Diagnosis of a Respiratory Disorder

diagnosing of a respiratory DisorderIntroductionRespiratory ailments be the comm ist ca manipulations of morbidness and mortality among small fryren of on the whole ripens. The presentation may vary from trivial to smell threatening symptoms. While a c argonfully conducted history and natural testing atomic number 18 vital for a correct diagnosis, various laboratory and radiological investigations aid in finally clinching the diagnosis.This chapter foc intakes on clinical assessment of the respiratory system in children. There is much overlap between the respiratory examination and that of other systems, and it is assumed that the reader has mastered basic somatogenetic examination skills. accountingThe evaluation of a child with respiratory disorder should start with the history of present illness, squeezeifi give the bouncet past history, family history as well as antenatal and birth histories. The parent should be asked the honcho complaint that prompted the consult ation, along with the circumstances at onset, frequency, duration, and rigourousness. History of prior manipulation should be obtained. History of past illness provide include all previous respiratory and other complaints. These include history of recurrent pneumonia (suggesting immunodeficiency, cystic fibrosis, anatomic ab ruleity, or bronchiectasis) known allergy and malnutrition. The family/ environmental history will provide information about history of contact or that apocalyptic of asthma in relatives, nutritional and financial status of the family, and history of delineation to allergens. Following are definitive clinical pointers in the history continual pneumonia points towards immunodeficiency, cystic fibrosis, anatomic ab patternity (gastroesophageal reflux), dysfunctional s hem inowing, or bronchiectasis. The child with a history of tracheoesophageal fistula repair is prone to tracheomalacia and gastroesophageal reflux cerebrate disorder.Atopy eczema, atopic derm atitis, hay fever, or known allergies, may be important in the child with continuing cough or recalcitrant asthma. nonstarter to thrive, frequent infections, rootage product transfusion, parental substance abuse, or poor growth may be a clue to an underlying immunodeficiency.History of contact with a case of tuberculosisEnvironmental history vulnerability to dust due to construction in the house/neighbourhood, front of embrace animals or birds, exposure to smoke, either from tobacco use or use of wood for heating, cooking, or both(prenominal).Associated complaints Headache may be a sign of sinus disease or, especially if occurring in the early morning, a provide of obstructive sleep apnea.Ocular symptoms such(prenominal)(prenominal) as conjunctivitis and blepharitis, as well as penurious symptoms, may indicate an atopic predisposition or in the early days infant a chlamydial infection. Recurrent spill the beans ulcers or thrush pot be associated with immunodeficiency, as may chronic or recurrent ear drainage. Poor feeding, edema, briefness of inkling, and exercise tolerance provoke be clues to the nominal head of congestive heart failure. Stool characteristics, abdominal bloating, and butterball food intolerance are important features of cystic fibrosis. Neurologic symptoms such as seizures or developmental delay are important in evaluating the child with apparent life-threatening events or suspected chronic or recurrent aspiration.PHYSICAL EXAMINATIONA thorough general physical examination is extremely important in the approach to a child with respiratory disorder. Recording the anthropometry is as important as are the presence of cyanosis, pallor and club. Use of accessory muscles of public discussion may indicate severity of respiratory distress and intercostal recession may point towards airline obstruction and a non-compliant lung. Supraclavicular and cervical lymph nodes should form part of the exanination routinely.Upper airwayAn exa mination of the upper airway will indicate presence of nasal foreign body or infection, tonsillar en whoppingment, or narrowing of the glottis. The position of the windpipe should be noted during examination of the neck. Deviation to one side may be seen with pneumothorax, neck mass, unilateral pulmonary agenesis or hypoplasia, or unilateral hyperinflation (as seen with foreign body or congenital cystic lung disorders). agencyInspectionInspection forms the first component of government agency examination. Presence or absence seizure of any deformity should be noted, as should the general perform of the agency. A barrel chest (increase anteroposterior dimension) denotes obstructive lung disease. The severity of this deformity shows increased lung volumes (functional residual capacity, residual volume, aggregate lung capacity, functional residual capacity/total lung capacity ratio, and residual volume/total lung capacity ratio) and is associated with radiographic findings of hyper inflation in children with poorly controlled asthma. Pectus carinatum (pigeon breast) or pectus excavatum (funnel chest) may be seen in patients who have chronically increased wager of steering, as in pulmonary fibrosis, cystic fibrosis, or poorly controlled asthma. The respiratory rate, preferably noted with the child at rest or asleep, is a very important indicator of pulmonary illness (though fever and metabolous acidosis can have an increased respiratory rate in the absence of pulmonary disease).Nasal flaring to reduce