Hypoxia (see Respiratory Failure in PICU Chapter for additional information)
• Failure of oxygen delivery or an inability of tissues to use oxygen
• Severe hypoxia can lead to cyanosis which can be seen with 5 g/dL of deoxyhemoglobin
• Hypoxemic hypoxia: Low arterial partial pressure of oxygen. Five causes include low inspired FiO2, hypoventilation, intrapulmonary and extrapulmonary shunt, V/Q mismatch and diffusion defect
• Workup: Pulse oximetry, ABG or arterialized capillary blood gas, hyperoxia test, CXR, CT, pulmonary function tests
Tachypnea (see next page for additional information)
• Pneumonia, asthma, pneumothorax, chest wall restriction, splinting, pulmonary embolism, anxiety, metabolic acidosis, upper airway obstruction, fever, FB (lower airway obstruction), chronic lung disease
• Workup: CXR, CT, CBC, glucose, nasopharyngoscopy, bronchoscopy, pulmonary function tests, lung biopsy
Stertor
• Nasopharyngeal: Choanal atresia, lingual thyroid or thyroglossal cyst, macroglossia or micrognathia, hypertrophic tonsils/adenoids
• Workup: Attempt to pass NG tube, lateral neck x-ray, nasopharyngoscopy
Stridor (see page 13-2 for additional information)
• Inspiratory: Extrathoracic. Laryngomalacia, tracheomalacia, bronchomalacia (chronic), croup, tracheitis, epiglottitis, retropharyngeal abscess (acute), laryngeal web/cyst, vocal cord paralysis, subglottic stenosis, foreign body, intraluminal tumor (subglottic
hemangioma or laryngeal papilloma) or external compression (cystic hygroma or tumor), angioedema, traumatic intubation, laryngospasm (hypocalcemic tetany), psychogenic
• Expiratory: Intrathoracic; mimics asthma, but tracheal/bronchial origin. Tracheomalacia, bronchomalacia, vascular rings, extrinsic compression, foreign body, psychogenic
• Workup: AP/lateral neck films to assess upper airway anatomy, chest film if suspect foreign body aspiration, direct bronch for persistent sx or foreign body, CT to r/o extrinsic compression, barium swallow to r/o vascular compression, tumor, or GERD, EGD or pH probe to r/o GERD, PFTs
Cough (see page 13-3 for additional information)
• Acute: URI, pneumonia, aspiration
• Chronic: Postnasal drip, GERD, bronchitis, TB, bronchiectasis, cough-variant asthma, toxic exposure (cigarette smoke), CHF, drug (ACE-I), ILD, COP, bronchiolitis obliterans, bronchiectasis, habit (psychogenic) cough
• Workup: ENT exam for s/sx allergic rhinitis, CXR +/− sputum culture if suspect infection, CT scan if suspect bronchiectasis or chronic ILD, empiric antacid if hx c/w GERD
Wheezing (see page 13-5 for additional information)
• Homophonous without signs of hyperinflation: Upper airway. Heterophonous with signs of hyperinflation: Lower airway
• Acute: Asthma, bronchiolitis, anaphylaxis, toxic inhalation, medication induced (β-blocker, ASA, indomethacin), aspiration, foreign body
• Chronic: Asthma, GERD, protracted bronchitis, CHF, vascular rings, tracheomalacia, cystic fibrosis, bronchopulmonary dysplasia, vocal cord dysfunction
• Workup: Consider CXR, PFTs, pH probe, fluoroscopy, or bronchoscopy
Hemoptysis (see page 13-8 for additional information)
• Airway inflammation/infection, pneumonia, TB, tumor, trauma, idiopathic pulmonary hemosiderosis (IPH), Heiner syndrome (assoc w/ cow’s milk), vasculitis (Wegener, Goodpasture, HSP, SLE), pulmonary HTN, pulmonary infarction, PE, AVMs,
coagulopathies, complication in CF
• Workup: Rule out nasopharyngeal pathology and GI sources; CXR, CBC (including platelets), coags, ANA, ANCA, chest CT, bronchoscopy, nasopharyngoscopy, PPD, UA
Pleuritic Chest Pain (see page 13-9 for additional information)
• Pneumothorax, chest wall trauma, pneumonia, pleural effusion, pulmonary embolism, pericarditis, asthma
• Workup: EKG, chest x-ray, CT scan
Apnea (see page 13-11 for additional information)
• Obstructive: Obesity, tonsillar and adenoid hypertrophy, micrognathia, macroglossia, Pierre Robin sequence
• Central: Infection, intraventricular hemorrhage, shaken baby syndrome, apnea of
prematurity, brainstem abnormalities, expiratory apnea, congenital or secondary central hypoventilation syndrome (Ondine’s curse)
• Workup: Polysomnography (PSG), pneumogram, brain MRI, lateral neck films,
nasopharyngoscopy