Your Child’s Breathing – PediaCast 490

Show Notes


  • Our Pediatrics in Plain Language Panel is back in the house as we explore your child’s breathing. We cover many terms and topics, including periodic breathing, respiratory distress, coughing, wheezing, stridor, asthma and croup… and we do it with words you can understand!


  • Breathing and Respiration
  • Periodic Breathing
  • Respiratory Distress
  • Coughing
  • Wheezing
  • Stridor
  • Asthma
  • Croup




Announcer 1: This is PediaCast.




Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.


Dr. Mike Patrick: Hello, everyone and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from Nationwide Children's Hospital. We are in Columbus, Ohio.


It's Episode 490 for May 13th, 2021. We're calling this one "Your Child's Breathing". I want to welcome all of you to the program.


So we have another Pediatrics in Plain Language edition of our podcast this week. And you will recall that our Plain Language Panel consist of Dr. Alex Rakowsky and Dr. Mary Ann Abrams, both with Primary Care Pediatrics at Nationwide Children's Hospital.




When they visit the studio, we double down on our efforts to avoid medical jargon and really try use plain language as we cover basic elements of childhood illness, injury, health and wellness. And when medical jargon cannot be avoided, or when it is necessary to use, we try to our best to explain exactly what we mean alongside that jargon in plain language.


And we hold each other accountable, correcting one another when medical jargon creeps in, which it tends to do because it's very easy for doctors to allow big or complicated words to slip into the conversation. Not because we're trying to impress anyone, but it's really because doctors are people. And for us, that medical jargon is simply part of our everyday vocabulary. We use it a lot on the job.




And so it is easy for it to slip out. But we don't do it on purpose. But it happens, and there it is. And when we fail to catch it, then really, we do a disservice to our patients and families. Because then, those who we are trying to care for may not understand exactly what we are trying to communicate. They may miss the importance or significance of what we're saying.


And this actually is where you come in as kids and teenagers, moms, dads, if you don't understand something your doctor is saying, that's not your fault. But if it happens. And you can't quite place the meaning of a word or a phrase, or you get the impression that there's greater importance or significance to the topic at hand, and yet you feel like you're missing something, please step in, interrupt right there on the spot. Get your questions answered.


Again, it's not your fault if you don't understand it. It's our fault. And we really do want that correction. So interrupt, just say, "Hey, hold on a second, because I want to make sure I'm understanding." And clarify what he or she is talking about or have him place the new information within the context of what you already know.




And don't feel bad about interrupting. Because the more that your provider progresses down that pathway of conversation, if you don't understand point A and you're thinking about point and what that means, and they're on to point B, C, and D, and you miss what they're saying, it's better just to stop the conversation and get things clarified.


And it's important to do because we're all in this together. We'll do our best to speak with plain language and explain exactly what we mean in a clear fashion. But when we fail and we will fail from time to time, moms and dads, please jump in and ask us to clarify because we really do want to communicate effectively. We want your child to receive the absolute best care possible.


We want you to understand why, why we're suggesting a specific treatment. We want you to know what to watch for should any complications arise or when treatment is not working as expected. We need your help in that though to keep us in check, as we attempt to improve our communication skills.




The topic of our Plain Language edition of PediaCast this week is your child's breathing. So we're going to explore normal breathing patterns, something called periodic breathing in babies, respiratory distress, what do we mean by that? Coughing, wheezing, stridor, asthma, croup, bronchiolitis, epiglottitis and more terms and topics related to your child's breathing.


And yes, I realize many of these terms and topics do not represent plain language, epiglottitis, bronchiolitis. But have no fear, once we get our panel assembled, we'll do our best to explain exactly what we mean.


First, let's cover our usual housekeeping items. Don't forget, you can't find PediaCast wherever podcasts are found. We are in the Apple and Google Podcast apps, also iHeartRadio, Spotify, SoundCloud, Amazon Music and most other podcast apps for iOS and Android. If you like what you hear, please remember to subscribe to our show so you don't miss an episode.




Also, please consider leaving a review wherever you listen to podcasts so that others who come along looking for evidence-based child health and parenting information will know what to expect.


We're also on social media and we love connecting with you there. You'll find us on Facebook, Twitter, LinkedIn, and Instagram. Simply search for PediaCast.


And then, we have that Contact link over at if you would like to suggest a future topic for the program.


Also, I want to remind you, the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your healthcare provider.


Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at


So, let's take a quick break. We'll get Dr. Alex Rakowsky and Dr. Mary Ann Abrams connected to the studio. And then we will be back to talk about your child's breathing. It's coming up right after this.






Dr. Mike Patrick: Our Pediatrics in Plain Language Panel is in the house once again. You'll recall that Dr. Mary Ann Abrams is an assistant professor of Pediatrics at the Ohio State University College of Medicine and a pediatrician with Primary Care Pediatrics at Nationwide Children's Hospital.


Dr. Alex Rakowsky, also an assistant professor of Pediatrics at Ohio State and a pediatrician with Olentangy Primary Care at Nationwide Children's.


Let's give a warm welcome back to our friends. Thanks again for being here, guys.




Dr. Alex Rakowsky: Thank you, Mike.


Dr. Mary Ann Abrams: Hi, Mike. It's great to be here today.


Dr. Mike Patrick: Thanks for stopping by.


Mary Ann, let's start with you. Always at the beginning of these episodes, you remind us about the importance of plain language. So tell us about that again. Why is this an important thing that we're taking on?


Dr. Mary Ann Abrams: I keep trying to think of something kind of special to say about plain language when we start our podcast. And there were a couple of thoughts that came to mind.


