Differentials
Asthma exacerbation
SIGNS / SYMPTOMS
Wheezing is paroxysmal, intermittent, usually diffuse, and decreases after bronchodilators. It is polyphonic, characterized by many different pitches. Cough is more prominent in asthma than in foreign body aspiration and is triggered by exercise, cold, sleep, and allergens; there is a personal and/or family history of atopy or asthma.
INVESTIGATIONS
Chest radiograph shows peribronchial cuffing and hyperinflation but does not rule out foreign body aspiration. Pulmonary function tests usually show reversible obstructive ventilatory impairment.
Cystic fibrosis with exacerbation
SIGNS / SYMPTOMS
Wheezing presents early in life; poor weight gain, diarrhea, and recurrent sinus and pulmonary infections; nasal exam may reveal polyps. Cough is productive and "wet," suggesting a suppurative process such as bronchiectasis; there may be a family history of bronchiectasis.
INVESTIGATIONS
Sweat chloride test; chest radiograph may reveal bronchiectasis but CT scan is more sensitive.
Acute COPD exacerbation
SIGNS / SYMPTOMS
Wheezing is diffuse, associated with increased mucus production and progressive dyspnea.
INVESTIGATIONS
Chest radiograph shows peribronchial cuffing and hyperinflation but does not rule out foreign body aspiration. Pulmonary function tests reveal obstructive ventilatory impairment.
Croup
SIGNS / SYMPTOMS
Seen in children from 6 months to 3 years old. The cough is characteristically described as having a barky, seal-like pattern and is often accompanied by stridor and chest wall or sternal indrawing. Symptoms are typically worse at night and increase with agitation.
INVESTIGATIONS
Diagnosis made on clinical grounds. Subglottic edema may be seen on radiograph or at laryngoscopy if performed.
Epiglottitis
SIGNS / SYMPTOMS
Patient may have high fever, sore throat, dysphonia, muffled voice, drooling, and dysphagia in addition to stridor and dyspnea. The child may assume the "tripod position" - sitting up with the neck extended and leaning forward with the jaw thrust out.
INVESTIGATIONS
Lateral neck radiograph can show the swollen epiglottis and aryepiglottic folds "thumb sign," but should be done only in case of doubt and after the airway is secured.
Central airway obstruction
SIGNS / SYMPTOMS
Wheezing is slowly progressive and unilateral in cases of obstruction distal to the main carina. Neonatal onset of cough suggests congenital tracheobronchomalacia.
INVESTIGATIONS
Chest radiograph may show tracheal or bronchial narrowing; chest CT scan provides detail about the mediastinum and is able to localize and quantify the degree of airway obstruction.
Infectious pneumonia
SIGNS / SYMPTOMS
Fever, rales, tachypnea, and cough productive of frothy or purulent sputum may occur if infection supervenes after foreign body aspiration.
INVESTIGATIONS
Chest radiograph may show lobar consolidation.
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