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.
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
- Disease: Pectus Excavatum | Cartilage Disorders
- Symptom/Presentation:Respiratory Distress
- Specialty: Allergy / Pulmonary Diseases | General Pediatrics | Surgery | Radiology / Nuclear Medicine / Radiation Oncology
- Age: Infant
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
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.
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.
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
Pediatric Education 