Wheezing
Wheezing: Excerpt from Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
Wheezes are adventitious breath sounds with a high-pitched, musical, squealing, creaking, or groaning quality. They’re caused by air flowing at a high velocity through a narrowed airway. When they originate in the large airways, they can be heard by placing an unaided ear over the chest wall or at the mouth. When they originate in smaller airways, they can be heard by placing a stethoscope over the anterior or posterior chest. Unlike crackles and rhonchi, wheezes can’t be cleared by coughing.
Usually, prolonged wheezing occurs during expiration when bronchi are shortened and narrowed. Causes of airway narrowing include bronchospasm; mucosal thickening or edema; partial obstruction from a tumor, a foreign body, or secretions; and extrinsic pressure, such as in tension pneumothorax or goiter. With airway obstruction, wheezing occurs during inspiration.
Act Now: Assess the degree of the patient’s respiratory distress. Is he responsive? Is he restless, confused, anxious, or afraid? Are his respirations abnormally fast, slow, shallow, or deep? Are they irregular? Can you hear wheezing through his mouth? Does he exhibit increased accessory muscle use; increased chest wall motion; intercostal, suprasternal, or supraclavicular retractions; stridor; or nasal flaring? Take his other vital signs, noting hypotension or hypertension, decreased oxygen saturation, and an irregular, weak, rapid, or slow pulse.
Help the patient relax, and administer humidified oxygen by face mask and encourage slow, deep breathing. Have endotracheal intubation and emergency resuscitation equipment readily available. Call the respiratory therapy department to supply intermittent positive-pressure breathing and nebulization treatments with bronchodilators. Insert an I.V. line for administration of drugs, such as diuretics, steroids, bronchodilators, and sedatives. Perform the abdominal thrust maneuver, as indicated, for airway obstruction.
Assessment
History
If the patient isn’t in respiratory distress, obtain his medical history. What provokes his wheezing? Does he have asthma or allergies? Does he smoke or have a history of a pulmonary, cardiac, or circulatory disorder? Does he have cancer? Ask about recent surgery, illness, or trauma or changes in appetite, weight, exercise tolerance, or sleep patterns. Obtain a drug history. Ask about exposure to toxic fumes or respiratory irritants. If he has a cough, ask how it sounds, when it starts, and how often it occurs. Does he have paroxysms of coughing? Is his cough dry, sputum producing, or bloody?
Ask the patient about chest pain. If he reports pain, determine its quality, onset, duration, intensity, and radiation. Does it increase with breathing, coughing, or certain positions?
Physical examination
Examine the patient’s nose and mouth for congestion, drainage, or signs of infection such as halitosis. If he produces sputum, obtain a sample for examination. Check for cyanosis, pallor, clamminess, masses, tenderness, swelling, jugular vein distention, and enlarged lymph nodes. Inspect his chest for abnormal configuration and asymmetrical motion, and determine if the trachea is midline. (See Detecting slight tracheal deviation, page 299.) Percuss for dullness or hyperresonance, and auscultate for crackles, rhonchi, or a pleural friction rub. Note absent or hypoactive breath sounds, abnormal heart sounds, gallops, or murmurs. (See Evaluating breath sounds.) Also note arrhythmias, bradycardia, or tachycardia. (See Wheezing: Causes and associated findings, pages 318 and 319.)
Pediatric pointers
Primary causes of wheezing in children include bronchospasm, mucosal edema, and accumulation of secretions, which may occur with such disorders as cystic fibrosis, aspiration of a foreign body, acute bronchiolitis, and pulmonary hemosiderosis.
Children are especially susceptible to wheezing because their small airways allow rapid obstruction.
Medical causes
Anaphylaxis
An allergic reaction, anaphylaxis can cause tracheal edema or bronchospasm, resulting in severe wheezing and stridor. Initial signs and symptoms include fright, weakness, sneezing, dyspnea, nasal pruritus, urticaria, erythema, and angioedema. Respiratory distress occurs with nasal flaring, accessory muscle use, and intercostal retractions. Other findings include nasal edema and congestion with profuse, watery rhinorrhea as well as chest or throat tightness and dysphagia. Cardiac effects include arrhythmias and hypotension.
Aspiration of a foreign body
Partial obstruction by a foreign body produces the sudden onset of wheezing and possibly stridor; a dry, paroxysmal cough; gagging; and hoarseness. Other findings include tachycardia, dyspnea, decreased breath sounds and, possibly, cyanosis. A retained foreign body may cause inflammation leading to fever, pain, and swelling.
