note recent exposure to smoke or noxious fumes or gases. Next, explore associated signs and symptoms. Does stridor occur with pain or a cough?
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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.)
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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.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Stridor:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
When the patient’s condition permits, obtain a patient history from him or a family member. First, find out when the stridor began. Has he had it before? Does he have an upper respiratory tract infection? If so, how long has he had it?
Ask about a history of allergies, tumors, and respiratory and vascular disorders. Note recent exposure to smoke or noxious fumes or gases. Next, explore associated signs and symptoms. Does stridor occur with pain or a cough?
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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?
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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.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Stertor, Stridor, and Airway Obstruction:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Nose and Nasopharynx
Congenital
Choanal Atresia
Causes obstructionof nasopharynx that may be unilateral or bilateral.Respiratory distress occurs with bilateraldisease unless the mouth is open because neonates are obligate nosebreathers.Best diagnostic test is flexible endoscopy.CT is used to delineate anatomy prior to surgery. Craniofacial Anomalies
2 autosomal-dominantdisorders, Apert syndrome and Crouzon syndrome, are caused by mutationsin gene encoding fibroblast growth factor receptor-2 on chromosome10q26. In both disorders, midface hypoplasia and shape of palatecontribute to airway obstruction.Apert syndrome is characterized byacrobrachycephaly, coronal craniosynostosis, shallow orbits, proptosis,hypertelorism, cutaneous and osseous syndactyly, broad distal phalanxof thumb and hallux of big toe, and variable mental retardation.Characteristic features of Crouzonsyndrome include craniosynostosis (especially of coronal, sagittal,and lambdoid sutures), shallow orbits, proptosis, hypertelorism,parrot-beaked nose, and variable mental retardation. Midline Masses
Nasal dermoidcyst may be suspected when pit or swelling is seen on dorsum ofnose in midline.Encephalocele is herniation of meningesand brain tissue into nasal area producing mass or swelling.CT demonstrates location and extentof these lesions. Biopsy is never performed if there is suspicionof intracranial communication. Infection/Inflammation
Rhinitis
Infectious or allergic rhinitis may causeinflammation and edema of nasal mucosa, causing upper airway obstruction(see Chap. 41, Nasal Discharge).
Adenoid Hypertrophy
Recurrentviral URIs and allergic rhinitis contribute to adenoid hypertrophy.Persistent snoring is common finding,and sleep apnea also may occur.History, physical exam, and lateralneck radiograph confirm diagnosis. Polyps
Nasal polyps can be visualized on nasal examas gray, smooth, soft, mobile masses. Predisposing causes are allergicrhinitis and cystic fibrosis.
Trauma
Trauma tonose and nasopharynx may produce significant swelling and bleeding, whichcause airway obstruction.Plain radiographs and CT provide valuablediagnostic information. Neoplasm
In childhood,most common benign tumors of nasal cavity are hemangioma and lymphangioma.In adolescence, most frequent benign tumor is juvenile angiofibroma.Malignant tumors include rhabdomyosarcoma, carcinoma, and lymphoma.Common presenting feature of thesetumors is nasal obstruction.Nasal speculum can be used to examinenasal cavity, while flexible nasopharyngoscopy permits visualizationof nasopharynx.CT of nasal cavity, nasopharynx, andsinuses locates mass and defines its extent. Histologic diagnosisis definitive. Oropharynx and Hypopharynx
Congenital
Micrognathia and Other Skull Base Abnormalities
Althoughmicrognathia can occur as isolated lesion, also can occur as partof Pierre Robin syndrome, which includes glossoptosis and cleftpalate.Another disorder with significant micrognathiais autosomal-dominant Treacher-Collins-Franceschetti syndrome, whosegene locus has been mapped to chromosome 5q32-33.1. Other characteristicfindings include downward slanting palpebral fissures, colobomaof lower lid, malar hypoplasia, and malformations of external ear(commonly microtia). Macroglossia
Can be associated with congenital hypothyroidism,Beckwith-Wiedemann syndrome, Hurler syndrome, and glycogen storagedisease type II. Diagnosis may be suspected from history and physicalexam. These disorders are discussed in other chapters.
Decreased Pharyngeal Muscle Tone
Decreased tone of pharyngeal musculaturemay contribute to noisy breathing, especially with cerebral palsyand trisomy 21.
