2025 – PAGE 435 – PULMONOLOGY
NASAL FOREIGN BODY
Look for a nasal foreign body if a child presents with blood-tinged nasal mucus, unilateral purulence or “generalized body odor.”
FOREIGN BODY ASPIRATION
A child with a foreign body aspiration usually presents within 24 hours and is associated with decreased or abnormal breath sounds on one side. The object typically goes down the right bronchus. Can also present as a cough that doesn’t seem to want to go away in a patient who is mobile. Can eventually lead to a postobstructive pneumonia.
VOCAL CORD NODULES
Vocal cord nodules may present with a hoarse voice or cry that is BETTER in the morning and worse with use.
PEARL: Vocal cord paralysis would not change in character.
MNEMONIC: It’s like an overuse disorder. Have you ever had a lecturer that has voice fatigue towards the end of a lecture? Imagine him or her having vocal cord nodules.
CHRONIC COUGH
Workup for a chronic cough should include a chest X-ray, a sweat chloride test, and a PPD. If all are negative and the patient is > 6 years of age, the next step should be to get spirometry. Other considerations include pertussis, a foreign body, asthma, and a psychogenic cough (especially if it’s honk-like and disappears at night).
PNEUMOTHORAX
Look for a pneumothorax in a tall, thin adolescent who uses marijuana and presents with chest pain. Treat with 100% OXYGEN if it is small. If it’s large (> 15%), try a needle aspiration to see if that helps you get rid of the air between the lungs and the pleura. If not, place a chest tube.
PEARL: Pain DOES NOT dictate management. A small pneumothorax is very benign.
FLAIL CHEST
A flail chest occurs when ribs break and become detached from the chest wall. It is life-threatening since the flailing broken ribs can lead to a pneumothorax. Provide adequate analgesia, give oxygen, consider surgical repair, and consider a needle aspiration or chest tube if a pneumothorax develops.
BRONCHIECTASIS
In bronchiectasis, there is destruction of the bronchial tree leading to dilation that is often visible on chest X-rays. It can cause a cough and even hemoptysis. The cough is often worse with changes in position. It’s associated with cystic fibrosis, alpha-1 antitrypsin deficiency, and emphysema.