What Causes Respiratory Distress?

Patient Presentation
A 3-month-old male was referred for a second opinion for chronic respiratory distress. The patient was a full-term infant who had transient tachypnea of the newborn and was monitored for 3 days without other interventions. His parents noted at about 3 weeks of age that his chest always seemed to “suck in.” At 6 weeks he was brought to his local physician who noted the “chest sucking” and told the family that he was having respiratory distress. He was given albuterol and oral steroids but the parents noted no changes with the treatment. They denied any color changes, difficulty feeding, pulling in at his neck, ribs or abdomen, splaying of the nasal alae, abnormal cries or other sounds. He did not have noisy breathing and it did not appear to bother him or change over time. His parents pointed out the “respiratory distress” while he was in the office. The family history was negative for any cardiac problems. There were “respiratory problems” in geriatric great uncles who were smokers.

The pertinent physical exam showed a smiling infant with a respiratory rate of 28, heart rate of 144, blood pressure of 80/40, temperature of 98.8° F., growth parameters in the 75-95% and his weight of 7.05 kg was tracking along the 90%. Oxygen saturation was 100% on room air taken pre-ductally. He had normal vocalizations when happy and when crying. While reclining in his mother’s lap, his abdomen was noted to be slightly more protuberant relative to his ribs. The lower sternum appeared to be more concave relative to the rest of the sternum and rib line. A tongue depressor placed horizontally across the ribs showed a concavity of 1.0 cm. The sternum and ribs were smooth without disruptions in the articulating surfaces. There was no head bobbing, nasal flaring, tracheal tugging, intercostal retractions or abdominal breathing. His HEENT examination, cardiac, abdominal and spine examinations were normal. The diagnosis of a mild pectus excavatum that was not causing respiratory distress was made. The parents were counseled that this was a common problem and that he only appeared to have his chest “sucking in” because his normal chest position was already concave and breathing accentuated the mild deformity. The natural history of the problem was discussed including that it possibly could become worse especially during times of accelerated skeletal growth such as puberty, but monitoring during regular health supervision visits was recommended.

Case Image

Figure 79 -Axial image from a computed tomography exam of the chest without contrast shows depression of the sternum and a pectus excavatum deformity of the chest wall.
Discussion
Pectus excavatum is a deformation of the chest wall where the sternum and ribs grow abnormally to form a concavity relative to normal positioning. Pectus carnitum is similar but forms a convexity. Pectus excavatum is much more common (90%) than pectus carnitum (7-8%) or other congenital chest wall deformities (2-3%). Pectus excavatum is usually noted at birth or in the first year of life. It may be relatively minor (the most common) or quite severe (rarer) with the concavity displacing internal organs and possibly causing pulmonary and/or cardiac abnormalities. Usually it is relatively stable, but may progress especially during times of rapid growth such as puberty. Thankfully most patients do not need treatment but severe pectus excavatum may cause psychological distress because of the chest wall appearance. Psychological distress, with or without pulmonary or cardiac abnormalities is an indication for treatment. Unfortunately surgical treatment is basically the only effective treatment available. Surgical techniques include open and closed procedures which involve basic elevation of the concavity through cartilage grafts or rodding.

Learning Point
The most common signs of respiratory distress are increased respiratory rate and work of breathing. Tachycardia is common and as distress moves towards respiratory failure mental status changes are noted. Other signs of respiratory distress includes:

  • Increased respiratory rate
  • Nasal flaring
  • Retractions – diaphragmatic, intercostal, subclavian, subcostal
  • Abnormal sound production – grunting, stridor
  • Difficulty speaking
  • Skin changes – paleness or cyanosis (central or peripheral Note Bene: cyanosis is a late sign)
  • Mental status changes – somnolence, head bobbing
  • Poor muscle tone
  • Cough and gag reflexes weak or absent
  • Absent or decreased breath sounds
  • Abnormal breath sounds – rhonchi
  • Tidal volume changes
  • Inspiratory-expiratory ratio changes

The differential diagnosis of respiratory distress includes:

