Acute dyspnea (peds)

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
• 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

• Stridor: upper airway obstruction (croup, epiglottitis, foreign body, anaphylaxis)
• Wheezing: lower airway disease (bronchiolitis, asthma, foreign body)
• Crackles: pneumonia, pulmonary edema, bronchiolitis
• Absent breath sounds: pneumothorax, large pleural effusion, severe bronchospasm
• Barking cough: croup

Differential Diagnosis

Pediatric Shortness of Breath

Pulmonary/airway

• Airway obstruction
  • Anaphylaxis
  • Angioedema
  • Aspirated foreign body
  • Asthma exacerbation

• Structural
  • Bronchopulmonary dysplasia
  • Choanal atresia
  • Neoplasm
  • Subglottic stenosis
  • Tracheoesophageal fistula
  • Tracheomalacia
  • Spontaneous pneumothorax

• Infectious
  • Bacterial tracheitis
  • Bronchiolitis (peds), URI
  • Croup
  • Epiglottitis
  • Pertussis
  • Pneumonia
  • Cystic fibrosis exacerbation

• Trauma
  • Rib fractures
  • Flail chest
  • Traumatic pneumothorax
  • Pulmonary contusion

• Other
  • Inhalation exposure
  • Meconium aspiration syndrome
  • Pulmonary edema
  • Pulmonary hypertension, cor pulmonale
  • Respiratory distress syndrome

Cardiac

• Congenital heart disease
• Vascular ring
• Cardiac tamponade
• Congestive Heart Failure (peds)
• Myocarditis (peds)

Other diseases with abnormal respiration

• Normal neonatal periodic breathing (misinterpreted by caregivers as abnormal)
• Brief resolved unexplained event
• Anemia
• Abdominal distension (e.g. SBO, liver failure
• Neonatal abstinence syndrome
• Decreased perfusion states
  • Pediatric shock
  • Sepsis (peds)
  • Dehydration (peds)
• Metabolic acidosis
  • Diabetic ketoacidosis (peds)
  • Inborn errors of metabolism
  • Salicylate toxicity
• CO Poisoning
• Diaphragm injury
• Renal Failure
• Electrolyte abnormalities
• Organophosphate toxicity
• Tick paralysis
• Fever (Peds)
• Panic attack
• Porphyria

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

• CXR: infiltrate, hyperinflation, pneumothorax, cardiomegaly, foreign body
• Lateral neck radiograph if concern for epiglottitis or retropharyngeal abscess (only if stable)
• CT angiography rarely needed (suspected pulmonary embolism, vascular ring)

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

• Croup: dexamethasone PO/IM, racemic epinephrine nebulized for moderate-severe
• Bronchiolitis: supportive care (suctioning, oxygen), high-flow nasal cannula if needed
• Asthma: albuterol, ipratropium, systemic corticosteroids; consider magnesium sulfate for severe
• Pneumonia: antibiotics based on age and severity
• Foreign body aspiration: if complete obstruction, follow BLS choking algorithm; bronchoscopy for partial obstruction
• Epiglottitis: minimize agitation, call anesthesia/ENT, OR for controlled intubation
• Pneumothorax: needle decompression followed by chest tube

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

• Acute dyspnea
• Intubation (peds)
• Neonatal RSI
• PALS
• Stridor (peds)
• Croup
• Bronchiolitis (peds)