First, the general introduction, plain is not baby talk or dumbing down. Plain language is using words and sentences that your grandmother would understand, that we call living room language. The bottom line is that it conveys the ideas you want to share in a way that is understandable to almost anyone.


And I came across a new way of talking about written materials or print materials because so much of the material that we read is important and we have to read so much. And in this podcast, I think a lot of times, we talk about spoken plain language. But the written material is important too.




And I always use the term 'reader-friendly' print materials because it means it's easy to read and it engages you and you want to read it. But what does that mean for all the reading we do on the computer, on laptops, on iPads and phones? And I found a new term called 'reader-friendly plain language materials'. So that captures all the different world of electronic communication and social media that talk about health and other topics as well.


So that a new little nuance term that I wanted to share. And then I thought maybe I would add a couple of stories from couple of people I know who shared experiences with a doctor or a physician. One where the doctor was very nice and cared a lot, very engaged, but spoke really rapid fire, really fast. And he used a lot of technical terms.




And even though this person, the patient, was really a smart person, highly educated, good reader, this person just felt lost. And the most important takeaway was that the person told me that they wouldn't have ever been able to ask a question because they were so lost that they never could formulate a question. Because they were working so hard to understand what they're being told about, what they had, and what they needed to do.


Dr. Mike Patrick: And this is the one who felt they were educated.


Dr. Mary Ann Abrams: Yeah.


Dr. Mike Patrick: And it's still really above them because medicine is not in their education wheelhouse.


Dr. Mary Ann Abrams: Exactly. Or even if they are in medicine, right? Maybe it's not your specialty like we're all pediatricians but what about when we're dealing with a parent maybe who has an adult onset type of disease that we don't see a lot? Or we're just really, really worried about a serious diagnosis. It makes all of us have a hard time understanding. So that's why plain language is so important.




Dr. Mike Patrick: Absolutely. And I mentioned during the introduction and I'll reiterate it again because I think it's so important. It really is okay to interrupt that exchange with your doctor at the moment when you're not understanding something. Because if you get two or three steps down the road and you're still thinking about what that first thing meant and you're not really listening anymore, just stop the conversation and ask for clarification.


And that's okay. It's not your fault that you don't understand. It's out fault that you're not explaining it well enough. And we need that feedback so we improve how we're speaking with patients and families.


Dr. Mary Ann Abrams: I just want to say that's exactly. It's hard to do that, right? But here's a little phrase you can say to make it a little easier. You can say, "Just a minute, doctor. I want to make sure I understand what you're saying." So no one can argue with that.


"Whatever you're saying, I want to make sure I understand it." That doesn't say, "You're not talking clearly." It just says, "I want to make sure I understand." So use that as a way to ask questions, chime in if you're not sure.




Dr. Mike Patrick: Just like you were at work. We're in all this together as a team to take care of your child. And so, if you were at work and you weren't understanding what a colleague was talking about, you would ask for clarification in the exam room, the same thing.


I do want to remind all of our listeners that we're kind of following along chapter by chapter with a book called What to Do When Your Child Gets Sick. It's from the Institute for Healthcare Advancement, which is a non-profit organization.


We do have a 40% off discount code. It's pod719. And you'd be able to get the book for $7.77 at the website for the Institute for Healthcare Advancement. It's also available at Amazon, Barnes & Nobles, but your discount code won't work at those locations.


And then, for all of this Plain Language that we're doing, we have a survey because we'd like to get your thoughts on what you think about these shows and how we can improve them. So if you wouldn't mind taking a few minutes to take the Pediatrics in Plain Language survey, you'll find it in the show notes for this episode, 490, over at the




And then, over on SoundCloud, we have a playlist of all of our Plain Language episodes. We're covering your child's breathing today, but we've done your child's mouth and nose, their mouth and throat, their ears and their nose, their eyes. We've covered basic concepts of fever and illness, newborn baby care, keeping kids safe, reading and family literacy and many many more. So please do check out that playlist.


All right, let's move on to our topic at hand. And the first question I want to ask you, Mary Ann, is what is breathing? Now, I know that sounds like a really basic question, but you hear other terms too like respiration, inspiration and expiration. So what do all these terms that surround breathing, what do they mean?


Dr. Mary Ann Abrams: Good question. So breathing is basically air moving in and out of our bodies. And we take that for granted. But why do we breathe, right? We all know what it feels like when you're out of breath because you've been running or working hard or whatever.




But the purpose of breathing is to really help our body get what we need to function to work, to get energy and to get rid of the by-products or the waste or whatever it is when our body produces energy and operates like it normally should. The main thing that comes in and out through our breathing is oxygen, which comes in and our body needs to make energy and the function. And then the main thing that comes out is carbon dioxide which is a by-product of our metabolism and the running of our body.


So the parts of breathing, I thought I would just kind of run through the path that air takes when it comes in and out of our body because we'll be taking about some of those parts as we go through our podcast today. Air comes in through our nose and our mouth. And each of those parts of our bodies has kind of special function.




The nose has little hairs or cilia and things like that help to filter air that comes in. And at least it kind of helps keep out some of the bigger things like maybe pollen and things that we might breathe in. Then, also our sinuses in the back of our nose help to warm the air when it's really cold outside.


So it brings that air into our body. And then it goes down to the back of our throat into the area that where our vocal cords are, the larynx, right around where our Adam's apple is on the outside of our body. And from there, it goes into what we call up in the windpipe or the trachea, which is a tube that comes from the back of our throat and our vocal cords down into our chest.


And that's a relatively bigger tube if you will that branches out into a couple slightly smaller but still relatively large tubes that lead to our lungs.




