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Approach to Wheeze

Samah Awad

Dua' Khwais &
Abdallah Hamarsheh

29 - 11 - 2013

. . .it is an abnormality in larynx cartilage where softening of it may predispose the larynx to collapse during breathing. cause upper airway obstruction but does not cause stridor ** laryngomalacia. due to airway narrowing and decrease air velocity. . where pitch of sound could be different according to site of obstruction. subside when baby is calm .If in the large airways as the trachea then it would be monophonic . is the most common congenital anomaly of stidor. it may be stridor. so noisy breath sound may not be wheeze. Characteristic features of stidor are: . infection. transmitted sound from URT … Stridor.usually increase when the baby gets irritable or when cries. Wheezing in Preschool Children stars after birth but subside by time so usually it does not need intervention or surgical repair unless sever -interfere with feeding and growth causing apparent life threatening event as cyanosis 1 . ** epiglottitis. laryngomalacia and many other DDx that are beyond our scope for this lecture. despite that sometimes when the baby gets irritable the wheeze may show up Examples of diseases that cause srtidor are.If in the small airways there would be diffuse narrowing then it would be polyphonic It is important to differentiate wheezing from other abnormal sounds.Position affects its intensity so it is worse if lying supine and flexed position But usually the position does not affect the wheezing. Is a sound the is produced due to obstruction in upper airway (extra thoracic) mainly during inspiration. an added abnormal sound. It could be polyphonic or monophonic. it is a continuous prolonged musical sound.

>> What cause the narrowing in the airways? 1. where there would be critical airflow velocity (reduced). or faulty mechanisms of airway clearance 2. due to tumors. Pathophysiology of Wheezing: As we said. which usually present as wheezing but could be missed until later age 2 or 4 after recurrent wheezing.  The most common type is proximal esophageal atresia with distal fistula. alterations in hydration of respiratory secretions. Airway Compression. Ashtma where mucosal edema and smooth muscle constriction are present 5. Increased secretions. where the esophagus is atretic (has no continuation) while the fistula is connecting the distal part of the esophagus with the trachea. CF due to the thick secretions 4. Pneumonia mainly if viral. Interstitial edema as happen if Congestive heart failure 3.  4 or 5 types. together these would cause the flow to be turbulenced so wheeze is produced. pneumonia. Constriction of bronchial smooth muscle 4. wheezing result from Partial obstruction of airways due to single or multiple points of airway narrowing. Tracheoesophageal Fistula. bronchogenic cyst or vascular ring Differential Diagnosis: • Infectious or Inflammatory process 1. misdiagnosed to have asthma 2 . Immotile cilia syndrome where the defect is in clearing the secretions • Congenital Anomalies 1. since wheezing could be presented with other respiratory tract symptoms and not isolated 3. if NG tube is inserted then it would coil and won’t pass into the stomach  H type fistula. It could be detected very early since baby start to vomit immediately after feeding. Airway collapse as in Airway malacia 5. enlarged lymph nodes. Bronchiolitis (most common) 2.

acyanotic CHD. but unfortunately those patients could be missed 2. He ended to have a gastrestomy tube because they were not able to establish a safe oral route of feeding. where the baby is known to have a cardiac problem but even with treatment of it he persist to wheeze all the time (usually inspiratory expiratory wheeze) due to the compression on the airways  Mechanical (external compression of the airways) 1. Foreign body aspiration Here the Dr talked about a 4 months baby who was referred to hospital as FTT.4 kg) and do not like the milk. kids with congenital heart disease. where by good examination you could hear the gallop rhythm and feel the hepatomegaly. then he was diagnosed to have laryngomalacia. his first presentation was wheezing. GERD. it was found that baby starts to cough and wheeze once the bottle is put in his mouth. Intrathoracic masses  Tumors 1. malignant 3 . Heart failure. Bronchial/tracheal stenosis • Aspiration syndromes (very imp) 1. by observing his feeding process. like VSD or PDA. was operated. Vascular ring 4. Benign. first the mother complained that her baby is not gaining weight (2. 2. Tracheomalacia/Bronchomalacia 3. Swallowing dysfunction  If laryngomalacia. Mediastinal mass 2. they could present with wheezing (mainly due to the interstitial edema formation in the lungs which cause airway narrowing). Airway compression due to cardiomegaly. Bronchogenic Cyst 5. where the larynx could not protect the air way properly  Cleft palate  CNS disease  Neuromuscular disease  Structural lesions 2. and so now he is gaining weight interestingly • Cardiogenic causes: 1. where they may aspirate the gastric content from below 3.

