Downloaded from thorax.bmj.com on 10 October 2007
TABLE 2 Suggested indications for performing a chest radiograph in a child with acute cough Indication Uncertainty about the diagnosis of pneumonia.
Possibility of an inhaled foreign body
Pointers suggesting that this is a presentation of a chronic respiratory disorder Unusual clinical course
Features 1. Fever and rapid breathing in the absence of wheeze/stridor. 2. Localising signs in chest* 3. Persisting high fever or unusual course in bronchiolitis. 4. Cough and fever persisting beyond 4-5 days. Choking episode may not have been witnessed but cough of sudden onset or presence of assymmetrical wheeze or hyperinflation
1. failure to thrive 2. finger clubbing 3. over inflated chest 4. chest deformity 1. Cough is relentlessly progressive beyond 2-3 weeks. 2. Recurrent fever after initial resolution.
Is there true haemoptysis? ***
Likely common diagnoses Pneumonia. N.B. chest radiograph is not always indicated- use to resolve uncertainty or in more severe cases **
Inhaled foreign body. Expiratory film may help in acute bronchial obstruction, but normal chest radiograph does not exclude foreign body. Bronchoscopy is the most important investigation. See chronic cough section
Pneumonia. Enlarging intrathoracic lesion TB Inhaled foreign body Lobar collapse Acute pneumonia Chronic lung disorder eg CF Inhaled Foreign Body TB Pulmonary Haemosiderosis Tumour, AV malformation
*Dull percussion, reduced air entry, crackles or bronchial breathing. ** Community Acquired Pneumonia Guidelines (38-40) *** true haemoptysis needs to be differentiated from spitting out blood secondary to nose bleeds, cheek biting, pharyngeal and oesophageal or gastric bleeding.
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