Definition / Supporting Information

Dyspnoea is the medical term for breathlessness.
It may be due to a range of underlying disorders.
Consider:
  •  
    Respiratory causes
  •  
    Non-respiratory causes such as:
     
    •  
      Sepsis
    •  
      Metabolic
    •  
      Neurological
    •  
      Cardiac
    •  
      Pharmacological

Essential History

Ask about:
  •  
    Onset
     
  •  
    Duration and frequency of attacks
  •  
    Any identifiable trigger event
  •  
    Any changes with position
     
    •  
      Unilateral lung disease may be worse when the patient lies on the affected side
  •  
    Associated signs and symptoms, such as:
     
  •  
    History (patient and family) of:
     
    •  
      Allergies
    •  
      Respiratory illness
    •  
      Smoking
    •  
      Prematurity
    •  
      Medications
    •  
      Environmental issues
       
      •  
        Consider house moulds and fuel poverty (cold homes)
    •  
      Recent travel

'Red Flag' Symptoms and Signs

Ask about:
Look for:
  •  
    Signs of exhaustion such as increasing lethargy accompanied by decreasing respiratory effort / air entry ("the silent chest")
  •  
  •  
    Meningism (see Bacterial Meningitis)
  •  
    Non-blanching rash
  •  
    Evidence of poor perfusion
  •   
    •  
      For example, croup or foreign body inhalation
  •  
    Evidence of increased respiratory effort
     
    •  
      Suprasternal / intercostal / sub-costal recession
    •  
      Nasal flaring
    •  
      Use of accessory respiratory muscles such as:
       
      •  
        Sternocleidomastoid (leading to head bobbing in infants)
      •  
        Abdominal muscles
      •  
        Intercostal muscles
  •  
    Grunting (may indicate airway collapse / consolidation eg, pneumonia)
  •  
    Tachypnoea (see Table 1)
  •  
    Hypoxia
     
    •  
      Clinically suspected due to presence of cyanosis and / or pallor
    •  
      Detected by pulse oximetry
  •  
    Apnoea
  •  
    Bradycardia or tachycardia (see Table 1)
  •  
    Absent / reduced breath sounds with a dull percussion note
     
    •  
      Pleural effusion
    •  
      Absent breath sounds with a hyperresonant sound / note on chest percussion:
       
      •  
        May indicate pneumothorax
      •  
        Prompts careful assessment for other associated signs such as mediastinal shift
  •  
    Signs of chronic lung or heart disease
     
    •  
      Barrel chest
    •  
      Finger clubbing
    •  
      Central cyanosis
    •  
      Paradoxical pulse
Table 1
 
Abnormal vital signs by age
Table 1
 
Abnormal vital signs by age
 

Age group (years)

 

Heart rate – tachycardia (bpm)

 

Heart rate – bradycardia (bpm)

 

Respiratory rate – tachypnoea (bpm)

 

Systolic blood pressure – hypotension (mmHg)

 

< 1

 

> 160

 

< 110

 

> 40

 

< 65

 

1–2

 

> 150

 

< 100

 

> 35

 

< 70

 

2–5

 

> 140

 

< 95

 

> 30

 

< 70

 

5–12

 

> 120

 

< 80

 

> 25

 

< 80

 

> 12

 

> 100

 

< 60

 

> 20

 

< 100

Adapted from: Samuels M, Wietska S, eds. Advanced Paediatric Life Support – The Practical Approach. 5th edn. Chichester: Wiley-Blackwell, 2011.