excessive narrowing (collapse) by 50% or more in tracheal diameter during forced exhalation. or cough. complaining of nothing but the wheeze that develop due to the malacia (not an inflammation). so they collapse Patients having this are usually called the happy wheezers since they live normally. Where the pressure out the airways is higher than what is inside. Both could be present together so patient have stridor and wheezing . It is mild that usually does not need intervention unless respiratory failure is present because of this. but usually it disapper by itself with time due to development of the cartilage **Q. Both of them have the same pathophysiology. generally results from weakness of the tracheal or mainstem bronchial walls that is caused by either softening of the supporting cartilaginous rings. Both could be mild or severe according to the degree of malformation. normal cartilage ring and membranous part of the trachea. where softening of the cartilage is present . Laryngomalacia. where narrowing or airway is obvious. usually depends on demonstrating an excessive degree of tracheal narrowing during quiet breathing. By consensus. it is an upper airway problem where the larynx is very soft and the epiglottis is collapsed so cannot close the airway appropriately. sometimes we need surgery by ENT Drs for that to be corrected by laser therapy to strengthen the connective tissue or the cartilage. the upper row are views of normal airways. 4 . so we should do the surgery to fix it. The lower row presents the tracheobroncho- malacia (TBM). or defective connective tissue of the posterior membrane due to a reduction in the size and number of elastic fibers Acquired TBM can occurs following prolonged endotracheal intubation or tracheostomy or with vascular anomalies. what is the difference between laryngomalacia and bronchomalacia? . Diagnosis by bronchoscopy or dynamic CT not x-ray. Tracheobronchomalacia: Here are views taken by bronchoscopy. forced exhalation. .

2 years 10 months of age. During the past 3 days. and his room air oxygen saturation was 96%. hyperlucency of the left lung since the foreign body here made valve like obstruction so air can enter but can not go out 5 . At this visit. Respiratory effort was normal. his respiratory rate was 28 breaths per minute. is a posterior view of double aortic arch. He had no wheezing or crepitations so. he developed an increasingly harsh. productive cough and has had emesis 1-2 times per day. show asymmetry in the inflation. Patient presents with wheezing and dysphagia Case Discussion: A previously healthy boy. left aortic arch (appears here in the right which is wrong) is connected with the right aortic arch. Here in the pic. His mother had brought him to the ED 10 days earlier because he was experiencing wheezing and cough. with markedly decreased aeration on the left. Vascular Ring: . and he continued to have episodes of coughing and gagging. The patient was afebrile. was brought by his parents to a pediatric emergency department (ED) with fever up to 103°F for 3 days and intermittent violent coughing episodes. Because the wheezing was not focal and the boy seemed to be well. after which he showed some improvement. his pulse was 118 beats/min. here is an inspiratory expiratory film. during expiratory. He appeared to be comfortable and had clear rhinorrhea. the patient’s father recalled that the child had choked on a plastic peg from a Lite-Brite toy approximately 3 weeks earlier. The patient was afebrile at that time and had no history of asthma. he was discharged with a prescription for albuterol and instructions for close follow-up with his pediatrician. pointing to the foreign body the right one. making a ring like structure around the trachea and the esophagus . He was administered albuterol in the ED for bilateral wheezing in the lung bases. It is an anomaly of the aortic arch development . what to do next? x-rays. The patient's parents administered the albuterol to him intermittently.

coins … They may even get the FB lodged in the esophagus. that would be better Children may have few symptoms after an initial choking episode. so they leave it. which may cause granuloma Evaluation of Wheezing: Any evaluation starts with good history then physical examination then take the lab you want  History: 1) Birth History:  Gestational age  Respiratory difficulties in neonatal period  Length for assisted ventilation  Oxygen supplementation 6 . peak incidence in 1-2 years of age. The foreign body was surrounded by large amounts of purulent secretions. If lodged in the upper airways. in a way that would compress the airways. or they could aspirate the small batteries. even that some parents do not recall the choking event >> sometimes it is hard to remove the FB. it would be really severe. >> usual course that they would choke. or even fatal if complete airway obstruction 2. where patient may come with wheezing and then after the lateral x-rays the coin is found in the esophagus • Laryngotracheal foreign bodies presentation depends on the level of obstruction: 1. When they start the mouthing and they develop a good motor skills to walk around and pick the foreign body. and a red plastic peg was removed from the left main-stem bronchus. peanuts especially. it can passed as minor event. The patient recovered well and had no complications Foreign body aspiration: • Majority of cases will be below age 3 years. they could aspirate the food. cough slightly and then that will be subside.The patient underwent bronchoscopy. If passed to the small airways.

