Wheezy Chest

Nader Fasseeh,
Prof. of Pediatrics, Respiratory and Allergy Unit,
Alexandria University, Egypt
 What is the role of the pediatrician or ENT
doctor faced with a child or infant with noisy
breathing ?
(1) to be able to differentiate between different respiratory
noises

(2) to determine the severity or respiratory compromise and the

need for immediate intervention

(3) to decide based upon history and clinical examination

whether a significant lesion is suspected

(4) to understand the consequences and management strategies

of the underlying lesion and to collaborate with colleagues
from related disciplines for follow-up and subsequent
management of the child.
 Respiratory Noises:
Wheeze, Rattling, Stridor, and Snoring

Wheeze • Intrathoracic airway obstruction

Rattling • Indicative of secretions in the trachea or major

bronchi

Stridor • Partial upper airway obstruction

Snoring • Partial upper airway obstruction mainly in naso-

or oropharynx

Towards Validating Diagnosed Respiratory Sounds Using Dynamic Time Warping at Alexandria University
Children Hospital (AUCH) – Egypt
Nader Fasseeh et al, Life Science Journal 2015;12(3s)
Respiratory Wheeze Sound Analysis Using Digital Signal Processing Techniques“
Ibrahim Akkary, Nader Fasseeh, Marwa A, et al; cicsyn2015-chairs@edas.info
 Why normal breathing is not
audible ?

Because the linear velocity of airflow

in the tracheobronchial tree is too low
to produce sound
 Definition:
High-pitched, musical, adventitious sound
produced by increased the linear velocity of
airflow through an abnormally narrowed
airway(s).

WHAT IS A WHEEZE?
 What is wheeze?

Character dependent on
1. flow rate and
2. properties of airway and surrounding tissue
Descriptions
1. Timing (expiratory or inspiratory, early or late)
2. Duration (long, short)
3. Pitch and composition (high or low, mono or poly)
 The pitch of wheeze
1- Degree of obstruction
2- Rate of air flow through the narrowed airway
3-Mass and elasticity of the tissues set into oscillation

Wheeze

Polyphonic Monophonic
wheeze wheeze
 Polyphonic (multi-tones) vs monophonic
(single tone)
Monophonic wheeze in children
Fixed airway obstruction:
1. foreign body,
2. tracheomalacia,
bronchomalacia,
3. Extrinsic compression eg
from vascular abnormalities,
lymph nodes

Polyphonic wheeze in children

Bronchiolitis, asthma, OB and
other various
wheezing phenotypes
 Chevalier Jackson recognized 100
years ago that

all that wheezes is not asthma

What is the narrowest part of the
normal lower respiratory tract ?

1) Terminal bronchioles
or
2) Trachea and the first four generation
of the bronchial tree
Total cross sectional
area

2 cm2

19 cm2

300 cm2
What is the narrowest part of the
normal lower respiratory tract ?

The trachea and the first four generation

of the bronchial tree
 Mechanism of wheeze
Narrowing of the trachea or major bronchi
directly or indirectly
1. Dynamic narrowing of the trachea or
major bronchi during expiration
because of widespread narrowing to
the medium and small airway

2. Localized obstruction of either the

trachea or major bronchi
Pst is not enough for
expiration

Palv= Pst + Ppl

Ppl increases to overcome
the resistance

Dynamic compression of the trachea and major

bronchi due to small airway obstruction
 Cause of Wheezing
• Not from obstruction of small airways –
Surface area too large

• From increased intrathoracic pressure +

decreased large airway pressure = vibration of
airway wall in large airways (Generations 1-5)
 Causes of wheezing
• Acute

• Recurrent

• Chronic
 Acute wheezing
What is the most common cause of
acute wheezing in infants and
children less than 2 years ?

1) Acute bronchiolitis
2) Bronchial asthma
3) Foreign body aspiration
 Acute wheezing
What is the most common cause of
acute wheezing in infants and
children less than 2 years ?

