Piper Francis, 17, has been playing softball with lifelong friends since second grade, but last year, she noticed she was having difficulty breathing during practice. She saw multiple doctors who prescribed her asthma inhalers that didn’t help. She was heartbroken and was preparing to transition from an active player to team manager. Then, in early 2025, she was referred to the Exercise Respiratory Center at Cook Children’s – Prosper where her care team identified her breathing issue and helped her recover. Now, she’s back on the softball field and excited to play in her senior year.

Pulmonology Care at Cook Children’s 

John Robertson, M.D., pediatric pulmonologist at Cook Children’s Medical Center - Prosper, was Piper’s advocate, quickly figuring out what she needed to improve her breathing and help her continue playing softball.

“Almost every day last year, I would feel tightness in my chest and throat. It felt like something was blocking my airway,” Piper said. “I’d show up at softball practice and have to sit out through half of it. Now I’ve been able to go back to practice after seeing Dr. Robertson. He immediately recognized my problem and I felt better in less than a month!”

Piper was diagnosed with three conditions – exercise-induced asthma, exercise-induced laryngeal obstruction (EILO) and dysfunctional breathing. 

“The big challenge is that the problems look like each other,” Dr. Robertson said. “Asthma labels are really common and doctors may be right most of the time, but when asthma medications don’t work, there are no standard guidelines pointing at what to do next. The symptoms of these diagnoses – EILO and dysfunctional breathing – aren’t a problem of diseased tissues. They’re normal structures functioning abnormally.”

EILO happens when the vocal cords or neighboring structures collapse on inhalation during strenuous exercise.

Dysfunctional breathing occurs when someone breathes primarily with chest muscles instead of the diaphragm, resulting in inefficient, fast, shallow breaths rather than slower and deeper ones.

Finally Diagnosed at Cook Children’s Exercise Respiratory Center

Piper was diagnosed with EILO and dysfunctional breathing with testing at Cook Children’s Exercise Respiratory Center, which opened in 2023. The Exercise Respiratory Center diagnoses, treats and researches the causes of exercise-induced respiratory symptoms for older children, adolescents and young adults. Some of the many duties of the researchers at the Exercise Respiratory Center, Rebecca Brovina, MSHS, BSN, RN, CPN, and Andy Kreutzer, PhD, CSCS, LSSWB, include gathering data and presenting findings to share with other medical professionals about the diagnosis and treatment of exercise-induced respiratory symptoms.

It’s one of three centers in the U.S. that test continuous laryngoscopy during exercise (CLE) for children and the only center in Texas. During this test, Dr. Robertson will use a scope to view the patient’s voice box and vocal cords while the child exercises. Dr. Robertson was recently named a finalist for D CEO's 2025 Excellence in Healthcare Awards for Outstanding Healthcare Innovator.

“We just finished our 100th CLE test recently,” Dr. Robertson said. “We perform maximal exercise tests, try to provoke the symptoms under investigation while we are examining the patient's voice box with a camera and measuring their breathing efficiency, so we can see what is malfunctioning precisely when symptoms are present.”

Athletic patients like Piper are typically treated within four to six weeks, consisting of four to six visits of physical therapy and/or speech therapy. Piper only needed three visits.

“Piper is a very special person,” Dr. Robertson said. “She’s a dedicated athlete, driven and very competitive and her success story has been inspiring for all of us!”

Physical Therapy and Speech Therapy: Learning How to Breathe Again

Dr. Robertson’s Exercise Respiratory team includes a physical therapist and a speech therapist. Part of Piper’s care includes learning how to breathe again – through her diaphragm instead of her chest.

“Throughout PT and speech therapy, I’ve learned a lot of new breathing techniques,” Piper said. “My symptoms have drastically changed. I can make it through an entire practice now without struggling and missing practice trying to breathe. Learning how to breathe correctly helped me the most!”

Now, whenever Piper feels chest pain, throat tightness, lightheadedness, or breathing difficulties, she first notices if she’s overlooking her breathing techniques and then makes a conscious effort to stay aware and focus on her breathing.

Finding Answers and Hope for Others

Since Piper’s care with Dr. Robertson and the Exercise Respiratory team, her health has drastically changed.