And as those tubes get further and further into our lungs, they get smaller and smaller and tinier and tinier and narrower and narrower. And ultimately, they lead to tiny little, we call them little tiny air sacs or little parts of our lungs.


You can think of it almost like broccoli. It just keeps getting smaller and smaller. There are little stems, then you have these little clusters where the air actually ends up in the lungs.


And then, the beauty of those little sacs is they're right next to capillaries or they have very thin walls in the blood in those capillaries. Capillaries are very tiny blood vessels that run between our arteries and our veins which carry blood to and from the heart and the lungs.


And the beauty of those little air sacs and those little capillaries is that when the air gets to that part of your lung, the oxygen crosses over that really thin wall into the bloodstream. And the carbon dioxide that's in the bloodstream crosses into the air sacs. And then that moves back up out of the lungs, back up the windpipe through the mouth, through the nose, and out into the atmosphere. So that is hopefully a nice summary of what breathing is.




Dr. Mike Patrick: That is fantastic. Some of those other terms, like when we hear respiration, technically, respiration is that exchange of oxygen where oxygen is going into the body and carbon dioxide is coming out. That also happens at the cell level where carbon dioxide comes out and oxygen goes in.


So technically, when we say respiration, it's that movement of gas whereas breathing is the movement of the entire air in and out of the body. And then, inspiration is when you breathe in. Expiration is when you breathe out. So just some of these other terms that are associated with breathing.


We do know that normal breathing changes as kids progress from being a baby to the teenage years. What are some of the ways in which breathing changes as we get older?




Dr. Mary Ann Abrams: I think the main difference is how fast we breathe. Babies breathe pretty fast normally, depending on whether they're asleep or wide awake or crying or upset. Or maybe they had fever. But assuming they're not sick, the breathing rate of the baby may be anywhere from 30 to 50 times a minute, 40 maybe is about average.


And as they get older, their lungs get bigger. They're able to breathe a little more deeply. So the normal breathing rate slows down.


And we have tables that tell us what the normal breathing rate is for a toddler and a 5-year-old and a 10-year-old and 14- to 16-year-old up to when we become adults, when the normal breathing rate maybe is about 14. So it goes maybe from 40 to 30 to 20 down to the teens.


Dr. Mike Patrick: And this is an important thing to consider because there are lots of things that can increase the respiratory rate or decrease the respiratory rate compared to what it should be. And so, that gives you an idea of certain diseases and problems in the body are happening when that respiratory rate changes.




One of the special things about breathing in little babies is something called periodic breathing that sometimes causes folks concern. What is periodic breathing in babies?


Dr. Mary Ann Abrams: It's kind of an interesting, I was going to say phenomenon, interesting thing about breathing, normal healthy breathing in full-term babies. There are sort of just like a little variation, a little bit of variety in how they breathe, especially maybe when they're asleep.

Periodic breathing is sort of alternating little cycles, if you will, of normal breathing and then little short pauses in the breathing. And those pauses can maybe be five to ten seconds. It doesn't hurt the baby. It doesn't cause them to turn blue or to struggle to breathe or to have their oxygen levels go too low that's in a dangerous way.




Sometimes, it can be more common in babies that are born prematurely. Most of the time, especially the preterm babies, the premature babies, it doesn't really cause problem for them. Once in a while, sometimes, in a premature baby, you have to pay a little bit more attention and see if it's affecting them.


But in general, periodic breathing, the short pauses are abnormal pattern that babies have, again, sometimes more commonly noticed at least when they're sleeping or really quite.


Dr. Mike Patrick: So periodic breathing, there's periods of these pausey, slow breathing, and then a period of normal breathing that's a little more rapid back and forth. So something to watch for in babies, but it's normal. It's not something that we get too concerned about.


Dr. Mary Ann Abrams: So they usually outgrow it by five to six months.




Dr. Mike Patrick: So just real little babies will do this. And then, another term that we should bring up is respiratory distress. What do we mean by that? Sometimes, you'll hear a doctor use that terminology. What is respiratory distress?


Dr. Mary Ann Abrams: Yes, so let's break that down. Respiratory, we've been talking about breathing and you pointed out how breathing and respiration, the exchange of the oxygen and the carbon dioxide are the fundamental purpose of breathing.


And so, we have this term, respiration, and if we have respiratory distress, that means that exchange of oxygen and carbon dioxide isn't working well. And then, the word distress, obviously, sounds like being upset or something is wrong. So something about this pattern that we've talking about is abnormal.


So we look for signs of distressed breathing or trouble breathing. And again, those can vary by the age of the baby or by maybe what's causing that distress. So the thing we tend to look for are a big increase in how quickly or how rapidly a baby is breathing or even a teenager. The rate that we talked about is going to be higher than we said the normal range is.




We look for things that show their body is working harder to breathe. And how do we know? We see things like the muscles that help us breathe are working harder. So the nostrils may flare. We can see flaring around the nostrils of the nose. We can sometimes see kids sitting up really high or leaning forward, really straight and leaning forward to try to get a good airway breathing through their mouth.


Now, the thing we look at a lot is their chest working harder, the spaces between their ribs sucking in and out, or maybe the spaces above their collar bone. Or the area below the rib cage where their stomach is going in and out fast and hard. If it's really bad, sometimes, you can see color change, some little light blue duskiness, we call it, around their nose or their lips and mouth.




And trouble speaking, trouble talking or for a baby, they may have trouble feeding, taking a bottle or breastfeeding or eating.


Dr. Mike Patrick: So Alex, let's turn to you and talk about another term that often comes up as we think about breathing, and that is cough. So what exactly is a cough and why does our body cough? Why do we do that?


