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Alya Putri Khairani | 130110110220 | E2

DIFFERENTIAL DIAGNOSIS OF WHEEZING

diseases

Continuous sound consisting of a whistling sound with a high pitch, thought to


be generated by gas flowing through narrowed airways Dorlands Illustrated
Medical Dictionary 32rd Ed
By three years of age, an episode of wheezing will have occurred in 40 percent
of children, and by six years of age, almost one half of children will have had at
least one episode of wheezing. Most infants and children with recurrent
wheezing have Asthma, but other causes should be considered in the differential
diagnosis.

Bronchiolitis
Mediastinal masses
Pneumonia
Primary ciliary
dyskinesia
Upper Respiratory Tract
Infection

Tracheobronchial
anomalies

Obstructive Sleep Apnea


Tumor or malignancy

ETIOLOGY
Wheezing occurs during the prolonged expiratory phase by the rapid passage of
air through airways that are narrowed to the point of closure. Infants' and young
children's bronchi are small, resulting in higher peripheral airway resistance. As
a result, diseases that affect the small airways have a proportionately greater
impact on total airway resistance in these patients. Infants also have less elastic
tissue recoil and fewer collateral airways, resulting in easier obstruction and
Atelectasis. The rib cage, trachea, and bronchi are also more compliant in
infants and young children, and the diaphragm inserts horizontally instead of
obliquely.

DIFFERENTIAL DIAGNOSIS
The most common diagnoses in children with wheezing are Asthma, Allergies,
Gastroesophageal Reflux Disease (GERD), Infections, and Obstructive
Sleep Apnea (OSA)
Common
Allergies

Asthma or reactive airway


disease
Gastroesophageal reflux
disease
Infectious

Uncommon

Rare

Bronchopulmonary
dysplasia

Bronchiolitis obliterans

Foreign body
aspiration

Congenital vascular
abnormalities
Congestive heart
failure

Vocal cord dysfunction

QUESTIONS TO DISTINGUISH THE ETIOLOGY OF WHEEZING IN


CHILDREN
Questions

Indications

How old was the patient when


the wheezing started?

Distinguishes congenital from


noncongenital causes

Did the wheezing start suddenly?


Is there a pattern to the
wheezing?

Foreign body aspiration


Episodic: Asthma
Persistent: Congenital or genetic
causes

Is the wheezing associated with a


cough?

GERD, sleep apnea, asthma, allergies

Is the wheezing associated with


feeding?

GERD

Is the wheezing associated with


multiple respiratory illnesses?
Is the wheezing associated with a
specific season?

Cystic fibrosis, immunodeficiency

Allergies: fall and spring

Cystic fibrosis

Croup: fall to winter

Immunodeficiency

Human Bocavirus*

Bronchitis

Alya Putri Khairani | 130110110220 | E2

Human Metapneumovirus: December


through April
RSV: Fall to Spring
Does the wheezing get better or
worse when the patient changes
position?

Tracheomalacia, anomalies of the


great vessels

Is there a family history of


wheezing?

Infections, allergic triad

Trial of Albuterol
(Proventil)
Exacerbated by
neck flexion;
relieved by neck
hyperextension

Vascular ring

Angiography
Barium swallow
Bronchoscopy
Chest radiography

* Although the prevalence of Human Bocavirus in the United States has not been well
studied, it is most common in the first, second, and fourth quarters of the year in Canada

PHYSICAL EXAMINATION
This table lists history and physical examination findings that suggest specific
causes of wheezing:
SIGNS AND
SYMPTOMS