Differential Diagnosis / Conditions

Table 2
 
Causes of dyspnoea
Table 2
 
Causes of dyspnoea
NewbornInfantOlder child
Congenital 

Choanal atresia or stenosis

 

Pierre Robin syndrome

 

Ankyloglossia (tongue tie)

 

Pulmonary agenesis

 

Eventration of the diaphragm

 

Diaphragmatic hernia

 

Tracheoesophageal fistula

 

Osteogenesis imperfecta

 

Congenital myasthenia gravis

 

Congenital heart disease

 

Tracheal web

 

Cystic fibrosis

 

Bronchomalacia

 

Laryngomalacia

 

Tracheomalacia

 

Congenital lung abnormality

 

Cystic fibrosis

Vascular 

Airway haemangioma

 

Vascular ring

 

Pulmonary oedema

 

Pulmonary venous hypertension

 

Persistent pulmonary hypertension of the newborn

 

Vascular ring

 

Pulmonary oedema

 

Pulmonary oedema eg, due to:

Infective 

Septicaemia

 

Pneumonia

 

Pertussis

 

Bronchiolitis

 

Pneumonia (bacterial / viral)

 

Pneumonia

 

Epiglottitis

 

Bacterial tracheitis

 

Croup

 

Retropharyngeal abscess

Inflammatory 

Interstitial lung disease

 

Meconium aspiration

 

Asthma

 

Bronchomalacia

 

Aspiration

 

Asthma

 

Anaphylaxis

 

Enlarged tonsils or adenoids

 

Inhalation / Ingestion of caustic substance

 

Hypersensitivity pneumonitis

 

Granulomatous disease

Neurological 

CNS depression

 

Hypoxia

 

Vocal cord paralysis

 

Diaphragmatic paralysis

 

Cord transection

 

Myasthenia gravis

 

Muscular dystrophy

 

Multiple sclerosis

 

Guillain-Barré syndrome

 

Pickwickian syndrome

Developmental 

Hyaline membrane disease

 

Hypoplastic lungs

 

Kyphoscoliosis

 

Ankylosing spondylitis

 

Pectus excavatum

Iatrogenic 

Tracheal stenosis (post-intubation)

 

Maternal drugs

 

Drugs (eg, antineoplastic agents, narcotics)

Environmental 

Foreign body

 

Foreign body

CardiacCardiac arrhythmias 

Cardiac arrhythmias

 

Cardiac arrhythmias

MetabolicAcidosis due to inborn errors of metabolismAcidosis due to inborn errors of metabolism 

Acidosis eg, due to:

Haematological 

Anaemia

 

Sickle-cell chest crisis

 

Anaemia

 

Sickle-cell chest crisis

Neoplastic 

Tumour

 

Vocal cord polyp

Traumatic 

Laryngeal trauma

 

Crush chest injury

 

Pneumothorax

 

Pneumomediastinum

Autoimmune 

Systemic lupus erythematosus

 

Scleroderma

IdiopathicIdiopathic pulmonary artery hypertensionIdiopathic pulmonary artery hypertension 

Fibrosis

Other 

Pleural effusion eg, due to:

  •  
    Pneumonia
  •  
    Malignancy
  •  
    Renal disease
  •  
    Hyperthyroidism
 

Obesity

 

Pregnancy

 

Stress / anxiety (panic attacks)

Investigations

Evaluation should progress only after the ABCs (airway, breathing, and circulation) of resuscitation have been addressed.
To be undertaken by non-specialist practitioners (eg, General Practitioner (GP) Team) or by specialist practitioners (eg, Emergency Department / Paediatric / Paediatric Respiratory Team(s)):
Investigations should be done on an individual basis and be guided by the clinical picture and clinical judgment as they may not always be required.
N.B. Current guidelines state that the following are not indicated in uncomplicated community acquired pneumonia:
  •  
    Chest X-ray
  •  
    Acute phase reactants (eg, white cell count and C-reactive protein)
  •  
    Microbiological investigations
Recommended evaluations:
  •  
    Full blood count and blood film
  •  
    Blood culture
  •  
    Capillary or venous blood gas measurement
  •  
    Urea / creatinine and electrolytes
  •  
    Bacterial and viral swabs
  •  
    Chest X-ray if suspicion of:
     
    •  
      Effusion
    •  
      Lobar collapse
    •  
      Chronic respiratory disease
  •  
    Pulmonary function tests such as peak flow and spirometry may be useful in children over 5 years of age
To be undertaken by non-specialist practitioners (eg, GP Team) or by specialist practitioners (eg, Emergency Department / Paediatric / Paediatric Respiratory Team(s)):
  •  
    Laryngoscopy, bronchoscopy, and oesophagoscopy may be used by paediatric specialists to identify a radiolucent foreign body.

