chapter 9 Evaluating the Respiratory System
Most children’s respiratory problems can be diagnosed with confidence by the time the history and physical examination are completed. Even when a specific diagnosis is not immediately clear, enough clues usually exist to allow you to narrow the possibilities to a manageable few. The anatomic-physiologic relationships of the respiratory system are readily revealed through symptoms and signs.
Understanding the origin and mechanism of abnormal respiratory sounds (e.g., stridor or wheeze) helps localize the site of an airway obstruction even if you have not yet pinpointed its cause. For children who require further investigations, a limited number of procedures, such as chest radiographs, pulmonary function tests, blood gas analyses, measurement of sweat chloride levels, and cultures, will clarify their problems. Immunology studies, bronchoscopy and biopsy, and further imaging studies are required less often.
Besides providing essential information about the child’s complaints, the process of history-taking helps establish a good rapport with the family. This rapport is especially important when dealing with children who have recurrent or chronic respiratory problems, such as asthma or cystic fibrosis (CF); it is essential for successful management.
Relevant details from the functional inquiry often clarify the diagnosis and uncover other problems that call for attention, such as allergic rhinitis or atopic eczema in a child with asthma. The physical examination usually confirms the suspicions aroused by a comprehensive history, but occasionally it reveals no abnormalities, and management then must be based largely on history.
Evaluating the respiratory system involves much more than examining the chest. Important clues often are located far from the thorax (e.g., finger clubbing may be associated with chronic pulmonary disease).
Resist the temptation to lead with your stethoscope. Auscultation is only a small part of respiratory examination, and often it is left until last unless the child is uncooperative. Other aspects of physical examination often make the auscultatory findings more easily interpretable; for example, finding decreased breath sounds over the left hemithorax can have different meanings depending on whether the trachea is midline, pulled to the left, or pushed to the right.
Obtaining the History
Taking a respiratory history from the parents is appropriate in very young children, but you should try to involve older children in the interview whenever possible, because they can provide valuable information about their symptoms. For instance, a child with asthma often admits to having a cough and shortness of breath as a result of physical activity at school—symptoms that often are not fully appreciated by the parents.
When asked for the child’s chief complaint, parents may respond with either a specific diagnosis or a symptom—often cough, wheeze, shortness of breath, noisy breathing, or recurrent respiratory infections. Their diagnosis may be correct, but it must be confirmed by a detailed history and a complete physical examination. A missed diagnosis, such as inhalation of a foreign body or unrecognized CF, can have significant implications for the child.
Parents must understand your terminology, and you must understand theirs (see Chapter 1). What parents describe as a wheeze may, in fact, be stridor. What you call asthma may mean something much more alarming to parents. Do not assume that parents understand what is meant by terms such as wheeze. Be prepared to imitate a wheeze, stridor, or whoop, or ask the parents to imitate the sound they are trying to describe.
Establishing whether the child makes the sound on inspiration or expiration may seem easy to you, but many parents have difficulty making that distinction.
Some parents have difficulty recalling the circumstances or triggers that cause or aggravate their child’s respiratory symptoms. This situation occurs frequently in children with asthma. Have a prepared list of common asthma triggers on hand to help them (Fig. 9–1).
Each symptom should be probed until it has been characterized well with respect to timing, aggravating and relieving factors, and associated features. Establish whether the symptoms are acute (less than 3 weeks’ duration); long-standing or chronic (more than 3 months’ duration); or recurrent (with symptom-free intervals of at least 2 weeks’ duration).
These answers help narrow the diagnostic possibilities when dealing with stridor or wheezing. To narrow the diagnostic possibilities further, try to relate symptoms to each other; for example, cough and stridor; cough and wheeze; and cough, wheeze, sputum, and failure to thrive.
Before completing the history, ask the parents and child what they see as the major problem. Parents occasionally bring up concerns they did not mention earlier in the interview. Likewise, do not assume that their concerns are the same as yours; often they are surprisingly different.
Chief complaints
Cough, wheeze, and recurrent infections are the most common complaints arising from respiratory diseases, although parents of younger children may complain that their child has noisy breathing. To characterize the main complaint, you must consider the child’s age, duration of the symptom, timing, aggravating and relieving factors, and the effect of previously prescribed medications.
Begin the history-taking for young children by asking about details of the pregnancy and birth. Ask about a history of maternal infections, drug use, cigarette smoking, and any problems during labor and delivery. The baby’s gestational age, birth weight, Apgar score, and need for resuscitation, oxygen, or assisted ventilation should be documented. Difficulty establishing feedings, episodes of apnea, or any evidence of respiratory distress in the neonatal period may set the stage for respiratory problems later in infancy. Dating the onset of symptoms can help; the closer to birth the symptoms began, the more likely they are due to a congenital disorder. If the child appeared well early in life, ask how old the child was when the symptoms began.
The following sections describe some common complaints and important questions to ask about them during history-taking.