Dr. Alex Rakowsky: So I want to go back to what Mary Ann said as far as sort of the anatomy, how the respiratory system or the way we breathe works because it helps kind of explain cough. So the upper part of what we call respiratory system, your nose and your mouth, are essentially the parts of the body that bring the air in.


Then you have that tube in the middle, the middle part of the system which is the trachea, which Mary Ann mentioned and it starts to break down into the lungs. And then the lungs are the lower respiratory system which are these very very microscopic little parts where the air, the oxygen gets into the blood.


So cough really is a way to protect from things getting down into the lungs that don't belong there or getting things out of the lung that don't belong there. So it's really two different mechanisms for the upper compared to the lower.




So for the upper respiratory system, or again, the mouth, the nose, the early parts of the airway, anything that doesn't belong, the body wants to keep out of there. So you cough if you have a little bit of sinus drain as you go, fluid get down there. If you're eating something, you start to gag.


If you have a post-nasal sort of drip, your body doesn't want that phlegm, that piece of candy that already get down to the lungs. So you're coughing to get that stuff out of there.


And it actually is the most common cause of cough. And then if you have things in your lungs already, so if you have fluid in there because of pneumonia, asthma, et cetera, you want to get that stuff out of there. Now, your body is coughing to get that fluid up into the upper airways. You can either swallow it or just to clear it out of the lungs.


So cough really has two mechanisms, but ultimately, its job is to keep fluid from coming in or things from coming in or things to be put out of the lungs.




Dr. Mike Patrick: So when you do have a cough in a child, what do you do for that? How are coughs treated?


Dr. Alex Rakowsky: So I think it really then depends on what's causing the cough. So start off, at the lower part of the respiratory system or the lower part of the breathing system in the lungs. So the common reasons to cough, if you have something down in your lungs is a pneumonia, which can be either virus or a bacteria, an asthma attack or something else going on with those lungs. You got smoke inhalation, et cetera.


So in that situation, you really try to figure what's causing that fluid in the lungs. So if it's an asthma attack, you sort of attack the asthma to make sure that fluid gets decreased. If it's a pneumonia due to bacteria which is actually not as common as the viral pneumonia, you can give antibiotics.


And if it's pneumonia due to virus or viral infection of lungs, like what you call RSV for example or bronchiolitis, then you help the child with their breathing to kind of clear some of that phlegm from the bottoms of the lungs.




And then for the upper part of the airway which is the more common one, you really try to figure out what the cause is. So if it's a child with allergies in the dead of summer, you can give him something to help the allergies.


If it's the winter, then you're looking at a child that may have a dry mouth or dry throat, you can give him lozenges.




Dr. Alex Rakowsky: Lozenges are like a little candy, like a cough drop, though.


Dr. Mary Ann Abrams: Maybe, got it.


Dr. Alex Rakowsky: I thought it was a common term. Sorry about that, like a little cough drop. But basically, you sort of like gives something to kind of help soothe the back of the throat.


But again, you're trying to figure out the causes. If it's a small child that didn't cough before and all of a sudden was coughing a lot, did they put something in their mouth and now, they're choking on it? So really, the key to cough is to figure out why is it there and try to get the reasons behind the cough to kind of get rid of it.




Dr. Mike Patrick: And that's a really good point. The cough drops or lozenge, you do want to make sure that it's a child who can maintain their airway. You certainly do not want to give those to little kids because it can be a choking hazard. But certainly, for older kids, it can definitely coat the back of the throat to soothe the throat and take that tickle away a little bit.


Honey can do the same thing. Although, again, you don't want to use that in babies that are less than a year old. Yeah, Mary Ann?


Dr. Mary Ann Abrams: I'm not trying to picky but maintain the airway. That's a very common term that I use with fellow pediatricians in the healthcare setting. I don't know how many people walk around talking about if their baby can maintain their airways. So I just want to kind of throw it that out there.


And in case, people hear it, it means can they cough something up if they start to choke, right? Or are they able breathe and get enough strength to breathe out if something kind of get stuck in their throat or they're struggling? Just thought I'd throw that out there as a plain language.




Dr. Alex Rakowsky: And I know, so far, we're talking about cough, keeping things from coming down or having things that are already in the lungs come up, so the reason for cough. But you can also have non-physical reasons for cough. So something called psychogenic cough. And they're sometimes called ticks, not the little crawly things that bite you and give you Lyme's disease.


But a tick is like a habit. And some kids will actually start having some coughing spells with a cold and then it becomes almost like a habit. So like a habit cough. And there may be nothing wrong with that child physically. There's nothing that they're trying to block from getting down or trying to get back up. But again, that's another fairly common reason for coughing.


Dr. Mike Patrick: And it may even be, if you have a viral infection, that virus destroys cells in the airway. And so it takes the body some time to rebuild those cells. And while it's rebuilding those cells, you may still have a cough.




Usually, those cells, the little cilia, little projections that wiggle, and so they help to keep things from getting down in the lungs or bringing things back up. And if those aren't working because your body is making new cells, then your body may cough. And sometimes, those coughs can last for two or three weeks because that's how long it takes the body to make those cells again even though the virus is completely gone.


Mary Ann, you're going to correct me there?


Dr. Mary Ann Abrams: No, I'm not. No, I wanted to point out what both of you just said reminded me that another cause of cough is whooping cough, right? Because, Alex, you talked about how you want to keep people from getting things the cause of cough. And whooping cough is not rare anymore, unfortunately. And so the whooping cough vaccine or the pertussis vaccine is very effective in preventing whooping cough and very important because it could be a very deadly disease in babies, especially.




And because we know now that teenagers and adults and babysitters and parents and grandparents can actually have a milder form of whooping cough and give it to young babies who can't maintain their airways as well as we can.