Infection/Inflammation
Tonsillar Hypertrophy
Hypertrophy of tonsils may be seen with recurrentviral URI or allergic rhinitis. Tonsils are enlarged and may causeupper airway obstruction.
Abscess
Peritonsillar, retropharyngeal, or lateralpharyngeal abscess may cause fever, difficulty swallowing, drooling,neck pain, and respiratory distress, including stridor (see Chap. 61, Sore Throat).
Foreign Body
Foreignbody in pharynx may cause acute onset of choking and airway obstruction.History and physical exam can be diagnostic;however, in some cases neck radiographs and nasopharyngoscopy maybe needed to locate the foreign body. Trauma
Any facialor neck injury can cause edema or hematoma formation that compromises airway.History, physical exam, radiographsof face and neck, and nasopharyngoscopy are usually diagnostic.Laryngoscopy and bronchoscopy alsomay be necessary depending on extent of injury. Early tracheostomyshould be considered.Inhalation injury from fire may causesevere edema of mouth, pharynx, and larynx, producing combinationof cough, hoarseness, and stridor. Visualization of larynx may beaccomplished by endoscopy. Neoplasm
Benign tumorsof tongue include hemangioma and lymphangioma. Most common malignanttumor of tongue is rhabdomyosarcoma.Hemangioma can usually be diagnosedclinically.CT or MRI defines extent of mass. Histologicdiagnosis is definitive. Supraglottic
Congenital
Laryngomalacia
Most commoncongenital anomaly affecting larynx.Inward collapse of aryepiglottic foldsis usual mechanism of stridor, which may occur at birth or may bedelayed for a few weeks.Respiratory distress and feeding difficultiesoccasionally occur. Stridor often improves with placement in proneposition, whereas agitation makes it worse.Flexible endoscopy is diagnostic procedureof choice.Resolution usually occurs in firstyear of life when these tissues become firmer. Only in extreme casesis tracheostomy required. Laryngeal Cyst and Laryngocele
Unusuallesions that are thought to arise from saccule of laryngeal ventricle.Fluid-filled mass is called cyst andair-filled mass is called laryngocele.Cyst usually causes airway obstructionat birth, whereas laryngocele usually causes airway problems laterin infancy.Lateral neck radiography shows massthat may be seen by flexible laryngoscopy. CT and MRI are usefulin determination of location and extent of mass. Infection/Inflammation
Supraglottitis
Infectionof supraglottic tissues that includes epiglottis.Generally caused by infection of encapsulatedorganisms.Usual age range is 1–5 yrs.Since introduction of H. influenzaetype b vaccine, occurrence of epiglottitis has markedly decreased.Now organisms usually cultured are S. pneumoniae, S. aureus, nontypeableH. influenzae, and group A Streptococcus.Onset is acute, with fever, inspiratorystridor, pain with swallowing, and drooling.Laryngoscopy should be performed toconfirm diagnosis but should be done with utmost caution and withanesthesiologist or otolaryngologist present. Gastroesophageal Reflux
Can be associatedwith coughing, gagging, and choking.Persistent stridor may occur as consequenceof severe gastroesophageal reflux, and laryngoscopic visualizationof upper airway may reveal inflammatory changes (see Chap. 55, Regurgitation and Vomiting). Hereditary Angioedema
Laryngeal edema can occur in this autosomal-dominantdisorder in which serum levels of C1 inhibitor are low or its functionis defective (see Chap. 17, Edema).
Trauma
Supraglottic stenosis may be due to traumaor may result from surgical procedures involving the airway.
Neoplasm
Laryngealpapillomas are caused by human papilloma viruses, which can be transmittedduring birth from infected mother to newborn.They may occur anywhere in airway,but most common location is larynx.Flexible laryngoscopy reveals mass,and histologic diagnosis is confirmatory. Glottic
Congenital
Laryngeal Web
Incomplete canalization of laryngeal airwayresults in formation of laryngeal web. This lesion usually occursat glottic level and produces aphonia or weak or husky voice. Stridoralso may occur, and laryngoscopy is diagnostic.
