Approach to Wheeze

Samah Awad

Dua' Khwais &

Abdallah Hamarsheh

29 - 11 - 2013
 Wheezing in Preschool Children

Wheeze, it is a continuous prolonged musical sound, an added abnormal sound, due to

airway narrowing and decrease air velocity. It could be polyphonic or monophonic,
where pitch of sound could be different according to site of obstruction.
- If in the large airways as the trachea then it would be monophonic

- If in the small airways there would be diffuse narrowing then it would be polyphonic

It is important to differentiate wheezing from other abnormal sounds, so noisy breath

sound may not be wheeze, it may be stridor, transmitted sound from URT …

Stridor. Is a sound the is produced due to obstruction in upper airway (extra thoracic)
mainly during inspiration.

Characteristic features of stidor are:

- usually increase when the baby gets irritable or when cries, subside when baby is
calm

- Position affects its intensity so it is worse if lying supine and flexed position

But usually the position does not affect the wheezing, despite that sometimes when the
baby gets irritable the wheeze may show up

Examples of diseases that cause srtidor are, croup, infection, laryngomalacia and many
other DDx that are beyond our scope for this lecture.

** epiglottitis, cause upper airway obstruction but does not cause stridor

** laryngomalacia,
- it is the most common congenital anomaly of stidor,
- it is an abnormality in larynx cartilage where softening of it may predispose the
larynx to collapse during breathing,
- it stars after birth but subside by time so usually it does not need intervention or
surgical repair unless sever

-interfere with feeding and growth causing apparent life threatening event as cyanosis

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 Pathophysiology of Wheezing:

As we said, wheezing result from Partial obstruction of airways due to single or multiple
points of airway narrowing, where there would be critical airflow velocity (reduced),
together these would cause the flow to be turbulenced so wheeze is produced.

>> What cause the narrowing in the airways?

1. Increased secretions, alterations in hydration of respiratory secretions, or faulty

mechanisms of airway clearance
2. Interstitial edema as happen if Congestive heart failure
3. Constriction of bronchial smooth muscle
4. Airway collapse as in Airway malacia
5. Airway Compression, due to tumors, enlarged lymph nodes, bronchogenic cyst
or vascular ring

Differential Diagnosis:

• Infectious or Inflammatory process

1. Bronchiolitis (most common)

2. Pneumonia mainly if viral, since wheezing could be presented with other
respiratory tract symptoms and not isolated
3. CF due to the thick secretions
4. Ashtma where mucosal edema and smooth muscle constriction are present
5. Immotile cilia syndrome where the defect is in clearing the secretions

• Congenital Anomalies

1. Tracheoesophageal Fistula,
 4 or 5 types,
 The most common type is proximal esophageal atresia with distal
fistula, where the esophagus is atretic (has no continuation) while the
fistula is connecting the distal part of the esophagus with the trachea. It
could be detected very early since baby start to vomit immediately after
feeding, if NG tube is inserted then it would coil and won’t pass into the
stomach
 H type fistula, which usually present as wheezing but could be missed
until later age 2 or 4 after recurrent wheezing, pneumonia, misdiagnosed
to have asthma

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 2. Tracheomalacia/Bronchomalacia
3. Vascular ring
4. Bronchogenic Cyst
5. Bronchial/tracheal stenosis

• Aspiration syndromes (very imp)

1. Swallowing dysfunction
 If laryngomalacia, where the larynx could not protect the air way properly
 Cleft palate
 CNS disease
 Neuromuscular disease
 Structural lesions
2. GERD, where they may aspirate the gastric content from below
3. Foreign body aspiration

Here the Dr talked about a 4 months baby who was referred to hospital as FTT, his first presentation was
wheezing, then he was diagnosed to have laryngomalacia, was operated, first the mother complained that
her baby is not gaining weight (2.4 kg) and do not like the milk, by observing his feeding process, it was
found that baby starts to cough and wheeze once the bottle is put in his mouth. He ended to have a
gastrestomy tube because they were not able to establish a safe oral route of feeding, and so now he is
gaining weight interestingly