And then, the other reason that you remind me of that was that you talked about how somebody's infection can irritate the stridor lining of the breathing tubes, the trachea, the windpipe, et cetera, and make that cough last longer. And with whooping cough, it can last a couple of months, even in adults.


So I just want to chime in there because I'm a big supporter of how important vaccinations are. And especially with COVID, we know kids are behind on their vaccines, too.


Dr. Mike Patrick: The medical jargon for whooping cough is pertussis. And so, when you hear about the DTaP vaccine, diphtheria, tetanus, pertussis is definitely an important one to prevent that. Alex, you were going to say something?




Dr. Alex Rakowsky: Yes, also, I just want to kind of make sure that people realize that cough isn't an actual illness. It's a symptom of an illness. So really, the key to cough is to figure out what's causing it. And that's why pediatricians are so opposed to cough suppressants because you're almost hiding the truth.


In other words, if I give a toddler a cough suppressant, they work sometimes. But it maybe that they're hiding a pneumonia that's going to get worse. It may be hiding something that the child swallowed. It may be hiding a viral illness that now is progressively getting worse.


Dr. Mary Ann Abrams: Yeah, I think that's a really important that you just made, Alex. And I was just going to add one more thing to why we don't like to give these medicines to children or young children, especially, and certainly not babies, is in addition to all those reasons you just listed, they also can cause side effects. And serious side effects, even sometimes, life-threatening side effects because they can almost make children stop breathing sometimes, depending on what's in this cough medicines, which is another word for cough suppressant.




So a lot of times, people really want a cough medicine and we don't want to give it and we need to explain why. And I know that can be disappointing sometimes when people worried about their baby's not getting any sleep or they're not getting sleep. But we really don't want to hide an underlying problem. We don't want to give a medicine that could cause a side effect.


Dr. Mike Patrick: And some of those side effects, as you mentioned, are really serious. Like they can cause depression in your breathing. Some of them can increase your blood pressure. They can increase your heart rate. Other ones have effects on the brain and sometimes, kids will almost seem like they're on drugs when they're on those medicines. And so, there are lots of reasons why we really like to try to avoid cough medicines, especially in young kids.


Dr. Mary Ann Abrams: And just to clarify, when you said depression in breathing, not depression like we are sad, but they can cause the breathing rate to get low.




Dr. Mike Patrick: Yeah, exactly.


All right, let's transition here a little bit and talk about wheezing, which is another term that we often hear as we think about our child's breathing. Mary Ann, what exactly is wheezing? Tell us about that.


Dr. Mary Ann Abrams: So I'm going to come back to that, hopefully, that picture that I painted with words earlier about how the breathing system, the respiratory system is set up. And you recall, the air comes in our nose and mouth, goes down the back of our throat into the trachea, then into those bronchi and bronchioles and those tiny little tubes in the lungs, taking the air with it.


So around all those little tubes, we have little tiny bands of muscle that surround those tubes. And they also have some sort of glands in them that can produce mucus and moisture to help keep the lung passages smooth and working well. So all that is normal.




But sometimes, if something irritates the lungs, and that could be a lot of different things. It could be cigarette smoke. It can be air pollution. It can be infections. It can be pollen. It can be allergies of other kinds and asthma itself.


They can cause those little muscles to have spasms and to contract or squeeze them. And when they do that, it makes those little tubes narrower and narrower and narrower. So you're trying to put the air through a smaller and smaller space. Like instead of a little pipe, it's now a straw and then even sometimes, thinner and thinner.


The other thing that can happen is those little glands that I talked about can get revved up. And that can cause a lot more fluid, liquid production, especially mucus. And it can cause irritation, or what we call inflammation, irritation and swelling in those tubes. So that those air passages get really, really narrow.




And if you think about what does it sound like when the wind is blowing and it's going down a narrow space, you hear a whistling sound. And that's what we hear when we listen with a stethoscope and sometimes can even hear it without a stethoscope when someone is wheezing. We hear the sound of that air being squeezed through those narrow locked-up kind of clogged breathing tubes.


Dr. Mike Patrick: It's kind of a hard thing to describe. And so I am going to put a link in the show notes for everyone to a YouTube video that has the sounds of a child wheezing. So you can play that and see exactly, or hear, I should say, exactly what wheezing sounds like.


And then we've done several episodes of PediaCast on asthma in the past. So I'm just going to put links to some of those episodes if you'd like to learn more about asthma and wheezing. One of them was all about asthma, Episode 444. We did one on exercise-induced asthma, which just means asthma that is associated with increased work as in exercising. That was Episode 427.




We also talked about a school-based asthma program in Episode 360. So just some other resources, therefore, if you'd like to learn more about wheezing and asthma.


Dr. Alex Rakowsky: Mike, if I can just add one more thing. It's also that a lot of times wheezing doesn't come by itself. In other words, you actually have coughing along with the wheezing. So if parents do listen to the sort of audio of a wheezing child, a lot of times, it can be hidden also, of coughing spells, a lot of phlegm, things like that.


So yeah, I know we're separating this out in separate categories. A lot of these things kind of come together. Just to be aware of that fact.


Dr. Mary Ann Abrams: That's a really good point. And just another rule of thumb is wheezing is more often a sound or a symptom that people when they're breathing out. And I know in a little bit, we're going to talk about another breathing pattern that's when someone is sick. And that is often affected more when people are breathing in. It's not 100% but like many things in medicine, there are some crossover between things.


Dr. Mike Patrick: So Mary Ann, how do we treat wheezing then? So once we have a child who's wheezing, we hear that, what should a parent do?




