TO WHAT EXTENT IS THE SOCIAL PROBLEM THAT IS DISABILITY A MATTER OF PRIVATE CONCERN FOR THE FAMILY?

Disability excites interest because disability is seen as a social problem i.e. it is seen either in terms of personal tragedy or of blame. Social problems generate public concern and private misery and call for collective action to remedy this (Worsley, 1972). Disability has been theorised in a number of different ways, most of which locate the problem in the individual rather than the broader social, political, and economic influences. This has implications for the location of the blame for social problems, such that they become depoliticised. The rise in the idea of the politics of minority groups is well documented and implies that in the case of people with disabilities who are unable to work the Government should provide a whole range of services.

Because most Governments are unwilling to commit themselves this far, disability is again defined as a social problem, and often the burden of care lies with the family (Moore, 2002). This paper will give an account of definitions of disability and the ways in which they impact on disabled people. There will be an exploration of the concept and history of the family and its contemporary diverse forms, and an examination of the ways in which the ideology of the family has problematised the concept of care. The paper will then assess how the family has been implicated in both solving and defining the problem of disability and to what extent the social problem that is disability is a matter of private concern for families.

Models of Disability

The medical model of health is the most powerful in western society, doctors introduced a ‘curative’ model of health that concentrated on the body where the hospital became the space for such models were put into practice (Walsh et al, 2000). This model situates ill health in the individual and ignores the social circumstances that may give rise to ill health, furthermore it has impacted on government healthcare policy throughout the twentieth century. The situation is exacerbated by the medicalisation of many conditions making them into a problem that can only be addressed by experts, as Brisenden(1986) comments:

The problem … is that medical people tend to see all difficulties solely from the perspective of proposed treatments for a ‘patient’, without recognising that the individual has to weigh up whether this treatment fits into the overall economy of their life. In the past especially, doctors have been too willing to suggest medical treatment and hospitalisation, even when this would not necessarily improve the quality of life for the person concerned. Indeed, questions about the quality of life have sometimes been portrayed as something of an intrusion upon the purely medical equation. (Brisenden, 1986:176).

The medical model leads to the treatment of people with disabilities as passive objects of medical attention. This is oppressive of disabled people and spreads to other social relationships, it sees disability as pathological i.e. rooted in a person’s biology, and thus unchanging. Contained within this model is the perception of people with disabilities as problematic. Disability has also been theorized as a personal tragedy, resulting in individuals with a disability being seen as victims. This results in policy making whereby people with disabilities need compensating for their disability.

This model also affects social relationships. The view of disability as personal tragedy individualises disability so that it becomes depoliticised and the disabled person must make his or her adjustments to that disability as best they can (Dalley, 1990). In locating disability within the individual society denies any responsibility to cater for the diversity of their needs (Oliver, 1990). The third way in which disability has been theorized is in the social model of disability. This model is becoming increasingly dominant in research on disability. Vassey (1992) has described it thus:

redefining disability in terms of a disabling environment, repositioning disabled people as citizens with rights, and reconfiguring the responsibilities for creating, sustaining and overcoming disablism (Vassey, 1992:44)..

Here the person is disabled because of the refusal of society to provide for example suitable access for the wheelchair user. This model stresses that a disabling society leads to the exclusion of people with disabilities. Oliver (1996) contends that this notion has been politically empowering for disabled people, and has allowed a previously contested notion to develop an agenda that has influenced policy making. Some people see disability as entirely a result of social structures and processes while others feel that society compounds the difficulties that disabled people encounter. Disability is not a universal category, people have different types and degrees of impairment, some can function well with technical aids while still others are, to a greater or lesser degree, dependent on the care of other people (Dalley, 1988).

The Concept and History of the Family

Parsons (1955) argued that the family is the primary place of socialization and serves to introduce and instill the norms and values of society. Parsons model was what is commonly known as the nuclear family, i.e. parents and children living together to provide the mutual love and support that individuals need to be productive members of society (Giddens, 2001). Murdock (1949 cited in Giddens, 2001) maintains that traditional concepts of the family are a universal phenomenon. Others criticise the nuclear model for being too narrow and for neglecting the fact that not all family members experience life in the same way (Abbott and Wallace, 1997).

Whether the nuclear family is regarded as universal depends largely on how the family is defined, certainly it is no longer the norm in contemporary society. Gittins (1993) maintains that there are a wide variety of domestic relationships. Thus relationships may be universal but the forms they take can be infinitely variable. There are many single parent families, whether through death, divorce or choice, there are also second marriages that often result in reconstituted families. The nuclear model relates specifically to nineteenth and early twentieth century ideological views of the family (Giddens, 2001).

