Dyspnea

Description

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.

History
  • 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.

Physical Exam
  • Lungs:
    • 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.
  • Heart:
    • 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

Tests

Pulse oximetry: Rapid assessment of oxygen perfusion

Lab

  • 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.

Imaging
Chest radiograph:
  • 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.

Differential Diagnosis

  • Congenital:
    • Subglottic stenosis
    • Vocal cord paralysis
    • Macroglossia
    • Pierre Robin sequence
    • Laryngeal atresia
    • Pulmonary sequestration
    • Pulmonary hypoplasia
  • Infectious:
    • Lower airway: Bronchiolitis; pertussis; pneumonia; tuberculosis
    • Upper airway: Croup; epiglottitis; tracheitis; peritonsillar abscess
  • Toxic, environmental, drugs: Aspiration:
    • Fluid
    • Foreign body
    • Carbon monoxide poisoning
    • Methemoglobinemia
    • Smoke inhalation
  • Tumors/Cysts:
    • 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
  • Pulmonary:
    • Asthma
    • Atelectasis
    • Pneumothorax
    • Pleural effusion
    • Hemorrhage
    • Embolism
  • Cardiac: Pulmonary edema
  • Renal:
    • Renal failure causing fluid overload
    • Metabolic acidosis
  • Hematologic:
    • Anemia
    • Sickle cell crisis/acute chest syndrome
  • Muscle weakness:
    • Duchenne muscular dystrophy
    • Spinal muscle atrophy
  • Miscellaneous:
    • High altitude
    • Exercise
    • Psychogenic hyperventilation
    • Anxiety/panic disorders

ALERT
In a child who presents with dyspnea, anxiety or panic disorder should be considered only after the more serious causes have been ruled out.

Initial Stabilization

Anaphylaxis is a medical emergency and mandates immediate action. Epinephrine, Benadryl, and possibly steroids are the drugs of choice for treatment.

General Measures

If hyperventilation is suspected, having the patient breathe into a brown paper bag can be useful in breaking the cycle of hypocarbia.

Surgery

Patients with pneumothorax may need surgical aspiration or chest tube placement.

Disposition

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”)

ICD-9

  • 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

FAQ

  • 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.

AUTHOR

Charles Schwartz, MD

BIBLIOGRAPHY

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