Dr. Mary Ann Abrams: So treating wheezing is partly related to treating what's causing the wheezing. And I think Alex did a nice job a little bit ago when he was talking about different things that cause coughing. A lot of those things are the same things that can cause wheezing. We call them a lot of times, triggers, meaning  that they lead to or they result in or cause the wheezing.


So assuming they have allergies, you treat the allergies. They have infection, you treat the  infection, depending on what kind of infection it is.

But if you need to treat the wheezing because it's causing them to have respiratory distress or even just to be breathing harder or not as well or to be coughing a lot so they can't sleep or whatever, there are kind of two approaches. We take what we call sort of rescue treatment, which is kind of a strong word, but it means treating the wheezing as it's happening.




And the main way we do that is with medicines that help to relax those muscles around the breathing tubes and somewhat help to decrease that extra fluid and mucus in there. Although that's a different kind of medicine that does that, that we'll talk about in a minute.


But the best way to do this is through breathing that medicine in. So it goes right to where the problem is. So we use inhalers and we used to use a lot of breathing treatments like nebulizers or aerosols.


But we're finding more and more that we can do most of it with just an inhaler. And sometimes, you need to attach something to the inhaler so that you don't have to get the timing just perfect. But by breathing that medicine down into the lungs, and depending on how much wheezing or how bad the wheezing is, sometimes two puffs every four to six hours, sometime two puffs every 20 minutes, depending on what's going on right at that point can help treat the wheezing itself.




And then, the other people piece is while people are wheezing and also to help prevent wheezing, we use medicines that help especially to decrease that irritation, the inflammation, the mucus, the extra fluid, et cetera in the lungs. And we can do a really good job of preventing the wheezing if people use that regularly, on a daily basis.


And again, that's also delivered by an inhaler, similarly depending on using a spacer or if they can time it, they can just inhale it directly. However, sometimes, people need to take a little short course of an anti-inflammatory medicine that's usually a steroid to help to treat the active wheezing and then move to the breathing steroid to help to keep it from coming back or prevent it in the future.




And a lot of people worry sometimes that the steroids are dangerous because they hear a lot of bad things about steroids. Steroid medicines, when they're used correctly in the lowest dose for the shortest period of time, are actually very effective and very helpful and help prevent more serious illness that can also be bad for people's health.


Dr. Mike Patrick: Absolutely. And those inhaled steroids, it's really a low dose that goes to the rest of the body. Most of that's just going to have an effect down in the lungs. So when kids are on in an inhaled steroid every day to prevent wheezing, especially those who would wheeze often without that, if you look at risk versus benefit, the benefit of that low-dose steroid that you're inhaling outweighs any risk that would be associated with it.


And one other thing I wanted to point out is just the importance of that spacer when you use inhaled medication. A lot of people think, well, as a child gets older, they may not need that spacer anymore. But really, study showed that even in adults, you get a much better delivery of the medicine down into the lungs when you use that spacer.




So really, everybody, even adults, should be using a spacer when they use a metered dosed inhaler, right, Mary Ann?


Dr. Mary Ann Abrams: Absolutely. And I appreciate you clarifying that. That's a really important point. Because it can be really hard to time that inhaler and to go directly into the lungs. But the spacer enables that to really get to where it needs to be and everyone should really use it.


I think Alex was going to add something.


Dr. Alex Rakowsky: Yeah, I know we're talking about maybe trying to prevent wheezing but there are some easy things that you can ask parents to work on. For example, smoking in the house, where smoke exposure can actually take children who are prone to wheezing and actually make them wheeze more. And that's a discussion to have with the families if they're looking for a reason to quit smoking, there may be a good one and it's hard to quit. But there may be a reason to stop.




And then, also look for allergy causes in the house. And a lot of our pulmonary folks or lung doctors will work with the families for what's possible causes of allergies or triggers in the house that get the wheezing worse. So besides just the medicine, again, that's kind of treating the symptom, but going back to what may be causing the wheezing. And sometimes, it's something that could be eliminated from the child’s environment.


Dr. Mike Patrick: Absolutely. Let's move on to another term that we often hear related to breathing. And that is stridor. So this is different than wheezing. Alex, explain to us what exactly is stridor.


Dr. Alex Rakowsky: So stridor is not the guy from Lord of the Rings. So that's not what we're talking about. So stridor actually is a tightness sound that you hear.


So let me kind of go back to our anatomy. And before we talk about the upper airway, the lower airway, and then spend a lot of time with that middle part, that sort of tube, what you call the larynx goes into the trachea and then spreads out into the lungs.




Stridor really is an issue or a problem with that middle part. And what's stridor is, it's sort of like a tightening of that middle part which then air can go through. It's almost like a whistling or a tightening of a sound, like air whistling through, let's say, a crack in a window.


Stridor is more common in small children because they have a smaller airway. And it can be caused by a lot of reasons. It can range from an infection which makes that airway even smaller. It has some phlegm in there. It can be something that they swallowed. It can be something pushing on that airway.


Or it can be something which they're just born with, something called trachea, which is the tracheomalacia, which means it's the airway that doesn't have the right tone, which in the early parts of life may be giving them some problems. And they have almost like a whistling sound when they're breathing.



Dr. Mike Patrick: Yeah, and just like I have a YouTube video of wheezing in the show notes, we also have another one on the sounds of stridor. So you can really take a listen to one after the other and kind of compare and contrast how wheezing and stridor are different.




As Mary Ann had said, wheezing is primarily when you're breathing out. And stridor occurs primarily when you're breathing in. Although you can also have inspiratory wheezing, which is some wheezing that you hear when you breathe in. But for the most part, wheezing is going to be when you breathe out. Stridor is going to be when you breathe in.


