Department Of Pediatrics & Child Health

Seminar On Approach To Wheezing Child

Moderator
Dr. Tegene Bikila (MD, Pediatrician)
By:
Desu Aredo
Dinu Akmel
march,2021 GC

09/25/2022 1
 OUTLINE
• The Anatomy of pediatrics respiratory system
• Wheezing and its Physiology
• Risk Factors and Etiologies Of Wheezing
• History and Physical Examination
• Investigation and Management
• Summary
• Reference

09/25/2022 2
 OBJECTIVE

• At the end of this seminar participants will be able to

– Identify the normal anatomy of the pediatrics age
group.
– Define wheezing.
– List risk factors and etiologies of wheezing child.
– Describe investigation and managements
principles of wheezing child.

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 PEDIATRICS AIRWAY ANATOMY

• The upper airway consists of the nose, paranasal

sinus, pharynx, larynx and the extrathoraic trachea.

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 CONT …
• The paediatric airway vs. the adult airway
 larger head and occiput Causing neck flexion &
leading to potential airway obstruction
 Larger tongue decrease in size of oral cavity.
 Decreased muscle tone
 Shorter & smaller trachea
 The trachea( 4 cm in neonates , 12 cm in adults)

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 CONT …
 The tracheal diameter varies ( 3 mm in the
premature infant to 25 mm in the adult)
 In children younger than 2 or 3 years old, the
cricoid ring (first tracheal ring) is the narrowest
 In older children and adults, the glottis is the
smallest part of the airway.
 At birth, a full-term infant 25 million alveoli; 300
million in adulthood

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 CXRS OF NORMAL BREATH SOUNDS
• patterns of breath sounds by their intensity, pitch,
and the inspiratory and expiratory phases
• Normal breath sounds are:
 Vesicular, or soft and low pitched:
 Bronchial ( manubrium)
 Bronchovesicular (1st and 2nd interspaces
anteriorly and between the scapulae)

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 CRITERIA OF ABNORMAL LUNG SOUNDS

• Lung sounds can be grouped under abnormal sounds

if one of the following criteria is fulfilled .
1. If the normal lung sounds deviates from their
normal respective location
 If bronchovesicular or bronchial breath sounds are heard
in locations distant from those listed, suspect that air-filled
lung has been replaced by fluid-filled or solid lung tissue.

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 CONT …
2. if the sound is adventitious (added) sounds
• Discontinuous sounds (crackles or rales):- intermittent,
nonmusical, and brief—like dots in time.
• Continuous sounds notably longer than crackle, but do
not necessarily persist throughout the respiratory cycle.
• Unlike crackles, they are musical . e.g. wheezes and
rhonchi.

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 ADVENTITIOUS (ADDED) SOUNDS

• Crackles:
 result from a series of tiny explosions when small
airways, deflated during expiration, pop open
during inspiration or
 Crackles result from air bubbles flowing through
secretions or lightly closed airways during
respiration.

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 CONT …
• Late inspiratory crackles in ILD and early CHF
• Early inspiratory crackles in chronic bronchitis and
asthma.
• Mid inspiratory and expiratory crackles in
bronchiectasis but are not specific for this diagnosis.
• Wheezes and rhonchi may be associated.

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 CONT …

• Rhonchi
 Coarse and harsh rales, low pitched.
 Heard during expiration or inspiration

 often clear with coughing

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 CONT …

• Pleural Rub
 Inflamed and roughened pleural surfaces grate
against each other as they are momentarily and
repeatedly delayed by increased friction
• Grunting
 Because of partially closed epiglottis

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 CONT …

• Stridor

 Wheeze that is entirely or predominantly inspiratory

is called stridor.
 It is often louder in the neck than over the chest wall.
 It indicates a partial obstruction of the larynx or
trachea.

09/25/2022 14
 WHEEZE

• Wheeze is a high pitched, continuous musical sound

produced, as a result of turbulent air flow through
abnormally narrowed airway.

• Its heard during expiration

• The noise heard during inspiration as a result extra

thoracic airway obstruction is called stridor

09/25/2022 15
 CONT …

• Monophonic
– Refers to a single-pitch sound that is produced in the
larger airways during expiration, as in distal
tracheomalacia or bronchomalacia.
• Polyphonic

– various pitches as air moves through different levels

of obstruction to flow, as in asthma.

09/25/2022 16
 PHYSIOLOGY OF WHEEZING

• Flow limitation in a compliant tube is accompanied

by the “flutter” of the walls at the site of flow
limitation.
• In the presence of airway obstruction, this flutter
may become large enough to generate sound.
• This sound is heard as wheezing.

09/25/2022 17
 CONT …

• Thus expiratory wheezing is a sign of expiratory flow

limitation.
• However, although wheezing implies the presence of
expiratory flow limitation, flow limitation can occur in
the absence of detectable wheezing.

