Seminar On Approach To Wheezing Child

ACSHMC
Pediatric department
Seminar presentation on approach to wheezing child
Modulator: Dr. Tamiru B. (MD, Ass’t professor of pediatrics and child
health)
By:
1. Habtom A.
2. Hasen H.
3. Irko S.
February 2024
Adama
03/11/2024 Approach to wheezing child 1
Outline
• Objectives
• Anatomy and physiology of pediatrics respiratory system
• Wheezing and its pathophysiology
• Risk factors and etiologies of wheezing
• Approach to wheezing child
• Summary
• Reference

Objective
At the end of this seminar participants will be able to:
• Identify normal anatomy of RS in pediatrics
• Define abnormal lung sounds( wheezing, stridor, . . .)
• List risk factors and etiologies
• History and physical examination
• Describe investigation and managements principles

Anatomy of respiratory system

Anatomy of RS cont’…
Pediatric airway in contrast of adult:
Understanding these differences is crucial for safe anesthesia and

airway management in pediatric patients
 Shape and Size
 Anatomical Variations
• Head and Neck
• Nose
• Mouth
• Pharynx



Physiology of respiratory system
The main functions are:
 Obtain oxygen from external Env't and supply it to blood.
 Removal of CO2 from blood to external Env't.
• In addition to functioning in gas exchange:
– Regulating blood pH,
– Contains receptors for the sense of smell,
– Produces sounds,
– Filters inspired air (pulmonary defence),
– Filter blood clots

Characteristics of normal breath
sounds
Patterns of normal breath sounds are identified by their:
Intensity
Pitch
Inspiratory and expiratory phases

Xcs of normal breath sounds cont’…
Normal breath/lung sounds

 Vesicular
 Bronchovesicular
 Bronchial
 Tracheal





Abnormal lung sounds
 If normal lung sounds deviates from their normal

respective location
 If sound is adventitious (added) sounds that are
superimposed on usual breath sounds.

Abnormal lung sounds cont’…
While auscultating lung sounds notice the following that

will help you to determine what type of abnormal sound you
are hearing:
Timing
Pitch
Discontinuous or continuous
Location

Adventitious sounds
A. Crackles
I. Coarse crackles: gurgling or bubbling sounds that does
not go away with coughing
Coarse crackles
Timing Occurs around the beginning of inspiration and can
extend into expiration and are longer than fine
crackles
pitch Low-pitched and louder than fine crackles
Brief 20-30 msec
Discontinue/continue Discontinuous
locations large airways like bronchi

Adventitious sounds cont’…
II. Fine crackles: light crackling or popping of a fire and it
doesn’t go away with coughing
Fine crackles
Timing Occurs toward the end of inspiration and
is brief (short)
pitch Soft, high-pitched, very brief 5-10msec
Discontinue/ Discontinuous
continue
locations Small airways

Crackles may be from abnormalities of:

 Lungs
Pneumonia
Fibrosis
early congestive heart failure
atelectasis, pulmonary fibrosis
 Airways
Bronchitis
bronchiectasis

B. Rhonchi: suggest secretions in large airways & often clear with
coughing.
Rhonchi
Timing Occurs mainly on expiration but could be heard along
with inspiration
pitch
Low-pitched and loud (≤200 Hz) with snoring quality
Discontinue/continue Continuous
locations large airways like trachea and bronchus
Conditions that can cause this are bronchitis, pneumonia & COPD
C. Pleural friction Rub: characterized by harsh-grating noise
and pain reported by patient with coughing, deep breathing,
laughing...
 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

Pleural friction Rub
Timing inspiration and expiration
pitch low-pitched
Discontinue/ Discontinuous or continuous depending the cause and

continue severity
locations pleural layers


D. Stridor: screeching noise from the throat area is a
harsh musical sound during inspiration due to partial
obstruction of lower portion of upper air way

E. Wheeze:
 Is relatively high pitched
 Continuous musical sound lasting longer than 250 msec,
 Produced as a result of turbulent air flow through abnormally
narrowed airway
 Like dashes in time
 (≥400 Hz) with hissing or shrill quality

• 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.

Pathophysiology 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.

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.

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 .
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.

Classification of wheezing
1. 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

Cont …
2. Late onset (“non-atopic”) wheeze

 Onset in the first 3 years of life, resolving in early adolescence
 15% of general-pop
 Never wheezer(51%)

Cont …
3. 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

Risk factors
• Male sex
• Maternal smoking during pregnancy
• Family history of asthma
• Nutrition
• Infection during (Prenatal ,Postnatal ,Infancy)

Cont …
• Exposure to environmental allergens

• Immunologic and molecular influences
• Daycare.
• Atopic dermatitis
• Prenatal and neonatal exposure to antibiotics.
• High infant adiposity

Etiology
• Allergy and asthma
• Genetic factor
• Acute bronchiolitis
• Congenital malformation
• Foreign body aspiration
• Gasteroespohageal reflux
• Trauma and tumors

Cont…

Cont…

Allergy and Asthma
Asthma is characterized by airway inflammation,

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

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

Pathophysiology
• 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.
Cont…

Cont…

Pathology and consequences

Cont …
• Triad asthma (rare).

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

Cont…

Asthma predictive index(API)
• Major
 Parent with asthma
 Physician diagnosed atopic dermatitis/eczema
 Inhalant allergen sensitization
specificity 97%
sensativity 15-57%
positive predictive value of 77%

Cont …
• Minor
 serum eosinophilia (≥4%)
 wheezing not associated with an upper

respiratory infection/colds
 physician diagnosed allergic rhinitis
 Food allergen sensitization

Cont…
Diagnosis
• > 4 episodes/year of wheezing lasting >1 day
affecting sleep in a child with one Major or two
Minor criteria

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.
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.

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

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.

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.

Approach to wheezing in child
History
The initial history of a wheezing infant should

describe the recent event Including
 onset
 Duration
 Pattern &
 Associated factor
Cont …
 Acute  Chronic or recurrent
 Tracheo-bronchomalcia
 Asthma
 Vascular
 Bronchiolitis
compression/rings
 Bronchitis
 Tracheal stenosis/ webs
 Laryngo-  Cystic lesions
tracheobronchitis  Lymphadenopathy
 Foreign body aspiration  Cardiomegaly
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
03/11/2024
compression.
Approach to wheezing child 59
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?

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?

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 Smoking during
pregnancy and passive smoker?

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?

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?
 Crowded living condition?
 Pets in house?

Physical examination
Focus on a localized complaints but Head-to-toe

 General appearance
 Signs of acute respiratory distress syndrome
 Vital signs
 BP, PR, RR, temperature
 Oxygen saturation
 Anthropometry (Wt, Ht, Hc, MUAC)
Cont …
 HEENT
 Nasal examination may reveal signs
o Allergic rhinitis
o Sinusitis,
o Nasal polyps
 Lymphoglandular System.
 LAP in tuberculosis patient
Cont …
 Respiratory System
 Inspection
o Pattern of breathing
o Respiratory distress, tachypnea, retractions.
o Structural abnormalities.
o Audible sound
o Cyanosis, clubbing , nasal flaring

Cont …
 Palpation
• tracheal deviation.
 Percussion
• Position of the diaphragm.

• Differences in resonance among lung regions.

Cont …
 Auscultation
• Characteristics and location of wheezing

• Monophonic or
• Polyphonic
• Air entry among different lung regions.
• Wheezing, Stridor, Ronchi, Rales

Cont …
 CVS
 Wheezing caused by CHF.
 Rales
 Abdomen
 Ascites in Fluid overload secondary to CHF.