Laryngeal Cleft
Cleft inlarynx is produced by failure of rostral development of tracheoesophageal septum.Stridor is often heard, and attemptsat feeding produce choking and coughing. Recurrent aspiration mayresult in pneumonia.Esophagraphy shows spillage of contrastinto trachea with swallowing. Endoscopy is confirmatory. Vocal Cord Paralysis
Vagus nerveby means of recurrent laryngeal nerve helps control vocal cord movement.Any lesion that affects these nerves may cause unilateral or bilateralvocal cord paralysis, which may be congenital or acquired.When 1 vocal cord is involved, airwaycompromise is usually minimal and weak or hoarse cry occurs. Onlywith periods of agitation or stress does stridor appear. Causesof unilateral vocal cord paralysis include recurrent laryngeal nervecompression or injury secondary to neck or mediastinal mass, enlargedleft atrium or pulmonary artery, and surgery, particularly cardiovascularor neck surgery.Stridor is characteristic of bilateralvocal cord paralysis. Cause is usually CNS lesion (e.g., hydrocephalus,intracranial hemorrhage, or Chiari malformation).Diagnosis of vocal cord paralysis canbe made by flexible laryngoscopy. Vocal cord(s) fails to abducton inspiration. Further investigation depends on suspected cause. Infection/Inflammation
Laryngitis
Usually associated with hoarseness and notwith stridor, unless inflammation is so severe that airway obstructionoccurs (see Chap. 31, Hoarseness).
Laryngeal Spasm
May be caused by repeated attempts at intubation,allergic reactions, and hypocalcemia. Manifestations of allergicreaction include urticaria, wheezing, and hypotension. Carpopedalspasm suggests tetany, in which case serum calcium should be measuredand intravenous calcium given immediately.
Foreign Body
Foreign body in glottic area may cause acuteonset of choking and coughing. Persistent stridor may be only manifestationof retained foreign body. Diagnosis may be suspected from historyand confirmed by neck radiography or laryngoscopy.
Trauma
Granuloma formation may occur secondary toendotracheal intubation. Obstruction can be minimal or severe.
Neoplasm
Laryngeal papillomas are discussed in thesection Supraglottic: Neoplasm.
Subglottic
Congenital
Subglottic Stenosis
Biphasicstridor usually occurs with congenital subglottic stenosis, yetvoice remains normal.Neck radiography may demonstrate subglotticnarrowing.Diagnosis is confirmed by rigid endoscopyunder general anesthesia. Cysts
Subglottic cysts can be congenital or occursecondary to airway intubation. Rigid endoscopy under general anesthesiais diagnostic.
Infection/Inflammation
Croup
In viralcroup subglottic edema produces airway obstruction and stridor.Most common cause is parainfluenza viral infection. Influenza viruses,rhinoviruses, respiratory syncytial virus, adenoviruses, and enterovirusesalso can cause croup. Age range is usually 6–36 mos.Symptoms of upper respiratory infectionare followed in 12–24 hrs by barky cough and stridor. Feveris variable finding. This is usually self-limited illness lasting3–7 days.Neck radiography may be performed ifpresentation is unusual or puzzling and diagnosis is uncertain. "Steeplesign" indicates airway obstruction and is consistent withdiagnosis of croup.Except for signs of infection, spasmodiccroup cannot be distinguished from viral croup. Onset is sudden,and episodes usually occur during night. Although pathogenesis remainsuncertain, episodes usually resolve during day and subside in afew days. Diagnosis is clinical. Bacterial Tracheitis
Usuallyfollows preexisting viral infection.Usual pathogens are S. aureus, S. pneumoniae,M. catarrhalis, and nontypeable H. influenzae.Average age of onset is 5 yrs.Clinical presentation is similar tothat of viral croup except these children appear more toxic. Theyhave worsening stridor with purulent tracheal secretions and areless responsive to racemic epinephrine. In most cases, trachealintubation is required because of severe airway obstruction.Radiography shows subglottic edemaand irregular tracheal densities. Flexible nasopharyngoscopy canidentify purulent secretions in airway, and rigid endoscopy shouldbe performed for debridement. This diagnosis should be consideredin older child with unusually severe croup. Trauma
Acquiredsubglottic stenosis is usually complication of prolonged endotrachealintubation and is generally more severe than congenital subglotticstenosis.Although airway films may be diagnostic,flexible endoscopy should be performed to visualize larynx and otherstructures above vocal cords. Occasionally, view of subglottis ispossible. Rigid endoscopy confirms diagnosis. Neoplasm
Subglottichemangioma is benign tumor that usually becomes symptomatic by 3–6 mosof age.Stridor may be inspiratory or biphasic.Barky cough and hoarseness also may occur.Neck radiography may show asymmetricsubglottic narrowing. CT or MRI is used to determine extent of thelesion.Diagnosis is confirmed by endoscopicexam under general anesthesia. Tracheobronchial
Congenital
Tracheomalacia
Presenceof misshapen or deficient tracheal cartilage rings contributes toabnormal collapse of trachea, called tracheomalacia.Onset is insidious and often episodic.Crying, coughing or feeding may lead to acute exacerbation. Stridoris typically expiratory. Cartilage becomes firmer with growth, andstridor usually resolves by 12–18 mos of age.Diagnosis can be confirmed by fluoroscopyor bronchoscopy, which demonstrates inspiratory collapse of extrathoracictrachea and expiratory collapse of intrathoracic trachea. Tracheal Web
Local narrowing of trachea produced by fibroustissue, and bronchoscopy is diagnostic.