  • Normal variant
    • Periodic breathing
    • Pectus excavatum or carnitum
  • Head and Neck
    • Choanal stenosis and atresia
    • Mass – congenital cysts, tumor
    • Small midface and/or enlarged structures relative to each other
      • Enlarged tonsils and adenoids
      • Enlarged tongue
  • Pulmonary
    • Asthma
    • Aspiration, chronic
    • Cystic fibrosis
    • Diaphragmatic hernia
    • Lobar emphysema
    • Tracheolayngomalacia
    • Subglottic stenosis
  • Cardiac
    • Cyanotic congenital heart disease
    • Non-cyanotic congenital heart disease – Vascular rings
  • Central Nervous System
    • Neuromuscular disease – Guillian-Barre syndrome, spinal cord injury
    • Seizures
  • Infection
    • General infection causing fever
    • Abscess – peritonsillar, retropharyngeal, pleural effusion
    • Bronchiolitis
    • Tracheolayngobronchitis
    • Epiglottitis
    • Infantile botulism
    • Pertussis
    • Pneumonia
    • Sepsis
  • Metabolic
    • Metabolic acidosis – diarrhea and dehydration
    • Drugs and toxins- salicylates
    • Diabetic ketoacidosis
    • Inborn errors of metabolism
  • Trauma
    • Penetrating – pneumothorax
    • Non-penetrating – crush, burn
    • Child maltreatment – smothering, choking
    • Foreign body
    • Near drowning
    • Smoke inhalation

Questions for Further Discussion
1. What are indications/criteria for respiratory failure?
2. What treatment should be given for respiratory failure?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Cartilage Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins. Baltimore, MD. 1996:228-232.

Seidel JS. Respiratory Distress in Pediatrics a Primary Care Approach. Berkowitz CD, ed.. W.B. Saunders Co. Philadelphia, PA. 1996;135..

Hebra A. Pectus Excavatum. eMedicine.
Available from the Internet at http://emedicine.medscape.com/article/1004953-overview (rev. 9/21/09, cited 12/16/09).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What are the Risks of Infertility after Pelvic Inflammatory Disease?

    Patient Presentation

    A 15-year-old female came to the emergency room with lower abdominal pain for 1 week. The pain was described as constant mild pain with episodes of worsening. She stated she had increased urinary frequency but no urgency, change in urine color or smell. She had normal stooling. The patient had her normal period 2 weeks ago and was sexually active without consistent use of any contraceptive method including condoms. She stated that she had a vaginal discharge but could not describe it further. She was also having some back pain. She had had no fever, chills, rash, and had been eating well. The past medical history was positive for a previous episode of pelvic inflammatory disease caused by Chlamydia several months previous that was diagnosed by cervical cultures and treated as an outpatient. Social history revealed tobacco smoking and beer drinking but no other alcohol or drugs. She denied any violence or being involved with the police. She was taking an anti-depressant.

    The pertinent physical exam showed an alert female in no distress with normal vital signs and growth parameters. Abdominal examination showed lower abdominal/suprapubic diffuse tenderness without radiation with no guarding. There was no flank tenderness or pain reproduction with palpation of the back. Her genitourinary examination showed a normal introitus. She had a nulliparous appearing cervix with yellowish discharge from it. Bimanual examination revealed cervical motion tenderness without adnexal fullness or masses. The uterus was anteverted and normal size. The rest of her examination was normal. The work-up included a normal urinalysis and a negative pregnancy test. Urinary screening test for Chlamydia trachomatis was positive as was a cervical culture later on. Urine screening and cervical cultures for Neisseria gonorrhea were negative. The diagnosis of recurrent pelvic inflammatory disease was made. The patient was treated with azithromycin, ceftriaxone in the emergency room and also to continued to take the doxycycline she was already taking for acne. The patient’s mother was very concerned about her daughter but refused human immunodeficiency virus screening as this had previously been done. The mother wanted to followup with a regularly scheduled appointment in 2 days with her daughter’s adolescent medicine specialist. The mother assured the emergency room physician that ongoing gynecological, psychological and social care was being obtained for her daughter, and appointments in the electronic medical record system supported the mother.

    Discussion
    Pelvic inflammatory disease (PID) is an inflammatory disease of the uterus, fallopian tubes and adjacent pelvic structures caused by ascending microorganisms from the vagina and cervix particularly Neisseria gonorrhea and Chlamydia trachomatis. Increased risks for PID includes early age at first intercourse, multiple sexual partners, intrauterine device insertion and tobacco smoking. Approximately 11% of reproductive age women are affected. PID increases the risk of dyspareunia, chronic pelvic pain, pyosalpinx, tubo- ovarian abscess, pelvic adhesions, ectopic pregnancy, and infertility. The overall complication rate is ~15-20% and these often require surgical treatment.

