Doctor123.org

Dyspnea, Pediatric

Basics

Description

- Respiratory - Upper airway - Infection (croup, tracheitis, peritonsillar abscess, epiglottitis) - Foreign body - Anaphylaxis - Anatomic abnormalities - Vocal cord dysfunction (VCD)

- Chest wall disorder - Neuromuscular weakness (Duchenne muscular dystrophy [DMD], spinal muscular atrophy [SMA]) - Scoliosis - Pectus excavatum

- Cardiovascular - Cardiac - Elevated pulmonary venous pressure - Congestive heart failure (CHF)

- Onset - Recurrent, discrete episodes associated with anxiety - Sudden - Foreign body, pneumothorax

- Hemoptysis - Worse when supine

- Temporal association - Exercise-induced - VCD, asthma, deconditioning, GERD

- Nocturnal - Persistent and progressive - Neuromuscular disease, ILD

- Infectious signs and symptoms - Fever, cough, rhinorrhea - Stridor, cough, rapid onset - Croup, tracheitis, abscess, epiglottitis

- Gastrointestinal signs and symptoms - Choking, gagging with feeds - Epigastric pain, discomfort

- Vital signs, oxygen saturation, temperature - Fever - Hypoxia suggestive of pulmonary and cardiac causes

- Weight, BMI - Breath sounds - Generalized decreased air entry - Bronchoconstriction, atelectasis

- Localized decreased intensity - Pneumothorax, pleural effusion, local obstruction, elevated hemidiaphragm, foreign body, pneumonia

- Egophony, bronchial breath sounds - Wheezing - Bronchoconstriction, foreign body, bronchiolitis

- Cardiac exam - Crackles, peripheral edema, hepatomegaly, gallop - Loud P2

- Extremities - Clubbing - Chronic pulmonary/cardiac disease

- Head and neck - Pharyngeal cobblestoning - Allergic shiners, nasal crease, swollen nasal turbinates - Rhinorrhea - Allergic rhinitis, infection

- Complete blood count with differential - Anemia; leukocytosis with left shift is a sign of infection.

- Glucose - Hyperglycemia can lead to diabetic ketoacidosis (DKA).

- Lung volumes - Restrictive lung disease (ILD, neuromuscular and chest wall diseases)

- Diffusion capacity - Mean inspiratory and expiratory pressure - Neuromuscular disease/weakness

A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity пїЅ

Pathophysiology

Abnormality in one of the following elements: пїЅ

  • Respiratory controller (breathing rate, depth)
  • Ventilatory pump (chest wall, pleura, airways)
  • Gas exchanger (alveoli, capillaries)
  • Cardiovascular derangements (cardiac output)

Etiology

  • RespiratoryUpper airwayInfection (croup, tracheitis, peritonsillar abscess, epiglottitis)Foreign bodyAnaphylaxisAnatomic abnormalitiesVocal cord dysfunction (VCD)Lower airwayAsthmaAspirationAirway malaciaHemorrhageInternal/external fixed compression (tumor, cyst, vascular)Parenchymal lung diseaseInfection (viral, bacterial, fungal)Interstitial lung disease (ILD)AtelectasisChronic lung disease (chronic obstructive pulmonary disease [COPD], cystic fibrosis)Chest wall disorderNeuromuscular weakness (Duchenne muscular dystrophy [DMD], spinal muscular atrophy [SMA])ScoliosisPectus excavatumPleuralPleural effusionPneumothorax
  • CardiovascularCardiacElevated pulmonary venous pressureCongestive heart failure (CHF)VascularPulmonary hypertension (PHTN)Pulmonary embolism (PE)
  • Toxic/metabolicMetabolic acidosis (diabetic ketoacidosis, salicylate intoxication, renal tubular acidosis [RTA])Renal failure causing fluid overload
  • OtherAnemiaDeconditioningObesityPanic attackPregnancyTraumaGastroesophageal reflux disease (GERD)

Diagnosis

Approach to Patient

  • Secure the airway and address life-threatening emergencies.
  • Identify those who will need intensive/emergency care and those who can be worked up in the office.
  • Distinguish new-onset dyspnea from deterioration of chronic disease.
  • Detailed history is key to diagnosis.