Tracheal Cysts
Usuallyasymptomatic, but large or infected ones may produce stridor and cough.Chest radiography usually shows cysticmediastinal structure adjacent to trachea.Other useful diagnostic tests includeesophagraphy, CT, and bronchoscopy. Tracheal Stenosis
Fibrousstrictures that narrow airway may occur anywhere in trachea, andbronchoscopy is diagnostic.Tracheal ring involves individual trachealrings or segmental areas of trachea that may not increase in sizewith growth. Rings resemble cartilage and lack membranous posteriorsegment.Chest radiography may show narrow orfunnel-shaped trachea. Bronchoscopy confirms diagnosis. Vascular Anomalies
Double aorticarch can compress trachea and esophagus and cause stridor, dysphagia, andapnea. Esophagraphy shows characteristic indentations of esophagus,with higher and larger indentation caused by right aortic arch andlower indentation caused by left aortic arch. MRI is confirmatory.Anomalous innominate artery originatesmore distally from aortic arch than normal and compresses rightanterior aspect of trachea just above carina. Stridor, persistentcough, and apnea may occur. Chest radiography shows anterior indentationof trachea. Demonstration of anterior compression of distal tracheaby pulsatile vessel at bronchoscopy is diagnostic.In pulmonary artery sling, left pulmonaryartery arises as branch of right pulmonary artery, courses betweentrachea and esophagus to reach left lung, and compresses right mainbronchus and esophagus. Chest radiograph shows anterior bowing ofright main bronchus, deviation of lower trachea to the left, unequalaeration of lungs, and mediastinal density between trachea and esophagus.Esophagraphy may show anterior indentation of esophagus just abovelevel of carina. MRI or cardiac catheterization with pulmonary angiographyis diagnostic. Infection/Inflammation
Retroesophagealabscess may cause fever and stridor due to compression of trachea.Chest radiography, esophagraphy, andCT are useful in diagnosis. Confirmation of diagnosis may only bepossible at surgery. Foreign Body
Trachealforeign bodies may produce choking and gagging followed by persistent coughingand stridor. Radiopaque foreign body may be recognized on chestradiograph; otherwise, bronchoscopy is confirmatory.Esophageal foreign body may compresstrachea and cause stridor, cough, and respiratory distress, sometimeswithout any esophageal symptoms (e.g., drooling, dysphagia, or pain).Chest radiography may show its location,whereas esophagraphy usually shows filling defect.Esophagoscopy is confirmatory. Trauma
Tracheal stenosis may occur from complicationsof intubation or, less commonly, tracheostomy. Bronchoscopy is diagnostic.
Neoplasm
Tracheal
Rare inpediatric population.Benign tumors include squamous papilloma,chondroma, and hemangioma, whereas malignant tumors include varioussarcomas and carcinomas.Presenting symptoms include persistentcough, expiratory stridor, and hemoptysis.Chest and airway radiography may identifymass lesion. Combination of tests that includes bronchoscopy, CT,and MRI can locate site and extent of lesion.Histologic diagnosis is definitive. Thyroid
Thyroid neoplasm may compress trachea andcause stridor. CT can demonstrate compression. See further discussionof thyroid neoplasms in Chap.42, Neck Masses.