Exposure to irritants (cig)  Frequency. difficulty breathing or SOB. Congenital heart disease with enlargement of left atrium compressing the left main stem bronchus) 4) Pertinent Family History  Asthma  Atopic disease ( atopic dermatitis. Pattern.Duration of wheezing  Generalized clinical course .Associated with triggers ( irritants. steatorrhea. cyanosis...Extraluminal airway obstruction ( enlarged lymph node/intrathoracic mass) .Associated with respiratory infection .Aspiration .GERD . pattern of the attack and if symptom free between the attacks 7 . specific allergens) . Circumstances of Recurrent Episodes Wheezing  Wheezing with respiratory infections Acute viral bronchiolitis ( RSV + or -)  Initial onset sudden. sweating. allergic rhinitis)  Cystic fibrosis 5) Response to medications for wheezing  Bronchodilators (Beta₂ agonist)  Anti-inflammatory medications  Antibiotics Also ask about swallowing problems.Associated with feeding/vomiting e. exacerbating and relieving factors.g.2) History of onset of wheezing  Age of onset  Other symptoms associated with the wheezing episode as cough or difficulty breathing 3) Timing. previous attacks.GERD . relation to position. triggering factors. diurnal variation. associated with coughing or chocking Consider respiratory foreign body  Insidious onset of wheezing .Associated with other organ system (e.g.

Murmurs. Stridor. Characteristics of Wheezing  Generalized or unilateral  Monophonic or polyphonic  Inspiratory. do not ask for every test. chest symmetry. Signs of Respiratory Distress  Retraction.  Physical Examination: 1. Respiratory Rate  Normal or elevated for age 3. 8 . Use of accessory muscles  Grunting. So It would vary depending on the suspected etiology of wheezing. because the history will guide you. we almost order it for every kid. tracheal deviation. growth parameters and pain ** FEV1 is difficult to be tested below age of 5 years so it is hard to diagnose asthma Laboratory Studies: You should pick what you want. Signs of Cardiac Disease  Clubbing. Chest x-ray. allergic salute) 6. Head bobbing 5. expiratory or both  Other adventitial lung sounds by auscultation 4. Signs of Allergic Diathesis  Atopic dermatitis  Allergic rhinoconjunctivitis  Allergic facies ( allergic shiners. presence of fever or not. Cardiomegaly and hepatomegaly Also exam the chest expansion. General Status  Well-nourished  Failure to thrive  Clubbing 2. Cyanosis.

RUL (right upper lope) opacity/ infiltrate.  In decubitus film (Lying on lateral side) the dependent lung will be compressed (more white) and less inflated than the other one (top one) which will look (hyperlucent.The pic in the right. and LLL opacity. is a right-side down decubitus (while the pt is lying laterally on his side) view of the chest which we ask for when we are suspecting a FB in a certain side . In the picture shown.Right lung is more lucent than the left . which are mostly atelectasis . . 9 . so normal CXR doesn’t exclude bronchiolitis . more black).This is a kid with FB aspiration . Hyperinflation is considered if more than 6 anteriorly and 8 posteriorly . X-rays: . this is a kid with Bronchiolitis.Asymmetry in chest expansion is seen . But bronchiolitis kid may show a normal x-ray. the 3 rd film is a right decubitus film where you expect the right lung to be less expanded than the left but the opposite happened (right lung is more inflated and black than the left) which makes you suspect a FB obstructing the right main stem bronchus and creating a ball-valve like mechanism.

but unfortunately we can not do in the appropriate technique here in our hospital due to the lack of appropriate settings This is a barium swallow detecting TE fistulae (Tracheoesophageal fistula) the H type where we could notice barium going to the stomach but also some go to the airways taking shape of the bronchi >> usually the patient feels tired after the study. . And this is diagnostic for swallowing dysfunction >> need a special radiologist or speech therapist to read it.Swallowing dysfunction . where is accumulate behind the epiglottis going down to the larynx then to the trachea.** we also ask for the decubitus film if pleural effusion Barium Swallow We ask for it if.Aspiration .Vascular Ring This is a picture for a kid with aspiration. the barium appears in black color. he would have some symptoms 10 .

R: Renal anomalies. when you find a vascular ring you should do a “MRI” or “MRA”. CT chest is done when we think of a mass or a congenital malformation of the lung . in the case of a foreign body we will use the rigid bronchoscope . and it Is the gold standard for diagnosis . sweat chloride of we are thinking of CF . this must be seen on an X- ray . in adults they can pass forceps but not for the case of foreign body retrieval .E: TEF. We actually can pass the forceps within the bronchoscope . echocardiogram if you are thinking of a cardiac etiology . this a picture of a bronchogynic cyst . A: Anal atresia. C: Cardic defects T.  Tracheo-esophageal fistula (TEF) could be part of VACTERL association V: Vertebral anomalies . L: Limb defects Bronchoscopy : When do I do a bronchoscopy ??? 1) Foreign body . here we see a posterior indentation of the esophagus caused by compression . so in this case the CT is asked for after we see the abnormality in the X-ray that suggests a mass or a cyst or other abnormality. The flexible bronchoscope has a very tiny suction channel . in order to help the sergeant when he operates because he will need the exact anatomy . upper gi studies or 24 ph probe if you are thinking about GERD . 11 . an it can be used to ventilate the baby . Other laboratory studies . that is important because we need details for the anatomy . we have two types of bronchoscopes the rigid and the flexible .this is a barium swallow that detected a vascular ring . because the rigid bronchoscope has a pipe shape. u can pick what ever you want according to the suspected etiology or disease .

