wheezing

All That Wheezes…All That Wheezes…

Andrew Lipton, MD, MPH&TMAndrew Lipton, MD, MPH&TMMAJ, USA, MCMAJ, USA, MC

Chief, Pediatric PulmonologyChief, Pediatric PulmonologySan Antonio Military Pediatric CenterSan Antonio Military Pediatric Center

What is a “wheeze”

Definitions of obstructive noises Stertor

• Low-pitched, rumbling• Inspiratory• Nasopharynx, oropharynx, nasal passage• Loudest over neck, cheeks

What is a “wheeze”

Definitions of obstructive noises Stridor

• Harsh noise caused by turbulent flow• Inspiratory = larynx• Expiratory = trachea• Biphasic = fixed lesion in subglottic region

What is a “wheeze”

Definitions of obstructive noises Wheeze

• Higher-pitched expiratory noise• Monophonic, homophonous = large airway

= expiratory stridor• Polyphonic, heterophonous, musical =

small airways

What is a “wheeze”

Definitions of obstructive noises Secretory Noise

• Gurgling, polyphonic, upper or lower airway

• Highly variable

0

0 0

-5 -5

0

+5

0

Pre-Inspiration

0

0 0

-7 -7

-3

+5

-2

-1

-1

Inspiration

0

0 0

-7 -7

-3

+5

-2

-2

-2

Inspiration

0

0 0

-8 -8

0

+8

0

End Inspiration

0

0 0

+30 +30

+38

-10

+30

+5

+20

+10

+5

Forced Expiration

0

0 0

+30 +30

+38

-20

+30

+1

+10

+5

+1

Forced Expiration

Stertor

Causes Choanal atresia Mandibular hypoplasia Macroglossia Nasal congestion Adenotonsillar hypertrophy Pharyngeal insufficiency Encephalocele Dermoid of base of tongue Thyroglossal duct cyst Lingual thyroid

Inspiratory Stridor

Causes Laryngomalacia Vocal cord paralysis

• Unilateral – left (recurrent laryngeal nerve)• Bilateral – brainstem

Laryngotracheoesophageal cleft Laryngocele Laryngeal polyp Abscess Hypotonia

Inspiratory Stridor

Laryngomalacia 60% of insp. stridor 90% require no intervention Improves when prone Worsens with activity Worsens over first 1-6mos, then improves Watch for FTT, apnea, cyanosis

Inspiratory Stridor

Causes Laryngomalacia Vocal cord paralysis

• Unilateral – left (recurrent laryngeal nerve)• Bilateral – brainstem• Not positional

Laryngotracheoesophageal cleft Laryngocele Laryngeal polyp - ? Maternal history Abscess Hypotonia

Biphasic Stridor

Causes Subglottic stenosis

• Congenital • Acquired – intubation, croup

Subglottic hemangioma Laryngeal web GERD

Biphasic Stridor

Causes Croup – acute barky cough, stridor, resp.

distress• Low grade fever• Rhinorrhea• Worse at night• 3mos-3yrs• Parinfluenza 1-3, RSV, Influenza• Fall/Winter

Biphasic Stridor

Causes Recurrent Croup

• Consider underlying airway anomaly• GERD• Spasmodic (reactive airways)

Expiratory Stridor

Causes Tracheomalacia Bronchomalacia Vascular Ring/Sling Complete Tracheal Ring Tracheoesophageal Fistula Bronchogenic Cyst Mediastinal Mass Foreign Body GERD

Expiratory Stridor

Causes Tracheobronchomalacia

• Deficient cartilage rings• Worse with exertion, agitation• Prolonged expiratory phase• Narrow trachea on expiratory lateral films• Primary vs. Secondary

BPD, TEF, vascular anomalies

Wheezing

Causes Asthma Bronchiolitis Pneumonia GERD – inflammation, bronchospasm Heart Failure – often presents around 2 mos BPD Other: CF, Ciliary Dykinesia, Food Allergy

History

Congenital or acquired Acute, Chronic, or intermittent Positional? Feeding – gag/choke/cough, suck,

emesis, fatigue Voice/cry quality

History

FTT – increased WOB, poor feeding• >90% - think of GERD

Cyanosis Apnea Fever Cough Nocturnal Sxs

History

Birth/Neonatal History Other anomalies: cardiac, hemangiomas,

eczema, CHARGE, VACTERL, Arnold-Chiari, hypotonia, etc.

Family Hx – anomalies, CF, immunodeficiency, asthma, GERD, atopy

Exposure – smoke, pollutants, irritants, Foreign body: toys, foods, older sibs

Exam

Nose Pharynx, tonsils, tongue, face, mandible, palate Neck Cardiac Chest Respiration:

• Pattern, rate,accessory muscle use, sounds, change with position, oxygenation

Abdomen – hepatomegaly, masses

Tone Skin – eczema, hemangiomas, cyanosis

Radiographs

Lateral neck Chest PA/Lateral CT Head/Neck/Chest UGI, Videofluoroscopic swallowing study Airway fluoroscopy MRI/MRA – chest, brainstem

Other Studies

Bronchoscopy• Flexible• Rigid

Laryngoscopy Polysomnography (sleep study) Echocardiography Infant PFTs pH Probe, scan ABG

Other Studies

Allergy testing Immunoglobulins CBC ABG Sweat Cl Ciliary Bx