“Emotionally, it makes me feel relieved,” Piper said. “I don’t have to worry about struggling at practice anymore and I can just show up and perform my best.”

Piper’s mom, Kristi Francis, noticed last year that she would come home from softball practice exhausted, had trouble breathing and it would take hours before she felt back to normal.

“It’s been a game changer for Piper,” Kristi said. “We went from doctor to doctor and no one really listened and everyone thought we were crazy. They didn’t believe her symptoms and we finally got to someone who knew exactly what to do.”

When to Seek Further Evaluation

“I feel like this condition needs to be more recognized and that a lot more people actually have it and just don’t know,” Piper said. 

General red flags for people to pay attention to and seek further evaluation:

1. If someone is labeled as having asthma and uses an inhaler, but still has lots of symptoms when the asthma treatment doesn’t help.
2. In EILO, there can be a symptom called stridor, which is exclusive to the voice box: stridor occurs when breathing in, usually as a loud, high-pitched sound that can be heard by others standing nearby. In asthma, wheezing happens during the breath out and is usually a quieter sound only noticed by the person experiencing the symptom.
3. Along with the symptoms above, experiencing dizziness and lightheadedness, passing out/coming close to passing out.

Finding the right diagnosis makes all the difference and can help athletes like Piper feel better, get back to competition and even breathe better than ever before.

Breathing in secondhand smoke isn’t healthy for children, whether the smoke comes from tobacco or marijuana.

Many of the same toxins and irritants in tobacco smoke are also present in marijuana smoke, according to the American Lung Association. Children who are exposed – at home, in the car or in other places – are indirectly inhaling any particles the smoke contains. No amount of secondhand smoke is safe.

What concerns doctors about secondhand smoke? “It can lead to chronic cough, mucus production and infection,” said Alice Phillips, M.D. at Cook Children’s Pediatrics Cityview. “If the child has asthma, it could trigger an asthma attack.”

It’s an increasingly common experience for Dr. Phillips to smell marijuana when patients and their families come to appointments. She detects the marijuana scent on parents and caregivers, as well as in the clothing of young children.

“In the past, I might have noticed one to two times per month, but now it is multiple times per week or even per day,” she said.

Daniel Guzman, M.D. encounters the marijuana odor on three or four patient families every shift he works in the Cook Children’s Emergency Department (ED). Dr. Guzman said he initiates conversations with those families, particularly if the child came to the ED with breathing problems. He points out his purpose is to share the medical perspective -- not invade anyone’s privacy.

“If they’re coming in for asthma issues, then I always have that conversation about smoke, whether it’s cigarette smoke or marijuana smoke that affects the lungs. We know short term that it can lead to more chronic asthma-like issues and other respiratory problems for these children,” Dr. Guzman said.

Education

Secondhand smoke falls in the category of preventable injuries that Dr. Guzman works to reduce through education. Maintaining a smoke-free environment can be compared to proactive safety measures like car seats, gun locks and lifejackets that are meant to keep children safe.

“That’s where the grassroots of all this starts. You make a change in one person, it can have a significant downstream effect, which can be life-changing,” he said. “It’s just a matter of continuing to have that conversation.”

As part of the routine exams with her teenage patients, Dr. Phillips discusses the risks of smoking, vaping and drug experimentation. Because recreational marijuana is illegal in Texas, the scent can pose a tricky situation in the pediatrician’s office. Parents aren’t always completely open when Dr. Phillips brings up the topic. She tries to communicate in ways that stick to the facts, avoid judgment, and demonstrate concern.

“I am the kids’ doctor but also their advocate,” Dr. Phillips said. “As doctors, we must walk the delicate tightrope of partnering with parents in the care for the kids.”

The American Lung Association advises:

• No one should be around secondhand marijuana smoke.
• Anyone exposed to secondhand marijuana smoke can have detectable levels of tetrahydrocannabinol (THC) in their systems. THC is the psychoactive or mind-altering “high” ingredient in marijuana. 
• Don’t allow smoking at any time or place children are present.

Dr. Phillips points out that children look to the adults in their lives for guidance.