• Cardiogenic causes:

1. Heart failure,
kids with congenital heart disease, acyanotic CHD, like VSD or PDA, they could
present with wheezing (mainly due to the interstitial edema formation in the lungs
which cause airway narrowing), where by good examination you could hear the
gallop rhythm and feel the hepatomegaly, but unfortunately those patients could
be missed
2. Airway compression due to cardiomegaly, where the baby is known to have a
cardiac problem but even with treatment of it he persist to wheeze all the time
(usually inspiratory expiratory wheeze) due to the compression on the airways

 Mechanical (external compression of the airways)

1. Mediastinal mass
2. Intrathoracic masses

 Tumors
1. Benign, malignant

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 Tracheobronchomalacia:

Here are views taken by bronchoscopy, the

upper row are views of normal airways,
normal cartilage ring and membranous part
of the trachea,

The lower row presents the tracheobroncho-

malacia (TBM), where narrowing or airway is
obvious. generally results from weakness of
the tracheal or mainstem bronchial walls that
is caused by either softening of the
supporting cartilaginous rings, or defective
connective tissue of the posterior membrane
due to a reduction in the size and number of elastic fibers

Acquired TBM can occurs following prolonged endotracheal intubation or tracheostomy

or with vascular anomalies.

Diagnosis by bronchoscopy or dynamic CT not x-ray, usually depends on

demonstrating an excessive degree of tracheal narrowing during quiet breathing, forced
exhalation, or cough.

By consensus, excessive narrowing (collapse) by 50% or more in tracheal diameter

during forced exhalation. Where the pressure out the airways is higher than what is
inside, so they collapse

Patients having this are usually called the happy wheezers since they live normally,
complaining of nothing but the wheeze that develop due to the malacia (not an inflammation).
It is mild that usually does not need intervention unless respiratory failure is present
because of this, so we should do the surgery to fix it, but usually it disapper by itself with
time due to development of the cartilage

**Q. what is the difference between laryngomalacia and bronchomalacia?

- Laryngomalacia, it is an upper airway problem where the larynx is very soft and the
epiglottis is collapsed so cannot close the airway appropriately; sometimes we need
surgery by ENT Drs for that to be corrected by laser therapy to strengthen the
connective tissue or the cartilage.
- Both of them have the same pathophysiology, where softening of the cartilage is present
- Both could be present together so patient have stridor and wheezing
- Both could be mild or severe according to the degree of malformation.

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 Vascular Ring:

- It is an anomaly of the aortic arch development

- Here in the pic, is a posterior view of double aortic
arch, left aortic arch (appears here in the right which is wrong)
is connected with the right aortic arch, making a
ring like structure around the trachea and the
esophagus
- Patient presents with wheezing and dysphagia

Case Discussion:

A previously healthy boy, 2 years 10 months of age, was brought by his parents to a pediatric emergency
department (ED) with fever up to 103°F for 3 days and intermittent violent coughing episodes. His
mother had brought him to the ED 10 days earlier because he was experiencing wheezing and cough. The
patient was afebrile at that time and had no history of asthma. He was administered albuterol in the ED
for bilateral wheezing in the lung bases, after which he showed some improvement. Because the
wheezing was not focal and the boy seemed to be well, he was discharged with a prescription for
albuterol and instructions for close follow-up with his pediatrician. The patient's parents administered the
albuterol to him intermittently, and he continued to have episodes of coughing and gagging. During the
past 3 days, he developed an increasingly harsh, productive cough and has had emesis 1-2 times per day.

At this visit, the patient’s father recalled that the child had choked on a plastic peg from a
Lite-Brite toy approximately 3 weeks earlier.

