Wheezing

Wheezing: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter

Thomas C. Bent

Wheezing is one of the most common respiratory complaints to present to primary care physicians. Although most often caused by asthma or chronic obstructive pulmonary disease, there are multiple causes. The correct diagnosis can usually be made with a careful history and physical examination and simple diagnostic testing.

Approach

 Although asthma is the first consideration in the wheezing patient—and most often the correct diagnosis—careful consideration of less common but potentially more dangerous causes must be considered.

 A. Wheezing in infants, children, and adults. The reasons patients wheeze vary dramatically, depending on age. For example, whereas asthma is the most common chronic pediatric disease in industrialized nations (1), inhalant allergens appear to be unimportant precipitants of wheezing in infancy (2). (Table 8.5).

 B. Wheezing versus stridor. Stridor, discussed in Chapter 8.8, is characterized as an inspiratory wheeze that implies major obstruction of the upper airway. Wheezing, in contrast, is defined as high-pitched, continuous (or of long duration) adventitious lung sounds that are superimposed on the normal breath sounds (3). The inspiratory phase of respiration is usually normal and the expiratory phase is prolonged. Unfortunately, the difference is not always obvious to the clinician. Vocal cord dysfunction, which is a psychosomatic disorder, can be difficult to differentiate from asthma. The episodes can include both inspiratory and expiratory wheezing and an upper airway cause is not clear (4).

 C. Special concerns: the emergency assessment. The immediate assessment of the acutely wheezing patient is essential. Regardless of whether the patient presents with an initial episode or a chronic condition, determine the degree of airway obstruction and the potential deterioration of the patient quickly. The reduction in intensity of wheezing can indicate acute decompensation, as air obstruction becomes too severe to allow the mechanical sounds of wheezing.

History

A. Onset. Is this the first episode? If so, were there problems with wheezing or asthma in childhood?

B. Exposures. Are there any precipitating factors? Have there been any recent exposures? Is there an exposure to cigarette smoke? What is the patient’s occupation?

1. Cigarette smoke is one of the most potent and ubiquitous avoidable allergens.

2. Occupational exposures can frequently be identified, especially among agricultural and industrial workers.

3. Family or household exposure to tuberculosis or pertussis can indicate an infectious cause.

 C. Concurrent illnesses. Has the patient recently suffered an upper respiratory infection or sinusitis? Is there a history of gastroesophageal reflux disease?

 D. Family history. A history of asthma, allergies, or atopic disease in family members can support the diagnosis of asthma.

E. Past history. A childhood history of atopic disease or allergies suggests adult onset asthma. Past history of exercise-induced wheezing also supports this diagnosis.

 F. Psychosocial aspects. Emotional stress can lead to exacerbation of chronic asthma. Psychogenic wheezing is a conversion disorder, which can coexist with other psychopathology.

Physical examination

 A. Vital signs. A full set of vital signs is essential to the assessment of the wheezing patient. The respiratory rate and the pulse are a more objective, and often more accurate, assessment of the severity of wheezing than the auditory volume of the wheezing itself. Fever suggests a concurrent respiratory infection. Hypotension is an ominous sign that points to a decompensating patient.

 B. Lung examination. During auscultation, note the location, intensity, and duration of wheezing. Wheezing caused by asthma, chronic obstructive pulmonary disease (COPD), or interstitial disease should be diffuse and symmetric and present during expiration. The expiratory phase will be prolonged. Focal obstruction (e.g., tumors and foreign bodies) can give asymmetric findings and inspiratory wheezing. Mucus plugging will change with cough. Rhonchi and crackles suggest a concurrent infectious process. Percussion and egophony can be present with consolidation.

Testing

A. Pulmonary function. A peak flow meter is a valuable initial assessment of airway obstruction and can be done quickly and cheaply in the office. It is also an excellent measure of progression of disease or success of treatment. Pulse oximeter is another quick, noninvasive office technique to assess the severity of both chronic disease and acute respiratory distress. Full spirometry, although not available in all primary care offices, gives additional diagnostic information that can differentiate among asthma, COPD, and fixed airway obstruction.

B. Chest x-ray study. Plain chest films will identify consolidation, masses, mediastinal shifts, and hyperaeration.

C. Clinical laboratory tests. A complete blood count may demonstrate signs of an acute bacterial infection. Polycythemia is a sign of chronic hypoxia (Chapter 16.5). Eosinophilia can indicate asthma or allergic disease (Chapter 16.2). Angiotensin-converting enzyme levels are elevated in sarcoidosis. A tuberculin skin test should be considered in all patients with wheezing or chronic cough.

Diagnostic assessment

The history and physical examination are the key elements to an acute diagnosis. A consistent exposure or reaction history, coupled with an elevated serum IgE or eosinophilia, indicates allergic disease. Wheezing in the setting of acute bronchitis or sinusitis is not true asthma and the patient can be reassured that this is not the beginning of a chronic disease. Inspiratory wheezing, or stridor, indicates upper airway obstruction or psychogenic wheezing. A normal, or nearly normal, peak flow is reassurance that good air exchange is occurring, regardless of the loudness of the wheezing. The pulse oximetry will differentiate between severe obstruction and poor cooperation with the peak flow testing. When confusion still exists, spirometry will clarify the diagnosis in most cases. The diagnosis and treatment of most cases of wheezing is within the scope of practice of the primary care physician.

References

1. Pryor MP. Noisy breathing in children. Postgrad Med 1997;101:103–111.

2. Martinati LC, Boner AL. Clinical diagnosis of wheezing in early childhood. Allergy 1995;50:701–710.

3. Meslier N, Charbonneau G, Racineux JL. Wheezes. Eur Respir J 1995;8:1942–1948.

4. Goldman J. All that wheezes is not asthma. Practitioner 1997;241:35–38.

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Book Source Details

• Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
• Author(s): Robert B. Taylor (editor)
• Year of Publication: 2000
• Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.

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More About This Book: Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter Authors: Robert B. Taylor (editor) Publisher: Lippincott Williams & Wilkins Copyright: 2000 ISBN: 0-78172-094-X

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