“Little eyes are always watching,” she said. “Just like we need to eat our vegetables to encourage good eating habits, we need to stay away from things which might be harmful to ourselves or potentially encourage the same habit in our kids.”

Story by Jean Yaeger. Video by Tom Riehm.

Babies and toddlers treated for viral respiratory infections at certain Cook Children’s locations can get their breathing checked at a special clinic that provides free follow-up visits. 

The clinic serves children ages 2 months to 2 years old who were previously admitted to these Cook Children’s facilities: Medical Center, Emergency Department (ED) or Urgent Care centers. What’s the benefit? For up to a week after these patients go home, their caregivers can bring them to be seen by therapists who specialize in caring for the lungs. 

No appointment is necessary at the Cook Children’s Respiratory Outpatient Clinic. But patients must have a referral from a provider at the Medical Center, ED or Urgent Care centers.   

The clinic is designed to give guidance and reassurance to parents whose little ones are continuing to recover from severe bronchiolitis. If a child has trouble breathing or other complications within seven days of being discharged, the experts at the clinic can do an evaluation. 

Janie Galindo found out about the clinic at the Cook Children’s Urgent Care center where her twins, Dallas and Dionne, tested positive for the respiratory syncytial virus (RSV) in October. Thanks to a referral from their Urgent Care provider, Janie had access to the clinic when her babies got sicker overnight. As soon as the clinic opened the next morning, they were there.   

Just as their mom suspected, Dallas’s and Dionne’s symptoms had gotten worse. A respiratory therapist met them at their vehicle and took them inside for evaluation. In their case, the clinic checkup ended with admission to the hospital.   

Janie is grateful for this resource. And she urges other parents to take advantage of the clinic, which Cook Children’s has offered every year since 2019 during peak season for respiratory illnesses. The clinic saw 119 patients from September through December 2022.

A surge in RSV and flu cases has hit hard in North Texas and nationwide in recent months, contributing to long wait times in health care settings. But the convenience of the Respiratory Outpatient Clinic at Cook Children’s can allow families to avoid returning to the crowded ED or Urgent Care locations where their child was recently treated. 

Families come to the clinic seeking peace of mind. Many children are doing OK and can go back home. Others might need additional treatment as Dallas and Dionne did. 

“It was so helpful,” Janie said. “If your babies aren’t better, just to ease your nerves, just take them in. It doesn’t hurt.” 

The clinic, located at the Medical Center in Fort Worth, is open through March. Hours are from 11 am-7 pm daily. Here’s how it works: 

• Get a referral and instructions when your child is discharged from Cook Children’s Medical Center, ED or Urgent Care with a bronchiolitis/RSV diagnosis.  You can come to the clinic as often as twice a day over the next week. 
• Park in the designated area, call the clinic when you arrive, and wait in your vehicle.
• In the meantime, registration personnel verifies that your referral is on record.     
• A respiratory therapist from the ED walks you to the clinic. The therapist checks your child for labored breathing, low oxygen, dehydration and other concerns. The therapist also determines if your child needs further medical attention.  
• There’s no charge, and insurance isn’t required. 

Cathy Carroll, respiratory director at Cook Children’s, said the clinic is structured to serve children with RSV or bronchiolitis who are otherwise healthy after they leave the Medical Center, ED or Urgent Care. If concerns arise while their children recover at home, parents can bring them to the clinic for a quick outpatient visit. “It’s very helpful, reassuring and a great experience for parents,” she said.

Carroll said the clinic is staffed by respiratory therapists who reinforce the educational tools that were provided when the patients were discharged earlier. The therapists take the opportunity to explain signs of low oxygen -- teaching parents to look for fast or shallow breaths, flared nostrils and bluish lips. It’s a model that aims to prevent unnecessary return trips to the ED or Urgent Care. 

The clinic was there when Dallas and Dionne needed help to fight RSV. This is their story. 

Two Too Sick  

Dionne and Dallas were born 15 weeks early, in August 2021. They each weighed less than 2 pounds, and their lungs weren’t fully developed. Dallas was intubated to help him breathe while in the neonatal intensive care unit (NICU). After several months in the NICU, the preemies were strong enough to join their parents and three older siblings at home in Fort Worth. 