1) Acute bronchiolitis
2) Bronchial asthma
3) Foreign body aspiration
 Acute wheezing
What is the most common cause of
acute wheezing episodes in older
children ?

1) Acute bronchiolitis
2) Bronchial asthma
3) Foreign body aspiration
 Acute wheezing
What is the most common cause of
acute wheezing episodes in older
children ?

1) Acute bronchiolitis
2) Bronchial asthma
3) Foreign body aspiration
 Acute wheezing
What is the most common cause of acute
wheezing arising from large airways
obstruction ?

1) Acute bornochiolitis
2) Bronchial asthma
3) Foreign body aspiration
 Acute wheezing
What is the most common cause of acute
wheezing arising from large airways
obstruction ?

1) Acute bornochiolitis
2) Bronchial asthma
3) Foreign body aspiration
 Differential Diagnosis of Wheezy Child
1. Infections/Inflammatory 1. Lower respiratory tract
infections (especially
2. Congenital anomalies viral etiology)
2. Bronchiolitis
3. Aspiration syndrome 3. Bronchial asthma
4. Bronchitis
4. Mechanical compression 5. Cystic Fibrosis
6. Allergic
5. Cardiogenic
Bronchopulmonary
6. Tumors Aspergillosis

7. Immune compromise
 Differential Diagnosis of Wheezy Child

1. Infections/Inflammatory Tracheoesophageal fistula

2. Congenital anomalies
Tracheomalacia
Laryngotracheoesophageal cleft
3. Aspiration syndrome Bronchomalacia
Tracheomalacia/bronchomalacia
4. Mechanical compression Tracheal stenosis
5. Cardiogenic
Vascular ring/pulmonary sling
Bronchial stenosis
6. Tumors Bronchogenic cyst

7. Immune compromise
 Differential Diagnosis of Wheezy Child
1. Infections/Inflammatory
Swallowing dysfunction
2. Congenital anomalies Neuromuscular abnormalities
Regurgitation
3. Aspiration syndrome Structural lesions mouth,
tongue,
4. Mechanical compression Gastroesophageal reflux
nasopharynx, and/or jaw
5. Cardiogenic Hiatal hernia
Familial dysautonomia
6. Tumors
Esophageal obstruction
7. Immune compromise Vascular ring
Esophageal dysfunction
 Differential Diagnosis of Wheezy Child
1. Infections/Inflammatory
Superior mediastinum Anterior mediastinum
Cystic hygroma Cystic hygroma
Thymic tumors Tymoma
2. Congenital anomalies
Teratoma Teratoma
Hemangioma Pericardial cyst
3. Aspiration syndrome
Abscess Thyroid lesions
Lymphoma
4. Mechanical compression Morgani hernia
Middle Mediastinum Posterior Mediastinum
Lymphoma Enterogenic cyst
5. Cardiogenic
Anomalies of great vessels Bronchogenic cyst
Bronchogenic cyst Neurenteric anomalies
6. TumorsAngiomatous lesions Esophageal lesions
Bochdalek hernia
Neurogenic tumor
7. Immune compromise
 Differential Diagnosis of Wheezy Child
1. Infections/Inflammatory
Airway compression
2. Congenital anomalies (ventricular septal defect,
patent ductus arteriosus,
3. Aspiration syndrome distended pulmonary artery,
and/or
4. Mechanical compression enlarged left atrium).
Left ventricular failure
5. Cardiogenic (distention of pulmonary
vascular bed) or obstructed
6. Tumors
pulmonary veins.
7. Immune compromise
 Differential Diagnosis of Wheezy Child
1. Infections/Inflammatory
Hamartoma
2. Congenital anomalies Benign
3. Aspiration syndrome
Lipoma
Chondroma
4. Mechanical compression Myoblastoma
Malignant
5. Cardiogenic
Bronchial adenoma
6. Tumors Sarcoma
Bronchogenic carcinoma
7. Immune compromise
 Diagnosis