The Family and Ideology

Until the late seventeenth century there was little or no distinction between the public and the private sphere, families generally worked the land and they did this together. The rise of industrialization and the growth of the towns brought massive changes to what had constituted family life up until that time. Feminists argue that for centuries women have been the subordinate sex in society and this subordination is largely a result of the fact that they have been born women rather than men. This subordination increased with industrialisation and the separation between public and private spheres (Oakley 1982).

The coming of the factory meant that the family was replaced as the unit of production. The growing dependence of children, Oakley (1982) states, led to women’s increased dependence on men and their restriction to the private sphere. Throughout the nineteenth century there was a growing idealisation of the feminine. Women were regarded as both physically and emotionally weaker than men and unfit for the same roles.

Victorian ideology said that women were created to help men and should thus remain at home. This primarily affected the middle classes but as the century progressed the working class were also influenced by this ideology, locking women into the housewife role (Oakley, 1982). Murdock (1949 in Giddens, 2001) argued that gender roles are the natural result of the biological differences between men and women. Men’s superior strength and women’s childbearing capabilities make the sexual division of labour the most sensible way of organising society.

Delphy (1977) maintains that this results in sexual inequality. Gender differences are not innate but socially constructed to serve the interests of the socially dominant group. Delphy contends that women are a separate class because the categories of man and woman are political and economic, rather than eternal biological categories. Within the family particularly, women form a class who are exploited by men, as Delphy states:

While the wage-labourer sells his labour power, the marrie woman gives hers away; exclusivity and non-payment are intimately connected. To supply unpaid labour within the framework of a universal and personal relationship (marriage) constructs primarily a relationship of slavery (Delpy, 1977:15).

This relationship has been exploited by successive Governments and is implicit in many social policy initiatives.

The Family and the Welfare State

The post-war welfare state which promised universal welfare provision, was set up on the assumption of full employment and the notion that men would go out to work while women stayed home (Abbott and Wallace, 1997).. Moore (2002) maintains that this is an ideological view of the family and how it might function. In the late 1970s the Tories actively discouraged alternatives to the traditional family e.g. cohabitation and gay partnerships (Abbott and Wallace, 1997). Since the Thatcher Government public and policy debates on family life, parenting and health have centered around the idea of responsibility (Such and Walker 2004) Moore (2002) maintains that in the thinking of the seventies and also in Labour’s Third Way, family members have a duty to help each other as it is not the job of the state to look after them.

The state takes over when no-one else is around to share the burden. The fact that the State has had to intervene, it is argued, is one of the reasons why the traditional family is on the decline. In a good society members should help each other without regard to personal benefit. The State should be there to provide a safety net when there is no other help available. New Labour advocate a mixed economy of welfare where welfare is provided in part by the state and partly by private companies operating for profit.

The shift from public to private has received much publicity and contributed to social problems and to social exclusion. Previously highly subsidized, or universal, services have either become part of the private sector, or have been subject to means testing, some welfare provision has been handed over to voluntary organizations. This has increased the likelihood that welfare and caring are now a private rather than a public responsibility (Giddens, 2001). This tends to stigmatise further those who are forced to rely on benefits, e.g. the disabled and their carers, usually women.

The State and Women’s Caring Role

Marxist feminists e.g. Walby (1990) argue that the gender ideology that has filtered down to the working classes has affected their solidarity as a class and this makes them more easily controllable by the Capitalist system. While Marxism gives an explanation of exploitation by the capitalist system it does not explain the inequalities between women and men. Delphy (1977) maintains that gender and sexual inequality should be the fundamental categories of feminist analysis. Marxism alone does not explain for example why women are seen as responsible for household tasks. Capitalism could still profit if men stayed at home. The Community Care Act of 1990 has imposed further responsibilities on women in the role of informal carers.

Dalley (1988) argues that much Government’s policy making has been based on ideologies of caring with the assumptions behind the idea of community care being based on outmoded notions of the family. In practice this notion of caring disadvantages women carers and also many disabled or older dependent relatives. Within such an ideology, the caring that women do in the home is considered to be a natural part of women’s role within the family. Thus, her caring role become invisible and shouldering the burden increases the likelihood that women will themselves be in need of care (Graham, 1993).

