What is the appropriate outpatient management for a 17‑year‑old adolescent presenting with shortness of breath?

Outpatient Management of a 17-Year-Old with Shortness of Breath

The appropriate outpatient management depends critically on establishing the underlying cause through confirmatory diagnostic testing—particularly spirometry—before initiating any inhaler therapy, as nearly one-third of patients treated empirically for presumed obstructive airway disease have no evidence of lung pathology. 1

Initial Diagnostic Approach

Essential History and Physical Examination Elements

• Assess for specific symptom patterns: Determine whether dyspnea is associated with wheezing, chronic cough, exercise limitation, stridor (especially biphasic), or occurs primarily with exertion 2, 3
• Identify critical risk factors: Document prematurity history (gestational age <37 weeks), smoking exposure, chemical exposures, medication use, and family history of atopy or asthma 2, 4
• Examine for key physical findings: Look for jugular venous distention, decreased breath sounds, wheezing, stridor, clubbing, or signs of respiratory distress (retractions, tachypnea, oxygen desaturation) 4, 5

Mandatory Initial Testing

• Spirometry (FEV1 and FVC) is essential before prescribing any inhaled medications, as 40.9% of patients receiving inhalers for shortness of breath never had pulmonary function testing, and 28.4% had no evidence of obstructive airway disease 1
• Chest radiography to evaluate for structural abnormalities, infiltrates, or cardiac enlargement 4
• Pulse oximetry to assess for hypoxemia 2
• Complete blood count and basic metabolic panel to exclude anemia and metabolic derangements 4

Management Based on Specific Diagnoses

If Asthma or Recurrent Wheezing is Confirmed

• For adolescents with chronic cough or recurrent wheezing, initiate a trial of inhaled corticosteroids with monitoring to assess for clinical improvement (delivered via metered-dose inhaler with spacer) 2
• Consider a trial of short-acting inhaled bronchodilators (such as albuterol) for symptomatic relief, with monitoring for response 2
• Do not prescribe bronchodilators or inhaled corticosteroids routinely in the absence of recurrent respiratory symptoms 2

If Post-Prematurity Respiratory Disease (PPRD) is Present

This applies only if the patient has a history of prematurity (gestational age <37 weeks):

• Avoid routine bronchodilator therapy unless recurrent symptoms (cough, wheeze) are present; if symptoms exist, trial short-acting bronchodilators with clinical monitoring 2
• Avoid routine inhaled corticosteroids unless chronic cough or recurrent wheezing is documented; if present, trial inhaled corticosteroids for approximately 3 months with symptom monitoring 2, 6
• Do not use diuretics routinely; if the patient was discharged from NICU on chronic diuretics, discontinue judiciously 2, 7

If No Obstructive Airway Disease is Found

• Consider alternative diagnoses: Heart failure (measure brain natriuretic peptide), pulmonary embolism (D-dimer if appropriate risk factors), interstitial lung disease, pulmonary hypertension, or psychogenic causes 4
• Chest CT is the most appropriate imaging study for suspected pulmonary causes when initial testing is unrevealing 4
• Consider specialized testing: Right heart catheterization for suspected pulmonary hypertension, or bronchoscopy for interstitial lung disease 4

If Stridor or Upper Airway Obstruction is Suspected

• Evaluate urgently for subglottic stenosis or other structural airway abnormalities, particularly if progressive exercise-induced dyspnea or biphasic stridor is present 3
• Bronchoscopy or airway endoscopy may be indicated for unexplained symptoms concerning for malacia or anatomic abnormalities 2

Critical Pitfalls to Avoid

• Never prescribe inhaled medications empirically without confirmatory pulmonary function testing, as 18.9% of patients on inhalers cannot be assigned any respiratory diagnosis and 6.1% have alternative conditions like heart failure 1
• Do not assume asthma based on symptoms alone in adolescents with prematurity history, as they may have fixed airway obstruction, tracheomalacia, or paradoxical responses to bronchodilators 2
• Avoid dismissing progressive dyspnea as "just asthma" without considering rare but serious causes like subglottic stenosis, especially if symptoms are exercise-induced and progressive 3
• Do not delay resuscitation while pursuing a formal diagnosis if the patient presents with acute respiratory distress 8

Monitoring and Follow-Up

• Schedule outpatient follow-up every 3-6 months to monitor general wellbeing, respiratory status, and lung function when treatment is initiated 2
• Reassess clinical response to any therapeutic trial (bronchodilators or inhaled corticosteroids) within 3 months to determine continuation 2, 6
• Obtain repeat spirometry to objectively document improvement or progression 2