PRESUMPTIVE
DIAGNOSIS

Associated with
feeding, cough, and
vomiting

Gastroesophageal reflux
disease

24-hour pH monitoring
Barium swallow

Associated with
positional changes

Tracheomalacia;
anomalies of the great
vessels

Angiography

CT or MRI
Heart murmurs or
cardiomegaly,
cyanosis without
respiratory distress

Cardiac disease

Chest radiography
Echocardiography

FURTHER EVALUATION

Bronchoscopy
CT Chest radiographyor
MRI
Echocardiography

Auscultatory
crackles, fever

Pneumonia

Chest radiography

Episodic pattern,
cough; patient
responds to
bronchodilators

Asthma

Allergy testing

Angiography

History of multiple
respiratory
illnesses; failure to
thrive

Cystic fibrosis or
immunodeficiency

Ciliary function testing


Immunoglobulin levels
Sweat chloride testing

Seasonal pattern,
nasal flaring,
intercostal
retractions

Bronchiolitis (RSV),
croup, allergies

Chest radiography

Stridor with
drooling

Epiglottitis

Neck radiography

Sudden onset of
wheezing and
choking

Foreign body aspiration

Bronchoscopy

TESTING FOR ASTHMA


Pulmonary function
testing

If the history or physical examination suggests Asthma, clinical guidelines


recommend pulmonary function testing. Spirometry is most accurate in

Alya Putri Khairani | 130110110220 | E2


children older than eight years and can detect reversible obstruction and
hyperresponsiveness in the airways.Current guidelines from the National Asthma
Education and Prevention Program recommend attempting spirometry in
children older than five years. Spirometry is being used in children as young as
three years, but standard reference values for younger children have not been
established. An abnormal bronchial challenge test with Methacholine
(Provocholine), cold air, or exercise provides more evidence for specific asthma
diagnoses, but these tests are usually not necessary unless the diagnosis is
uncertain.
In-office peak flow testing can be helpful to determine treatment effectiveness in
children four years and older. Although it is effort-dependent, it can be used to
compare pre- and postbronchodilator forced expiratory volume and to assess the
patient's response to treatment over time

to Bernoulli's principle). The internal airway pressure ultimately begins to


increase and barely reopens the airway lumen. The alternation of the airway(s)
between nearly closed and nearly open produces a "fluttering" of the airway
walls and a musical, "continuous" sound. The flow rate and mechanical
properties of the adjacent tissues that are set into oscillation determine the
intensity, pitch, composition (monophonic or polyphonic notes), duration (long or
short), and timing (inspiratory or expiratory, early or late) of this dynamic
symptom and sign
Wheezes are heard more commonly during expiration because the airways
normally narrow during this phase of respiration. Wheezing during expiration
alone is generally indicative of milder obstruction than if present during both
inspiration and expiration, which suggests more severe airway narrowing.
In Asthma, the markedly increased airway resistance (airflow obstruction)
contributes to the characteristic physiologic and clinical changes observed
during active or symptomatic periods. Airways tend to close early during
expiration, and hyperinflation results. Although breathing at high lung volumes
tends to maintain open airways, this response demands increased muscular
work of breathing to provide adequate ventilation, which is increased secondary
to stimulation of airway receptors and hypoxi . Most asthmatics complain of
greater difficulty during inspiration than expiration, due to the uncomfortable
work of breathing necessary to ventilate hyperinflated, abnormally stiff, or
noncompliant lungs

References:
http://www.aafp.org/afp/2008/0415/p1109.html#afp20080415p1109-t2

WHEEZING IN ASTHMA
Wheezing may result from localized or diffuse airway narrowing or obstruction
from the level of the larynx to the small bronchi. The airway narrowing may be
caused by bronchoconstriction, mucosal edema, external compression, or partial
obstruction by a tumor, foreign body, or tenacious secretions . Wheezes are
believed to be generated by oscillations or vibrations of nearly closed airway
walls . Air passing through a narrowed portion of an airway at high velocity
produces decreased gas pressure and flow in the constricted region (according

CONCLUSION
In the mildest form, wheezing is only end expiratory. As severity increases, the
wheeze lasts throughout expiration. In a more severe asthmatic episode,
wheezing is also present during inspiration. During a most severe episode,
wheezing may be absent because of the severe limitation of airflow associated
with airway narrowing and respiratory muscle fatigue. Asthma can occur without
wheezing when obstruction involves predominantly the small airways. Thus,
wheezing is not necessary for the diagnosis of asthma. Furthermore, wheezing
can be associated with other causes of airway obstruction,

References:
http://www.ncbi.nlm.nih.gov/books/NBK358/
http://emedicine.medscape.com/article/296301-clinical