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Pulmonary diseases account for almost 50% of deaths in children younger than 1 year and about 20% of all hospitalizations of children younger than 15 years. Approximately 7% of children have a chronic respiratory disorder. Understanding the pathophysiology of many pediatric pulmonary diseases is enhanced by an appreciation of the normal growth and development of the lung.
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Normal fetal lung development progresses through five stages (embryonic, pseudoglandular, canalicular, saccular, alveolar) with considerable overlap in the timing of each stage. Interruption of the sequence leads to significant neonatal pulmonary difficulties that may be lifelong. The normal human term newborn infant does not have a full complement of alveoli at birth, usually 100–150 million; this will increase with normal growth to the adult number of 300–600 million alveoli. Infants born prematurely may have difficulty transitioning from fetal life to air breathing due to incomplete alveolarization. This may be accentuated by additional stresses such as higher altitude, suboptimal nutrition, poor air quality, or infections.
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Schittney
JC: Development of the lung. Cell Tissue Res 2017;367:427–444. doi: 10.1007/s00441-016-2545-0
[PubMed: 28144783]
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PHYSICAL EXAMINATION OF THE RESPIRATORY TRACT
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The complete pulmonary examination includes inspection, palpation, auscultation, and percussion. Inspection of respiratory rate and work of breathing is critical to the detection of pulmonary disease. Tachypnea, decreased sensorium, inconsolability, increased respiratory effort, retraction, poor color, and reduced movement suggest hypoxemia. Palpation of tracheal position, symmetry of chest wall movement, and vibration with vocalization can help in identifying intrathoracic abnormalities. A shift in tracheal position from midline suggests pneumothorax or significant unilateral atelectasis. Tactile vibrations (fremitus) may change with consolidation or air in the pleural space. Auscultation should assess the intensity and symmetry of breath sounds and the presence of abnormal sounds such as fine or coarse crackles, wheezing, or rhonchi. Wheezing or prolonged expiration suggests intrathoracic airways obstruction. Knowing the lung anatomy helps identify the location of the pathology (Figure 19–1). Percussion may identify tympanic or dull sounds that can help define an effusion or pneumothorax but can be challenging in young children.
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Acute findings such as cyanosis and altered mental status or chronic signs of respiratory insufficiency including growth failure and digital clubbing suggest pulmonary disease. Evidence of cor pulmonale (loud pulmonic component of the second heart sound, hepatomegaly, elevated neck veins, and, rarely, peripheral edema) signifies pulmonary hypertension and may accompany advanced lung disease.
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Respiratory disorders can be secondary to disease in other systems. It is therefore important to look for other conditions ...