Dyspnea, Pediatric

Basics

Description

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

Pathophysiology

Abnormality in one of the following elements: �

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

Etiology

Respiratory
- Upper airway
  - Infection (croup, tracheitis, peritonsillar abscess, epiglottitis)
  - Foreign body
  - Anaphylaxis
  - Anatomic abnormalities
  - Vocal cord dysfunction (VCD)
- Lower airway
  - Asthma
  - Aspiration
  - Airway malacia
  - Hemorrhage
  - Internal/external fixed compression (tumor, cyst, vascular)
- Parenchymal lung disease
  - Infection (viral, bacterial, fungal)
  - Interstitial lung disease (ILD)
  - Atelectasis
  - Chronic lung disease (chronic obstructive pulmonary disease [COPD], cystic fibrosis)
- Chest wall disorder
  - Neuromuscular weakness (Duchenne muscular dystrophy [DMD], spinal muscular atrophy [SMA])
  - Scoliosis
  - Pectus excavatum
- Pleural
  - Pleural effusion
  - Pneumothorax
Cardiovascular
- Cardiac
  - Elevated pulmonary venous pressure
  - Congestive heart failure (CHF)
- Vascular
  - Pulmonary hypertension (PHTN)
  - Pulmonary embolism (PE)
Toxic/metabolic
- Metabolic acidosis (diabetic ketoacidosis, salicylate intoxication, renal tubular acidosis [RTA])
- Renal failure causing fluid overload
Other
- Anemia
- Deconditioning
- Obesity
- Panic attack
- Pregnancy
- Trauma
- Gastroesophageal 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

Onset
- Recurrent, discrete episodes associated with anxiety
  - Panic attacks
- Sudden
  - Foreign body, pneumothorax
Associated signs and symptoms
- "Tightness"�
  - Bronchoconstriction (asthma)
- Stridor
  - Upper airway obstruction
- Wheezing
  - Lower airway obstruction
- Chest pain
  - Pneumothorax, PE, pleural effusion
- Hemoptysis
  - Hemorrhage
- Worse when supine
  - Pulmonary edema
Temporal association
- Exercise-induced
  - VCD, asthma, deconditioning, GERD
- Nocturnal
  - Asthma, GERD
- Persistent and progressive
  - Neuromuscular disease, ILD
Infectious signs and symptoms
- Fever, cough, rhinorrhea
  - Pneumonia, bronchiolitis
- Stridor, cough, rapid onset
  - Croup, tracheitis, abscess, epiglottitis
Gastrointestinal signs and symptoms
- Choking, gagging with feeds
  - Aspiration
- Epigastric pain, discomfort
  - GERD
Exposures
- Salicylates, allergens
PE risk factors include immobilization, surgery, smoking, pregnancy, central catheter, history of deep vein thrombosis
History of cardiac disease
- PHTN, CHF
Diabetes history
- Polyuria, polydipsia, polyphagia

Physical Exam

Vital signs, oxygen saturation, temperature
- Fever
  - Infection
- Hypoxia suggestive of pulmonary and cardiac causes
Weight, BMI
- Chronic disease, obesity
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
  - Consolidation/pneumonia
- Wheezing
  - Bronchoconstriction, foreign body, bronchiolitis
- Crackles
  - Infection, ILD (especially if crackles don't clear with coughing)
- Barking quality of cough
  - Croup
- Stridor
  - Upper airway obstruction
Cardiac exam
- Crackles, peripheral edema, hepatomegaly, gallop
  - CHF
- Loud P2
  - PHTN
Extremities
- Clubbing
  - Chronic pulmonary/cardiac disease
- Cyanosis
  - Shunting
- Calf tenderness
  - DVT
Musculoskeletal
- Generalized muscle weakness
  - DMD, SMA, other neuromuscular diseases
Head and neck
- Pharyngeal cobblestoning
  - GERD, allergic rhinitis
- Allergic shiners, nasal crease, swollen nasal turbinates
  - Allergic rhinitis
- Rhinorrhea
  - Allergic rhinitis, infection
- Pharyngeal erythema, uvular deviation
  - Peritonsillar abscess

Diagnostic Tests & Interpretation

Lab
First Line

Arterial blood gas
- Hypercarbia suggests impending respiratory failure; distinguishes metabolic from respiratory acidosis
Complete blood count with differential
- Anemia; leukocytosis with left shift is a sign of infection.
Glucose
- Hyperglycemia 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 radiograph
- Identify pleural effusion, pneumothorax, consolidation, cardiomegaly, hyperinflation

Special Considerations

CT
- High-resolution CT to diagnose ILD; spiral CT angiography to diagnose PE
Echocardiography
- Signs of PHTN; heart failure; structural abnormalities

Diagnostic Procedures/Other

Pulmonary function tests
- Spirometry
  - Obstructive lung disease (asthma); distinguish upper from lower airways obstruction
- Lung volumes
  - Restrictive lung disease (ILD, neuromuscular and chest wall diseases)
- Diffusion capacity
  - ILD
- Mean inspiratory and expiratory pressure
  - Neuromuscular 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)
Electrocardiogram
- Readily available test to rapidly diagnose heart disease
Cardiopulmonary exercise testing
- Indicated 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. �

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 �DJ, Bushby �KMD, Amin �RS, 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. �[View Abstract]
Deutch �GH, Young �LR, Deterding �RR, 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. �[View Abstract]
Maher �KO, Reed �H, Cuadrado �A, et al. B-type natriuretic peptide in the emergency diagnosis of critical heart disease in children. Pediatrics. 2008;121(6):e1484-e1488. �[View Abstract]
Morris �MJ, Christopher �KL. Diagnostic criteria for the classification of vocal cord dysfunction. Chest. 2010;138(5):1213-1223. �[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 �MD, Schwartzstein �RM, Adams �L, 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. �[View Abstract]
Ullrich �CK, Mayer �OH. Assessment and management of fatigue and dyspnea in pediatric palliative care. Pediatr Clin North Am. 2007;54(5):735-756,xi. �[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.

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