Pediatric emergency medicine trisk 1662 1662
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The diagnosis of CLD is established on the basis of chronic respiratory
symptoms superimposed on a background of neonatal lung disease. Nevertheless,
a chest radiograph characteristically shows hyperexpansion and streaky or patchy
infiltrates, punctuated by areas of alternating local hyperaeration and atelectasis.
Comparison to previous radiographs is often helpful in distinguishing chronic
changes from acute processes.
Newborn screening should identify most children with CF, but screening is
dependent on the state standards, and the test does not have 100% sensitivity.
Thus, infants with recurrent wheezing, particularly in combination with failure to
thrive and chronic diarrhea should be referred for sweat chloride or DNA testing.
A patient suspected of having congenital or acquired heart disease should have
an electrocardiogram and a chest radiograph performed in the ED. Definitive
diagnosis generally requires echocardiography. A barium swallow, computed
tomography scan, or magnetic resonance imaging is usually sufficient to diagnose
the presence of a vascular ring or sling, although computed tomography
angiography or magnetic resonance angiography may be necessary for exact
anatomic definition.
Because pulmonary hemorrhage may present with hemoptysis, a complete
blood count and coagulation studies should be obtained. Sputum cultures may
detect bacteria, fungi, viruses, or acid-fast bacilli. Chest radiograph may show
diffuse scattered opacities. Bronchoalveolar lavage from bronchoscopy may also
be useful for detecting hemosiderin-laden macrophages.
APPROACH
The evaluation of a wheezing child begins with an immediate assessment of the
degree of respiratory distress and consideration of the need for general supportive
measures. Patients with impending respiratory failure should be managed
aggressively, as outlined in Chapter 7 A General Approach to the Ill or Injured
Child , and in Chapter 71 Respiratory Distress . Clinical features suggestive of
impending respiratory failure include severe respiratory distress, agitation or
lethargy, dusky mucous membranes, signs of autonomic excess (e.g., tachycardia,
diaphoresis, peripheral vasoconstriction), poor air movement on lung
auscultation, pulse oximetry reading of less than 90%, and elevated noninvasive
end-tidal carbon dioxide measurements. Blood gas analysis may also aid in
recognizing and monitoring the progression of respiratory failure.
Supplemental oxygen should be offered promptly to any patient with
respiratory distress and adjusted to maintain a pulse oximeter reading of 93% or
greater. Higher-altitude medical centers may accept lower pulse oximetry
