wheezing
TRANSCRIPT
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