Should be tailored to each patient according to

the history, clinical examination, and the
investigations needed
 Characteristics of Wheezing

• Generalized or unilateral wheezing

• Audible with or without stethoscope
• Monophonic or polyphonic wheezes
• Inspiratory, expiratory, or both
• Associated with coughing
• Intermittent or persistent
• Other adventitial lung sounds (crackles or rales)
 Investigations
• X-ray chest
• Barium upper GIT study
• PFT
• Tuberculin test
• CT chest
• MD-SCT chest with virtual bronchoscopy
• Bronchoscopy
• Ph monitoring of lower esophagus
• Sweat chloride test and/genetic study
 Conclusion
• Wheezing is indicative of intrathoracic airway
obstruction
• Monophonic wheeze is indicative of large caliber
airway obstruction
• Polyphonic wheeze is indicative of small and medium
airway obstruction
• Persistent and recurrent wheeze is an indication of
FFB
• FFB is a safe and important tool for diagnosing many
causes of recurrent and persistent wheeze in infants
and children
 Conclusions
• With no definitive gold standard for the definition of breath
sounds in young children, terminology is confusing, both for
medical staff and for parents

• Many studies and surveys support the hypothesis that parents

of young children are using the word wheeze inappropriately,
both in the hospital setting and in the community. Also, they
are using the term wheeze to describe other sounds such as
ruttles or rattles

• Imprecise use of the term wheeze by parents has potentially

important implications for clinical trials as well as for the
diagnosis and therapy of respiratory disease
Bronchiolitis
Nader Fasseeh
 Definition
Bronchiolitis is a common acute, contagious
respiratory illness of infants and young
children that involves the LRT.

*Bronchiolitis is a viral syndrome

Etiology
 Infectious agents associated with bronchiolitis
RSV 50%
Parainfluenza viruses 25%
Type 1 8%
Type 2 2%
Type 3 15%
Adenovirus 5%
Mycoplasma pneumonia 5%
Rhinovirus 5%
Influenza virus 5%
Type A 3%
Type B 2%
 Causes of LRTI
RSV

Rhino virus ( RV)

Human Metapneumo virus ) HMPV)

Corona virus

Human bocavirus

Para-influenza viruses

Adenovirus

Influenza virus
 Epidemiology
Seasonality
RSV Winter and early
Parainfluenza type 1 spring
Corona virus Winter
Parainfluenza type 2 Throughout the year
type 3
Influenza virus Short period
 RSV Is Easily Transmitted but Can Be Prevented

• Transmission occurs by droplets, large particles, and fomites1

• RSV survives up to 8 hours on stethoscopes2 and up to 7 hours
on hard, nonporous surfaces1
• More than 50% of medical personnel are infected when RSV is
prevalent in the community3
• Nosocomial infection remains a serious problem4,5
• Prevention techniques may help reduce the spread of RSV5
• Maximize hand washing and use alcohol-based hand cleaners
• Carefully handle contaminated materials and quarantine those
infected
• Limit contact with hospital visitors, especially young children
• Educate parents about the importance of RSV disease
prevention
1. Hall CB, et al. J Infect Dis. 1980;141:98-102.
2. Blydt-Hansen T, et al. Pediatr Infect Dis J. 1999;18:164-165.
3. Hall CB, et al. Pediatrics. 1978;62:728-732.
4. Hall CB. Clin Infect Dis. 2000;31:590-596. 22
5. Groothuis J, et al. J Perinatol . 2008;28:319-323.
Sex
Bronchiolitis is slightly more common in boys
Risk factors
Prematurity
Congenital heart diseases High risk
Chronic lung diseases (BPD) factors
Immune deficiency
Absence of breast feeding
Low risk
Crowded environment
Poor immunization compliance factors
Exposure to passive smoking
 Populations at High-risk for Severe RSV Disease

