2025 – PAGE 428 – PULMONOLOGY

BIPHASIC STRIDOR

Biphasic stridor means there’s inspiratory AND expiratory stridor. Can be a glottic or subglottic obstruction.

PEARL: If you see the word STENOSIS, think biphasic stridor since the air struggles to get in and out due to this “fixed obstruction.”

• SUBGLOTTIC STENOSIS: This classically presents in children as a BIphasic stridor, because it’s a fixed obstruction.
  • PEARL: There is a STRONG association with previous intubation!
• EPIGLOTTITIS: Not all children will have stridor, if they do, look for it to be biphasic. Note that this is a SUPRAglottic stenosis. Look for the drool and the thumbprint sign (see ID). Also look for immigrant status or missed immunizations (H. flu).

CONGENITAL PULMONARY DISEASE

CONGENITAL DIAPHRAGMATIC HERNIA

If a congenital diaphragmatic hernia is noted on a prenatal ultrasound, the baby should be INTUBATED at birth because it can result in early respiratory distress due to pulmonary hypertension. Children can have problems for days to weeks, and this can even be fatal due to persistent pulmonary hypertension. Listen for decreased breath sounds on the left side since the bowel is in the left hemithorax. Chest X-ray will show a small, atelectatic right lung, and the heart may be pushed over, causing heart sounds to be heard on the right side of the sternum. These children often have a flat or scaphoid ABDOMEN.

CONGENITAL PULMONARY MALFORMATIONS

Consider one of these congenital pulmonary malformations in any child presenting with a recurrent unilateral pneumonia.

• CONGENITAL BRONCHOGENIC CYSTS: Most common cause of lung cysts. Usually found incidentally, and patients are typically asymptomatic.
• CONGENITAL CYSTIC ADENOMATOID MALFORMATION(CCAM, AKA CAM): This is a rare congenital, non-malignant mass (may have solid or semisolid components on imaging) that can be found in either side of the lungs. Presents with respiratory distress in the neonatal period. Usually an entire lobe of lung is replaced by a non-working cystic piece of abnormal lung tissue.
• CONGENITAL LOBAR EMPHYSEMA: Most common cause of neonatal pulmonary cysts.
• PULMONARY SEQUESTRATION(AKA INTRAPULMONARY SEQUESTRATION, AKA EXTRA­PULMO­NARY SEQUESTRATION): This is cystic OR solid lung tissue that does not connect to the tracheobronchial tree. It has its own blood supply and can be associated with recurrent pneumonias, a chronic dry cough, and wheezing in teenagers. The recurrent pneumonias are always on the same side. Surgical lobectomy is curative.