Medical mystery: Why was a healthy teenager struggling to breathe?
Why was this teen soccer player having trouble breathing?
A 16-year-old girl was rushed to the emergency department with difficulty breathing. Her symptoms had started suddenly 45 minutes earlier during a soccer game.
Soccer was her sport — she lived and breathed soccer since she was 5 years old. Recently, she had started having trouble breathing during some games and practices. Her primary care pediatrician prescribed an albuterol inhaler to use 10 minutes before playing. The inhaler helped sometimes, but not that day.
In the emergency department, the triage nurse determined that the teen was experiencing significant respiratory distress: gasping for air and coughing. She didn’t have a fever and her blood oxygen level was normal, but her respiratory and heart rates were elevated. She complained that her throat and chest felt tight and that she could not take a deep breath. Her voice sounded hoarse.
The triage nurse passed her to the treatment team to start medicine for an asthma attack — continuous inhaled albuterol and a dose of oral steroids. The teen did not respond to this front-line treatment.
Mysterious breathing difficulty
Our patient presented with difficulty breathing and respiratory distress. One of the first things we consider is asthma, the most common chronic respiratory condition of childhood. It causes the lungs’ airways (tubes that carry air to and from the lungs) to become swollen and produce thick mucus. Also, the muscles surrounding the airways spasm, further narrowing, which causes shortness of breath, coughing, and wheezing.
Some people have symptoms with exercise and this is known as exercise-induced asthma. Inhaled albuterol works for temporary, fast-acting relief within 10 minutes of administration. However, our patient did not have wheezing in her lungs, and she did not respond to treatment for asthma, making this diagnosis unlikely.
Another consideration in a teen who presents with respiratory distress is pneumonia, a common lung infection. Normally, the small sacs in the lungs (alveoli) are filled with air, but in pneumonia, the air sacs are filled with pus and other fluid. Our patient did not have a fever, and her symptoms started suddenly, making pneumonia unlikely. She also tested negative for common causes of pneumonia: respiratory syncytial virus (RSV), flu, and COVID-19. Incidentally, she was previously vaccinated for COVID and flu.
The sudden onset of our patient’s symptoms made us concerned about a panic attack, a type of anxiety disorder. A panic attack occurs when someone has sudden, intense physical symptoms with a feeling of unexplained and paralyzing fear. The symptoms can include shortness of breath, a racing heart rate, and chest pain (like that of a heart attack). Panic attacks may last 10 to 20 minutes. Our patient said she felt happy, had many close friends, and was doing very well at school. Score? Mood, 10; stress, 0. In the absence of underlying mood issues and stressors, a panic attack was unlikely.
Not asthma, not pneumonia, and not a panic attack — what could this be? Three things stood out:
This has happened before (but not as severe).
She complained of difficulty breathing despite normal lung sounds.
She had a hoarse voice.
Solution
Our patient’s diagnosis was vocal cord dysfunction (VCD). VCD is a condition in which the vocal cords close partially with a deep breath, when they should stay open. The vocal cords are two pieces of tissue stretched across the voice box that vibrate to make sound speaking. VCD is typically triggered by colds or infections, stressful situations, air pollution, or, as was the case with our patient, high-exertional exercise.
VCD is treated by an ear, nose, and throat doctor (otolaryngologist), a lung doctor (pulmonologist), a speech therapist, and sometimes a psychologist. It’s teamwork — together they identify triggers and help the patient learn to relax the vocal cords while breathing.
Difficulty breathing is one of those symptoms that needs to be taken seriously the first time and every time. Respiratory distress can be life-threatening, so don’t hesitate to call 911. Often, if your child has concerns of exercise-induced symptoms, a PCP will prescribe an inhaler as a first move to treat presumed asthma. If the inhaler is not effective, it’s critical to let your child’s PCP know. The best defense is to vaccinate your children against all possible infections that could contribute to a respiratory problem.
Melissa Olsakowski is a pediatric resident and Rima Himelstein is an adolescent medicine specialist at the Nemours’ Children’s Hospital in Delaware.