Approach to a patient with cough or difficulty in breathing

Causes

1. Infective Disorders of Airway

• Common cold
• Sinusitis (post-nasal discharge)
• Tonsillitis, Pharyngitis, Laryngitis
• Laryngotracheobronchitis, Bronchiolitis
• Pneumonia
• Measles, whooping cough

2. Inflammatory Disorders of Airway

• Asthma and Loeffler’s syndrome, TPE
• Inhalation of environmental irritants like tobacco, smoke dust.

3. Pleural pathology

• Pleural effusion
• Empyema

4. Suppurative Lung Disease

• Bronchiectasis
• Cystic fibrosis
• Foreign body retained in bronchi
• Lung abscess

5. Anatomic Lesions

• Congenital malformations, Sequestrated lobe
• Bronchomalacia, Tumors
• Tracheal stenosis, H-type TEF
• Vascular ring
• Tracheomalacia

6. Irritative

• Post-nasal discharge
• Sinusitis
• GERD
• Irritation of EAM

7. Psychogenic

• Habitual cough

8. Interstitial Lung Disease
9. Compression of Airways

• Lymph nodes
• Retropharyngeal abscess
• Mediastinal mass

10. Non-pulmonary causes

• CCF, pericardial effusion, constrictive pericarditis
• Congenital heart diseases.

11. Abdominal Causes

• Diaphragmatic hernia, eventration of diaphragm, intra-abdominal masses
• Massive ascites

Life-threatening causes

• Croup
• Laryngeal edema
• FB
• Pertussis
• Bronchiolitis
• Asthma
• Pneumonia
• Toxic inhalation
• CCF

Respiratory sounds

History

1. Acute /chronic

• Considered to be chronic if > 2-3 weeks.
• Significant overlap.

2. Age of patient

• Infancy- GERD, swallowing dysfunction, CCF associated with CHD.
• Toddlers- RAD, passive smoking, ciliary dyskinesia.
• Adolescents – infections (TB), RAD, psychogenic.

3. Past history

• URTI- Post-infectious, irritative, sinusitis.
• H/o contact with TB.

4. Associated symptoms

• Fever, nasal discharge suggest infection.
• Fever with chills or night sweats suggests TB.
• Sputum production indicates bronchiectasis or other lower-airway pathology- with the headache or facial edema – sinusitis

5. Quality of cough

• Productive cough suggests lower airway infection, CF/bronchiectasis.
• Barking seal-like cough is usually associated with croup.
• Honking or brassy cough is typical in habitual or psychogenic cough.
• Disease of the smaller airways (eg asthma or bronchiolitis)- high-pitched, “ tight” cough.

6. Pattern of cough

• Night time cough suggests Reactive Airway Disease.
• With nighttime/early morning cough, consider sinusitis.
• Paroxysmal with whoop – pertussis
• Seasonal cough suggests an allergy.

7. Sputum

• Purulent- suppurative lung disease.
• Mucoid – asthma (yellowish sputum in some cases due to  eosinophils).
• Hemoptysis – bronchiectasis, MS, CF or FB.

8. History of choking (i.e. Retained FB, etc.)

9. FTT/ severe undernutrition
10. CF, immunodeficiency.
11. Chronic cough– TB, bronchiectasis, pertussis, CF, severe chronic asthma or immunodeficiency syndrome.
12. Immunization history DPT, measles, BCG

Physical Examination

1. General appearance:-

• Evidence of FTT – consider CF, immunodeficiency.
• Pallor – severe anemia
• Cyanosis – hypoxemia/heart disease.
• Subconjunctival hemorrhage – pertussis
• Tachypnea, use of accessory muscle – respiratory distress.
• Grunting, nasal flaring, head nodding, wheezing
• Stridor, in combination with cough, generally indicates obstruction at the level of larynx or trachea.
• JVP – raised in CCF.

2. Vital signs:-

• Fever – infective pathology.
• Pulse – tachycardia–CCF, fever, distress.
• RR- to be counted for 1 minute when the child is calm.

4. Clubbing:-

• Bronchiectasis, lung abscess, cystic fibrosis.

5. ENT Examination:-

• Nose – nasal discharge – blood stained/ serous/ purulent; DNS.
• Polyps – allergy.
• Pharynx – congested/ grey membrane.
• Tonsils – enlargement/ congestion/pus points.
• Ear – discharge (ASOM), retraction of TM.

6. Signs of atopic disease:-

• Eczema, transverse nasal crease, rhinitis, mucosal cobblestoning, injected conjunctivae – consider RAD, allergy.

7. Sinusitis: – Periorbital edema, sinus tenderness, purulent posterior pharyngeal drainage, halitosis

System Examination

Respiratory system:-
Inspection

• Intercostal or subcostal indrawing.
• Intercostal fullness (pleural effusion, empyema) or crowding of ribs (collapse, fibrosis).
• Decreased movement of either hemithorax.
• Suprasternal recessions – suggestive of narrowing or obstruction of upper airways (laryngeal diphtheria, acute laryngotracheobronchitis, laryngeal/tracheal FB and angioneurotic edema).
• The position of the trachea (trail sign).

Palpation

• Feel for abnormal vibrations – rhonchi, friction rub, crackles, crepitus (subcutaneous emphysema- pertussis).
• Vocal fremitus.
• Expansion of hemithorax.

Percussion

• Area of dullness- pleural effusion (shifting dullness), empyema, consolidation.
• Hyper-resonant – pneumothorax.
• Percuss for upper margin of liver dullness.

Auscultation

• Compare air entry B/L.
• Bronchial breath sounds.
• Added sounds – crackles, rhonchi, pleural friction rub.
• Vocal resonance
• Absent/ decreased – pleural effusion, atelectasis.
• Increased – consolidation, atelectasis with patent bronchus.

Never forget to examine:

• Cardiovascular System
• Abdomen

Investigations

1. Complete blood count

• Hb -anemia
• Total and differential count- infections.
• Eosinophilia – TPE, Loeffler’s syndrome.

2. Sputum

• AFB
• Eosinophils suggest an asthmatic process or hypersensitivity process of the lung.
• PMN cells suggest infection.
• Lipid laden macrophages- suggest recurrent aspiration.
• Routine or special cultures based on likely pathogens.

3. Pulse Oximetry

• For bedside evaluation/monitoring hypoxia.

4. Blood C/S

• Important in any infective pathology.

5. ABG

• Estimation of partial pressures of O₂ and CO₂ in blood along with blood P^H is used for making the diagnosis of respiratory failure or metabolic acidosis (sepsis/shock)

6. X- rays

• CXR – especially in heart diseases, pneumonia not resolving with treatment, pleural effusion.

-Infiltrates may suggest pneumonia, bronchiolitis, pneumonitis, TB, CF, bronchiectasis.
-Volume loss may be seen with foreign body aspiration.
-Hyperinflation suggests RAD or CF.
-Mediastinal nodes may indicate infection (esp. TB, fungus) or malignancy.

• Sinus films – sinusitis.
• Lateral neck X-rays – acute epiglottitis, retropharyngeal abscess.
• Barium swallow –TEF, GERD.

7. CT – Scan

• Bronchiectasis (HRCT).
• Lymph nodes, pleural pathologies.

8. Pulmonary Function Tests

• To diagnose and follow the course of chronic respiratory illness.

9. Immune workup

• Ig levels
• HIV testing

10. Bronchoscopy:-

• To remove a foreign body or obtain samples (BAL).

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