    Learning Point
    After 1 episode of PID, about 12% of women will be infertile. After a second episode this rises to ~25% and after a 3rd episode this increases to ~50%. Overall there is a doubling of the risk of infertility after each episode.

    The PEACH (Pelvic Inflammatory Disease Evaluation and Clinical Health) study which evaluated outpatient versus inpatient treatment for PID found a rate of ~18% infertility with a mean long-term followup of 35 months. This study included patients 14-37 years but without subgroup analysis of adolescents. In another study, these researchers found that barrier methods (especially male condoms) significantly helped to prevent chronic pelvic pain, recurrent PID, and infertility.

    Questions for Further Discussion
    1. What are the recommended treatment options for PID?
    2. What are the recommendations for treating partners of patients with known PID and how are the partners contacted locally?
    3. What are the legal requirements for treating minors with sexually transmitted infections?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Pelvic Inflammatory Disease, Chlamydia Infections, and Gonorrhea</a.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Ness RB, Soper DE, Holley RL, Peipert J, Randall H, Sweet RL, Sondheimer SJ, Hendrix SL, Amortegui A, Trucco G, Songer T, Lave JR, Hillier SL, Bass DC, Kelsey SF. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol. 2002 May;186(5):929-37.

    Ness RB, Randall H, Richter HE, Peipert JF, Montagno A, Soper DE, Sweet RL, Nelson DB, Schubeck D, Hendrix SL, Bass DC, Kip KE. Pelvic Inflammatory Disease Evaluation and Clinical Health Study Investigators. Condom use and the risk of recurrent pelvic inflammatory disease, chronic pelvic pain, or infertility following an episode of pelvic inflammatory disease. Am J Public Health. 2004 Aug;94(8):1327-9.

    Lareau SM, Beigi RH. Pelvic inflammatory disease and tubo-ovarian abscess. Infect Dis Clin North Am. 2008 Dec;22(4):693-708, vii.

    Hills JB, Lockrow E. Pelvic Inflammatory Disease. eMedicine.
    Available from the Internet at http://emedicine.medscape.com/article/256448-overview (rev. 8/27/2009, cited 11/30/09).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • When Can an Infant See Color?

    Patient Presentation
    A 5-day-old male came to clinic for his health supervision visit. He was breastfeeding and eliminating well. His parents noted that he was more alert than they remembered his older sister at the same age.. The past medical history showed a full-term infant with no prenatal or natal complications. He received all his normal newborn care including passing his hearing screening. His neonatal screen was negative also. The family history and review of systems were negative including no history of visual problems other than older family members needing reading glasses.

    The pertinent physical exam showed an alert male infant who was 3.468 kg (down 5% from birth weight) with normal vital signs and growth parameters. He was mildly jaundiced in the face and sclera only and the rest of his examination was normal. The diagnosis of a healthy male infant was made. During the interview his parents said they had a mobile that had black and white cards for a newborn and colored cards for an older infant and they wanted to know when to switch the cards. The pediatrician said that infants were born with relatively clear vision of only a few inches (distance between holding the newborn in a cradled elbow to parent face) and that they developed the ability to see red colors within a couple of weeks. He did not know when the other colors became clear, but said he would try to look it up and tell them at the next visit. The pediatrician also discussed safety issues including using a mobile in the infant’s crib and when to take it out of the crib.

    Discussion
    Infants are hyperopic (farsighted) at birth because of the relatively short axial length of the globe and ocular optics. Astigmatism occurs in 15-30%. These refractive errors are gone for most infants by 9-12 months. Newborns can fixate at birth but accurate visual fixation occurs by 6-9 weeks. Accommodation (fixating on near objects) is also evident at birth but is not accurate until about 2-3 months. Visual acuity (defining fine details) is normal by 6-8 months. Stereopsis (3-D vision) has a rapid onset at 3 months and is normal around 6 months.

    Learning Point
    Contrast sensitivity (the ability to detect brightness differences or shades of grey) occurs by 10 weeks.
    Color vision begins as early as 2 weeks (red) and by 3 months is normal.

    Questions for Further Discussion
    1. List signs that may indicate a serious vision problem.
    2. How common are color vision problems?
    3. How could color blindness affect a child’s education?
    4. What items are considered safe to be in a newborn’s crib and when should they be removed?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Eye Diseases

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Hamer RD, Mirabella G. What Can My Baby See? Smith-Kettlewell Eye Research Institute.
    Available from the Internet at http://www.ski.org/Vision/babyvision.html (1990, cited 11/30/09).

