• Subglotic stenosis
• Vocal cord paralysis
• Macroglossia
• Pierre Robin syndrome
• Laryngeal atresia
• Pulmonary sequestration
• Pulmonary hypoplasia

• Lower airway
  • Bronchiolitis
  • Pertussis
  • Pneumonia
  • Tuberculosis

• Upper airway
  • Croup
  • Epiglottitis
  • Tracheitis
  • Peritonsilar abscess

• Aspiration
  • Fluid
  • Foreign body
• Carbon monoxide poisoning
• Methemoglobinemia
• Smoke inhalation

• Head/Neck
  • Dermoid cysts
  • Brancial cleft cysts
  • Lingual thyroid
  • Hemangioma
  • Teratoma
  • Papilloma
  • Brain stem tumor
• Thoracic
  • Teratoma
  • Cystic hygroma
  • Bronchogenic cyst
  • Pericardial cyst
  • Neurogenic tumor
  • Lymphoma
  • Leukemia
• Abdominal mass
  • Hepatic mass
  • Hepatoblastoma
  • Neuroblastoma

• Anaphylaxis

• Asthma
• Atelectasis
• Pneumothorax
• Pleural effusion
• Hemorrhage
• Embolism

• Pulmonary edema

• Renal failure causing fluid overload
• Metabolic acidosis

• Anemia
• Sickle cell crisis
• Acute chest syndrome

• Duchenne muscular dystropy
• Spinal muscle atrophy

• High altitude
• Exercise
• Psychogenic hyperventilation
• Anxiety
• Panic disorders

Question: Onset of dyspnea? What was the patient doing at the time of onset (if acute)?
Significance: In a small child, acute onset may be related to aspiration of a foreign body or liquid. If the patient was unsupervised, foreign body is a high probability. If the dyspnea occurred over days, other respiratory, cardiac, or renal should be suspected.

Question: Any fever, cough, chest pain, runny nose?
Significance: This would suggest an infectious etiology. The chest pain could be related to a pneumothorax, which can occur spontaneously in some individuals.

Question: Anyone at home sick or have respiratory problems and/or illness?
Significance: Leading toward infection. However, in some cases of congenital heart disease a respiratory virus such as RSV can make an otherwise stable patient into a critically ill child.

Question: Is there history of wheezing or asthma?
Significance: Children who have a history of wheezing are likely to reexacerbate their lung disease.

Question: Has the child ever been hospitalized or had respiratory problem in the past?
Significance: Children that have been hospitalized for respiratory problems are likely to have subsequent difficulty with other respiratory problems.

Question: Any history of cardiac problems or ever been diagnosed with a murmur?
Significance: In the absence of an infectious type or wheezing type of history, a murmur can help the examiner focus on the cardiac examination.

Finding: Crackles or rhonchi auscultate
Significance: Lower lung disease such as pneumonia or bronchiolits. Fluid overload can cause bilateral crackles.

Finding: Wheezing auscultated
Significance: Wheezing is usually heard on expiration. Suggest an obstructive lung disease such as asthma or reactive airways disease or anaphylaxis.

Finding: Distant or absent breath sounds
Significance: Foreign body aspiration blocking air movement. Pneumothorax should also be suspected.

Finding: Barking cough
Significance: Croup, which is usually caused by parainfluenza virus. It also could be foreign body.

Finding: Symptoms worse in supine position
Significance: Could be secondary to pulmonary edema or compression by a mediastinal mass.

Finding: Egophony auscultate
Significance: Pleural effusion should be suspected.

Finding: Loud murmur or gallop auscultated
Significance: Cardiac disease in which pulmonary edema can be etiology of the dyspnea.

Finding: Cyanosis
Significance: Poor oxygen perfusion

Finding: Low blood pressure and poor skin perfusion
Significance: The patient can be in shock. Quick identification of the type of shock is needed to correct the underlying problem.

Finding: Clubbing of the digits
Significance: Suggests chronic disease such as cystic fibrosis or cardiac disease

Finding: Drooling, with mouth open in an ill appearing child
Significance: Suggests epiglotitis and need for careful evaluation (see Epiglottitis)

Finding: Abdominal mass palpated
Significance: Could be causing compression of lungs

Finding: Acites or edema
Significance: Fluid overload either from renal or cardiac etiology

Test: Chest radiograph
Significance: Look for appearance of the lung fields for the different types of pneumonia. Evaluate the heart size and the pulmonary vascularity for fluid overload. Hyperinflation suggest an obstructive pulmonary disease such as asthma. A hyperinflated (usually right lobe) darkened lobe is suspicious of a foreign body present. Seeing a shift in the heart and seeing a lung edge is common in pneumothorax or effusion. Fluid in the costophrenic angle suggests an effusion.

Test: Pulse oximetry
Significance: A quick assessment of oxygen perfusion

Test: Arterial blood gas
Significance: A more detailed assessment of oxygenation and acidosis. A blood gas will also delineate metabolic versus respiratory acidosis and also can show if compensation has occurred.

Test: Complete blood count with differential
Significance: First, an elevated white blood count with a left shift differential can be a sign of infection. If the patient has pallor, the hemoglobin can be evaluated to see if the patient is anemic. A CBC also can be helpful in patients in which leukemia or other oncologic diseases are suspected.

Test: Mantoux (PPD)
Significance: A history of family members with tuberculosis or immigrants from a country where TB is prevalent, a PPD should be placed with anergy panel.

Q: Is dyspnea, in most cases, pulmonary in nature?
A: Yes, it is in most cases. However, if infectious, foreign body, and asthma etiologies are ruled out, a non-respiratory cause must be investigated

• Any patient that has unstable vital signs, inability to oxygenate, and needs critical care services.
• Any patient with a suspected foreign body aspiration will need a bronchcosopy surgical consult.
• If asthma is suspected, use criteria as noted in asthma (see Asthma).
• Any patient with epiglotitis will need an otolaryngologist to evaluate the patient under general anesthesia (see Epiglottitis).
• Anaphylaxis is a medical emergency and mandates immediate action. Epinephrine, benadryl, and possibly steroids are the drugs of choice for treatment.
• Any patient that has a pneumothorax. May need surgical aspiration or chest tube placement (see Pneumothorax).
• Any patient where an oncologic process suspected. Referral to a tertiary care center with a critical care unit and with a pediatric oncologist (see Leukemia).

• A child who presents dyspnea, anxiety, or panic disorder should only be considered once the more serious etiologies have been ruled out.
• If hyperventilation is suspected, a brown paper bag can be useful to break the cycle of hypocarbia.

Denny FW. Acute respiratory infections in children: etiology and epidemiology. Pediatr Rev, 1987;9(5):135–146.

Dibs SD, Baker MD. Anaphylaxis in children: a 5-year experience. Pediatrics 1997;99(1):E7.

Holroyd HJ. Foreign body aspiration: potential cause of coughing and wheezing. Pediatr Rev 1988;10(2):59–63.

McIntosh K. Respiratory syncytial virus infections in infants and children: diagnosis and treatment. Pediatr Rev 1987;9(6):191–196.

Schidlow DV, Callahan CW. Pneumonia. Pediatr Rev 1996;17(9):300–309.

Segel GB. Anemia. Pediatr Rev 1988;10(3):77–88.