it is unknown wither the infection triggered the asthma or if that the child has a predisposition of wheezing after the infection . and because of the varying patterns A common early presentation of asthma is wheezing and cough that follows a URTI “a viral infection” . only select those that you need to perform . Severe asthma can rarely cause clubbing . but mostly it doesn’t . *A common question is : Does my child have asthma ??? To diagnose asthma in a preschool age is considered to be hard . • Asthma can begin at any age • In infancy. wheezing is usually associated with RTI • It is difficult to distinguish an initial episode of asthma triggered by viral RTI from wheezing due to viral bronchiolitis 12 . because performing a lung function test is quit hard . So we do not have to order all the tests .

this pattern is known as intermittent asthma and episodic asthma and transient . Some would continue to have persistent symptoms throughout childhood and may continue until adulthood even between the attacks and it is called a chronic or persistent asthma . those Children have atopy (IgE mediated inflammation) . so the mother would complain of wheezing and cough that starts with a runny nose . This figure is very important  When a healthy baby becomes infected with RSV . that happens to about 90% of infants most get symptoms of common cold Minority experience Bronchiolitis which is the most common cause of hospitalization in first year of life Cough might be presented in both . common cold and bronchiolitis 25-50% will have intermittent pattern of asthma manifested as recurrent wheezing associated with viral RTI . 13 . they react showing hyper responsiveness to certain allergens . remission is common in later in childhood . those children are symptom free between the attacks .

• Poor response to anti-inflammatory agents . passive smoker kids are more likely to develop asthma . dogs . cats . *How to Diagnose Asthma in Preschool years ? • Recurrence of symptoms ( wheezing. *Who Gets Asthma? • Genetic Factors Some evidence that supports the presence of genetic attributuin -Asthma presents in 25% of the offspring of a parent with asthma -Higher concordance in MZ twins compared to DZ twins • Environmental Factors -Children who are exposed to certain allergens . increase the risk of developing asthma -Airway hyper-responsiveness and IgE-mediated sensitivity to inhalant allergens in infancy are associated with persistent asthma -Tobacco smoke has synergistic effect with inhalant allergens . cough. inhaled steroids will not prevent the attacks . labored breathing) • Positive Family history of asthma supports the diagnosis • Reversibility of symptoms either spontaneously or with treatment ( good response to the Trial of inhaled bronchodilator in a clinic or an emergency room would be a strong evidence to diagnose asthma if symptoms resolve) *Clinical Pattern of Asthma Transient (Intermittent) asthma • Symptoms occur with viral RTI exclusively • Symptom free between the attacks • Lack of IgE-mediated allergy • Remission of symptoms by school age ( most likely) . it could minimize the severity and the duration of the attack but it doesn’t remove it 14 . dust mite and so on . by 5-6 years these patients wont have symptoms .

• Respond to controller ( anti-inflammatory agents) ***note: the determining of the pattern is very important to the finding of the proper treatment *What goes against asthma ? • Symptoms presenting in a neonate who required assisted ventilation • Wheezing associated with spitting-up formula • Digital clubbing. abnormal stool • Presence of a cardiac murmur • History of chocking • Persistent unilateral wheezing • Failure to thrive • Persistence of wheezing in spite of optimal asthma therapy Initiation of Controller Therapy in Children 0-4 yo ( NIH Guidelines Four or more episodes of wheezing in the past year that lasted for more than one day and affected sleep 15 . might persist to adulthood . • The bronchodialators usually relief the attack but the controller does not prevent an attack Chronic (Persistent) asthma • They are symptomatic between the attacks • Atopy present (evidence IgE positive to allergens) • Continue to have asthma symptoms .

Samah Awad :) ** We had removed the bronchiolitis part from here . 16 .. One of the following: Two of the following: AND • Parenteral history of asthma • Food allergy • Atopic dermatitis • 4 % peripheral eosinophilia OR • Evidence of sensitization to • Wheezing apart from cold aeroallergen • Any evidence of allergy or atopy Done by: Dua’ Khwies & Abdullah Hamarsheh ** this lecture has been reviewed by Dr. and added a separate lecture about it to the package .