ABP Pediatric Pulmonology common mistakes
ABP Pediatric Pulmonology · Understand the traps and how to avoid them.
Labels a child with twice-monthly night cough and normal spirometry as 'mild intermittent asthma' and discharges on a short-acting beta-agonist alone, without documenting impairment or risk domains.
Equates symptom frequency with severity and skips the risk domain (exacerbations, prior systemic steroids, lung function); also accepts night cough as asthma without considering alternative diagnoses.
What to do instead
Apply the EPR-3/2020 severity grid (impairment plus risk) before starting treatment, reassess control at follow-up, and explicitly exclude vocal cord dysfunction, GERD, and habitual cough before committing to a controller.
Reads a flow-volume loop with only an inspiratory plateau as 'variable intrathoracic obstruction' and pursues asthma therapy rather than airway imaging.
Pattern recognition is learned as a list rather than a localization algorithm, so the inspiratory and expiratory limbs are swapped under time pressure.
What to do instead
Use a fixed algorithm: inspiratory limb only = variable extrathoracic; expiratory limb only = variable intrathoracic; both limbs = fixed obstruction; then choose direct laryngoscopy, bronchoscopy, or CT accordingly.
Uses a single sweat chloride of 40 mmol/L to rule out cystic fibrosis in an infant with steatorrhea and failure to thrive.
Memorizes 60 mmol/L as the cutoff but forgets the intermediate 30-59 mmol/L range, the need for two tests, and falsely low results in edematous or malnourished infants.
What to do instead
Repeat sweat testing on two occasions with adequate sweat weight, then proceed to CFTR sequencing and functional testing; classify intermediate results as CFSPID and follow longitudinally rather than declaring CF excluded.
Prescribes azithromycin or oral steroids for a 4-month-old with typical viral bronchiolitis because of wheeze and a 'prolonged' course.
Extrapolates preschool wheeze and asthma data to infants and over-reads coarse breath sounds or mild focal findings as bacterial superinfection.
What to do instead
Treat typical bronchiolitis supportively (oxygen, hydration, suctioning); reserve antibiotics, steroids, and bronchodilators for defined exceptions, and reassess for apnea, dehydration, or an alternative diagnosis such as pertussis or pneumonia.
Diagnoses obstructive sleep apnea in a 5-year-old with an AHI of 1.5 using adult cutoffs, or excludes OSA because a single overnight oximetry study was normal.
Adult AHI thresholds are overlearned, and oximetry is assumed to be a sufficient screen despite poor sensitivity for hypopneas and hypercapnia in children.
What to do instead
Use pediatric thresholds (AHI greater than 1 abnormal, greater than 5 moderate, greater than 10 severe) and confirm with attended polysomnography; interpret oximetry only as an adjunct, never as a rule-out.
States that alveolarization is complete by 36 weeks' gestation and that surfactant production begins in the canalicular stage, then uses this to explain survival at 23 weeks.
Compresses the canalicular, saccular, and alveolar stages into a single timeline and confuses surfactant appearance with air-blood barrier thinning.
What to do instead
Memorize a staged timeline: pseudoglandular (5-17 weeks), canalicular (16-26 weeks), saccular (24-38 weeks), alveolarization (late gestation to at least 2-3 years, continuing slowly thereafter); tie viability to saccular development and surfactant at about 24-28 weeks.
Recommends immediate lobectomy for an asymptomatic prenatally diagnosed CPAM in a newborn before any postnatal imaging or observation.
Reflex fear of malignant transformation and unfamiliarity with spontaneous regression and the natural history of small asymptomatic lesions.
What to do instead
Risk-stratify: observe asymptomatic lesions with postnatal imaging and serial follow-up, and reserve resection for symptomatic lesions, enlarging cysts, recurrent infection, or diagnostic uncertainty; discuss timing and evidence with the family.
Escalates to high-flow nasal cannula in a child with impending respiratory failure and then delays intubation for hours because oxygen saturation remains above 90% on 2 L/kg/min.
Treats saturation as the primary endpoint and underestimates fatigue, rising CO2, and the masking effect of high flow on work of breathing.
What to do instead
Define explicit failure criteria (persistent tachypnea, retractions, rising PaCO2, altered mental status, inability to protect the airway), reassess every 30-60 minutes, and set a pre-declared intubation threshold rather than titrating to saturation alone.
Stages asthma severity using absolute FEV1 in liters rather than percent predicted or z-score, or applies the adult 200 mL/12% bronchodilator response cutoff to a 7-year-old.
Adult pulmonary function rules are overlearned and absolute volumes are easier to read off the report than GLI z-scores.
What to do instead
Interpret spirometry with GLI z-scores and percent predicted for age, height, sex, and ethnicity; use pediatric bronchodilator responsiveness criteria (for example, FEV1 increase of at least 12% with attention to absolute change appropriate for size) and trend values over time.
Labels a child's chronic wet cough as 'recurrent bronchitis' for years without obtaining nasal nitric oxide, chest imaging, or genetic testing, missing primary ciliary dyskinesia and allowing bronchiectasis to progress.
Anchors on the most common diagnosis and treats repeated antibiotic courses as confirmation rather than as a signal to broaden the differential.
What to do instead
For chronic wet cough beyond 4 weeks, pursue a structured workup: chest radiograph, sweat chloride, nasal nitric oxide, immunoglobulins, and referral for bronchoscopy or HRCT; consider PCD when neonatal respiratory distress, situs inversus, or year-round wet cough coexist.