Approach to Child with Wheezing

Dato Dr. Ahmad Fadzil

Consultant of Paediatric Respiratory HTAA

Respiratory sound

Wheezing
Stridor
Stertor
Gruttle/Rattle
Snoring
Crepitation fine, coarse,
Transmitted sound
Heavy breath (mouth breather)

Wheeze

Sound
Airway turbulence
Airway obstruction
Monophasic
Biphasic
Monophonic
Polyphonic

STRIDOR

wheeze

Recognized

 Airway obstruction - where

Bronchospasm
Secretion
Mass
Airway narrowing

Airway Development and wheeze

Neonate trachea = size peripherals airway of
adult produce high pitch sound
Infant bronchus = wheeze
Important : airway size
Biphasic wheeze severe obstruction.
The coarser the wheeze the larger airway
obstruction.

 Louder do not indicate severity,

clinical sign & symptoms

mild

moderate

severe

Aetiology
Anatomy Obstructions

Common Causes

Acute bronchiolitis
Viral pneumonia
Asthma
Post viral infection
Hyperactive airway previous lung damage
- recurrent pneumonia
- recurrent aspiration or GERD
- congenital lung lesion

Bacteria pneumonia/pulmonary TB
Bronchiectasis, foreign body, anaphylaxis reaction
Cystic fibrosis, congenital lung lesion.

Causes - age
Infant 3 years old
Infection bronchiolitis, viral pneumonia.
Wheezing disorders asthma, post-viral wheeze.
Development abnormalities
- tracheo-oesophageal fistula
- bronchomalacia, airway compression syndromes,
congenital heart disease
Host defence defect (CF, ciliary dyskinesia, defects of
immunity)
Post-viral syndromes ( Bronchiolitis obliterans, airway
stricture)
Recurrent aspiration syndrome and GERD.
Perinatal BPD, congenital infection, meconium pneumonitis

Preschool

Infection viral or atypical pneumonia

Development anomaly
Foreign body
Aspiration syndromes
Typical wheezing/Wheezing disorder asthma
Chronic obstructive lung disorder
bronchiectasis, bronchiolitis obliterans, BPD.

School
Typical wheezing/wheezing disorder asthma
Development anomaly
Chronic obstructive lung disease.

Wheezing in children longitudinal

data.
At least 20 %
children wheeze at
age 1 year
At least 50 %
children had
wheezing episodes
by 6 year old.

History

Cause
Severity
Recurrent/persistent
Acute/Chronic
Effect to the children overall growth,
development, ability to function.
Effect to parents and family.

History
- Antenatal congenital infection, maternal smoking
- Natal prematurity, meconium, ventilated
- Postnatal persistent tachypnea, cough, ventilated
When wheeze, URTI/cold, admission.
LRTI.
Associated feature tachypnea and cough
Severity each episode.
Feeding problems.
Dysmophism and CNS (hypotonia/hypertonia)
Foreign body
Recurrent chest infection or recurrent fever
Failure to thrive
Cardiac problem

 Family history of atopy (allergic rhinitis,

asthma, eczema)
Environmental history smoking, nursery,
irritant pollution, pets.

Physical examination

General examination clubbing

Growth - FTT
Dysmophism
Chest deformity
Listen to the breath sound wheeze
Respiratory examination- localized sign
Severity of respiratory distress
CVS
CNS

Clinical clue
Symptoms present from birth,
perinatal lung problem

Developmental anomaly, perinatal

infection, CF, CLD, ciliary
dyskinesia

Family history unusual lung

disease

CF

Recurrent febrile illness

Infective cause, host defense

defect

FTT

CF, host defense defect

Feeding problem

Aspiration syndrome, GERD.

Abnormal voice or cry

Neurodevelopment abnormality

Focal physical sign

Focal developmental abnormality

End of History & Examination

Acute
Recurrent
Persistent

- Mild
- Moderate
- Severe
- Growth and
development

Trachea
Bronchus
Bronchi
Bronchioles
- Proximal
- Distal

Infection or post-infection
Congenital/structure
Hyperactive
Inflammation
Immune
Cardiac/CNS

IX
Cause
Severity
Chest x-ray

CXR: Whats the

finding?

CXR: Whats the

finding?
Mediastinal shift
to the right
Hyperinflated left
lung
Thin wall cyst in
the left lung

Investigations
Suspected
cause of
wheezing

Plain
x-ray

Barium
swallow

Upper airway/
larynx

Trachea/largeAirway abn.

Lung
parenchyma

++

Foreign body

++

Reflux and
aspiration

++

++

cardiac

++

pH
study

CT-scan

Bronchoscopy
/BAL
+++

++

+++
+++

++
+++

++

+
++

++

Others

Sweat test.
Immune study.
Nasal biopsy.
RAST.
Skin prick test.

Recurrent wheeze
Bronchiolitis
Bronchiolitis
Bronchiolitis
Bronchiolitis

Bronchiolitis Bronchiolitis
Asthma
Bronchiolitis
Viral pneumonia
viral induces wheeze.
Asthma

Recurrent wheeze
Infection?
Hyperactive airway?
Asthma? 80 % of childhood asthmatic
symptoms started before 3 years old.
Many children wheeze resolved without
treatment.
When to treat?
When the next attack?
Can we prevent it?

Phenotype

Martinez et al

Clinical (ERS Guideline)

Episodic viral wheeze trigger by viral
infection (URTI)
Multi-trigger wheeze not only viral others
such as allergen, exercise, weather,
environment pollution like cigarette smoke.
Not stable, change over time

API indexs

Clinical: Asthma
Increase probability

Lower probability

Symptoms with cold only, with no

interval symptoms.
Isolated cough in the absence of
wheeze or difficulty in breathing.
History of moist cough.
Prominent dizziness, lightheadedness, peripheral tingling.
Repeated normal physical
examination of chest when
symptomatic.
No response to trial of asthma
therapy.
Clinical features pointing to
alternative diagnosis.

More than one of the following

symptoms wheeze, cough,
difficulty in breathing, chest
tightness particularly if these are
recurrent, worse at night and early
in the morning, occurred in
response to, or are worse after,
exercise or other triggers such as
pets, cold or damp air, or with
emotion or laughter or occurred
apart from cold.
Personnel history of atopic
disorder,
Family history of atopic disorder
and/or asthma.
Widespread wheeze heard on
auscultation.
History of improvement in
symptoms or lung function in
response to adequate therapy.

BGMA 2009 children diagnosis.

Management

Cause
Severity

Acute wheezing
Bronchiolitis severity, treat the symptoms.
Hypertonic saline and salbutamol nebuliser.
Viral pneumonia - conservative

Persistent wheezing.
Structure/congenital
Post- viral wheeze support ?oral
prednisolone

Recurrent wheeze to treat or not

Asthma treat accordingly to achieve good
control.
Hyperactive airway GERD, aspiration, post
infection lung syndrome (BO, bronchiectasis).
Control the hyperactive airway and treat the
cause.
BPD treat accordingly. Aim good QOL and
optimized lung development.
Structure/congenital treat accordingly

Recurrent wheezer preschool,

?asthma, viral induced wheeze

Episodic or multi-trigger
API index
Atopy
Environment
Severity background and admissions

Recurrent wheezer
Acute B2 agonist.
Chronic
Preventer
Episodic both intermittent or persistent
montelukast work. Very high intermittent ICS.
Multitriigger both work. Atopy better ICS.

TQ