Conditions* Pathophysiology
Premature Birth1,2 • Interrupted lung
development
• Decreased maternally-
transmitted antibody
levels
Chronic Lung Disease • Bronchial
(CLD)1-3 hyperresponsiveness
• Reduced lung reserve
Hemodynamically • Cyanotic heart disease
Significant Congenital • Pulmonary
Heart Disease (CHD)4 hypertension

1. Weisman LE. Pediatr Infect Dis J. 2003;22(2 suppl):S33-S39.

2. Colin A, et al. Pediatrics. 2010;126:115-128. * List of conditions is not exhaustive
3. Panitch HB. Pediatr Infect Dis J. 2004;23:S222-S227.
4. Cohen, et al. Pediatr Cardiol. 2008;29:382-387. 9
 High-risk Infants Have an Increased Rate of
RSV-related Hospitalization

RSV-related Hospitalizations in Infants <6 Months of Age

Premature Infants with Infants with
Infants CHD CLD / BPD
Annual Rate per 100 Infants

60
56.3
55 Approximately Approximately Approximately

10 8.0 8.2
9.4
12.1
2x 3x 13x
4.4 Greater Risk Greater Risk Greater Risk
5 for RSV-related for RSV-related for RSV-related
Hospitalization Hospitalization Hospitalization
0
Low 33-<36 29-≤32 ≤28 CHD CLD/
Risk* wGA wGA wGA BPD Compared to Low-risk Infants

Adapted from Boyce et al. J Pediatr. 2000;137:865-870.

A retrospective analysis of 3,553 hospitalizations for RSV-related illness in children
enrolled in the Tennessee Medicaid system from July 1989 through June 1993.

*Low risk was defined by researchers as all infants studied who were not diagnosed with bronchopulmonary dysplasia (BPD) or CHD, who
were not premature, or who did not have other conditions (asthma, previous respiratory hospitalization, cystic fibrosis, cancer, human
immunodeficiency virus infection, immunodeficiency, use of chronic oral steroids, chronic renal disease, diabetes mellitus, congenital
abnormalities of the respiratory system, tracheoesophageal fistula, esophageal atresia and stenosis, neonatal respiratory distress syndrome,
and other respiratory conditions of the fetus and newborn).

1. Boyce TG, et al. J Pediatr. 2000;137:865-870.

10
Age incidence
The peak age incidence of RSV brochiolitis is
between 2-6 month.
Approximately 80% of all cases occur during the
first year of life.
The attack rate
10-20 cases per 100 children in the first year
The attack rate in members of affected families is
about 50% and in infants < 1 year is 60%
Reinfection is common, 75% of previously infected
children will have a second infection in their second
year.
Sex
Bronchiolitis is slightly more common in boys
Risk factors
Prematurity
Congenital heart diseases High risk
Chronic lung diseases (BPD) factors
Immune deficiency
Absence of breast feeding
Low risk
Crowded environment
Poor immunization compliance factors
Exposure to passive smoking
•The illness is mild in the majority of cases

•1% to 5% requires hospitalization

•Mortality 0.5%
•Period of infectivity for RSV is 7 days and
for Parainfluenza virus 7 to 14 days
•Incubation period for RSV is 2-9 days and
for Parainfluenza virus 2-10 days
Pathophysiology
 Viral infection Edema
Ventilatory
supply Bronchiolar Inflammation
obstruction Mucus
Venilatory Cellular debris
demand Airway resistance

Complete obstruction Ball valve obstruction

Atelectasis Air trapping
V/Q mismatch
Hypoxia
 Premature Birth Alters Airways

49
1. Langston C, et al. Am Rev Respir Dis. 1984;129:607-613. 2. Hall CB. N Engl J Med. 2001;344:1917-1928
 Premature Birth Interrupts Lung Development and
Alters Airway Development
Fetal Development4
• Premature infants have
underdeveloped lungs: Alveoli
are not uniformly present until 36
weeks GA1,2
• 34 week GA infants have 52% of
the lung volume seen in term 8 wGA 16 wGA

infants1,2 Premature4,* Term4,*

• Increased mechanical stress and
exposure to higher oxygen levels
in the extrauterine environment
may alter airway development3