Cough
Whether cough is the principal complaint or a secondary complaint, obtain as much information as possible about it. For example:
Coughing associated with sputum production is always a serious complaint in a child. Remember that infants, younger children, and some older children cannot or will not spit but rather swallow their sputum. Try to establish the color, volume, odor, and viscosity of the sputum and the presence or absence of blood. In infants, it is always important to establish whether a cough is associated with feeding and whether there is associated choking or spluttering, which may occur in children with gastroesophageal reflux, a tracheoesophageal fistula, or swallowing incoordination. Short, dry, or loud honking coughs that occur only when the child is awake and that are associated with parental anxiety but show no evidence of underlying respiratory disease suggest a nervous (habitual) or psychogenic cough. Such coughs may last for weeks or months and can be difficult to treat.
Although it is generally agreed that postnasal drip can cause a “throat-clearing” type of cough, particularly at night, it is doubtful that this process can cause a troublesome chronic daytime cough in children. It is more likely that a similar pathologic process affects the nose, sinuses, and tracheobronchial tree, such as that occurring in children with asthma, allergic rhinitis, and sinusitis.
Noisy Breathing
The nonspecific complaint of “noisy breathing” usually can be narrowed down to one of five specific possibilities—snoring, stridor, wheezing, grunting, or “rattly” breathing (see the section on physical examination later in this chapter). Many parents and some physicians make the mistake of believing that noisy breathing indicates chest (bronchopulmonary) problems, whereas in many infants and children, the noise originates in the nose, nasopharynx, or upper airway.
Recurrent Respiratory Infections (“Colds”)
Obtain a full description of a typical occurrence of respiratory infection, establishing whether the episode included an infectious contact, fever, rhinorrhea, earache, sore throat, facial pain, headache, or lymphadenopathy. A cough associated with wheeze, chest pain, or shortness of breath suggests lower respiratory tract involvement. Ask about the response to previous treatment, but understand that some parents are convinced that viral respiratory tract infections have responded to antibiotic therapy.
Remember, parents vary considerably in their tolerance for recurrent respiratory infections in their children. They may be unaware that the average preschooler has six to eight such infections per year, the majority occurring during the winter months, making it seem that one infection has run into the next. When a youngster is an only child, he or she may have lacked the opportunity to pick up respiratory illnesses from siblings before starting day care, nursery school, or kindergarten. For such children, the first year in a group setting often results in an above-average number of infections.
In evaluating the child with recurrent respiratory illnesses, always assess the extent of exposure (i.e., the number of contacts) both at home and in group settings, such as day care.
Finally, what parents describe as a “cold” may or may not represent a viral respiratory infection. Wheezing episodes often are preceded by 24 to 48 hours of nasal congestion and cough, and although these symptoms may be due to a viral infection that initiates wheezing after a day or two, they occasionally represent the “prewheezing” manifestations of an allergic response to an inhaled allergen.
Chest Pain
Chest pain in children is not uncommon, especially in adolescents, but as an isolated complaint, it is usually a benign phenomenon. When chest pain is accompanied by other symptoms and signs, the diagnosis may be obvious, as in the chest pain from coughing in a child with asthma. When the underlying diagnosis is less clear, remember that organic chest pain can arise from a limited number of anatomic structures (i.e., the chest wall, myocardium, pericardium, esophagus, or pleura). Questions that ferret out the site of origin often bring rewards.
In teenagers, chest pain often is traced to minor transient chest wall problems that do not affect general health. Sometimes a little chest wall tenderness can be demonstrated upon applying pressure. Many teenagers who complain of chest pain report sudden recurrent pain that lasts only a few seconds or minutes. Typically, the pain “catches them” if they try to take a deep breath. Many of us have experienced these pains ourselves. They appear to be due to a transient involuntary spasm of intercostal muscles, possibly analogous to nocturnal leg cramps (“growing pains”) or to the sudden “foot-in- a-knot” cramps that many adults experience, especially at night. In persons with costochondritis (Tietze syndrome), also a relatively benign condition, localized tenderness may be found (with or without swelling) over one of the costochondral junctions.
Laboratory investigations, electrocardiograms, and imaging procedures are uniformly unhelpful in the child with chest pain, unless they are indicated by solid historical or physical evidence of abnormality.
A teenager’s chest pain is often a psychosomatic complaint, reflecting anxiety generated by some major family life event, such as a relative’s myocardial infarction or malignant disease. Always ask teenagers who complain of chest pain whether they are worried that it might be serious. For example, you might ask, “Some people with chest pain are worried that it might be something serious—how about you?” Always ask about serious illness among family or friends.
Shortness of Breath (Dyspnea)
Shortness of breath rarely occurs in isolation. Associated signs of infection may suggest pneumonia, pleural effusion, or bronchitis. Accompanying pain may suggest pneumothorax, rib fractures from trauma, or pleurisy.
