Pediatric emergency medicine trisk 1654 1654
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Emergencies ). Mediastinal or hilar lymph node enlargement may be the result of
malignancy, sarcoidosis, or a mycobacterial or fungal infection. Mediastinal
tumors that are most likely to produce pulmonary symptomatology include
lymphoma, neuroblastoma, pheochromocytoma, ganglioneuroma, thymoma,
teratoma, or thyroid carcinoma; however, any malignancy can metastasize to the
lungs and cause extrinsic compression of the airways.
Among the rarest causes of wheezing in children are congenital structural
anomalies of the respiratory tract, including bronchogenic cysts, cystic
malformations of the lung, congenital lobar emphysema, intrinsic stenosis, and
webs. Respiratory symptoms typically begin in the neonatal period or early
infancy. The predominant clinical features are determined by the site of
abnormality within the tracheobronchial tree. Stridor and a croupy cough are
typical of laryngotracheal constriction, whereas wheezing and recurrent
pneumonia are more characteristic of bronchial narrowing. Respiratory findings
generally worsen with intercurrent respiratory infection and may accentuate with
crying and activity. Some diagnoses are discovered only when persistence of
symptoms necessitates imaging studies.
Bronchiectasis is the term used to describe irreversible bronchial dilatation, and
is the common end result of various disease processes. The most common cause
is CF, but bronchiectasis may also be caused by primary ciliary dyskinesia,
immunodeficiency disorders, congenital anatomic abnormalities, and infection.
Cough is prominent and accompanied by purulent sputum production.
Even though the diagnosis of bronchitis is more commonly associated with
adult patients, children may develop a nonspecific bronchial inflammation
associated with various viral agents. The pathophysiology is similar to
bronchiolitis and may be preceded by upper respiratory symptoms. Cough is
usually prominent and may be followed by wheezing.
Other rare conditions are listed in Table 84.2 .
EVALUATION
History
Thorough history taking is the key to arriving at an accurate diagnosis in a child
with wheezing. In particular, consideration of the age at onset, course and pattern
of illness, and associated clinical features provide a useful framework for
approaching a differential diagnosis ( Figs. 84.1 and 84.2 ).
In patients with respiratory distress, it may be necessary to perform a focused
history pertaining to life-threatening causes of wheezing ( Table 84.1 ). Such a