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 CONT …

(A) Normal Inspiration.

(B) Normal expiration.
• Intraluminal pressures are slightly positive in
relation to atmospheric pressure, so air is
forced out of the lungs.
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 CONT …

(C)Extra thoracic obstruction (obstructed inspiration).

• Respiratory dynamics occurring with upper airway
obstruction.
(D) Intra thoracic obstruction (obstructed expiration).
• Respiratory dynamics occurring with lower airway
obstruction.
09/25/2022 20
 CLASSIFICATION OF WHEEZING

• Transient early wheeze .

 Present in the first year of life, resolving by
early school years.
 19.9% of general-pop.

 Wheeze at least once with a lower respiratory

infection before the age of 3 years, but never
wheeze again.

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 CONT …

• Late onset (“non-atopic”) wheeze .

 Onset in the first 3 years of life, resolving in early
adolescence
 15% of general-pop

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 CONT …

• Persistent (“atopic”) wheeze.

 Onset in mid-preschool years with persistence into
adolescence.
 13.7% of gen-pop.

 Has wheezing episodes before age 3 yr and is still

wheezing at 6 yr of age.

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 RISK FACTORS
• Male sex
• Maternal smoking during pregnancy
• Family history of asthma
• Nutrition

• Infection during

(Prenatal ,Postnatal ,Infancy)

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 CONT …
• Exposure to environmental allergens
• Immunologic and molecular influences
• Daycare.
• Atopic dermatitis
• Prenatal and neonatal exposure to antibiotics.
• High infant adiposity

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 ETIOLOGY
• Allergy and asthma
• Genetic factor
• Acute bronchiolitis
• Congenital malformation

• Foreign body aspiration

• Gasteroespohageal reflux
• Trauma and tumors

09/25/2022 26
 Allergy and Asthma

 Asthma is characterized by airway inflammation,

bronchial hyperactivity and reversibility of
obstruction.
 Affects boys over girls (11.5:7.5%).

09/25/2022 27
 CONT …

• The three most common manifestation of childhood

asthma:
1. Preschooler with recurrent wheeze or cough
2. School aged child with asthma
3. Difficult-to-control or severe asthma in
childhood

09/25/2022 28
 CONT …

• The symptoms of asthma are due to airflow

obstruction resulting from the cumulative effects of:
 Smooth muscle constriction around airways

 Airway wall edema.

 Intraluminal mucus accumulation.
 Inflammatory cell infiltration of the sub mucosa.

 Basement membrane thickening.

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 CONT …

• Triad asthma (rare).

 Asthma + hyperplasic sinusitis/ nasal polyposis +
hypersensitivity to aspirin & NSAID.

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 Asthma predictive index(API)

• Major
 Parent with asthma
 Physician diagnosed atopic dermatitis/eczema
 Inhalant allergen sensitization

09/25/2022 31
 CONT …

• Minor
 serum eosinophilia (≥4%)
 wheezing not associated with an upper
respiratory infection/colds
 physician diagnosed allergic rhinitis
 Food allergen sensitization

09/25/2022 32
 CONT …

• 60% of children with early-onset wheezing will stop

wheezing.
• 14% are at significant risk for persistent asthma.
• Have a 48% and 67% PPV for asthma and persistent
wheezing, respectively, at age 6 yr.
• 92% and 77% NPV for asthma and persistent wheezing,

respectively.
09/25/2022 33
 CONT …
• Genetic factor
 More than 100 genetic loci have been associated with
asthma.
 Its also linked with proinflammatory, proallergic gene in
chromosome 5(IL-4).
 ADAM 33 is another gene.
 74% concordance between monozygotic twins.
 35% concordance between dizygotic twins.
09/25/2022 34
 Acute Bronchiolitis
 Viral disease RSV(50%), human metapneumovirus
 More common in boys, who have not been breast
fed and live in crowded conditions
 Host anatomic and immunologic factors play a
major role in the severity
 Characterized by bronchiolar obstruction with
edema, mucus, and cellular debris

09/25/2022 35
 CONT …

• Foreign body aspiration

 Can cause acute or chronic wheezing
 Esophageal foreign body can transmit
pressure to membranous trachea, which
cause a compromise of airway lumen.

09/25/2022 36
 CONT …

• Trauma and tumors

 Accidental or non accidental aspirations, burns or
scalds of the tracheobronchial tree can cause
inflammation.
 Any space occupying lesions either in the lung
itself or to the ling can cause tracheobronchial
compression and obstruction to airflow.