In general, it's one way that you can try to differentiate between the two. But check out those YouTube videos. And then we'll give you a little bit more compare and contrast between the two.


So then, Alex, what are some of the things that causes the stridor?


Dr. Alex Rakowsky: Stridor is something that's usually sort of should sound alarm bells in the family. And get it checked out because it's not a common finding. And a lot of times stridor maybe something that's serious.




So definitely, kind of keep that in mind. So start off with that. Because again, it's where the airways getting tighter. So, I'll start off with real basic thing. So, some infants are born with the smaller airway. They're born with most likely sort of tighter airway. In that situation, the stridor actually is due from just the way they're built. And they may just outgrow it at that time.


And there's something called tracheo or laryngomalacia, which is you can hear or used by your doctors or providers that you see.


And then, working your way down, there's some classic viruses that will give you stridor because they cause a swelling of the airway and then put some phlegm in there. So, croup is probably the most common one that people know. And it kind of gives you almost like this barky sort of cough, usually in the early winter and then in the sort of late winter, early springtime.


And it's scary. We've had two kids actually have croup. And even as a pediatrician, it really kind of scares you when your child's kind of having this sound.




And then, the one we tend to forget about, because we tend to focus on infections, is a child swallowed something. So, if a child  wasn't having any stridor at all and all of a sudden having a lot of stridor, especially they're salivating or having saliva come up, thinking about the fact that they have something going down there.


Or if they're eating in the backseat or they're sort of eating and you didn't see what was going on. Then you're worry about something stuck in that middle part of the airway that gave you the stridor.


Dr. Mike Patrick: All right, so let's say that we have a child and we've determined that they do have stridor. They're making some noise when they breath. Obviously, whenever a child is making noise persistently when they breath, you just start hearing it all the time. Whether it's when they're breathing in or out and you're not sure if it's stridor, it's wheezing, you want to see someone. And you want to see someone sooner rather than later because breathing is so critical and important.


But let's say that we do determine that it is stridor, how do we treat that? How do we go about treating stridor in kids?




Dr. Alex Rakowsky: I think the main almost like theme of this entire podcast episode is that these are all symptoms. And it's a matter of finding what's giving you the symptoms. And stridor is no different that wheezing or cough. We're really trying to find what's the main cause.


So there are really three common causes of stridor, the three that kind of dominate what we see as pediatricians. The first scenario is smaller child, preschool child, early elementary school child who has a head cold, maybe a low-rate fever. It's dead of winter or early spring. And also when they have a barky cough as it gets darker and later in the day.


That's most likely due is something called croup. Croup is really classic viral illness that we see in that time of year. And most cases, if the child's comfortable beside that barky cough, no need to rush to the hospital. But if there's any concerns, then definitely get seen. And we see this all the time in urgent care.




Things that you can do at home is to take the child outside, get some cool air, almost like putting ice to a swollen ankle. You're essentially putting some cool air to an airway. Try to get some moisture because croup also produces a lot of phlegm. So if you have some of the moisture, it makes the phlegm a little looser so they can also kind of cough it off.


So that's probably the most common cause of stridor in a slightly older kids. If you have a toddler whose toddling around the house or sitting in the backseat, no one is watching them and all of a sudden develops sudden stridor, think that they have something stuck in the airway. That's the situation where you really want to make sure, one, that they're breathing because if not, then it's time for 911 and CPR.


If they are breathing, then you still want to get that seen because there's something in that airway is kind of now stuck in that middle part of the airway system. And you want to get that out. So that's probably scenario number two that you think about stridor.




And the third one is we see this a lot as pediatricians, infant comes in for a four-week well child visit, two-week well child visit. And they kind of have the noisy breathing. And when they're sleeping, they actually have almost this kind of almost like a whistling sound. So it's not your classic like really tight sound but it is still stridor.


And then, you worry about something called, we talked about just a little bit before, it's either laryngo or where the tone of the larynx is a little looser or tracheomalacia. In those situations, lot of those kids is just going outgrow it, with really no therapy or medications needed.


And you basically ask the parents just to keep an eye on it. If it gets worse when they're eating, if it gets to the point where they seem like they're struggling to catch their breath, then you definitely have to get that seen.


But a lot of those infants just kind of clear up on their own. It's a fairly common finding in infants.




When I think of stridor, those are the three that kind of come to mind. And I cover like 99% of the stridor cases that I see either as a general pediatrician or urgent care doc.


Dr. Mike Patrick: Absolutely. When it is caused by croup, which you had mentioned, in addition to moisture in the air and kind of cooler air helping, sometimes kids need some steroid medication to decrease the swelling around the voice box that's causing that stridor when they have croup. And sometimes, they needed aerosol with the medicine call epinephrine to really reduce that swelling.   


So these aren't things that you would necessarily do at home but if that barky cough's not getting better and it's progressing to a noise every time your child breathes in, you definitely want it be seen sooner rather than later. If your doctor's office is closed, go to an urgent care or an emergency department, so you can get those kinds of treatments for the croup.


And then, one other thing I want to mention is something that I have actually never seen, thankfully, as a provider, but generations of pediatricians before me did see often. And that's something called epiglottitis.




And epiglott is that little flap in the back of the throat that when you swallow covers the trachea or the airway so that food doesn't go down the wrong pipe. And sometimes in the past, that would get inflamed and cause really bad stridor. And that was a real medical emergency oftentimes caused by bacteria called Haemophilus influenza type b.


And that's one of the things that we do vaccinate against in infancy, it's the Hib vaccine. And Alex, just talk about the importance of that vaccine and how it's really changed the practice of pediatrics?