The U.S. Centers for Disease Control and Prevention puts children like Dionne and Dallas in a category for higher risk from RSV, due to their impaired lungs at birth. Other higher-risk groups include infants younger than 6 months old, and children with heart disease or weakened immune systems. 

One day in October, Dallas started running a fever, coughing and throwing up. Dionne soon came down with similar symptoms. The 14-month-old siblings were too sleepy to play or eat. Dionne, who is normally feisty, wanted to be held constantly. Dallas, who is normally cuddly, wanted to be left alone. Then he started breathing rapidly. 

“I don’t think this is a cold,” Janie thought at the time. She took both twins to Cook Children’s Urgent Care, where they were tested for flu, COVID-19 and RSV. The RSV tests came back positive, but their vital signs weren’t alarming. 

Urgent Care staff gave Janie a referral to the Respiratory Outpatient Clinic and encouraged her to take the twins for a follow-up visit if their illness changed for the worse anytime in the next week. Back at home, Janie grew concerned when the babies had more trouble keeping food down. And she thought Dallas’s lips began to look gray.  

“They were really groggy. They weren’t crying because they didn’t have energy. They were just blah. Dallas had a really bad cough. Dionne wasn’t doing good at coughing it out.” Janie wanted a medical professional’s opinion. 

So she took the twins to the clinic’s designated parking area when it opened at 11 am. Within the hour, therapists were evaluating their condition. Dallas and Dionne then were admitted to the Medical Center, receiving oxygen and IV fluids for dehydration. A high-flow oxygen device was used on Dallas because his oxygen level kept dropping when he slept, Janie said. 

The twins perked up quickly. They wanted to eat and play with toys in their hospital room. But their airflows still needed monitoring, and they needed rest. Dionne stayed in the hospital for six days; Dallas for nine.  

Janie said she appreciates that because of the referral from Urgent Care, the clinic already had the background on Dionne’s and Dallas’s diagnoses. That made it easier and faster to get checked out by respiratory experts the next day without having to go back to Urgent Care. “It was nice to already know what was going on. We were just following up on that.”   

More info on RSV 

Most of the time, an RSV infection causes a mild illness like a cold. But it can also lead to bronchiolitis or pneumonia in young children. Early symptoms are runny nose, decrease in appetite and cough. Get medical help right away for more serious symptoms:

• Fast, shallow breathing, indicated by the belly moving up and down quickly and the area around the ribs sinking in. 
• Extreme fussiness, can’t be comforted.   
• Sleepiness, won’t wake up for feedings. 
• Poor appetite and fewer wet diapers.  
• Blue color to the lips, tongue or fingernails. 

Help prevent the spread of RSV by washing your hands often, avoiding close contact with sick people, covering your coughs and sneezes, and staying home when you’re sick. 

Just Breathe. Open Up. You Matter.

This is the meaning behind the Joy Campaign, which aims to prevent youth suicide. Cook Children's launched the effort in April after a record number of suicidal patients were admitted to our hospital. Over the past nine weeks, we've released a series of articles about this issue and the increasing need for mental health resources.

This week, we're giving families a tool to use during difficult times. Six of our therapists and psychologists created the coping skills videos below. They show different techniques kids and teens can use when they feel stress, anxiety and depression. These are the same coping skills our experts teach their patients. We hope these videos give young people a way to express themselves and foster hope for better days ahead.

“Coping skills are essential for children when they are having a hard time processing their emotions, or are unsure of how to handle their feelings,” said Lisa Elliott, Ph.D., psychologist and clinic manager of the Behavioral Health Clinic at Cook Children’s in Denton.

Whether it’s drawing how you feel, writing it down, acting it out, or even taking a moment to breathe, these videos illustrate how to reset your body and mind.

“While dealing with our emotions isn’t always easy, I find it is helpful for children to have resources that are easy to use when they are sad, mad, or even frustrated,” said Kim Cox, clinical therapist at Cook Children Medical Center. “If children know how to help themselves, they are more likely to do so instead of potentially doing something that isn’t safe.”