History

  • OnsetRecurrent, discrete episodes associated with anxietySuddenForeign body, pneumothorax
  • Associated signs and symptoms"Tightness"пїЅBronchoconstriction (asthma)StridorWheezingChest painPneumothorax, PE, pleural effusionHemoptysisWorse when supine
  • Temporal associationExercise-inducedVCD, asthma, deconditioning, GERDNocturnalPersistent and progressiveNeuromuscular disease, ILD
  • Infectious signs and symptomsFever, cough, rhinorrheaStridor, cough, rapid onsetCroup, tracheitis, abscess, epiglottitis
  • Gastrointestinal signs and symptomsChoking, gagging with feedsEpigastric pain, discomfort
  • Exposures
  • PE risk factors include immobilization, surgery, smoking, pregnancy, central catheter, history of deep vein thrombosis
  • History of cardiac disease
  • Diabetes historyPolyuria, polydipsia, polyphagia

Physical Exam

  • Vital signs, oxygen saturation, temperatureFeverHypoxia suggestive of pulmonary and cardiac causes
  • Weight, BMI
  • Breath soundsGeneralized decreased air entryBronchoconstriction, atelectasisLocalized decreased intensityPneumothorax, pleural effusion, local obstruction, elevated hemidiaphragm, foreign body, pneumoniaEgophony, bronchial breath soundsWheezingBronchoconstriction, foreign body, bronchiolitisCracklesInfection, ILD (especially if crackles don't clear with coughing)Barking quality of coughStridor
  • Cardiac examCrackles, peripheral edema, hepatomegaly, gallopLoud P2
  • ExtremitiesClubbingChronic pulmonary/cardiac diseaseCyanosisCalf tenderness
  • MusculoskeletalGeneralized muscle weaknessDMD, SMA, other neuromuscular diseases
  • Head and neckPharyngeal cobblestoningAllergic shiners, nasal crease, swollen nasal turbinatesRhinorrheaAllergic rhinitis, infectionPharyngeal erythema, uvular deviation

Diagnostic Tests & Interpretation

Lab

First Line

  • Arterial blood gasHypercarbia suggests impending respiratory failure; distinguishes metabolic from respiratory acidosis
  • Complete blood count with differentialAnemia; leukocytosis with left shift is a sign of infection.
  • GlucoseHyperglycemia can lead to diabetic ketoacidosis (DKA).
  • Viral testing (polymerase chain reaction [PCR], direct fluorescent antibody [DFA], culture)Diagnose viral infection; consider influenza in winter months.

Special Considerations

  • B-type natriuretic peptide (BNP)Diagnostic marker to help recognize heart disease when access to echocardiography not readily available

Imaging

First Line

  • Chest radiographIdentify pleural effusion, pneumothorax, consolidation, cardiomegaly, hyperinflation

Special Considerations

  • CTHigh-resolution CT to diagnose ILD; spiral CT angiography to diagnose PE
  • EchocardiographySigns of PHTN; heart failure; structural abnormalities

Diagnostic Procedures/Other

  • Pulmonary function testsSpirometryObstructive lung disease (asthma); distinguish upper from lower airways obstructionLung volumesRestrictive lung disease (ILD, neuromuscular and chest wall diseases)Diffusion capacityMean inspiratory and expiratory pressureNeuromuscular disease/weakness
  • Bronchoscopy with bronchoalveolar lavage (BAL)Dynamic visualization of airways to diagnose fixed (vascular) or dynamic (bronchomalacia) airway compression; bacterial, viral, and fungal cultures; lipid-laden macrophages (aspiration); hemosiderin-laden macrophages (hemorrhage)
  • ElectrocardiogramReadily available test to rapidly diagnose heart disease
  • Cardiopulmonary exercise testingIndicated when initial evaluation fails to yield diagnosis; distinguish cardiac and respiratory causes and deconditioning

Treatment

  • Secure airway and stabilize the patient.
  • Treatment should be directed at the underlying cause of dyspnea.
  • Consider palliative/symptomatic treatment once underlying or reversible cause has been addressed.