09/25/2022 37
 HISTORY & PHYSICAL
EXAMINATION

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 History
The initial history of a wheezing infant should
describe the recent event Including

 onset
 Duration
 Pattern &
 Associated factor
 CONT …

 Acute  Chronic or recurrent

 Asthma  Tracheo-bronchomalcia

 Vascular compression/rings
 Bronchiolitis
 Tracheal stenosis/ webs
 Bronchitis
 Cystic lesions
 Laryngo-tracheobronchitis
 Lymphadenopathy
 Foreign body aspiration
 Cardiomegaly

09/25/2022 40
 CONT …
Pattern of wheezing

Persistent wheezing presenting very early in life.

-Suggests a congenital or structural abnormality.

Intermittent/episodic or paroxysmal wheezing

-characteristic finding in patients with asthma

Slowly progressive onset of wheezing may be a sign of

extraluminal bronchial compression.

09/25/2022 41
 Question that lead to Dx

 All wheezing are not Asthma.

 Did the onset of symptoms begin at birth or

thereafter?
 Is the infant a noisy breather and when is it most
prominent?
 Is the noisy breathing present on inspiration,
expiration, or both?

09/25/2022 42
 CONT …

 Is there a history of cough apart from wheezing?

 Was there an earlier lower respiratory tract
infection?
 Is there a history of recurrent upper or lower
respiratory tract infections?
 Have there been any hospitalizations, or intensive
care unit admissions for respiratory distress?

09/25/2022 43
 CONT …

 Is there a history of eczema?

 Does the infant cough after crying or cough at night?
 How is the infant growing and developing?
 Is there a maternal history of genital herpes simplex
virus infection?

09/25/2022 44
 CONT …
 What was the gestational age at delivery?

 Was the patient intubated as a neonate?

 Does the infant bottle-feed in the bed or the crib,

especially in a propped position?

 Are there any feeding difficulties including choking,

gagging, arching, or vomiting with feeds?

09/25/2022 45
 CONT …

 Is there any new food exposure?

 Is there a toddler in the home or lapse in supervision

in which foreign-body aspiration could have occurred?
 Change in caregivers or chance of non-accidental
trauma?

09/25/2022 46
 PHYSICAL EXAMINATION

 General appearance

Signs of acute respiratory distress syndrome

 Vital signs
BP, PR, RR, temperature

Oxygen saturation
Anthropometry (Wt, Ht, Hc, MUAC)

09/25/2022 47
 CONT …

 HEENT
 Nasal examination may reveal signs
o Allergic rhinitis
o Sinusitis,
o Nasal polyps
 Lymphoglandular System.
 LAP in tuberculosis patient.

09/25/2022 48
 CONT …

 Respiratory System

 Inspection
o Pattern of breathing
o Respiratory distress, tachypnea, retractions.
o Structural abnormalities.

o Audible sound
o Cyanosis, clubbing , nasal flaring

09/25/2022 49
 CONT …
…
 Palpation
• Supratracheal LAP or tracheal deviation.
 Percussion
• Position of the diaphragm.
• Differences in resonance among lung regions.

09/25/2022 50
 CONT …

 Auscultation
• Characteristics and location of wheezing
• Monophonic or
• Polyphonic
• Air entry among different lung regions.
• Wheezing, Stridor, Ronchi, Rales

09/25/2022 51
 CONT …
.…
 CVS
 Wheezing caused by CHF.
 Rales
 Abdomen
 Ascites in Fluid overload secondary to CHF.

09/25/2022 52
 CONT …

 Integumentary
 Skin for eczema (common in atopic patients).
 Color change in the skin.
 Clubbing of nails.

09/25/2022 53
 CONT …

Signs And Symptoms Presumptive Diagnosis

Associated with feeding, Gasteroeshophageal

cough, and vomiting reflux disease (GERD)

Auscultatory crackles Pneumonia

Episodic pattern, cough: Asthma

patient responds to
bronchodilators

09/25/2022 54
 CONT …

Signs And Symptoms Presumptive

Diagnosis
Exacerbated by neck flexion: Vascular ring
relived by neck hyperextension

Heart murmurs or cardiomegaly Cardiac disease

with or with out cyanosis

History of multiple respiratory Cystic fibrosis or

illnesses; failure to thrive immunodeficiency

09/25/2022 55
 CONT …

Signs And Symptoms Presumptive Diagnosis

Seasonal pattern, nasal flaring, Bronchiolitis (RSV),

intercostal retraction croup, allergies

Sudden onset of wheezing and Foreign body aspiration

choking

09/25/2022 56
 History +Physical examination

Gives clue

Diagnostic Investigation To Order

 CONT …

 Complete blood count

 Important in patients with chronic or systemic
symptoms and may reveal
o Anemia
o Leukocytosis
o Leukopenia
o Eosinophilia
09/25/2022 58
 CONT …