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:491.

    Monitoring Visual Development. Texas School for the Blind and Visually Impaired.
    Available from the Internet at http://www.tsbvi.edu/Education/infant/page7.htm (rev. 9/4/2007, cited 11/30/09).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Causes Different Types of Cries?

    What Causes Different Types of Cries?

    Patient Presentation
    A 5-day-old female came to clinic with what parents described as a “weak” cry. She began to have less energy the night before, and was nursing less vigorously too. She was still urinating well. Her parents reported she had a normal, vigorous cry previously and that her 2-year-old sibling had rhinorrhea. The past medical history revealed a full-term infant with an uncomplicated prenatal, birth and hospital course. Her mother had rupture of membranes 1 hour before delivery and had no maternal fever. The review of systems showed the infant to have no fever, emesis, constipation, apnea, respiratory distress, stridor, cyanosis or rashes.

    The pertinent physical exam showed an infant who appeared tired. Although she was able to breastfeed normally, it took 40 minutes and she had a weak cry intermittently. Her weight was 3.587 kilograms, down from her birth weight of 3.795 kilograms. She had a temperature of 99.9° rectally and the rest of her vital signs were normal. HEENT examination revealed mild clear rhinorrhea, and the rest of her examination was normal. The diagnosis of a viral upper respiratory infection causing an elevated temperature and fatigue in a newborn was made. The laboratory evaluation showed a normal complete blood count and C-reactive protein for age. Her newborn screening test was normal. A blood culture was sent. As the family lived 90 miles away from the hospital, she was admitted for observation for possible occult bacteremia or sepsis. The patient’s clinical course over the next 30 hours showed her to remain afebrile and slowly appear to feed better and for her cry and tiredness to improve to that of a normal newborn. Cultures were negative and the infant was discharged home without further problems on follow-up.

    Discussion
    Crying is a primary vocalization for infants and small children, and remains a part of the vocalization repertoire over a person’s lifetime. Infant crying leads to feeding and nutrition for the child, protection (skin irritation from diaper contents, pain), and increased social interaction (through attempts to calm). Crying is described in terms of quantity and quality, with much written about the quantity of crying, as in the “colicky” infant. For more information about colic see What Should I Do? I Just Can’t Get Him to Stop Crying?

    Less is written about the qualitative features of crying, but many parents are able to pick their own child’s cry out of many children who are crying. Seasoned clinicians are able to walk down a hallway and point out which child is hungry, tired, in pain, etc. The cry “that’s just not right” can bring worry and even panic to the heart of parents and clinicians alike.

    Cries that are abnormal qualitatively may need further evaluation. For acute changes in crying, parents will often complain of “weak” cries indicating that it is not as lusty and vigorous as normal. Often this is due to a temporary infection. Abnormal cries that are consistent over time usually need further evaluation.

    Learning Point
    Qualitative descriptions of various cries includes:

    • High-pitched, shrieking
      • Abnormal central nervous system
        • Cornelia de Lange syndrome – like a bleating lamb
      • Cri-du-chat syndrome- like a cat
      • Cerebral irritability (i.e. meningitis, hydrocephalus, kernicterus)
      • Malnutrition especially marasmus
    • Gravel in the Mouth
      • Laryngitis
    • Grunting
      • Pneumonia
      • Sepsis
    • Irritated
      • Pain – long-lasting, intense, high-pitched
      • Tired, cold, hungry infant – short duration, thin sounding
    • Hoarseness
      • Hypothyroidism
      • Trauma to the hypopharynx
      • Vocal cord paralysis
    • Muffled
      • Epiglottis
    • Stridorous
      • Foreign body
      • Infection – abscesses, croup, epiglottitis
      • Laryngeal abnormalities
      • Oropharynx abnormalities
      • Tracheal abnormalities
      • Neoplasm
    • Vigorous and lusty
      • Healthy, full-term infant
      • Healthy, premature infant
    • Weak or whimpery
      • Muscle weakness
        • Muscular dystrophy
        • Myasthenia gravis
      • Infection

    Questions for Further Discussion
    1. What is the definition of colic?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: infant and Newborn Care and Common Cold.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:296.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:34-35, 414-417, 1273.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital