From the Guidelines
The emergency department workup for a pediatric patient presenting with shortness of breath without a history of asthma should begin with a thorough assessment of vital signs, including respiratory rate, oxygen saturation, heart rate, blood pressure, and temperature, as well as a physical examination focusing on respiratory effort and signs of distress, such as retractions, nasal flaring, and cyanosis, as recommended by the management guidelines for community-acquired pneumonia in infants and children older than 3 months of age 1.
Initial Assessment and Management
The initial assessment should include checking for response, as outlined in the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1.
- The child's airway, breathing, and circulation (ABCs) should be evaluated, and supplemental oxygen should be provided if oxygen saturation is below 92% 1.
- The physical examination should focus on respiratory effort, auscultation for wheezing, crackles or decreased breath sounds, assessment for retractions, nasal flaring, and cyanosis.
- Laboratory tests to consider include a complete blood count to evaluate for infection, and a chest X-ray to identify pneumonia, foreign body aspiration, or other structural abnormalities.
Further Management and Disposition
- If respiratory distress is significant, a trial of bronchodilator therapy with albuterol may be appropriate even without a history of asthma.
- For suspected bacterial infections, empiric antibiotics such as amoxicillin or ceftriaxone may be indicated, as suggested by the guidelines for the management of community-acquired pneumonia in infants and children older than 3 months of age 1.
- Blood gas analysis should be considered in moderate to severe respiratory distress to assess for hypoxemia or hypercarbia.
- The differential diagnosis should include viral bronchiolitis, pneumonia, foreign body aspiration, anaphylaxis, and first presentation of asthma.
- Disposition depends on response to treatment, with admission indicated for persistent hypoxemia, increased work of breathing, or inability to maintain hydration, as recommended by the guidelines for the management of community-acquired pneumonia in infants and children older than 3 months of age 1.
From the Research
Pediatric Shortness of Breath Workup
- The workup for pediatric shortness of breath in the emergency department may vary depending on the underlying cause, with asthma and lower respiratory tract infections being common causes in adolescents 2.
- However, in cases where there is no history of asthma, other causes such as severe idiopathic subglottic stenosis should be considered, as presented in a rare pediatric case 2.
- The evaluation and treatment of pediatric asthma in the emergency department is well-established, with current evidence supporting the use of inhaled bronchodilators and systemic steroids as first-line agents 3.
- Despite the focus on asthma management, it is essential to consider other potential causes of shortness of breath in pediatric patients without a history of asthma, and to tailor the workup and treatment accordingly.
Key Considerations
- Biphasic stridor and progressive exercise-induced shortness of breath may be indicative of severe idiopathic subglottic stenosis, a rare but important consideration in pediatric patients 2.
- The high prevalence of asthma and its potential to progress from mild to life-threatening underscores the importance of a thorough understanding of acute asthma management in the emergency department 3.
- A comprehensive workup for pediatric shortness of breath should take into account the patient's medical history, physical examination, and laboratory results to determine the underlying cause and guide treatment.