The patient was afebrile, his respiratory rate was 28 breaths per minute, his pulse was 118
beats/min, and his room air oxygen saturation was 96%. He appeared to be comfortable and
had clear rhinorrhea. Respiratory effort was normal, with markedly decreased aeration on
the left. He had no wheezing or crepitations

so, what to do next?

x-rays, here is an inspiratory expiratory film,

pointing to the foreign body

the right one, during expiratory, show asymmetry

in the inflation, hyperlucency of the left lung
since the foreign body here made valve like
obstruction so air can enter but can not go out

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The patient underwent bronchoscopy, and a red plastic peg was removed from the left main-stem
bronchus. The foreign body was surrounded by large amounts of purulent secretions. The patient
recovered well and had no complications

Foreign body aspiration:

• Majority of cases will be below age 3 years, peak incidence in 1-2 years of age.
When they start the mouthing and they develop a good motor skills to walk
around and pick the foreign body, they could aspirate the food, peanuts
especially, or they could aspirate the small batteries, coins …

They may even get the FB lodged in the esophagus, in a way that would compress the airways, where
patient may come with wheezing and then after the lateral x-rays the coin is found in the esophagus

• Laryngotracheal foreign bodies presentation depends on the level of obstruction:

1. If lodged in the upper airways, it would be really severe, or even fatal if
complete airway obstruction
2. If passed to the small airways, that would be better Children may have few
symptoms after an initial choking episode.

>> usual course that they would choke, cough slightly and then that will be subside, it
can passed as minor event, even that some parents do not recall the choking event

>> sometimes it is hard to remove the FB, so they leave it, which may cause granuloma

Evaluation of Wheezing:

Any evaluation starts with good history then physical examination then take the lab you
want

 History:
1) Birth History:
 Gestational age
 Respiratory difficulties in neonatal period
 Length for assisted ventilation
 Oxygen supplementation

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2) History of onset of wheezing
 Age of onset
 Other symptoms associated with the wheezing episode as cough or difficulty
breathing

3) Timing, Pattern, Circumstances of Recurrent Episodes Wheezing

 Wheezing with respiratory infections
Acute viral bronchiolitis ( RSV + or -)
 Initial onset sudden, associated with coughing or chocking
Consider respiratory foreign body
 Insidious onset of wheezing
- Aspiration
- GERD
- Extraluminal airway obstruction ( enlarged lymph node/intrathoracic mass)
- Exposure to irritants (cig)
 Frequency- Duration of wheezing
 Generalized clinical course
- Associated with respiratory infection
- Associated with triggers ( irritants, specific allergens)
- Associated with feeding/vomiting e.g.,GERD
- Associated with other organ system
(e.g., Congenital heart disease with enlargement of left atrium
compressing the left main stem bronchus)

4) Pertinent Family History

 Asthma
 Atopic disease ( atopic dermatitis, allergic rhinitis)
 Cystic fibrosis

5) Response to medications for wheezing

 Bronchodilators (Beta₂ agonist)
 Anti-inflammatory medications
 Antibiotics

Also ask about swallowing problems, difficulty breathing or SOB, previous attacks,
cyanosis, steatorrhea, diurnal variation, relation to position, exacerbating and
relieving factors, triggering factors, sweating, pattern of the attack and if symptom
free between the attacks

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  Physical Examination:
1. General Status
 Well-nourished
 Failure to thrive
 Clubbing

2. Respiratory Rate
 Normal or elevated for age

3. Characteristics of Wheezing
 Generalized or unilateral
 Monophonic or polyphonic
 Inspiratory, expiratory or both
 Other adventitial lung sounds by auscultation

4. Signs of Respiratory Distress

 Retraction, Stridor, Use of accessory muscles
 Grunting, Head bobbing

5. Signs of Allergic Diathesis

 Atopic dermatitis
 Allergic rhinoconjunctivitis
 Allergic facies ( allergic shiners, allergic salute)

6. Signs of Cardiac Disease

 Clubbing, Murmurs, Cyanosis, Cardiomegaly and hepatomegaly

Also exam the chest expansion, chest symmetry, tracheal deviation, presence of fever
or not, growth parameters and pain

** FEV1 is difficult to be tested below age of 5 years so it is hard to diagnose asthma

Laboratory Studies:

You should pick what you want, do not ask for every test, because the history will guide
you. So It would vary depending on the suspected etiology of wheezing.

