Shortness of breath. A subjective feeling of having difficulty breathing.
Signs and Symptoms
Approaches to the patient: General goal is to identify the organ system responsible for the dyspnea and to determine whether the process is acute or chronic:
- Phase 1: Determine if the cause is respiratory or cardiac in nature. If it is 1 of these 2, is the patient clinically stable and can he or she protect his or her airway? It is important to identify those who will need intensive/emergency care and those who can be worked up in the office.
- Phase 2: Inquire about the duration of symptoms and the circumstances around the onset of the dyspnea. History and physical exam should focus on respiratory and cardiology. If these 2 have been ruled out, other causes must be evaluated.
- Phase 3: Inquire about other medical problems of the patient.
- Onset of dyspnea and what the patient was doing at the time of onset (if acute):
- In a small child, acute onset may be related to aspiration of a foreign body or liquid.
- If the patient was unsupervised, foreign body is a high probability.
- If the dyspnea occurred over days, other respiratory, cardiac, or renal causes should be suspected.
- Any fever, cough, chest pain, or runny nose suggests an infectious cause. Chest pain could be related to a pneumothorax, which may occur spontaneously in some individuals.
- Anyone at home who is sick or has respiratory problems/illness leads toward infection; however, in some cases of congenital heart disease, a respiratory virus such as respiratory syncytial virus can make an otherwise stable patient into a critically ill child.
- Children who have a history of wheezing or asthma are likely to re-exacerbate their lung disease.
- Children who have been hospitalized for respiratory problems in the past are likely to have subsequent difficulty with other respiratory problems.
- In the absence of an infectious type or wheezing type of history, if the patient has ever been diagnosed with a murmur or has a history of cardiac problems, it may help the examiner focus on the cardiac exam.
- Crackles or rhonchi on auscultation: Lower lung disease such as pneumonia or bronchiolitis. Fluid overload may cause bilateral crackles.
- Wheezing on auscultation: Usually heard on expiration; suggests an obstructive lung disease such as asthma or reactive airways disease, or anaphylaxis
- Distant or absent breath sounds: Foreign body aspiration blocking air movement. Pneumothorax should also be suspected.
- Barking cough: Croup is usually cased by parainfluenza virus.
- Symptoms worse in supine position: May be secondary to pulmonary edema or compression by a mediastinal mass
- Egophony on auscultation: Suspect pleural effusion.
- Loud murmur or gallop on auscultation: Cardiac disease in which pulmonary edema may be cause of the dyspnea
- Cyanosis: Poor oxygen perfusion
- Low BP and poor skin perfusion: The patient may be in shock. Quick identification of the type of shock is needed to correct the underlying problem.
- Clubbing of the digits: Suggests chronic disease such as cystic fibrosis or cardiac disease
- Drooling with mouth open in an ill-appearing child: Suggests epiglottitis and need for careful evaluation (see “Epiglottitis”)
- Abdominal mass palpated: May cause compression of lungs
- Ascites or edema: Fluid overload from either renal or cardiac cause
Pulse oximetry: Rapid assessment of oxygen perfusion
- Arterial blood gases:
- More detailed assessment of oxygenation and acidosis
- Delineates metabolic versus respiratory acidosis
- May show if compensation has occurred
- CBC with differential:
- Elevated WBC count with a left shift differential may be a sign of infection.
- If the patient has pallor, evaluate the hemoglobin to see if the patient is anemic.
- May be helpful in patients in whom leukemia or other oncologic diseases are suspected
- Mantoux test with purified protein derivative: Include with anergy panel for patients with family history of tuberculosis or who are immigrants from countries where tuberculosis is prevalent.
- Look for appearance of the lung fields for the different types of pneumonia.
- Evaluate heart size and pulmonary vascularity for fluid overload.
- Hyperinflation suggests an obstructive pulmonary disease such as asthma. A hyperinflated (usually right lobe), darkened lobe is suspicious for foreign body.
- A shift in the heart and presence of a lung edge are common in pneumothorax or effusion.
- Fluid in the costophrenic angle suggests an effusion.
- Subglottic stenosis
- Vocal cord paralysis
- Pierre Robin sequence
- Laryngeal atresia
- Pulmonary sequestration
- Pulmonary hypoplasia
- Lower airway: Bronchiolitis; pertussis; pneumonia; tuberculosis
- Upper airway: Croup; epiglottitis; tracheitis; peritonsillar abscess
- Toxic, environmental, drugs: Aspiration:
- Foreign body
- Carbon monoxide poisoning
- Smoke inhalation
- Head/neck: Dermoid cysts, branchial cleft cysts, lingual thyroid, hemangioma, teratoma, papilloma, brainstem tumor
- Thoracic: Teratoma, cystic hygroma, bronchogenic cyst, pericardial cyst, neurogenic tumor, lymphoma, leukemia
- Abdominal mass: Hepatic mass, hepatoblastoma, neuroblastoma
- Allergy: Anaphylaxis
- Pleural effusion
- Cardiac: Pulmonary edema
- Renal failure causing fluid overload
- Metabolic acidosis
- Sickle cell crisis/acute chest syndrome
- Muscle weakness:
- Duchenne muscular dystrophy
- Spinal muscle atrophy
- High altitude
- Psychogenic hyperventilation
- Anxiety/panic disorders
In a child who presents with dyspnea, anxiety or panic disorder should be considered only after the more serious causes have been ruled out.
Anaphylaxis is a medical emergency and mandates immediate action. Epinephrine, Benadryl, and possibly steroids are the drugs of choice for treatment.
If hyperventilation is suspected, having the patient breathe into a brown paper bag can be useful in breaking the cycle of hypocarbia.
Patients with pneumothorax may need surgical aspiration or chest tube placement.
Issues for Referral
- Unstable vital signs, inability to oxygenate, and need for critical care services
- Suspected foreign body aspiration; needs a surgical consultation for bronchoscopy
- If asthma is suspected, use criteria in the chapter on Asthma.
- Patients with epiglottitis need an otolaryngologist to evaluate the patient under general anesthesia (see “Epiglottitis”).
- Suspected oncologic process: Referral to a tertiary care center with a critical care unit staffed by a pediatric oncologist (see “Leukemia”)
- 300.11 Dyspnea functional
- 300.11 Dyspnea hysterical
- 306.1 Dyspnea psychogenic
- 428.1 Dyspnea cardiac
- 493.2 Dyspnea chronic
- 493.9 Dyspnea asthmatic (bronchial) (see also Asthma)
- 493.9 Dyspnea with bronchitis (see also Asthma)
- 770.89 Dyspnea newborn
- 786.01 Dyspnea hyperventilation
- Q: In most cases, is dyspnea pulmonary in nature?
- A: Yes, it is in most cases. However, if infectious, foreign body, and asthma causes are ruled out, nonrespiratory causes must be investigated.
Charles Schwartz, MD
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