This is borne out by the increasing number of women who suffer from disabilities and mental health problems. Women’s caring role is further undermined by the idea that any health care that matters is given by professionals. When this is accompanied by Government discourses of self-help, self-reliance and the responsibility of the family this adds to the social stigma that disabled people face. It focuses on the disability, not the person themselves, inevitably this places an added strain on families. The prevalence of the medical model of health and the ways in which families are kept under-informed regarding the disability of a family member, particularly a child, affects family relationships. Gregory (1991) maintains that when a person is diagnosed as ‘diabled’ this affects the ways in which society and the family respond to and deal with that person.

Families themselves can tend to see the disabled family member as ‘sick’ and different. Gregory (1991) found that having a disabled family member also affected the way in which mother’s viewed themselves because ideological images of motherhood focus on having an able child. Thus a woman may feel that she is somehow not a mother because of the ways in which society defines motherhood. Press reports on disabled children and their families usually present them in terms of sacrifice and heroism (Gregory, 1991). This can affect family members response to the disabled person, their forced reliance on the medical model, and the view of disability as a tragedy becomes universalized. This misses the individual’s personal needs and circumstances. It seems that increasingly the social problem of disability is becoming a matter of private concern for the family. The NHS appears to take this view. While doctors may diagnose a physical or learning disability families are often left to cope without either sufficient information or professional help. In a number of cases families have reported that hospitals have refused to admit non-emergency cases unless a parent or carer remains on site to provide additional support (http://www.cafamily.org.uk/rda-uk.html). A shortage of nursing staff and the increasing tendency to perform surgery on a day care basis means that many families are left with extra caring responsibilities once they take the disabled child or adult home. (http://www.cafamily.org.uk/rda-uk.html).

Conclusion

Ideologies of the family and the medical model of disability exacerbate the social problems of disability. Discourses of family responsibility place a much greater burden on many people, particularly women who bear the burden of responsibility of care. Such discourses tend to make women who find it difficult to cope feel that they are a failure. This in turn reflects back on the disabled person who may feel that they are a burden. Clearly current policies and debates over partnership between the Government and families and family responsibility is moving closer to the view that disability is no longer a public concern but a private family one. Dalley (1988) argue that some form of institutional care e.g. supported living should replace care in the family. While there are support structures in place for people with disabilities, the extent to which informal carers have access to such facilities is very limited (Baldwin and Twigg, 1990).. Perhaps supported living arrangements along with family involvement in personal care would, arguably, take some strain off of the family and give more independence to the person with disabilities thus making the social problem of disability a shared public and private concern rather than simply a concern for the family.

Bibliography

Abbott, P. and Wallace, C. 1997. An Introduction to Sociology: Feminist Perspectives. London, Routledge.

Baldwin, S and Twigg, J. 1991 Women and community care: Reflections on a debate in Maclean, M and Groves, D eds 1991 Women’s Issues in Social Policy London, Routledge

Crowe, G. and Hardey,M.1992. Diversity and ambiguity among lone-parent households in modern Britain. In Marsh, C. and Arber, S. (Eds.) 1992. Families and Households: Divisions and Change. London: Macmillan. Dalley, G. 1988 Ideologies of caring: Rethinking Community and Collectivism London, Macmillan

Delphy, C 1977 The Main Enemy London, Women’s Research and Resource Centre

Giddens, A. 2001. (4th ed). Sociology. Cambridge, Polity Press.

Gittens, D. 1993 The Family in Question: Changing households and familial ideologies London, Macmillan

Graham, H. 1993 Hardship and Health in Women’s Lives Hemel Hempstead, Harvester/Wheatsheaf

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Oliver, P. 1990 The Politics of Disablement Basingstoke, Macmillan

Oliver, M 1996 Social Work with Disabled People Basingstoke Macmillan.

Such, E. and Walker, R. 2004 Being responsible and responsible beings: children’s understanding of responsibility Children and Society 18 (3) Jun 2004, pp.231-242

Swain, J. Heyman, B and Gilmour, M 1998 Public Research, private concerns: Ethical issues in the use of open-ended interviews with people who have learning disabilities in Disability and Society 13 (1) pp. 21-36

Thomas, C. eds 2004 Disabling Barriers, Enabling Environments London, Sage

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Introduction

Respiratory disorders are the commonest causes of morbidity and mortality among children of all ages. The presentation may vary from trivial to life threatening symptoms. While a carefully conducted history and physical examination are vital for a correct diagnosis, various laboratory and radiological investigations aid in finally clinching the diagnosis.

This chapter focuses on clinical assessment of the respiratory system in children. There is much overlap between the respiratory examination and that of other systems, and it is assumed that the reader has mastered basic physical examination skills.