nasal resistance to flow of air and the use of accessory muscles of respiration such as the sternocleidomastoid muscles indicates respiratory distress as do retractions or indrawing of the skin of the neck and chest. Respiratory distress may also be seen in children with neuromuscular disorders. An verifiable way of assessing the degree of dyspnea is asking the child to count and noting the highest total reached in a single breath.The respiratory pattern and d epth may also point towards a particular pathology. Shallow and rapid respiration is seen in children with restrictive lung disease. Similarly, rapid and deep respiration (hyperpnea), can be seen in children with hypoxia and metabolic acidosis while alkalosis results in slow, shallow breaths. Hyperpnea alternating with apnea (Biots respiration) is associated with primeval nervous lesions involving the respiratory centers. Cheyne-Stokes respirations seen in comatose patients is marked by in stages increasing and decreasing respirations.Likewise, the relative length of the respiratory phases (the inspiratory/expiratory ratio) is important. As the inspiratory and expiratory phases are roughly equal, a lengthened spillage may indicate obstructive diseases such as bronchiolitis, acute accent exacerbations of asthma, and cystic fibrosis. While some abdominal breathing, is normal up to 6 or 7 years of age, conspicuous respirations of this type in a child, however, generally reflect a p ulmonary abnormality such as pneumonia, or respiratory muscle weakness.PalpationAlthough more generally thought of in terms of the abdominal examination, palpation is important in the respiratory examination as well. It is used to confirm the visual observations of chest wall shape and pilgrimage. Palpation is performed by placing the entire hand on the chest and feeling with the palm and fingertips. Friction rubs may be mat as high-frequency vibrations in synchrony with the respiratory pattern. Tactile fremitus, the transmission of vibrations associated with vocalization, is at quantify problematical to assess in children because of a lack of cooperation and a high-pitched function lower-pitched vocalization is more effectively transmitted. It is best felt with the palmar aspects of the metacarpal bone and phalangeal joints on the costal interspaces. Decreased fremitus suggests airway obstruction, pleural fluid, or pleural thickening, whereas increased fremitus is associate d with parenchymal desegregation. Occasionally a thud can be felt high in the chest or in the neck, a finding suggestive of a free tracheal foreign body. one and only(a) can also assess chest excursion by placing the men with the fingertips anterior and thumbs posterior and noting the degree of chest wall movement, comparing excursion of one side with the other by noting the movement of the thumbs away from the midplane (the spinous processes). The point of maximal impulse, frequently shifted to the left in cardiac disease, may be shifted inferiorly and to the right in severe asthma, a astronomical left-sided pleural effusion, or a tension pneumothorax. With ample left-sided atelectasis, it may be shifted to the left.PercussionPercussion should be performed with the child upright with the head in neutral position, and using the indirect method (a single finger from one hand strikes on a finger of the other hand fixed on an interspace). A gentle force should be used so as to av oid causing injury, especially in a young child). Sounds normally elicited by percussion of the chest are as followsTympany Normally perceive with percussion of the abdomen, is seen in the chest with a massive pneumothorax.Resonance This is the normal state in the chest it is sometimes called vesicular resonance.Hyperresonance Accentuation of the normal percussion is seen with states of hyperinflation like emphysema, asthma, or free intrapleural air. fall test A resonant metallic sound perceive with a stethoscope when tapping a coin that is held flat against the chest with another coin it indicates a pneumothorax.Dullness A flat, thud-like sound, this sound is associated with pleural fluid or parenchymal desegregation. lusterlessness This sound can be mimicked by percussing over muscle its presence in the chest suggests massive pleural effusion.AuscultationAuscultation of the chest should be performed with the age appropriate stethoscope (with chest pieces for premature infants, infants, children, and adolescents/adults). The diaphragm of the chest piece (pressed tightly against the skin) is used to filter out gloomy sounds, thereby isolating treble sound, and the bell (held lightly on the chest) is used preferentially to isolate low-pitched sounds.The upper lobes are best heard by listening anteriorly in the infraclavicular regions, the lower lobes by listening posteriorly below the scapulae, and the right midriff lobe and lingula by listening anteriorly lateral to the lower third of the sternum. either lobes can be heard in the axillae.It is also important to keep away the timing (continuous, early, or late), pitch (high, medium, or low), and character (fine, medium, or coarse) of sounds. These sounds can be divided into breath sounds (produced by the movement of gas by means of the airways), voice sounds (modifi cations of phonation not heard distinctly in the normal state), and adventitious sounds (neither breath or voice sounds).Breath SoundsVe sicular breath sounds are the sounds heard during respiration in a healthy