Dyspnea
Dyspnea is defined as “shortness of breath,” so it is important to determine the effect of activity on breathing. Worsening when supine does not reliably differentiate left-sided cardiac disease from pulmonary causes of dyspnea in children. Attention to the respiratory pattern and exam (e.g., Cheyne-Stokes breathing, or wheezing) should help determine the source of the dyspnea. Dyspnea may not be apparent if the patient is paralyzed or profoundly weak.
Differential Diagnosis
- Dyspnea is driven by an aberration in the mechanics of breathing; consider the pathway taken by oxygen to the tissues, and the mechanics of getting it there
- Hypoxia
–Low O2 delivery to tissues increases effort to deliver it, including increased respiratory effort
–Any cause of hypoxia will lead to dyspnea (decreased availability, V/Q mismatch due to pneumonia or other lung disease)
- Obstructive disease causes increased effort to move air
–Upper airway: Nasal congestion, choanal atresia, FB, tonsils, adenoids, macroglossia, decreased tone, retropharyngeal abscess, laryngomalacia, VCD/paralysis, laryngeal web or polyp, subglottic stenosis
–Lower airway: Asthma, BALT, bronchiolitis obliterans, tracheobronchomalacia, bronchial atresia, bronchiectasis, bronchitis, CF, PCD, hemangioma, polyps, TEF
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Restrictive disease
–Small or stiff lungs, chest wall disease (e.g., obesity, kyphoscoliosis, chest deformity), respiratory muscle weakness (Duchenne muscular dystrophy, paralysis)
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Parenchymal disease
–Pneumonia, congenital lesions
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Vascular disease
–Pulmonary hypertension, sequestered lung
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Cardiac disease
–Congenital cyanotic heart disease (e.g., TOF,
TAPVR, TGA)
–Pericarditis
–Myocarditis
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Compression of the lung
–Pneumothorax
–Tumors (e.g., cyst, teratoma)
–Elevated diaphragm
–Effusions (e.g., empyema, hemothorax)
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Pulmonary embolism (rare)
Workup and Diagnosis
- History
–Determine first the urgency of the problem; some patients who appear to be less dyspneic because of fatigue or weakness are at greater risk of respiratory failure
–Is there dyspnea at rest? Increased O2 consumption with activity increases symptoms; dyspnea at rest suggests a more severe problem, a fixed degree of hypoxia, or diminished compensatory mechanisms (e.g., profound weakness)
–Does oxygen help? If not, it may represent a fixed mechanical problem (e.g., severe obstruction or chest wall disease), shunt, or other severe V/Q mismatch
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Physical exam
–Inspection and palpation are important; abnormal mechanics or hyperinflation may suggest etiology
–Loud monophonic sounds (stridor, wheeze) suggest large airway obstruction; polyphonic wheezes suggest small airway disease
-
Oximetry is very useful but may not be accurate
-
Labs
–ABGs (low PaO2 and SaO2 or high PaCO2suggests interventions)
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Studies
–Chest film and CT for parenchymal disease
–MRI/MRA for vascular anatomy; V/Q scan
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ECG, Echo, or catheterization for cardiac disease
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Pulmonary function test for obstructive or restrictive disease
Treatment
-
Dyspnea is a sign of respiratory distress, but it is not treated with sedation (increases risk of respiratory failure or arrest)
-
Oxygen
–First line in the treatment of hypoxia
–Use caution if it is accompanied by hypercapnea (as in chronically cyanotic patients or with COPD), because the respiratory effort may be driven by the hypoxia, and there will be a decrease in respiratory drive leading to increases in PaCO2(rare in children unless there is CCHD)
-
Airway lesions may require intervention to provide relief; target underlying illnesses (e.g., treat pneumonia with antibiotics) but persist in efforts to improve mechanics (e.g., chest physiotherapy to clear secretions)
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Surgical stabilization of abnormal chest wall or of anatomic abnormality
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Asthma therapy may provide relief even when asthma is not the “primary” problem (e.g., muscular dystrophy)
Book Source Details
- Book Title: In A Page: Pediatric Signs and Symptoms
- Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
- Year of Publication: 2007
- Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Breathing difficulties
Read excerpts from these other book chapters related to Breathing difficulties:
Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.
More About Causes of Breathing difficulties
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More About This Book:
Title: In A Page: Pediatric Signs and Symptoms
Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 1-4051-0427-9
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» Next page: DYSPNEA, TACHYPNEA, AND ORTHOPNEA (Differential Diagnosis in Primary Care)
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