 Sputum stain and culture

 Mycobacterial or fungal infection
 Radiography
 Cardiomegaly
 Pulmonary vessels
 Pulmonary edema
 Mediastinal masses

09/25/2022 59
 CONT …

 Enlarged lymph nodes

 the presence of vascular rings
 Foreign body aspiration
 Pulmonary function test to quantify the
response to bronchodilators

09/25/2022 60
 CONT …

 Barium Swallow
 Swallowing dysfunction
 Aspiration syndromes
 Gastro esophageal reflux
 Some cases of tracheoesophageal fistula

09/25/2022 61
 CONT …
 Sweat test

 A test for cystic fibrosis

 Bronchoalveolar Lavage
 Provide helpful information regarding
secondary infection, and aspiration.
 Allows cytology and molecular analyses.

 hypersensitivity

09/25/2022 62
 CONT …

 Chest computed tomography

 Mediastinum mass
 Large airways compression
 Lung parenchyma injury
 Bronchoscopy
 To exclude tracheomalacia

09/25/2022 63
 CONT …

 Endoscopy
 Foreign body aspiration
 Persistent symptoms
 Inadequate response to therapy
 Magnetic resonance angiography to check vascular
problem

09/25/2022 64
 Treatment principle

Depends on underlying cause

 Immediate…..Oxygen
 Asthma…Bronchodilators , corticosteroids
 Infections .…… .… Antibiotics
 Foreign body………Endoscopy /
bronchoscopy.
 Mediastinal mass……..surgery
 Remember

• Tracheal and bronchomalacia :- avoid β2 agonists

such as albuterol decrease in smooth muscle tone.
• Avoid sedative drug E.g. Opioids as can cause
depress Respiratory function
• Risk of aspiration of oral feeding=>NG tube
Table 231-1. Causes of Recurrent or Persistent Wheeze
  FEATURES OBJECTIVE FINDINGS
Asthma Worse with exercise or respiratory infections Reversible obstruction on PFTs
Responds to bronchodilators Heterophonies wheeze
Responds to steroids Positive broncho-provocation

Tracheomalacia Worse with activity or agitation Homophonous wheeze

Poor response to bronchodilators Airway collapse on fluoroscopy
Poor response to steroids Collapsible trachea on bronchoscopy

Bronchomalacia Worse with activity or agitation Homophonous wheeze

Poor response to bronchodilators Airway collapse on fluoroscopy
Poor response to steroids Collapsible bronchus on bronchoscopy

Foreign body Sudden onset Differential breath sounds

Heart failure or pulmonary
edema
Bronchiolitis
Vocal cord dysfunction
May have a history of choking Differential hyperinflation or collapse on
radiograph
Poor response to albuterol Hepatomegaly
Poor growth Radiograph with increased fluid
Responds to diuresis
Infant: URI symptoms Positive viral studies
Poor response to all therapies PFTs: normal or with abnormal inspiratory loop
Severe distress reported Laryngoscopy: vocal cord adduction during
inspiration

Cystic fibrosis Poor growth, GI symptoms Positive sweat test

Gastro esophageal reflux and
aspiration
Vascular compression
Recurrent pneumonias
Variable response to bronchodilators Positive reflux evaluation (upper GI, nuclear scan
Often worse after meals or pH probe)
Central wheeze Indentation on esophagram
No bronchodilator response Anatomy demonstrated on thoracic MRI

Large airway abnormality No response to therapy Flattened or square flow-volume loop

(stenosis, complete rings, Worse with activity Obstruction visible on imaging or bronchoscopy
compression) Stridor noted at times

GI, Gastrointestinal; MRI, magnetic resonance imaging; PFTs, pulmonary function tests; URI, upper respiratory infection. 67
 SUMMERY
• There is a difference between the adult and the
pediatric respiratory system.
• The normal breath sounds are tracheal,
bronchial, vesicular and bronchovesicular
• Abnormal lung sounds are rhonchi, crackles,
grunting, stridor, and wheezing

09/25/2022 68
 CONT …

• Wheezing is the production of a musical and continuous

sound that originates from oscillations of air in
narrowed airways.
• Main risk factors for wheezing are asthma, infection,
allergic reactions.
 Etiologies are genetic factor, acute bronchiolitis, allergy
and asthma
09/25/2022 69
 REFERENCES

1. Samantha A. house, shawn L.ralston: Nelson Textbook Of

Pediatric Medicine, 21st edition, 2020 (Chapter 418)
2. National asthma education and prevention panel report 3,
guidelines for the diagnosis and manegment of asthma 2009.
3. Lynn S. Bickley Barbarabate’s guide for physical examnation
seventh edition.
4. Khoulood fakhoury, gregory redding uptodate 21.6, 2013.

09/25/2022 70
Thank you
71