24 wGA to 35 wGA 36 wGA to 3 years

*Adapted from Moore. Pictures are artistic renditions and are designed to emphasize
terminal acinus development and not the entire conducting airway system4.
1. Colin A, et al. Pediatrics. 2010;126:115-128.
2. Langston C, et al. Am Rev Respir. 1984;129:607-613.
3. Hoo AF, et al. Pediatrics. 2002;141:652-658.
4. Moore KL, et al. In: The Developing Human: Clinically Oriented Embryology. 7th Ed. Philadelphia, PA: Saunders. 2003:241-253.
13
 Clinical Picture

General symptoms of pneumonia

Local signs of emphysema
 •History of contact with minor RTI
•Mild URTI for several days
•Gradual development of
Spasmodic cough
Irritability
RD
Refusal of feeding
Signs •
•Extreme RD (rapid and shallow breathing)
•Hyperresonance lung on percussion
•Diminished air entry *Prolonged expiratory phase
•Widespread fine crackles, and wheeze
 X-ray
Hyperinfated lungs
Peribronchial thickening
30% scattered areas of consolidation
Laboratory findings
WBC are usually within normal range
ABG: Low PaO2 (correlates well with the
severity of the disease
Late increased PaCO2
Antigen detection
•Immunofluirescence DFA or IFA
Rapid, accurate , highly sensitive and specific
ELISA•
 Diagnosis
•Bronchiolitis is mainly a clinical diagnosis
•Infant less than one year
•In winter
•Develop rapid wheeze following URT
•With widespread crackles and marked
pulmonary hyperinflation of X-ray
•RSV Ag detection by FA or ELISA in naso-
pharyngeal secretion provides supportive
evidence
 Differential Diagnosis
• Asthma
•Bronchopneumonia
•Chlamydial pneumonia
•Aspiration pneumonia
•Cystic fibrosis
•Acute respiratory failure
•Heart failure
•Salicylate poisoning
Treatment
Is mainly supportive
1-Supportive therapy
2-Specific therapy
3-Controversial therapy

4-Experimental therapy
5-Preventive therapy
•Infants with mild disease can be cared at home
•If RD or difficulty with feeding develops the
infant is in need for hospitalization.
1-Supportive
Position
Setting at 30 to 40°
Fluid therapy
•Adequate fluid intake by IV± NGT
•Should not in excess of 75% of normal
requirement (SIADH)
 2-Specific therapy
Oxygen therapy
*Headbox or oxygen tent with added humidity
and sufficient oxygen to relieve hypoxia
*Oxygen saturation should be maintained
>92% and measured continuously
Ribavirin
•Is a synthetic nucleoside with anti-RSV properties.
•Dissolved in sterile water and nebulized into a tent or
oxyhood by a small-particle aerosol generator
during 12-18 h each day for 3 to 7 days
 Candidates for Ribavirin therapy
High risk
•CHD
•Chronic lung disease (BPD, cystic fibrosis)
•Premature infants
•Immunodeficiency
Severely ill infants
•PaO2 less than 65 mm Hg
•Increasing PaCO2
Mechanical ventilation
For respiratory failure is well tolerated and
safe in acute bronchiolitis
Extracorporeal membrane oxygenation
Is used successfully in infants with RSV
whose condition deteriorated despite
maximal ventilator management
 3-Controversial therapy
•Nebulized salbutamol
ipratropium bromide
If no beneficial response is observed after
several treatments, it should be discontinued

Corticosteroids•
In cases who respond to bronchodilators
 4-Experimental therapy
•IM of recombinant interferon 2a

•IV immunoglobulin containing RSV

neutralizing antibodies
 5-Preventive therapy
RSV vaccine for infants at high
risk for bronchiolitis
Thank You