The coping skills in these videos are simple and don’t require much time or effort. They can be used anytime you want to create a sense of calm and improve mood.

Being a pediatrician is a special job. You get involved in not only a child’s life, but become a part of the entire family. I was diagnosed with asthma at the age of 4, and this is the reason I became a pediatrician. My pediatrician growing up was so wonderful and caring of both myself and my parents, I wanted to be just like her, providing compassionate care to children.

Our delightful environment in North Texas tends to allow for year ‘round allergies, which can exacerbate asthma and wheezing.

So when should you take your child to the doctor to check their cough or wheezing?

The answer is, any time you are concerned and your normal medications aren’t enough. Some asthma is seasonal when allergens are worse in the air, some asthma is activity-induced, and your child will require an as-needed emergency inhaler called Albuterol. When Albuterol is needed more than once or twice a week for cough, wheezing, or difficulty breathing, it’s time to talk to your pediatrician about starting an inhaled steroid maintenance inhaler.

This is taken every day, and the inhaled steroid lessens the likelihood you’ll need to use the emergency inhaler. There is also a commonly prescribed chewable or swallowed pill called Singulair that is helpful in keeping allergies and asthma symptoms better controlled. When your child has worsening night time cough, trouble keeping up with peers during physical activity, or wheezing, it’s time to schedule an appointment with the pediatrician to discuss increasing or changing medications.

During an acute asthma exacerbation from whatever cause (viral illness, change in seasons, allergy flare, etc), the doctor will often prescribe a short course of oral steroids, around the clock albuterol nebulizer treatments or inhaler use, and perhaps a round of antibiotics if they are deemed necessary. It is critical to take all medications as prescribed. Just because your child feels “better”, doesn’t mean that it is time to stop daily asthma medications. They are better because the medications are working, and stopping any maintenance medicines can cause irreparable damage to their lungs. Let’s keep our children at their best by coming to the doctor at the first sign of respiratory distress, and quickly managing asthma and wheezing.

When is it asthma, and when is it something else?

It's hard to think about right now, but it only a couple of months we will see cooler weather and winter will be here before you know it. Winter season brings on LOTS of cold viruses, all 847 of them, and several can cause wheezing or trouble breathing, also known as reactive airway disease.

Especially known is the dreaded RSV, but other viruses can affect the lungs too, and require extra support from nebulizer treatments to even oxygen given in the hospital. Some children are highly susceptible to every common cold virus spiraling into a reactive airway disease/ asthma/ wheezing episode, and require a doctor visit every 1-2 weeks it can seem. So when it is just “asthma”, and when should the pediatrician and parent confirm it’s not something worse?

When something doesn’t feel right, come in and talk to your doctor. It may be nothing. It may be just another cold and cough virus. But maybe, and it’s a very small chance, but maybe it is something more. And you as the parent deserve to be listened to, to have your concerns validated and heard. And we as the Pediatrician, promise to do right by your child and not only treat in the moment, but plan for further investigation if necessary. Don’t ever feel awkward or hesitant coming in to the office to check the cough or snotty nose virus; I’d rather reassure you that it’s a simple virus and not something more.

Listen to your gut, and I’ll listen with my ears and my heart.

So what is difficulty breathing? How do you tell if your baby or child is having it?

In babies there are 3 main considerations to look for difficulty breathing:

1. The nose - When babies are having difficulty breathing, their nostrils will flare open and closed with each breath.
2. The area below the rib cage - Babies will begin to use their bellies to help them breathe when they are having trouble, this will look like sucking in and out of the area below the ribs.
3. Rapid breathing - Babies already breathe fast and they can breathe at a really unpredictable rates. But if you feel like the rate is faster over a sustained period, it could mean that they are having difficulty breathing.

In older children, there are some similar and some different ways you can assess difficulty breathing:

1. Watching - Just like babies, you can watch an older child under their ribs to see if they are breathing harder than normal.
2. Assessing activity - Are they able to go about their normal activities or are they getting short of breath?
3. Say the alphabet - Can they say the alphabet without breathing? How far can they get?

Obviously these aren't perfect assessments and children should be seen if you are worried. Any change in alertness or change in color (blue or duskiness) is an emergency.