Dr. Alex Rakowsky: So I actually am few years older than you. So when I started the residency in early 90s, epiglottitis was actually still seen. I saw I think 13 or 15 cases as an intern.




And the Hib vaccine actually came out early second year of my residency. It's a three-year residency program. So it actually came out pretty quickly as soon as I kind of got into residency. And the rate of epiglottitis has actually bottomed out.


In most any winter shifts, you will have at least one child in ICU that have Hib-related either pneumonia, epiglottitis, which is not as common, or meningitis. And these were devastating illnesses.


I actually took care of a patient in my community clinic as a resident who had Hib epiglottitis who then couldn't breathe for like a long time and had some significant brain damage. So he basically is like a complex care patient.


Unfortunately, I saw a lot of complications. I did ID fellowship after residency and still saw some case of Hib meningitis not do well. So, this is a vaccine that's a total life saver, life changer.




And I'm not that old and my kids may beg to differ, but this is something I still saw as a resident. And it's funny, they had a recent sort of like case of the week for the residency program about six months ago, where you had to guess this really rare cause of this child's fever. And right after, it end up being Hib meningitis.


And I was thinking, I used to see that on a weekly basic. So life has changed a lot where it's gone from everybody's like, "I got to think about Hib meningitis to case of the week because it's so rare." So I'm very thankful for this vaccine.


Dr. Mike Patrick: The Hib vaccine and the pneumococcal vaccine, kind of similar organisms that can cause meningitis and epiglottitis and such. So those baby shots are really really important.


All right, well that kind of brings us to a close here. Alex, I always ask you at the end to remind us about Primary Care Services at Nationwide Children's Hospital. You guys are a really big group?


Dr. Alex Rakowsky: Yeah. If I can just add more thing, for stridor, with all these things, I know we are talking that these are symptoms and you have to find a reason, there's a reason for urgent cares and emergency rooms to exist. And that's for to take care of children who may have something seriously wrong with them.




And anything airway, I think cough is something that most parents are kind of comfortable with. But you hear wheezing, if you hear stridor, it's not something that you see on a routine basis, definitely get seen. Because again, these are symptoms of something that can be very serious. So, these are symptoms, I mean, we got trained, anything that have stridor, you should tell them over the phone to come back again as soon as they can.


So that maybe this like one last point about this is that, yes, we can figure most of these things up pretty quickly. But that's why we have ERs and urgent cares just to kind of help out of that.


So to get to our system, we're the largest academic, that means affiliated with sort of teaching hospital, pediatric clinic system in the country. Last year, I think we had a close of 300,000 visits. And we follow up about 100,000 children in our clinic system.




We have coming in July, I think a total of now 17 clinics that we cover, which is a large amount. And mostly in the Columbus area, we have a few mobile vans that kind of cover some of the outlying areas.


And it's a very diverse population. The clinic where I work is about 40% recent immigrants. And there's another clinic on the east side is about 40%, 50% Hispanic. There's one in the west side, it's about 50% Somali. We have one in the northern clinic, that's about 30% Nepalese families.

So it's a very diverse group. And we try to take care of all the patients that we see. About half the clinics have residents. Most of them are pediatric residents. We have two clinics where we have family medicine residents from some of our outside hospitals rotate as well.




And then, medical students go to I think 10 of the 17 or 11 of the 17 clinics. It's a big endeavor and I think we do some really nice work.


Dr. Mike Patrick: Yeah, you guys really do a fantastic job. I'm going to put a link in the show notes to Primary Care Pediatrics at Nationwide Children's so folks can learn more about what you do and where your services are available. That'll be again in the show notes over at


Lots of links actually in the show notes. So if you want to learn more about all these things that we've been talking about, we'd actually done a lot of PediaCasts on many of these issues.


One that we didn't really bring up much today was bronchiolitis, which can be associated with wheezing. Mary Ann had talked about the mucus and inflammation down deep in the lungs in the little babies because their air tubes are so small. When they get a viral infection, they can get a lot of wheezing if they don't have asthma just because of all the mucus that's down there. And then that results in the condition called bronchiolitis.




We have a show that we did on croup and bronchiolitis. It's Episode 447 and we'll put a link to that in the show notes if you'd like to learn more about croup and bronchiolitis.


We also have some Continuing Medical Education podcast for the providers who were in the crowd. We did one on management of asthma. That was PediaCast CME 50. And then we've also done some shows on school-based asthma therapies. I had mentioned exercise-induced asthma.


So lots of additional links and podcast episodes if you'd like to delve deeper into issues associated with your child's breathing. And then definitely check out those YouTube videos on wheezing and stridor so you can listen and hear exactly what it is that we've been talking about.


All right, so as always, we really appreciate it when Dr. Alex Rakowsky and Dr. Mary Ann Abrams stop by. They are our Pediatrics in Plain Language panel and with Primary Care Pediatrics at Nationwide Children's Hospital.




So Mary Ann and Alex, thank you both so much for stopping by today.


Dr. Alex Rakowsky: Thank you so much for having us, as always. Take care.


Dr. Mary Ann Abrams: You're welcome. Thank you, Mike. I thought that was a great session and it's always good to see you guys. And I look forward to our next plain language and pediatric podcast.




Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that. Also, thanks to our guests this week, Dr. Mary Ann Abrams and Dr. Alex Rakowsky, both with Primary Care Pediatrics at Nationwide Children's Hospital.




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Also, don't forget about our sibling program, PediaCast CME. It's similar to this program. We do turn the science up a couple notches and offer free Continuing Medical Education credit for those who listen. Of course, that includes doctors, but also nurse practitioners, physician assistants, nurses, pharmacist, psychologist, social workers, even dentists.




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Thanks again for stopping by. And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So, long, everybody.




Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.


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