Medications

  • Opioids (parenteral/oral/inhaled)
  • Anxiolytics

Additional Treatment

General Measures

  • Oxygen
  • Pulmonary rehabilitation
  • Movement of cool air (face fan)

Alert

In patients with hypercapnic chronic respiratory failure, hypoxemia might be the primary drive to breathe; supplemental oxygen will remove the hypoxic respiratory drive and cause apnea. пїЅ

Issues for Referral

  • Unstable vital signs, unsecure airway, inability to oxygenate, and need for critical care services
  • Surgical consultation for foreign body removal with rigid bronchoscopy
  • Pulmonary referral for severe asthma, hemorrhage, ILD, CF, DMD, SMA, flexible bronchoscopy, chronic mechanical ventilation
  • Cardiac referral for cardiac disease, PHTN
  • Endocrinology referral for diabetes
  • Nephrology referral for RTA and renal failure

Surgery/Other Procedures

  • Evacuation of tension pneumothorax with chest tube
  • Pleural drainage/video-assisted thoracic surgery for loculated empyema
  • Rigid bronchoscopy for foreign body retrieval
  • Flexible bronchoscopy and laryngoscopy for visual diagnosis and BAL

Additional Reading

  • Birnkrant пїЅDJ, Bushby пїЅKMD, Amin пїЅRS, et al. The respiratory management of patients with Duchenne muscular dystrophy: a DMD care considerations working group specialty article. Pediatr Pulmonol. 2010;45(8):739-748. пїЅ[View Abstract]
  • Deutch пїЅGH, Young пїЅLR, Deterding пїЅRR, et al. Diffuse lung disease in young children: application of a novel classification scheme. Am J Respir Crit Care Med. 2007;176(11):1120-1128. пїЅ[View Abstract]
  • Maher пїЅKO, Reed пїЅH, Cuadrado пїЅA, et al. B-type natriuretic peptide in the emergency diagnosis of critical heart disease in children. Pediatrics. 2008;121(6):e1484-e1488. пїЅ[View Abstract]
  • Morris пїЅMJ, Christopher пїЅKL. Diagnostic criteria for the classification of vocal cord dysfunction. Chest. 2010;138(5):1213-1223. пїЅ[View Abstract]
  • National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Asthma Education and Prevention Program; 2007. NIH Publication No. 07-4051.
  • Parshall пїЅMD, Schwartzstein пїЅRM, Adams пїЅL, et al. An official American Thoracic Society Statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med. 2012;185(4):435-452. пїЅ[View Abstract]
  • Ullrich пїЅCK, Mayer пїЅOH. Assessment and management of fatigue and dyspnea in pediatric palliative care. Pediatr Clin North Am. 2007;54(5):735-756,xi. пїЅ[View Abstract]

Codes

ICD09

  • 786.09 Other respiratory abnormalities
  • 786.1 Stridor
  • 786.07 Wheezing

ICD10

  • R06.00 Dyspnea, unspecified
  • R06.1 Stridor
  • R06.2 Wheezing
  • R06.09 Other forms of dyspnea

SNOMED

  • 267036007 Dyspnea (finding)
  • 70407001 Stridor (finding)
  • 56018004 Wheezing (finding)

FAQ

  • Q: In most pediatric cases, is dyspnea pulmonary in nature?
  • A: In most cases, yes. Nonetheless, a systematic approach looking at all organ systems should be employed when addressing a patient with dyspnea.
  • Q: How does the etiology of dyspnea differ in adults?
  • A: In adults, the most common causes of dyspnea are asthma, COPD, ILD, myocardial dysfunction, and obesity/deconditioning. Whereas asthma and obesity are common in children, COPD, ILD, and myocardial disease are much more common in adults.