Diagnostic Approach of

Dyspnea in Children

Nastiti Kaswandani
Dyspnea approach
symptom (subjective) VS sign (objective)
 symptom: sensory experience (sensation),
that only could be feel and judge by the
patient  psychologic disturbances

 sign: respiratory distress, patient breath with

difficulties, involvement of additional
respiratory muscle  physiologic disturbances
 Dyspnea approach
Acute VS Chronic
(sudden onset) (long standing)
 acute: often resolves with treatment of the
underlying condition
 chronic: usually result in progressive
dysfunction, severe disability, and eventual
death

the lecture focus on acute dyspnea

Chest and Respiratory System
Dyspnea classification
pathophysiology, anatomic, disorders

EXTRA Obstruction of proximal / larger

FLOW thorax airway
disorders
INTRA Obstruction of distal / smaller
thorax airway

INTRA Lung parenchyma disorders

thorax Extra-pulmonary disorders
VOLUME
disorders
EXTRA Lung compliance disorders
thorax Respiratory center disorders
Dyspnea classification
pathophysiology, anatomic, disorders

EXTRA Obstruction of proximal / larger

FLOW thorax airway
disorders
INTRA Obstruction of distal / smaller
thorax airway

INTRA Lung parenchyma disorders

thorax Extra-pulmonary disorders
VOLUME
disorders
EXTRA Lung compliance disorders
thorax Respiratory center disorders
 Extra-thorax FLOW disorders
Obstruction of proximal / larger airways
 rhinitis with nasal obstruction, nasal polyp
 cranio-facial malformation
 OSAS
 tonsil-adenoid hypertrophy
 laringo-tracheo-malacia
 larynx papilloma
 diphtheria
 croup, epiglottitis
 thymus hypertrophy
• clinical: inspiratory stridor
• age : infant – below five
Acute Laryngitis
Thymus hyperplasia
Vascular Rings
Secondary Tracheomalacia (Extrinsic)

 Compression disorder
 Collection of congenital vascular
anomalies that encircle and
compress the esophagus and
trachea
 Diagnostics seen on MRI and
echocardiograph
Dyspnea classification
pathophysiology, anatomic, disorders

EXTRA Obstruction of proximal / larger

FLOW thorax airway
disorders
INTRA Obstruction of distal / smaller
thorax airway

INTRA Lung parenchyma disorders

thorax Extra-pulmonary disorders
VOLUME
disorders
EXTRA Lung compliance disorders
thorax Respiratory center disorders
Intra-thorax FLOW disorders
Obstruction of distal / smaller airways
 asthma
 bronchiolitis
 vascular ring in small airways
 solid foreign body aspiration
 lymph node enlargement pressure

• clinical: expiratory effort

• age: infants, below five age – bronchiolitis
Bronchiolitis
Dyspnea classification
pathophysiology, anatomic disorders

EXTRA Obstruction of proximal / larger

FLOW thorax airway
disorders
INTRA Obstruction of distal / smaller
thorax airway

INTRA Lung parenchyma disorders

thorax Extra-pulmonary disorders
VOLUME
disorders
EXTRA Lung compliance disorders
thorax Respiratory center disorders
Intra-thorax VOLUME disorders
Lung Parenchyma Disorder
 pneumonia (infection, aspiration)
 atelectasis
 pulmonary edema
 near drowning
 sepsis

clinical: inspiratory effort

Dyspnea classification
pathophysiology, anatomic disorders

EXTRA Obstruction of proximal / larger

FLOW thorax airway
disorders
INTRA Obstruction of distal / smaller
thorax airway

INTRA Lung parenchyma disorders

thorax Extra-pulmonary disorders
VOLUME
disorders
EXTRA Lung compliance disorders
thorax Respiratory center disorders
Intra-thorax VOLUME disorders
Extra-pulmonary disorders
 pneumothorax, pneumomediastinum
 cardiomegaly, heart failure (perfusion)
 pleural effusion (incl’ empyema, hematothorax)
 hernia diaphragmatica
 diaphragmatica eventration
 intra-thorax mass (non pulmonary)
 chest trauma (rib fracture, lung contusion)
 thorax deformity (pectus excavatum, scoliosis)

klinis : inspiratory effort

Dyspnea classification
pathophysiology, anatomic, disorders

EXTRA Obstruction of proximal / larger

FLOW thorax airway
disorders
INTRA Obstruction of distal / smaller
thorax airway

INTRA Lung parenchyma disorders

thorax Extra-pulmonary disorders
VOLUME
disorders
EXTRA Lung compliance disorders
thorax Respiratory center disorders
Extra-thorax VOLUME disorders
Lung compliance disorders
 neuromuscular disorders (CP, GBS, MG)
 gastritis, peptic ulcer
 extreme obesity
 peritonitis, appendicitis, acute abdomen
 aerophagia, meteorismus
 ascites
 hepato-splenomegali
 abdominal solid tumor

clinical: inspiratory constraint

Dyspnea classification
pathophysiology, anatomic disorders

EXTRA Obstruction of proximal / larger

FLOW thorax airway
disorders
INTRA Obstruction of distal / smaller
thorax airway

INTRA Lung parenchyma disorders

thorax Extra-pulmonary disorders
VOLUME
disorders
EXTRA Lung compliance disorders
thorax Respiratory center disorders
Extra-thorax VOLUME disorders
Respiratory center disorders

 anemia
 metabolic acidosis
 CNS infections: meningitis, encephalitis
 encephalopathy (typhoid, DHF, metabolic)
 psychologic (anxiety, usually adolescent)
 poisoning: salycylate, alcohol
 trauma capitis
 CNS disease sequelae

clinical: deep rapid breathing

Clinical approach

symptomatology dyspnea

pathophysiology evaluation

pathology etiology

treatment treatment ~ etiology

Dyspnea clinical approach - 1
first step : ANAMNESIS
 identity: age, sex, etc
 dyspnea:
 acute, chronic, recurrent
 degree of dyspnea
 how long has been dyspneic
 timing of dyspnea: at rest, at activity, day or night
 triggers, factors make worse / better
 response to therapy
 underlying cardiopulmonary / neuromuscular disease
 associated symptoms: chest pain, cough, wheezing
 other signs & symptoms

 80% of cases can be diagnosed

Dyspnea clinical approach - 2

next step : PHYSICAL EXAMINATION

 inspiratory : nasal flaring, retraction (supra
sternal, intercostal, subcostal, epigastrium),
chest indrawing (retraksi arkus kosta)
 expiratory : prolonged expirium, wheezing,
abdominal muscle contraction

 respiratory examination: respiratory rate;

stridor, symmetry of breath sound & on
percussion; rales; sign of heart failure
 other holistic examination
Dyspnea clinical approach - 3

further step : SUPPORTING EXAMINATION

 Routine blood examination

 Pulse oximetry
 Imaging diagnostic: CXR, ultrasound,
 Blood gas analysis
 Pulmonary function test
 Electrocardiography, echocardiography
 Rhinoscopy, laryngoscopy, bronchoscopy
Dyspnea clinical approach - 4

last step : TREATMENT

 based on etiology
 first aid: give O2, before we can identify
the etiology; since most cases need it
 other cases, does not need O2 (see next)
Dyspnea classification
maybe oxygen is not needed

EXTRA Obstruction of proximal / larger

FLOW thorax airway
disorders
INTRA Obstruction of distal / smaller
thorax airway

INTRA Lung parenchyma disorders

thorax Extra-pulmonary disorders
VOLUME
disorders
EXTRA Lung compliance disorders
thorax Respiratory center disorders