Shortness Of Breath (Pediatric)

More plumbing… Just like Eustachian tubes, pediatric lungs and tracheas are simply smaller than they are in adults. As such, any bit of inflammation can lead to all kinds of difficulty breathing. Colds, fevers and ear pain are some of the top reasons for late night pediatric ER visits. Parents of these kids often look exhausted. Parents of kids struggling to catch their breath have a look of terror mixed in.

Red Flags:

• Retractions (Each breath seems to be sucking in the soft tissues between ribs and collar bones.)
• Leaning forward onto extended arms, and refusing to lean back (We call this “tripoding.”)
• Color change (Bluish lips being quite concerning)
• Neonates (Congenital heart problems may take a few weeks after birth before becoming apparent.)
• Lethargy and exhaustion (Bad markers)
• Apnea (No breaths for 20 seconds or more)
• Drooling
• Struggling to speak
• Unvaccinated (Epiglottitis is all but history thanks to the H.flu vax. Whooping cough, however, is enjoying a resurgence.)
• Cystic fibrosis or other underlying lung disease
• Neuromuscular illness (Guillan Barre, muscular dystrophy, etc.)
• Neonates and honey (botulism)
• Allergic to bees and just got stung
• “Junior was sucking on my coins a minute ago. Now one’s missing.”

Happy Words

• Better with one neb
• Better with cool mist
• Better sitting up
• Better after leaving uncle Murray’s tobacco den
• “He was barking like a seal at home, but the drive here in the cool air seems to have helped.”
• “The hot steam bath helped.”
• “He seems to get better when I hold his head up to the freezer.”
• “Everyone has a cold at home and junior lost his inhaler. Can we get one today?”
• “We have a neb machine at home, but just need the drops.”

The majority of kids I see in ERs who are short of breath have wheezing or “stridor” when they inhale (e.g. croup). Or sometimes the wheezes come with exhalation (e.g. bronchiolitis, asthma). For those with fevers and crackling lungs with productive coughs we start to think about bronchitis or pneumonia.

If we hear what sounds like a barking seal at triage, then cool mist with prednisolone or some other steroid is often very effective. Rarely do we use epinephrine as well. For kids with expiratory wheezing, we often nebulize albuterol which can be remarkably effective. If that helps, then these kids may leave with inhalers and steroids as well. Addition of a “spacer” is the added finesse. Depending on the history, if we suspect bacterial infection, an antibiotic may be chosen, such as amoxicillin or rarely azithromycin. Chest X-ray may also be offered, though I try to limit these as much as possible.

For kids who improve in the ER, I think follow up is more important than anything. So often I’ll give these parents my number, because parental fear itself can amplify any of these conditions.

Of course there are many other causes of dyspnea, including caustic inhalations like the “vog” on Hawaii, aspirin toxicity, anaphylaxis, pneumothorax, pulmonary emboli, congenital, or neurological problems. But these are quite rare.

I’d love to conclude with the usual “Call Pre-R,” but in this case that’d be gutsy. Of course I’m happy to help with albuterol refills and conversation. But if your kid is truly short of breath with any red flags, the ER really should be your next stop. Consider 911, or if there’s time, then drive with car windows cracked or down for some nice cool breeze. Maybe play some Jack Johnson for some background soothing, because fear itself can be half the battle.

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