Management of Exertional Shortness of Breath in Children

Diagnostic Approach

The American Academy of Allergy, Asthma, and Immunology recommends performing spirometry and detailed pulmonary examination to determine if shortness of breath is associated with underlying conditions such as restrictive lung conditions or exercise-induced bronchoconstriction in children with exertional dyspnea 1, 2
The American Academy of Allergy, Asthma, and Immunology suggests conducting an indirect challenge test (exercise challenge) rather than direct challenge (methacholine) for assessing EIB, as indirect challenges are more sensitive for detection in children 1, 2
For exercise challenge testing, the American Heart Association recommends ensuring heart rate reaches and sustains at least 95% of maximum heart rate in children to accurately assess exercise-induced dyspnea 1, 2
The American Thoracic Society recommends considering cardiopulmonary exercise testing to determine if exercise-induced dyspnea and hyperventilation are masquerading as asthma, which is common in children and adolescents 1, 3
Differentiate between EIB and exercise-induced laryngeal dysfunction (EILD) through appropriate challenge tests and potentially flexible laryngoscopy during exercise, as recommended by the American Academy of Otolaryngology 1, 4

Exercise-induced bronchoconstriction (EIB) is a common cause of exertional dyspnea in children, according to the American Academy of Allergy, Asthma, and Immunology 1, 2
Poor physical conditioning is the most common reason for exercise-induced dyspnea in children, as stated by the American Academy of Pediatrics 3
Exercise-induced laryngeal dysfunction (EILD) is a potential cause of exertional dyspnea in children, as noted by the American Academy of Otolaryngology 1, 4
Exercise-induced anaphylaxis (EIAna) should be considered when respiratory symptoms are accompanied by systemic symptoms like pruritis, urticaria, and hypotension, as recommended by the American Academy of Allergy, Asthma, and Immunology 5, 3
Cardiac causes of exertional dyspnea in children should be referred to a cardiologist, as advised by the American Heart Association 6

The American Academy of Allergy, Asthma, and Immunology recommends prescribing inhaled short-acting β2-adrenergic receptor agonists (SABAs) like albuterol for protection against EIB and for accelerating recovery of pulmonary function in children 2, 7
Use a single dose of SABA on an intermittent basis (less than 4 times per week) before exercise to protect against or attenuate EIB, as suggested by the American Academy of Allergy, Asthma, and Immunology 2, 7
Be cautious with daily use of β2-adrenergic agents as this can lead to tolerance manifested as reduced protection against EIB, as warned by the American Academy of Allergy, Asthma, and Immunology 2, 7
Schedule regular follow-up visits as medications can differ in effectiveness over time due to variability of asthma, environmental conditions, and intensity of exercise, as recommended by the American Academy of Allergy, Asthma, and Immunology 1, 7

Avoid misdiagnosis of asthma in cases of dysfunctional breathing or reaching physiological limits, as this leads to unnecessary medication use, as cautioned by the American Thoracic Society 3
For children with obesity, recognize that dyspnea may be associated with increased oxygen cost of breathing without bronchoconstriction, as noted by the American Academy of Pediatrics 3
Monitor for signs of exercise-induced anaphylaxis, which can present with respiratory symptoms plus systemic manifestations, as recommended by the American Academy of Allergy, Asthma, and Immunology 5, 3
If symptoms persist despite appropriate management, refer to appropriate specialists (pulmonologist, cardiologist) for further evaluation, as advised by the American Academy of Allergy, Asthma, and Immunology 1, 6

Schedule regular office visits to assess response to therapy and adjust management as needed, as recommended by the American Academy of Allergy, Asthma, and Immunology 1, 2
Reassess diagnosis if there is poor response to initial management, as suggested by the American Academy of Allergy, Asthma, and Immunology 1, 7