individual. They are low-pitched, with a relatively longer inspiratory phase and a shorter expiratory phase and are louder on inspiration. These sounds emanate from the lobar and segmental airways and are then transmitted through normal parenchyma.Bronchial breath sounds are usually louder than vesicular sounds and have short inspiratory and long expiratory phases. They are higher pitched and louder during expiration. They may be the result of consolidation or compression (i.e., airlessness) of the underlying parenchyma. A similar sound can be heard by listening directly over the trachea.Bronchovesicular breath sounds, as the name implies, are intermediate between vesicular and bronchial sounds. The respiratory phases are roughly equal in length. This sound is felt to be indicative of a lesser degree of consolidation or compression (airlessness) than bronchial sounds. Bronchovesicular (and sometimes bronchial ) breath sounds can occasionally be heard in normal individuals in the auscultatory triangle (the knowledge domain in the back bound by the lower border of the trapezius, the latissimus dorsi, and the rhomboideus study muscles) and the right upper lobe.Wheezes are continuous musical sounds, more commonly expiratory in nature, and usually associated with short inspiratory and prolonged expiratory phases. They can be of single (monophonic) or multiple (polyphonic) pitches, which are higher pitched than vesicular sounds. These can often be very difficult to distinguish from snoring and upper airway sounds such as stridor.Stridor is a musical, monophonic, often high-pitched sound, usually thought of as inspiratory in nature it can be expiratory as well, such as when produced by partial obstruction of a central, typically extrathoracic airway. Its presence in both inspiration and expiration suggests severe, fixed airway obstruction.Voice SoundsThe normal lung parenchyma filters vocaliz ation so that verbalize sounds are not usually heard during auscultation and normally spoken syllables are indistinct. Bronchophony is the distinct transmission of spoken syllables as the result of an underlying consolidation or compression. More severe consolidation or compression results in the transmission of whispered sounds or whispered pectoriloquy. Egophony is very similar to bronchophony but has a nasal quality as well. It may reflect an underlying effusion, consolidation or compression, or both conditions.Adventitious SoundsFine crackles are thought to be the result of the fickle reopening of alveoli that closed during the previous exhalations. These occur exclusively during inspiration and are associated with conditions such as bronchitis, pneumonia, pulmonary infarction, and atelectasis. They can also be normal when heard in the posterior lung bases during the first few breaths on awakening. They may be imitated by rolling several strands of hair between the thumb and exponent in front of the ear or by pulling apart Velcro. Hammans sign, also called a mediastinal crunch, is the finding of crackles associated with systole and is suggestive of pneumomediastinum.Coarse crackles are popping sounds likely produced by the movement of thin fluids in bronchi or bronchioles. They occur early in inspiration and occasionally in expiration as well, may be audible at the mouth, and may seduce or change pattern after a cough. They can sometimes be heard in the anterior lung bases during exhalation to residual volume. An pillowcase of these sounds is the crackles typically heard in patients with cystic fibrosis. Rhonchi (sometimes more descriptively called large airway sounds) are gurgling or bubbling sounds usually heard during exhalation. These sounds are the result of movement of fluid within larger airways. In individuals with pleural inflammation, a pleural friction rub may be heard. This loud, pebbly sound may come and go over a short period of time. I t is usually associated with a subpleural parenchymal inflammatory process.OTHER SIGNS AND SYMPTOMS uniteClubbing is the broadening and thickening of the ends of the fingers and toes that occur as the result of connective meander hypertrophy and hyperplasia and increased vascularity in the distal phalanges, in response to chronic hypoxia. It can be confirmed clinically by checking for Schamroths sign. Causes of clubbing are as followsBronchiectasisSevere pneumonia, lung abscess, or empyemaInterstitial lung disease (autoimmune and infectious) pulmonic arteriovenous malformationHepatopulmonary syndromePulmonary malignancyCyanotic congenital heart diseaseBacterial endocarditisInflammatory bowel diseaseThyrotoxicosisFamilialCyanosisThe use of cyanosis as a clinical indicator of hypoxemia is confounded by a number of factors such as skin pigmentation, poor lighting, the presence of boom out polish, or hypothermia. Cyanosis occurs when the concentration of reduced arterial hemoglobin ex ceeds 3 g/dL. Clinical impression of cyanosis should be verified by arterial billet gas analysis or pulse oximetry.Pulsus paradoxusPulsus paradoxus (fluctuation in systolic blood pressure with respiration) may sometimes be associated with obstructive pulmonary disease. The arterial pressure falls during inspiration and rises with exhalation. It is quantified as the difference between the systolic pressures measured during inspiration and expiration. Pulsus paradoxus is useful in evaluating children with cystic fibrosis and asthma, in which a value of more than 15 mm Hg has been found to investigating