Hyperventilation
Hyperventilation is a common symptom in adolescents and is seen more often in girls. They may complain, “I can’t catch my breath,” “I can’t get enough air,” “I have trouble breathing,” or even “I have wheezing.” You also can detect hyperventilation by specifically questioning teenagers who present with other anxiety-related complaints.
When you suspect that a teenager may be hyperventilating, ask whether he or she has ever had any problem with swallowing. Sometimes teenagers will reveal that they often sense a “lump” in the throat and have difficulty swallowing (the so-called globus hystericus). Other features sometimes associated with such psychosomatic complaints are dilated pupils or, for unexplained reasons, an absent or highly suppressed gag reflex, so that you can practically touch the epiglottis with a tongue depressor without eliciting a gag.
Inquire about events leading up to the hyperventilation, and be aware that some adolescents with asthma have acute episodes of dyspnea triggered by vigorous exercise or participation in sports, leading to anxiety and subsequent hyperventilation.
Previous hospitalization
Record the dates and circumstances of previous hospitalizations and treatments. Try to determine whether the hospitalizations resulted from failed medical management at home and whether the parents have sufficient information and the tools required to reduce the frequency of future hospitalizations.
Medications
It is not enough simply to list the medications given to a child. Dosages and timing of administration are essential information. Try to distinguish between the medication regimen the child is supposed to be following and what the child actually takes. Remember that compliance with regularly prescribed medications in children is very poor. Ask, “Many children have trouble remembering to take their medications—does this ever happen to you?” If the child replies in the affirmative, ask, “How many times a week do you remember to take your medications?”
For patients using home nebulizers, record details of how the medications and diluent are mixed and administered. Inquire about the particular devices being used to deliver aerosol medications and the technique used (i.e., open-mouth versus closed-mouth technique when using metered aerosols), or if a spacer device is used (e.g., Aerochamber), which one. Ask about adverse effects from medications. Some children experience adverse effects from normal therapeutic doses of bronchodilators.
Immunizations
Inquire whether the child has received influenza or pneumococcal vaccines in addition to his or her regularly scheduled immunizations.
Smoking
Ask who smokes in the child’s environment and how much. The history of smoke exposure applies not only to the home and the family car but also to friends and relatives who visit the home and visits to relatives or friends in their homes. Does smoke exposure aggravate the child’s respiratory symptoms? Ask the child how he or she feels when exposed to smoke. Parents who smoke often say their child does not have respiratory symptoms when exposed to their cigarette smoking, but the child may tell quite a different story. Remember, children as young as 10 years may smoke cigarettes; always ask about this possibility out of parents’ hearing.
Environmental factors
Ask about the effects of exposure to specific home environments and inhalants—for example, moldy basements, dusty areas, sprays, perfumes, and substances the parents may use in their occupations—because they can trigger symptoms. Ask about symptoms from exposure to (1) grass, trees, and pollens; (2) dust and chalkboard dust at school; and (3) pets at home or in the homes of family or friends. Regularly recurring symptoms during a particular season may provide the essential tip-off to allergies; for example, the child may have symptoms related to trees in spring, grass in summer, and ragweed in autumn. Symptoms occurring at school sometimes can be difficult to sort out, to the frustration of many parents.
Family history
A history of similarly affected family members not only helps the diagnostic process, as in conditions such as asthma or CF, but it also offers some understanding of the family’s experience with the disease. A family may seem overly worried about a child’s asthma until you discover that an uncle died during an asthma attack. Also inquire whether the parents are related.
Pets
List all pets with which the child comes into contact, both inside and outside the home. Ask whether the child has any symptoms when such exposures occur, and describe examples of symptoms, such as itchy eyes or nose. Not infrequently, a child admits to having symptoms upon being exposed to the pet of a neighbor or relative but not to his or her own pet.
Exercise-related symptoms
The relationship between increased physical activity and respiratory symptoms is important. Toddlers with asthma often cough when they are excited or when they are tickled. Ask about symptoms associated with normal activities, such as running or bike riding, during school recess, or when participating in sports, and particularly during cooler weather in the fall and winter. Rather than asking parents whether their child has symptoms during gym class in school, ask the child what happens when he or she runs around the gym at school. Sometimes, the previously undiagnosed asthmatic patient replies, “I cough.” For older children, the type of exercise that triggers symptoms is important. Activities such as cross-country running, soccer, competitive basketball, hockey, and ice skating, which do not allow for a rest period, often can aggravate asthma, particularly if carried out in cold, dry air. Ask children previously diagnosed as having asthma whether they take any medication before, during, or after exercise, and if so, whether it prevents or reduces the symptoms.
School absenteeism
Parents may underestimate or overestimate the amount of school time a child misses because of respiratory symptoms. Brief absences often are forgotten. Checking the school records may give you a more accurate picture of absenteeism. Ask the parents to obtain the information or, with their permission, contact the school.
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