Mediastinal Masses
Some mediastinalmasses including teratoma, lymphangioma, and lymphoma may compresstrachea and cause stridor.Combination of tests, including chestCT and MRI as well as bronchoscopy, can locate and determine extentof lesion.Histologic diagnosis is definitive. Psychogenic
In pediatricpopulation, this type of stridor is most common in adolescent girls.Often history of psychologic stress exists.Stridor may be heard in inspiration,expiration or both. Associated findings include cough, hoarseness,and dyspnea.In some cases, flexible laryngoscopymay reveal paradoxic vocal cord motion, in which vocal cords adductrather than abduct in inspiration. Diagnostic Approach
Stertorand stridor are signs of upper airway obstruction. With seriousairway obstruction, establishing control of the airway and maintainingventilation are the most important immediate priorities. In absenceof life-threatening airway obstruction, prompt but thorough investigationis essential.Age of onset is useful in diagnosis.Onset of stridor at birth or during neonatal period suggests laryngomalacia,laryngeal web, vocal cord paralysis, or vascular ring. In infancyand childhood, onset of acute stridor suggests croup, supraglottitis,or foreign body. Most common cause of persistent stertor in children2–8 yrs of age is adenoid or tonsillar hypertrophy.Phase of respiration in which stridoroccurs, pitch of the sound, character of voice or cry, and changein position help in assessing degree of obstruction and its localization.The phaseof respiration associated with different levels of airway obstructionhas already been described.Variation in pitch depends on leveland degree of obstruction. Coarse low-pitched snoring sounds (stertor)localize lesion to nose, nasopharynx, or oropharynx. Harsh inspiratorystridor may occur with supraglottic, glottic, or subglottic lesions.Stridor associated with deep barking cough signifies subglotticor tracheal obstruction, whereas stridor associated with hoarsenessor change in character of voice or cry signifies glottic lesion.When infants with laryngomalacia orinnominate artery compression are placed in prone position withneck extended, stridor decreases. After history and physical exam, othertests may be useful depending on suspected diagnosis. These includeneck and chest radiography and flexible laryngoscopy. If resultsof these tests are normal, upper GI radiographic series with attentionto the pharynx and esophagus should be considered. With suspectedobstruction below glottis, bronchoscopy is necessary. Usefulnessof esophagoscopy, CT, and MRI depends on suspected diagnosis.Histologic diagnosis is necessary forany suspected neoplasm except perhaps hemangioma, which can usuallybe recognized clinically.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
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.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Stridor:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
When the patient's condition permits, obtain a patient history from him or a family member. First, find out when the stridor began. Has he had it before? Does he have an upper respiratory tract infection? If so, how long has he had it?
Ask about a history of allergies, tumors, and respiratory and vascular disorders. Note recent exposure to smoke or noxious fumes or gases. Next, explore associated signs and symptoms. Does stridor occur with pain or cough?
Then examine the patient's mouth for excessive secretions, foreign matter, inflammation, andswelling. Assess his neck for swelling, masses, subcutaneous crepitation, and scars. Observe the patient's chest for delayed, decreased, or asymmetrical chest expansion. Auscultate for wheezes, rhonchi, crackles, rubs, and other abnormal breath sounds. Percuss for dullness, tympany, or flatness. Finally, note burns or signs of trauma, such as ecchymoses and lacerations.
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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.)
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Source: Nursing: Interpreting Signs and Symptoms, 2007
STRIDOR AND SNORING:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The approach to the diagnosis involves a careful examination of the air
passage with the laryngoscope and bronchoscope (if necessary, under
anesthesia). If these have negative findings, a thorough neurologic
examination should be performed and a Tensilon test may be indicated.
Laryngismus stridulus in children may be terminated by putting the child in
a steam bath; this helps to establish that diagnosis. Skin testing for
allergies may be necessary. A sleep study is often necessary to rule out
neurogenic or obstructive sleep apnea.
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Source: Differential Diagnosis in Primary Care, 2007
WHEEZING:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
CBC, chest x-ray, sputum smear, and cultures will help to diagnose
infectious causes of wheezing. Bronchial asthma can be diagnosed by sputum
for eosinophils and pulmonary function testing. Cardiac asthma (due to CHF)
can be diagnosed by a venous pressure and circulation time,
electrocardiogram (EKG) and echocardiography. Bronchoscopy may be necessary
if a foreign body is suspected.
