Acute dyspnea (peds): Difference between revisions

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{{PediatricPage|acute dyspnea}}
{{PediatricPage|acute dyspnea}}
==Background==
==Background==
*Breathing complaints are among the most common reasons for pediatric ED visits
*Breathing complaints are among the most common reasons for pediatric ED visits<ref>Gehri M, et al. [Acute dyspnea in children]. Rev Med Suisse. 2005 Feb 16;1(7):486-90. PMID 15790016</ref>
*Infants and children have higher predisposition to respiratory failure relative to adults
*Infants and children have higher predisposition to respiratory failure relative to adults
**Higher resting metabolic rate requires more oxygen
**Higher resting metabolic rate requires more oxygen
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===Key Physical Exam Findings by Etiology===
===Key Physical Exam Findings by Etiology===
*'''Stridor''': upper airway obstruction ([[croup]], [[epiglottitis]], foreign body, [[anaphylaxis]])
*'''Stridor''': upper airway obstruction ([[croup]], [[epiglottitis]], foreign body, [[anaphylaxis]])<ref>Fallot A. Respiratory distress. Pediatr Ann. 2005 Nov;34(11):885-91; quiz 893-4. PMID 16353650</ref>
*Wheezing: lower airway disease ([[bronchiolitis]], [[asthma]], foreign body)
*Wheezing: lower airway disease ([[bronchiolitis]], [[asthma]], foreign body)
*Crackles: pneumonia, pulmonary edema, bronchiolitis
*Crackles: pneumonia, pulmonary edema, bronchiolitis

Latest revision as of 10:44, 22 March 2026

This page is for pediatric patients. For adult patients, see: acute dyspnea

Background

  • Breathing complaints are among the most common reasons for pediatric ED visits[1]
  • Infants and children have higher predisposition to respiratory failure relative to adults
    • Higher resting metabolic rate requires more oxygen
    • Anatomical differences (e.g. smaller diameter airways) predispose to respiratory failure — 1mm of edema causes 60% reduction in cross-sectional area in an infant vs. 20% in an adult
    • Cartilaginous rib cage with less respiratory reserve
    • Obligate nose breathers until approximately 6 months of age
  • The vast majority of pediatric cardiac arrests are secondary to respiratory failure
  • Included here are other respiratory chief complaints: tachypnea, irregular breathing, abnormal respiratory sounds, cyanosis, which parents may have noticed

Clinical Features

Signs of Respiratory Distress

  • Tachypnea (most sensitive early sign)
  • Increased work of breathing: nasal flaring, retractions (subcostal, intercostal, suprasternal), head bobbing (infants)
  • Accessory muscle use, tripoding
  • Grunting (sign of impending respiratory failure — creates auto-PEEP)
  • Cyanosis (late and ominous sign)
  • Altered mental status, poor tone (impending respiratory arrest)

Signs of Respiratory Failure

  • Decreased or absent breath sounds
  • Bradypnea or irregular respirations
  • Poor air exchange despite increased effort
  • Apnea, agonal breathing
  • Altered mental status, unresponsiveness

Key Physical Exam Findings by Etiology

Differential Diagnosis

Pediatric Shortness of Breath

Pulmonary/airway

Cardiac

Other diseases with abnormal respiration

Evaluation

Immediate Assessment

  • ABCs — do not delay treatment for workup
  • Pulse oximetry (continuous if distressed)
  • Bedside glucose
  • Assess position of comfort (allow child to remain in parent's lap if stable)

Laboratory

  • Blood gas (capillary or venous): assess pH, pCO2 (rising CO2 = impending failure)
  • CBC if infection suspected
  • BMP if metabolic cause suspected
  • BNP if cardiac etiology considered
  • Blood culture if sepsis concern

Imaging

Bedside

  • POCUS: assess for pneumothorax, pleural effusion, pericardial effusion, B-lines (pulmonary edema), cardiac function

Management

Immediate Interventions

  • Position of comfort
  • Supplemental oxygen for SpO2 <90% (or <94% in neonates with known cardiac disease per local protocols)
  • Bag-valve-mask ventilation if apneic or inadequate respirations
  • Prepare for intubation (peds) / Neonatal RSI if impending respiratory failure
  • Epinephrine IM if anaphylaxis suspected
  • Needle decompression if tension pneumothorax suspected

Condition-Specific

Disposition

Admit / PICU

  • Respiratory failure or impending respiratory failure
  • Requiring supplemental oxygen beyond brief ED course
  • Significant work of breathing not improving with treatment
  • Toxic appearance or altered mental status
  • Need for continuous monitoring or frequent treatments
  • Suspected epiglottitis, retropharyngeal abscess, or other surgical airway emergency

Discharge

  • Resolved symptoms after treatment (e.g., mild croup responding to steroids)
  • Mild asthma exacerbation responding to bronchodilators with normal SpO2 on room air
  • Reliable caregivers with clear return precautions
  • Return precautions: increased work of breathing, poor feeding, color change, altered behavior, fever

See Also

External Links

References

  1. ↑ Gehri M, et al. [Acute dyspnea in children]. Rev Med Suisse. 2005 Feb 16;1(7):486-90. PMID 15790016
  2. ↑ Fallot A. Respiratory distress. Pediatr Ann. 2005 Nov;34(11):885-91; quiz 893-4. PMID 16353650
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