History

The evaluation of a child with respiratory disorder should start with the history of present illness, significant past history, family history as well as antenatal and birth histories. The parent should be asked the chief complaint that prompted the consultation, along with the circumstances at onset, frequency, duration, and severity. History of prior treatment should be obtained. History of past illness will include all previous respiratory and other complaints. These include history of recurrent pneumonia (suggesting immunodeficiency, cystic fibrosis, anatomic abnormality, or bronchiectasis) known allergy and malnutrition. The family/ environmental history will provide information about history of contact or that suggestive of asthma in relatives, nutritional and financial status of the family, and history of exposure to allergens. Following are important clinical pointers in the history:

1. Recurrent pneumonia: points towards immunodeficiency, cystic fibrosis, anatomic abnormality (gastroesophageal reflux), dysfunctional swallowing, or bronchiectasis. The child with a history of tracheoesophageal fistula repair is prone to tracheomalacia and gastroesophageal reflux–related disease.
2. Atopy: eczema, atopic dermatitis, hay fever, or known allergies, may be important in the child with chronic cough or recalcitrant asthma.
3. Failure to thrive, frequent infections, blood product transfusion, parental substance abuse, or poor growth may be a clue to an underlying immunodeficiency.
4. History of contact with a case of tuberculosis
5. Environmental history: exposure to dust due to construction in the house/neighbourhood, presence of pet animals or birds, exposure to smoke, either from tobacco use or use of wood for heating, cooking, or both.
6. Associated complaints: Headache may be a sign of sinus disease or, especially if occurring in the early morning, a result of obstructive sleep apnea.

Ocular symptoms such as conjunctivitis and blepharitis, as well as nasal symptoms, may indicate an atopic predisposition or in the young infant a chlamydial infection. Recurrent mouth ulcers or thrush can be associated with immunodeficiency, as may chronic or recurrent ear drainage. Poor feeding, edema, shortness of breath, and exercise tolerance can be clues to the presence of congestive heart failure. Stool characteristics, abdominal bloating, and fatty food intolerance are important features of cystic fibrosis. Neurologic symptoms such as seizures or developmental delay are important in evaluating the child with apparent life-threatening events or suspected chronic or recurrent aspiration.

PHYSICAL EXAMINATION

A thorough general physical examination is extremely important in the approach to a child with respiratory disorder. Recording the anthropometry is as important as are the presence of cyanosis, pallor and clubbing. Use of accessory muscles of respiration may indicate severity of respiratory distress and intercostal recession may point towards airway obstruction and a non-compliant lung. Supraclavicular and cervical lymph nodes should form part of the exanination routinely.

Upper Airway

An examination of the upper airway will indicate presence of nasal foreign body or infection, tonsillar enlargement, or narrowing of the glottis. The position of the trachea should be noted during examination of the neck. Deviation to one side may be seen with pneumothorax, neck mass, unilateral pulmonary agenesis or hypoplasia, or unilateral hyperinflation (as seen with foreign body or congenital cystic lung disorders).

Chest

Inspection

Inspection forms the first component of chest examination. Presence or absence of any deformity should be noted, as should the general shape of the chest. A barrel chest (increased anteroposterior dimension) denotes obstructive lung disease. The severity of this deformity shows increased lung volumes (functional residual capacity, residual volume, total lung capacity, functional residual capacity/total lung capacity ratio, and residual volume/total lung capacity ratio) and is associated with radiographic findings of hyperinflation in children with poorly controlled asthma. Pectus carinatum (“pigeon breast”) or pectus excavatum (“funnel chest”) may be seen in patients who have chronically increased work of breathing, as in pulmonary fibrosis, cystic fibrosis, or poorly controlled asthma. The respiratory rate, preferably noted with the child at rest or asleep, is a very important indicator of pulmonary illness (though fever and metabolic acidosis can have an increased respiratory rate in the absence of pulmonary disease).

Nasal flaring to reduce nasal resistance to airflow and the use of accessory muscles of respiration such as the sternocleidomastoid muscles indicates respiratory distress as do retractions or indrawing of the skin of the neck and chest. Respiratory distress may also be seen in children with neuromuscular disorders. An objective way of assessing the degree of dyspnea is asking the child to count and noting the highest number reached in a single breath.

