APPROACH TO CHILD

WITH WHEEZING
PURPOSE OF THIS
PRESENTATION
Wheeze  Causes of wheeze  Approach to
child with wheeze  History  GPE  Chest
Examination  Tests  Radiography 
Pulmonary Function Tests  Response to
treatment  Laboratory studies ( CBC, Sweat
chloride), Endoscopy.
What is wheeze?
• Wheeze is a continuous musical sound(whistling),
longer than 250 msec, heard due to
narrowing/compression of the airways.
• Can be high-pitched or low-pitched, consists of
multiple or single notes and occurs during
inspiration or expiration.
• Monophonous (large or central airway obstruction)
Polyphonous ( Small airway narrowing)
• Heard during auscultation.
 HISTORY
• Acute onset of wheeze=foreign body aspiration (hx of
choking)
• Intermittent/paroxysmal wheeze=asthma
• Persistent wheeze= sudden onset- foreign body
aspiration
• slow onset- extra luminal bronchial compression by a
growing mass or lymph node or interstitial lung disease.
• Wheeze associated with cough:
• Wet cough + wheeze=bronchiectasis, cystic fibrosis, primary
ciliary dyskinesia, asthma, chronic aspiration)
• Dry cough + wheeze=asthma, airway malacia or compression,
foreign body or vascular ring
• Wheeze associated with feeding? Or any other diff like
choking/gagging/arching with feeds?
• Change in position? Worsening or improvement?
• Family hx of asthma
• Any prep tx of asthma and did it improve the condition?
• exposure to any new food?
• Child’s supervision
• Any earlier LRTI? or hx or contact with an older person with
RTI?
• Birth History:
- gestational age at the time delivery?
- was the infant intubated after birth?
 PHYSICAL EXAMINATION
• General examination of a wheezy child should include
-measurement of weight and height
-growth chart for s/o FTT
-vital signs specially R/R and oxygen saturation
-evaluate signs of atopic diseases: skin for eczema,
hemangioma, rash etc
-allergic shiners
-a complete chest examination, and cardiac, skin, and nasal
examinations
• The nose and throat examination should note appearance of
the nasal mucosa (eg, color, congestion), swelling of the face
or tongue, and signs of rhinitis, sinusitis, or nasal polyps.
• Check for all signs of respiratory distress:
- nasal flaring
- subcostal/supraclavilar/ recession
- cyanosis
- use of accessory muscles
- tracheal tugging
• Chest Examination:
-any chest deformities( increased AP Diameter)
-hyper-inflated chest/barel shaped/liver pushed
down
- Hoover’s sign
• Any dullness to percussion? (consolidation)

-The cardiac examination should focus on findings

that might indicate heart failure, such as murmurs,
a 3rd heart sound (S3 gallop), and jugular venous
distention.
• AUSCULTATION:
- location + character of wheeze (diffuse vs
localized; inspiratory, expiratory, or both)
- other breath sounds: fine crackles/overt ronchi
- prolongation of expiratory phase
- barely audible breath sounds (sever disease
with nearly complete bronchial obstruction)
DIFFERENTIALS
Causes Of Wheezing
 Investigations
• Chest X-Ray(AP and Lateral views):

A. Children with new onset wheezing with undetermined

etiology.

B. Chronic persistent wheezing not responding to treatment.

C. Suspected foreign body aspiration.

Chest x-Ray findings:

Generalized Hyperinflation: Indicated by flattening of

diaphragm and an increased AP chest diameter– suggests
diffuse obstruction of small airways Ex: Asthma, cystic
fibrosis, primary ciliary dyskinesia.
Localized hyperinflation: suggests localized bronchial
obstruction –structural abnormalities/ foreign body
aspiration.

Other findings: atelectasi, bronchiectasis, mediastinal

masses, cardiomegaly, enlarged lymph nodes, pulmonary
vessels or pulmonary edema.
Chest CT scan:

1. Mediastinal masses or lymph nodes.

2. Vascular anomalies.

3. Bronchiectasis.

Function Tests (spirometry): can assess airflow obstruction and

response to bronchodilators.

Barium Swallow:

1. GERD

2. TEF

3. VASCULAR RINGS

4. SWALLOWING DYSFUNCTION
• Other investigations:
1. Sweat chloride test: Cystic fibrosis screening in
children with chronic lung problems, failure to
thrive and diarrhea.
2. Immunoglobulin levels: screen for
immunodeficiency.
3. Rapid antigen testing, viral cultures, sputum
gram stain and culture.
 Treatment
• Comfort the child
• Offer frequent liquids
• Bronchodilators
• Inhaled short acting beta-2 agonist
• Salbutamol – 100ug/ puff , 2 puffs
• Child < 5 years – inhaler + spacer
• Response unpredictable
• Ipratropium bromide
• Anticholinergic agent
• Can be used as an adjunct therapy
• Useful in tracheal or Broncho malacia
• Oral/ IV steroids
• Atopic wheeze thought to be caused by asthma
• Inhaled steroids
• Maintenance therapy in known reactive airways bujt not
in acute illnesses
• Recommended for multiple trigger wheeze
• Montelukast
• Episodic/ viral wheeze
• Started when symptoms of a viral cold develop
• No role of antibiotics unless secondary bacterial
infection
Acute bronchiolitis:-
• Hospitalize
• Mainstay treatment is supportive
• Hypoxemic – cool humidified oxygen
• Avoid sedatives
• Keep patient elevated at 30 degrees
• NG tube feeding to avoid aspiration
• Tracheal intubation
• Bronchodilators – short term improvement
• Nebulized epinephrine
• A 3-year-old boy presents to the ER with a cough, wheeze,
and increasing shortness of breath that began shortly after
the onset of a low-grade fever and rhinorrhea 24 hrs ago. His
RR is 40 bpm, HR 130 bpm and oxygen sat 89%. Examination
of the chest reveals moderate intercostal and subcostal
retractions. On auscultation, you note reduced breath
sounds throughout the lung fields with widespread
expiratory wheeze. Other than a clear nasal discharge, the
remainder of the physical examination reveals no
abnormalities.
• What would the DD be?

• What investigations would you do?

• What would the treatment be?

Important points:
• All wheezes are not asthma
• It is important to re-evaluate and reconsider
differential diagnosis if the clinical picture does not fit
THANK YOU

ALSA HUSSAIN 15-49

SHANDANA KHAN 15-149
YUSRA SHAFAAT KHAN 15-164
LUQMAN KHAN 15-184