eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Reactive Airway Disease: Differential Diagnoses & Workup

Author: Eric S Chin, MD, Consulting Staff, Department of Emergency Medicine, Kaiser Permanente Hospital, South San Francisco
Contributor Information and Disclosures

Updated: Jun 30, 2009

Differential Diagnoses

Anaphylaxis
Pediatrics, Respiratory Distress Syndrome
Pediatrics, Anaphylaxis
Pneumonia, Aspiration
Pediatrics, Croup or Laryngotracheobronchitis
Pediatrics, Foreign Body Ingestion
Pediatrics, Pneumonia

Other Problems to Be Considered

Cystic fibrosis
Enlarged mediastinal mass
Gastroesophageal reflux (GER)
Laryngeal webs
Roundworms
Tracheoesophageal fistula
Vascular rings
Ventricular septal defect (VSD)

Workup

Laboratory Studies

  • A complete blood count (CBC) may be indicated for a suspected viral infection (lymphocytosis, leukopenia), parasitic infection (eosinophilia), or hemosiderosis.
  • An arterial blood gas (ABG) determination should be performed for any patient in status asthmaticus to check for hypoxia, hypercarbia, or acidosis; alternatively, a venous blood gas measurement can be used to assess for hypercarbia and acidosis and combined with pulse oximetry monitoring.
  • An assessment of electrolyte levels may reveal hypokalemia in patients who are using albuterol.
  • Although theophylline is prescribed less frequently, a theophylline level is useful for those on the drug.

Imaging Studies

  • Routine radiography does not need to be part of the initial routine workup of asthma.9  
  • Consider chest radiography if increased temperature, absence of family history of asthma, and the presence of localized wheezes or rales.
    • Hyperinflation
    • Peribronchial thickening
    • Atelectasis
    • Radiographs may provide evidence of foreign body, associated vascular anomalies, cardiac enlargement, pulmonary hypertension, infiltrates, or masses. 

Other Tests

  • All chronically wheezing infants and children with chronic asthma should have a sweat chloride test for cystic fibrosis at a subsequent primary care provider (PCP) visit or during inpatient evaluation.
  • A tuberculosis skin test may be indicated if significant risk factors exist.
  • Allergy testing
  • Exercise tolerance testing

Procedures

  • Spirometry (decreased forced expiratory volume in one second [FEV1])
    • Bedside spirometry is the primary procedure for children with RAD who are older than 5 years.
    • Patients with decreased FEV1 require further evaluation and treatment.
  • A barium swallow may be indicated to determine any esophageal, pulmonary, or vascular pathology, particularly a tracheoesophageal fistula.
  • Bronchoscopy (rarely indicated) Table 1. Peak Flow Rates in Liters per Minute10

    Open table in new window

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    Table
    Height in
    Inches    		Average
    Rate    		Range*Height in
    Inches    		Average
    Rate    		Range*
    40150110-19056330240-420
    41160115-20557340240-420
    42170120-22058360260-460
    43180130-22059375270-480
    44190135-24560390280-500
    45200145-25561400290-510
    46210150-27062415300-530
    47220160-28063430310-550
    48230165-29564445320-570
    49240175-30565460330-590
    50250180-32066480345-615
    51260190-33067500360-640
    52270195-34568515370-660
    53280200-36069530380-680
    54300215-38570550395-705
    55315225-40571570410-730
    Height in
    Inches    		Average
    Rate    		Range*Height in
    Inches    		Average
    Rate    		Range*
    40150110-19056330240-420
    41160115-20557340240-420
    42170120-22058360260-460
    43180130-22059375270-480
    44190135-24560390280-500
    45200145-25561400290-510
    46210150-27062415300-530
    47220160-28063430310-550
    48230165-29564445320-570
    49240175-30565460330-590
    50250180-32066480345-615
    51260190-33067500360-640
    52270195-34568515370-660
    53280200-36069530380-680
    54300215-38570550395-705
    55315225-40571570410-730

    *Includes 95% of white males aged 7-20 years.Derived and adapted from J Pediatr 1979;95:192-6.
  • Peak expiratory flow (PEF) is the most common form of pulmonary function test monitoring. Record the best of 3 attempts. Possible life-threatening asthma exacerbation with PEF predicted of less than 30%; severe exacerbation, with less than 50%; and moderate exacerbation, with less than 80%.

More on Pediatrics, Reactive Airway Disease

Overview: Pediatrics, Reactive Airway Disease
Differential Diagnoses & Workup: Pediatrics, Reactive Airway Disease
Treatment & Medication: Pediatrics, Reactive Airway Disease
Follow-up: Pediatrics, Reactive Airway Disease
Multimedia: Pediatrics, Reactive Airway Disease
References
Further Reading
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Further Reading

Clinical guidelines

 Managing asthma long term in children 0-4 years of age and 5-11 years of age. In: National Asthma Education and Prevention Program (NAEPP). Expert panel report 3: guidelines for the diagnosis and management of asthma. Bethesda (MD): National Heart, Lung, and Blood Institute; 2007 Aug. p. 281-325.

Global Initiative for Asthma (GINA), National Heart, Lung and Blood Institute (NHLBI). Global strategy for asthma management and prevention. Bethesda (MD): Global Initiative for Asthma (GINA), National Heart, Lung and Blood Institute (NHLBI); 2007. 92 p.

Managing exacerbations of asthma. In: National Asthma Education and Prevention Program (NAEPP). Expert panel report 3: guidelines for the diagnosis and management of asthma. Bethesda (MD): National Heart, Lung, and Blood Institute; 2007 Aug. p. 373-417.

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Keywords

reactive airway disease in children, asthma, pediatric asthma, exercise induced asthma, exercise-induced asthma, asthma treatment, asthma assessment, asthma symptoms, asthma triggers, asthma causes, bronchospasm, obstructive airway disease, childhood asthma, hypersensitivity reaction, wheeze, wheezing, RAD, airway inflammation, upper respiratory infection, tachypnea, dyspnea, cyanosis, intercostal retractions, nasalpolyps, nasal secretions, diaphoresis, hyperresonance, pulsus paradoxus, decreased peak expiratory flow rate, pectus carinatum, clubbing, subcutaneous emphysema, respiratory syncytial virus infection, RSV infection, Mycoplasma pneumoniae, pet dander, cockroach allergen, dust mite allergen, molds, pollen, weather changes, bronchiolitis, gastroesophageal fistula, cystic fibrosis

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Contributor Information and Disclosures

Author

Eric S Chin, MD, Consulting Staff, Department of Emergency Medicine, Kaiser Permanente Hospital, South San Francisco
Disclosure: Nothing to disclose.

Medical Editor

Debra Slapper, MD, Consulting Staff, Department of Emergency Medicine, St Anthony's Hospital
Debra Slapper, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center
Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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