The respiratory pattern and depth may also point towards a particular pathology. Shallow and rapid respiration is seen in children with restrictive lung disease. Similarly, rapid and deep respiration (hyperpnea), can be seen in children with hypoxia and metabolic acidosis while alkalosis results in slow, shallow breaths. Hyperpnea alternating with apnea (Biots respiration) is associated with central nervous lesions involving the respiratory centers. Cheyne-Stokes respirations seen in comatose patients is marked by gradually increasing and decreasing respirations.

Likewise, the relative length of the respiratory phases (the inspiratory/expiratory ratio) is important. As the inspiratory and expiratory phases are roughly equal, a prolonged expiration may indicate obstructive diseases such as bronchiolitis, acute exacerbations of asthma, and cystic fibrosis. While some abdominal breathing, is normal up to 6 or 7 years of age, conspicuous respirations of this type in a child, however, generally reflect a pulmonary abnormality such as pneumonia, or respiratory muscle weakness.

Palpation:

Although more generally thought of in terms of the abdominal examination, palpation is important in the respiratory examination as well. It is used to confirm the visual observations of chest wall shape and excursion. Palpation is performed by placing the entire hand on the chest and feeling with the palm and fingertips. Friction rubs may be felt as high-frequency vibrations in synchrony with the respiratory pattern. Tactile fremitus, the transmission of vibrations associated with vocalization, is at times difficult to assess in children because of a lack of cooperation and a higher-pitched voice; lower-pitched vocalization is more effectively transmitted. It is best felt with the palmar aspects of the metacarpal and phalangeal joints on the costal interspaces. Decreased fremitus suggests airway obstruction, pleural fluid, or pleural thickening, whereas increased fremitus is associated with parenchymal consolidation. Occasionally a “thud” can be felt high in the chest or in the neck, a finding suggestive of a free tracheal foreign body. One can also assess chest excursion by placing the hands with the fingertips anterior and thumbs posterior and noting the degree of chest wall movement, comparing excursion of one side with the other by noting the movement of the thumbs away from the midline (the spinous processes). The point of maximal impulse, frequently shifted to the left in cardiac disease, may be shifted inferiorly and to the right in severe asthma, a large left-sided pleural effusion, or a tension pneumothorax. With massive left-sided atelectasis, it may be shifted to the left.

Percussion

:

Percussion should be performed with the child upright with the head in neutral position, and using the indirect method (a single finger from one hand strikes on a finger of the other hand placed on an interspace). A gentle force should be used so as to avoid causing injury, especially in a young child). Sounds commonly elicited by percussion of the chest are as follows:

• Tympany : Normally heard with percussion of the abdomen, is seen in the chest with a massive pneumothorax.
• Resonance: This is the normal state in the chest; it is sometimes called
  
  vesicular resonance.
  
• Hyperresonance: Accentuation of the normal percussion is seen with states of hyperinflation like emphysema, asthma, or free intrapleural air.
• Coin test: A resonant metallic sound heard with a stethoscope when tapping a coin that is held flat against the chest with another coin; it indicates a pneumothorax.
• Dullness: A flat, thud-like sound, this sound is associated with pleural fluid or parenchymal consolidation.
• Flatness: This sound can be mimicked by percussing over muscle; its presence in the chest suggests massive pleural effusion.

Auscultation:

Auscultation of the chest should be performed with the age appropriate stethoscope (with chest pieces for premature infants, infants, children, and adolescents/adults). The diaphragm of the chest piece (pressed tightly against the skin) is used to filter out low-pitched sounds, thereby isolating high-pitched sound, and the bell (held lightly on the chest) is used preferentially to isolate low-pitched sounds.

The upper lobes are best heard by listening anteriorly in the infraclavicular regions, the lower lobes by listening posteriorly below the scapulae, and the right middle lobe and lingula by listening anteriorly lateral to the lower third of the sternum. All lobes can be heard in the axillae.

It is also important to specify the timing (continuous, early, or late), pitch (high, medium, or low), and character (fine, medium, or coarse) of sounds. These sounds can be divided into breath sounds (produced by the movement of gas through the airways), voice sounds (modifi cations of phonation not heard distinctly in the normal state), and adventitious sounds (neither breath or voice sounds).

Breath Sounds

Vesicular breath sounds are the sounds heard during respiration in a healthy individual. They are low-pitched, with a relatively longer inspiratory phase and a shorter expiratory phase and are louder on inspiration. These sounds emanate from the lobar and segmental airways and are then transmitted through normal parenchyma.

Bronchial breath sounds are usually louder than vesicular sounds and have short inspiratory and long expiratory phases. They are higher pitched and louder during expiration. They may be the result of consolidation or compression (i.e., airlessness) of the underlying parenchyma. A similar sound can be heard by listening directly over the trachea.