Treatment Approach

Severe dyspnoea is a medical emergency and if not treated promptly, the child may progress to respiratory failure and death. Assessment and treatment should be initiated without delay using the ABC approach.
To be undertaken by non-specialist practitioners (eg, GP Team) or by specialist practitioners (eg, Emergency Department / Paediatric / Paediatric Respiratory Team(s)):
  •  
    Give oxygen to a child with oxygen saturation below 92% or if dyspnoea is severe
  •  
    Reassure the child and family
  •  
    Stay with the child and call for help if necessary
  •  
    Manage the underlying disorder
     

Specific Treatment

To be undertaken by specialist practitioners (eg, Emergency Department / Paediatric / Paediatric Respiratory Team(s)):
Severe dyspnoea
  •  
    Assess the adequacy of the airway
  •  
    Remove foreign bodies, if present
  •  
    Treat bronchospasm with β2-agonists eg, salbutamol
  •  
    If the child cannot effect adequate ventilation, consider the need for mechanical ventilation
  •  
    Assess:
     
    •  
      The heart
    •  
      Peripheral circulation
    •  
      Intravascular volume status
    •  
      Blood oxygen-carrying capacity
  •  
    Treat any disturbances found as appropriate:
     
    •  
      Vasopressors for low cardiac output
    •  
      Fluids or blood transfusion for reduced blood volume
    •  
      Diuretics for volume overload
  •  
    Administer oxygen until the cause of dyspnoea is known

When to Refer

Refer urgently to specialist practitioners (eg, Emergency Department / Paediatric / Paediatric Respiratory Team(s)) if:
  •  
    There are any 'red flag' symptoms and signs listed above (consider emergency transport)
  •  
    There are associated conditions, such as:
     
    •  
      Prematurity
    •  
      Congenital or acquired heart disease
    •  
      Chronic lung disease
    •  
      Underling metabolic or neurological disorder
  •  
    Radiology, spirometry, endoscopy or surgical procedures are likely to be required or to gain a second opinion
  •  
    Signs of underlying malignancy such as lymphadenopathy or splenomegaly
     

When to Admit

  •  
    If there are signs and symptoms of respiratory failure or impending respiratory failure (see 'Red Flag' Symptoms and Signs - above)
  •  
    If there is hypoxia while breathing room air

'Safety Netting' Advice

  •  
    Advise the family / carers to seek urgent medical review if there is:
     
    •  
      Worsening respiratory rate or distress
    •  
      Increasing lethargy / exhaustion
    •  
      Decreasing intake of fluids
    •  
      Pale, grey or cyanosed appearance
    •  
      Concern that their child is deteriorating

Patient / Carer Information

*Please note: whilst these resources have been developed to a high standard they may not be specific to children.

Resources

National Clinical Guidance

British guideline on the management of asthma (pdf), SIGN clinical guideline 153, Scottish Intercollegiate Guidelines Network and the British Thoracic Society.
Suspected cancer: recognition and referral (Web page). NICE clinical guidance NG12. National Institute for Health and Care Excellence.
Bronchiolitis in children: diagnosis and management (Web page). NICE guidance NG9. National Institute for Health and Care Excellence.
Feverish illness in children: Assessment and initial management in children younger than 5 years (Web page), NICE clinical guideline CG160, National Institute for Health and Care Excellence.
Asthma (Web page) NICE clinical guideline QS25, National Institute for Health and Care Excellence.

Suggested Resources

 

*Please note: these resources include links to external websites. These resources may not have national accreditation and therefore PCO UK cannot guarantee the accuracy of the content. 

Difficulty in Breathing (Web page), Spotting the Sick Child

Acknowledgements

Content Editor: Dr Will Christian
Clinical Expert Reviewers: Dr Simon Langton Hewer
GP Reviewer: Dr Ian A Dunn
AAP Reviewer: Thomas McInerny, MD, FAAP
Paediatric Trainee Reviewer: Dr Don Srimal Darren Ranasinghe
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