Chest x-ray, we almost order it for every kid.

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 X-rays:

- this is a kid with Bronchiolitis,

- RUL (right upper lope) opacity/ infiltrate, and LLL
opacity, which are mostly atelectasis
- Hyperinflation is considered if more than 6 anteriorly
and 8 posteriorly
- But bronchiolitis kid may show a normal x-ray, so
normal CXR doesn’t exclude bronchiolitis

- This is a kid with FB aspiration

- Asymmetry in chest expansion is seen
- Right lung is more lucent than the left
- The pic in the right, is a right-side down decubitus (while the pt is lying laterally
on his side) view of the chest which we ask for when we are suspecting a FB in a
certain side .
 In decubitus film (Lying on lateral side) the dependent lung will be compressed
(more white) and less inflated than the other one (top one) which will look
(hyperlucent, more black). In the picture shown, the 3 rd film is a right decubitus
film where you expect the right lung to be less expanded than the left but the
opposite happened (right lung is more inflated and black than the left) which
makes you suspect a FB obstructing the right main stem bronchus and creating a
ball-valve like mechanism.

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** we also ask for the decubitus film if pleural effusion

Barium Swallow

We ask for it if,

- Swallowing dysfunction
- Aspiration
- Vascular Ring

This is a picture for a kid with aspiration, the barium

appears in black color, where is accumulate behind the
epiglottis going down to the larynx then to the trachea.
And this is diagnostic for swallowing dysfunction

>> need a special radiologist or speech therapist to read

it, but unfortunately we can not do in the appropriate
technique here in our hospital due to the lack of
appropriate settings

This is a barium swallow detecting TE fistulae

(Tracheoesophageal fistula) the H type where we
could notice barium going to the stomach but also
some go to the airways taking shape of the bronchi

>> usually the patient feels tired after the study, he

would have some symptoms

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this is a barium swallow that detected a vascular ring , here we see a
posterior indentation of the esophagus caused by compression , when you
find a vascular ring you should do a “MRI” or “MRA”, that is important
because we need details for the anatomy , in order to help the sergeant
when he operates because he will need the exact anatomy . and it Is the
gold standard for diagnosis .

CT chest is done when we think of a mass or a congenital malformation of

the lung , this a picture of a bronchogynic cyst , this must be seen on an X-
ray .

so in this case the CT is asked for after we see the abnormality in the X-ray
that suggests a mass or a cyst or other abnormality.

 Tracheo-esophageal fistula (TEF) could be part of VACTERL

association
V: Vertebral anomalies , A: Anal atresia, C: Cardic defects T,E: TEF, R: Renal anomalies, L: Limb
defects

Bronchoscopy :
When do I do a bronchoscopy ???

1) Foreign body , we have two types of bronchoscopes the rigid and the flexible , in the case of a
foreign body we will use the rigid bronchoscope , because the rigid bronchoscope has a pipe
shape.
We actually can pass the forceps within the bronchoscope , an it can be used to ventilate the
baby .

The flexible bronchoscope has a very tiny suction channel , in adults they
can pass forceps but not for the case of foreign body retrieval .

Other laboratory studies , u can pick what ever you want according to the
suspected etiology or disease , sweat chloride of we are thinking of CF , upper gi
studies or 24 ph probe if you are thinking about GERD , echocardiogram if you are
thinking of a cardiac etiology .

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 So we do not have to order all the tests . only select those that you need to perform .

Severe asthma can rarely cause clubbing , but mostly it doesn’t ,

*A common question is :
Does my child have asthma ???

To diagnose asthma in a preschool age is considered to be hard , because performing a lung

function test is quit hard , and because of the varying patterns

A common early presentation of asthma is wheezing and cough that follows a URTI “a viral
infection” , it is unknown wither the infection triggered the asthma or if that the child has a
predisposition of wheezing after the infection .