Bronchovesicular breath sounds, as the name implies, are intermediate between vesicular and bronchial sounds. The respiratory phases are roughly equal in length. This sound is felt to be indicative of a lesser degree of consolidation or compression (airlessness) than bronchial sounds. Bronchovesicular (and sometimes bronchial) breath sounds can occasionally be heard in normal individuals in the auscultatory triangle (the area in the back bound by the lower border of the trapezius, the latissimus dorsi, and the rhomboideus major muscles) and the right upper lobe.

Wheezes are continuous musical sounds, more commonly expiratory in nature, and usually associated with short inspiratory and prolonged expiratory phases. They can be of single (monophonic) or multiple (polyphonic) pitches, which are higher pitched than vesicular sounds. These can often be very difficult to distinguish from snoring and upper airway sounds such as stridor.

Stridor is a musical, monophonic, often high-pitched sound, usually thought of as inspiratory in nature; it can be expiratory as well, such as when produced by partial obstruction of a central, typically extrathoracic airway. Its presence in both inspiration and expiration suggests severe, fixed airway obstruction.

Voice Sounds

The normal lung parenchyma filters vocalization so that whispered sounds are not usually heard during auscultation and normally spoken syllables are indistinct. Bronchophony is the distinct transmission of spoken syllables as the result of an underlying consolidation or compression. More severe consolidation or compression results in the transmission of whispered sounds or whispered pectoriloquy. Egophony is very similar to bronchophony but has a nasal quality as well. It may reflect an underlying effusion, consolidation or compression, or both conditions.

Adventitious Sounds

Fine crackles are thought to be the result of the explosive reopening of alveoli that closed during the previous exhalations. These occur exclusively during inspiration and are associated with conditions such as bronchitis, pneumonia, pulmonary infarction, and atelectasis. They can also be normal when heard in the posterior lung bases during the first few breaths on awakening. They may be imitated by rolling several strands of hair between the thumb and forefinger in front of the ear or by pulling apart Velcro. Hamman’s sign, also called a

mediastinal crunch,

is the finding of crackles associated with systole and is suggestive of pneumomediastinum.

Coarse crackles are popping sounds likely produced by the movement of thin fluids in bronchi or bronchioles. They occur early in inspiration and occasionally in expiration as well, may be audible at the mouth, and may clear or change pattern after a cough. They can sometimes be heard in the anterior lung bases during exhalation to residual volume. An example of these sounds is the crackles typically heard in patients with cystic fibrosis. Rhonchi (sometimes more descriptively called

large airway sounds

) are gurgling or bubbling sounds usually heard during exhalation. These sounds are the result of movement of fluid within larger airways. In individuals with pleural inflammation, a pleural friction rub may be heard. This loud, grating sound may come and go over a short period of time. It is usually associated with a subpleural parenchymal inflammatory process.

OTHER SIGNS AND SYMPTOMS

Clubbing:

Clubbing is the broadening and thickening of the ends of the fingers and toes that occur as the result of connective tissue hypertrophy and hyperplasia and increased vascularity in the distal phalanges, in response to chronic hypoxia. It can be confirmed clinically by checking for Schamroth’s sign. Causes of clubbing are as follows:

• Bronchiectasis
• Severe pneumonia, lung abscess, or empyema
• Interstitial lung disease (autoimmune and infectious)
• Pulmonary arteriovenous malformation
• Hepatopulmonary syndrome
• Pulmonary malignancy
• Cyanotic congenital heart disease
• Bacterial endocarditis
• Inflammatory bowel disease
• Thyrotoxicosis
• Familial

Cyanosis:

The use of cyanosis as a clinical indicator of hypoxemia is confounded by a number of factors such as skin pigmentation, poor lighting, the presence of nail polish, or hypothermia. Cyanosis occurs when the concentration of reduced arterial hemoglobin exceeds 3 g/dL. Clinical impression of cyanosis should be verified by arterial blood gas analysis or pulse oximetry.

Pulsus paradoxus:

Pulsus paradoxus (fluctuation in systolic blood pressure with respiration) may sometimes be associated with obstructive pulmonary disease. The arterial pressure falls during inspiration and rises with exhalation. It is quantified as the difference between the systolic pressures measured during inspiration and expiration. Pulsus paradoxus is useful in evaluating children with cystic fibrosis and asthma, in which a value of more than 15 mm Hg has been found to

INVESTIGATION: