Wheezing

Breath sounds are made by air flow through airways. Normally they are fairly quiet and somewhat louder during inspiration as air flows toward the stethoscope. Wheezing is defined as continuous breath sounds that are more prominent during expiration and often accompanied by expiratory prolongation. Wheezes may be monophonic or polyphonic, representing one or many sites of origin for the wheeze. High-pitched wheezes originate from smaller airways; low-pitched wheezes (sometimes called rhonchi) originate from larger airways. All breath sounds (normal and abnormal) are louder in young children because of their relatively thinner chest walls.

Differential Diagnosis

Lower airway (expiratory, polyphonic)

• Extraluminal compression of airways
  –Parenchymal: Pneumonia, pulmonary edema, bronchogenic cyst
  –Vascular: Ring, sling, “cardiac wheeze”
  –Lymphatics: Enlarged lymph nodes (TB, sarcoidosis, malignancy)
  –Structural: CLE, scoliosis, or chest wall deformity with airway “kinking”
• Transluminal change in airway
  –Asthma: Inflammation, edema, hyperemia, mucus gland hypertrophy and proliferation, smooth muscle bronchospasm
  –Bronchiectasis/bronchitis
  –Cystic fibrosis
  –Ciliary disease: Primary ciliary dyskinesia, dysfunction due to ETS or hyperoxia
  –Anatomic: Hemangioma, polyps, TEF, bronchial atresia, BALT, bronchiolitis obliterans, tracheobronchomalacia
  –Immunologic disorders (e.g., IgA deficiency)

• Intraluminal change in airway
  –Mucus (increased production or decreased clearance), pus (infected sputum), blood
  –Foreign body
  –Aspirated food or stomach contents secondary to gastroesophageal reflux
  Upper airway (usually inspiratory and monophonic)

• Nasal (congestion, choanal atresia, FB)
• Oropharyngeal (tonsils, adenoids, macroglossia, foreign body, decreased tone, retropharyngeal abscess)
• Laryngeal (laryngomalacia, vocal cord dysfunction or paralysis, laryngeal web or polyp, subglottic stenosis)

Central nervous system
• Structural disease (e.g., Arnold-Chiari malformation leading to vocal cord paralysis)
• Functional (e.g., vocal cord dysfunction, chronic aspiration)

Workup and Diagnosis

• History
  –Triggers: Viral disease, irritants, and allergic disease
  –Improvement with β -agonists or steroids suggests asthma
  –Worsening with ETS suggests asthma or bronchitis; with exercise, EIA or VCD; with β-agonists, bronchomalacia
  –Delayed onset with exercise suggests EIA; rapid onset with exercise suggests VCD (teens) or bronchomalacia (babies)
  –Age of onset: First month, structural problems (e.g., bronchomalacia); first year, RSV bronchiolitis, GER, or aspiration; early childhood, asthma, possible FB aspiration; adolescence, asthma and VCD
  –Other symptoms: Hemoptysis, chronic cough, weight loss (CF, TB, bronchiectasis, malignancy, recurrent infection, or immunodeficiency); weakness, hypotonia (neuromotor disease, Down syndrome, aspiration); choking on feeds (upper airway disease, TEF, chronic aspiration)

• Exam findings
  –High pitch indicates smaller airways; low pitch, larger airway(s); inspiratory, extrathoracic airway; expiratory, intrathoracic airways; biphasic, fixed obstruction or two sites; expiratory prolongation, small airways or severe larger airways
• Diagnostic tests: CXR may show hyperinflation, peribronchial cuffing, congenital lesions; CT, tissue density abnormalities, airway lesions; MRI, airway, blood vessel interface; MRA defines vascular anatomy; nuclear med, reflux and V/Q studies; PFT, volume and air flow; bronchoscopy, lavage and visualize
• Blood gas; disease-specific studies (e.g., sweat test)

Treatment

• Asthma is treated with layered therapy for acute symptom control (“rescue” medicine) and prevention of disease (“controller” medicine)
  –Rescue medicines are inhaled β-agonists (immediate) or steroids (rapid)
  –Controller medicines include ICS, leukotriene modifiers, anti-inflammatory agents, and long-acting bronchodilators

• Bronchomalacia is treated with atrovent and/or ICS
• Treat/eliminate underlying triggers

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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