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

Differential diagnosis

Cont …

Investigations
 Complete blood count
 Important in patients with chronic or systemic

symptoms and may reveal
o Anemia
o Leukocytosis
o Leukopenia
o Eosinophilia
Cont …
 Sputum stain and culture

 Mycobacterial
 Radiography
 Cardiomegaly
 Pulmonary vessels
 Pulmonary edema
 Mediastinal masses
Cont …
 Enlarged lymph nodes

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

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

Cont …
 Sweat test
 A test for cystic fibrosis
 Bronchoalveolar Lavage
 Provide helpful information regarding
secondary infection, and aspiration.
 Allows cytology and molecular analyses

Cont …
 Chest computed tomography

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

Treatment principle
Depends on underlying cause

 Immediate…..Oxygen
 Asthma…Bronchodilators , corticosteroids
 Infections .…… .… Antibiotics
 Foreign body………Endoscopy /
bronchoscopy.
 Mediastinal mass……..surgery
Summary
• There is a difference between the adult and the
pediatric respiratory system.
• The normal breath sounds are bronchial, vesicular
and bronchovesicular
• Abnormal lung sounds are rhonchi, crackles,
stridor, and wheezing

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
References
1. 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 Barbara bate’s guide for physical examnation
eleventh edition. Chapter 8, page (311-318)
4. Khoulood fakhoury, gregory redding uptodate 21.6, 2013.

Thank you

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ACSHMC

• Anatomy and physiology of pediatrics respiratory system

• Wheezing and its pathophysiology

• Risk factors and etiologies of wheezing

• Approach to wheezing child

03/11/2024 Approach to wheezing child 2

• Define abnormal lung sounds( wheezing, stridor, . . .)

• List risk factors and etiologies

• History and physical examination

• Describe investigation and managements principles

03/11/2024 Approach to wheezing child 3

03/11/2024 Approach to wheezing child 4

Understanding these differences is crucial for safe anesthesia and

03/11/2024 Approach to wheezing child 6

03/11/2024 Approach to wheezing child 7

03/11/2024 Approach to wheezing child 8

03/11/2024 Approach to wheezing child 9

03/11/2024 Approach to wheezing child 10

Normal breath/lung sounds

03/11/2024 Approach to wheezing child 11

03/11/2024 Approach to wheezing child 12

03/11/2024 Approach to wheezing child 13

03/11/2024 Approach to wheezing child 14

03/11/2024 Approach to wheezing child 15

 If normal lung sounds deviates from their normal

03/11/2024 Approach to wheezing child 16

While auscultating lung sounds notice the following that

03/11/2024 Approach to wheezing child 17

03/11/2024 Approach to wheezing child 18

03/11/2024 Approach to wheezing child 19

Crackles may be from abnormalities of:

03/11/2024 Approach to wheezing child 20

03/11/2024 Approach to wheezing child 22

Discontinue/ Discontinuous or continuous depending the cause and

locations pleural layers

03/11/2024 Approach to wheezing child 23

03/11/2024 Approach to wheezing child 24

03/11/2024 Approach to wheezing child 25

03/11/2024 Approach to wheezing child 26

– various pitches as air moves through diﬀerent levels

03/11/2024 Approach to wheezing child 27

03/11/2024 Approach to wheezing child 28

03/11/2024 Approach to wheezing child 29

(A) Normal Inspiration.

(C) Extra thoracic obstruction (obstructed inspiration).

03/11/2024 Approach to wheezing child 31

1. Transient early wheeze

03/11/2024 Approach to wheezing child 32

2. Late onset (“non-atopic”) wheeze

03/11/2024 Approach to wheezing child 33

3. Persistent (“atopic”) wheeze

03/11/2024 Approach to wheezing child 34

03/11/2024 Approach to wheezing child 35

• Exposure to environmental allergens

03/11/2024 Approach to wheezing child 36

• Allergy and asthma

• Foreign body aspiration

• Trauma and tumors

03/11/2024 Approach to wheezing child 38

03/11/2024 Approach to wheezing child 39

Asthma is characterized by airway inflammation,

03/11/2024 Approach to wheezing child 40