• Asthma can begin at any age

• In infancy, wheezing is usually associated with RTI

• It is difficult to distinguish an initial episode of asthma triggered by viral RTI from wheezing due
to viral bronchiolitis

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 This figure is very important 

When a healthy baby becomes infected with RSV , that happens to about 90% of infants most
get symptoms of common cold

Minority experience Bronchiolitis which is the most common cause of hospitalization in first
year of life

Cough might be presented in both , common cold and bronchiolitis

25-50% will have intermittent pattern of asthma manifested as recurrent wheezing associated
with viral RTI , remission is common in later in childhood , this pattern is known as intermittent
asthma and episodic asthma and transient , those children are symptom free between the
attacks , so the mother would complain of wheezing and cough that starts with a runny nose .

Some would continue to have persistent symptoms throughout childhood and may continue
until adulthood even between the attacks and it is called a chronic or persistent asthma , those
Children have atopy (IgE mediated inflammation) , they react showing hyper responsiveness to
certain allergens .

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 *Who Gets Asthma?

• Genetic Factors
Some evidence that supports the presence of genetic attributuin
-Asthma presents in 25% of the offspring of a parent with asthma
-Higher concordance in MZ twins compared to DZ twins

• Environmental Factors
-Children who are exposed to certain allergens , cats , dogs , dust mite and so on , increase the
risk of developing asthma

-Airway hyper-responsiveness and IgE-mediated sensitivity to inhalant allergens in infancy are

associated with persistent asthma

-Tobacco smoke has synergistic effect with inhalant allergens , passive smoker kids are more
likely to develop asthma .

*How to Diagnose Asthma in Preschool years ?

• Recurrence of symptoms ( wheezing, cough, labored breathing)

• Positive Family history of asthma supports the diagnosis

• Reversibility of symptoms either spontaneously or with treatment

( good response to the Trial of inhaled bronchodilator in a clinic or an emergency room would be
a strong evidence to diagnose asthma if symptoms resolve)

*Clinical Pattern of Asthma

Transient (Intermittent) asthma

• Symptoms occur with viral RTI exclusively
• Symptom free between the attacks

• Lack of IgE-mediated allergy

• Remission of symptoms by school age ( most likely) , by 5-6 years these patients wont have
symptoms .

• Poor response to anti-inflammatory agents , inhaled steroids will not prevent the attacks , it
could minimize the severity and the duration of the attack but it doesn’t remove it

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 • The bronchodialators usually relief the attack but the controller does not prevent an attack

Chronic (Persistent) asthma

• They are symptomatic between the attacks

• Atopy present (evidence IgE positive to allergens)

• Continue to have asthma symptoms , might persist to adulthood .

• Respond to controller ( anti-inflammatory agents)

***note: the determining of the pattern is very important to the finding of the proper
treatment

*What goes against asthma ?

• Symptoms presenting in a neonate who required assisted ventilation

• Wheezing associated with spitting-up formula

• Digital clubbing, abnormal stool

• Presence of a cardiac murmur

• History of chocking

• Persistent unilateral wheezing

• Failure to thrive

• Persistence of wheezing in spite of optimal asthma therapy

Initiation of Controller Therapy in Children 0-4 yo

( NIH Guidelines

Four or more episodes of wheezing in the past year that lasted for more than one day and affected
sleep

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 One of the following: Two of the following:
AND
• Parenteral history of asthma • Food allergy

• Atopic dermatitis • 4 % peripheral eosinophilia

OR
• Evidence of sensitization to • Wheezing apart from cold
aeroallergen
• Any evidence of allergy or
atopy

Done by: Dua’ Khwies & Abdullah Hamarsheh

** this lecture has been reviewed by Dr. Samah Awad :)

** We had removed the bronchiolitis part from here ,, and added a separate lecture about

it to the package .

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