Aspiration pneumonitis
With aspiration pneumonitis, wheezing may accompany tachypnea, marked dyspnea, cyanosis, tachycardia, fever, a productive (eventually purulent) cough, and pink, frothy sputum.
Asthma
Wheezing is an initial and cardinal sign of asthma. It’s heard at the mouth during expiration. An initially dry cough later becomes productive with thick mucus. Other findings include apprehension, prolonged expiration, intercostal and supraclavicular retractions, rhonchi, accessory muscle use, nasal flaring, and tachypnea. Asthma also produces tachycardia, diaphoresis, and flushing or cyanosis.
Bronchial adenoma
An insidious disorder, bronchial adenoma produces unilateral, possibly severe wheezing. Common features are chronic cough and recurring hemoptysis. Symptoms of airway obstruction may occur later.
Bronchiectasis
Excessive mucus commonly causes intermittent and localized or diffuse wheezing. A copious, foul-smelling, mucopurulent cough is classic. It’s accompanied by hemoptysis, rhonchi, and coarse crackles. Weight loss, fatigue, weakness, exertional dyspnea, fever, malaise, halitosis, and late-stage clubbing may also occur.
Bronchitis (chronic)
Chronic bronchitis causes wheezing that varies in severity, location, and intensity. Associated findings include prolonged expiration, coarse crackles, scattered rhonchi, and a hacking cough that later becomes productive. Other effects include dyspnea, accessory muscle use, barrel chest, tachypnea, clubbing, edema, weight gain, and cyanosis.
Bronchogenic carcinoma
Obstruction may cause localized wheezing. Typical findings include a productive cough, dyspnea, hemoptysis (initially blood-tinged sputum, possibly leading to massive hemorrhage), anorexia, and weight loss. Upper extremity edema and chest pain may also occur.
Chemical pneumonitis (acute)
Mucosal injury causes increased secretions and edema, leading to wheezing, dyspnea, orthopnea, crackles, malaise, fever, and a productive cough with purulent sputum. The patient may also have signs of conjunctivitis, pharyngitis, laryngitis, and rhinitis.
Emphysema
Mild to moderate wheezing may occur with emphysema, a form of chronic obstructive pulmonary disease. Related findings include dyspnea, tachypnea, diminished breath sounds, peripheral cyanosis, pursed-lip breathing, anorexia, and malaise. Accessory muscle use, barrel chest, a chronic productive cough, and clubbing may also occur.
Inhalation injury
Wheezing may eventually occur. Early findings include hoarseness and coughing, singed nasal hairs, orofacial burns, and soot-stained sputum. Later effects are crackles, rhonchi, and respiratory distress.
Pneumothorax (tension)
A life-threatening disorder, tension pneumothorax causes respiratory distress with possible wheezing, dyspnea, tachycardia, tachypnea, and sudden, severe, sharp chest pain (commonly unilateral). Other findings include a dry cough, cyanosis, accessory muscle use, asymmetrical chest wall movement, anxiety, and restlessness. Examination reveals hyperresonance or tympany and diminished or absent breath sounds on the affected side, subcutaneous crepitation, decreased vocal fremitus, and tracheal deviation.
Pulmonary coccidioidomycosis
Pulmonary coccidiodomycosis may cause wheezing and rhonchi along with cough, fever, chills, pleuritic chest pain, headache, weakness, malaise, anorexia, and a macular rash.
Pulmonary edema
Wheezing may occur with pulmonary edema, a life-threatening disorder. Other signs and symptoms include coughing, exertional and paroxysmal nocturnal dyspnea and, later, orthopnea. Examination reveals tachycardia, tachypnea, dependent crackles, and a diastolic gallop. Severe pulmonary edema produces rapid, labored respirations and a productive cough with frothy, bloody sputum. The patient may also exhibit diffuse crackles, arrhythmias, hypotension, a thready pulse, and cold, clammy, cyanotic skin.
Pulmonary embolus
Rarely, diffuse, mild wheezing occurs in pulmonary embolus. The condition is characterized by dyspnea, chest pain, and cyanosis.
Pulmonary tuberculosis
In late stages, fibrosis causes wheezing. Common findings include a mild to severe productive cough with pleuritic chest pain and fine crackles, night sweats, anorexia, weight loss, fever, malaise, dyspnea, and fatigue. Other features are dullness on percussion, increased tactile fremitus, and amphoric breath sounds.
Thyroid goiter
Thyroid goiter may be asymptomatic, or it may cause wheezing, dysphagia, and respiratory difficulty related to a compressed airway.
Tracheobronchitis
Auscultation may detect wheezing, rhonchi, and crackles. The patient also has cough, slight fever, sudden chills, muscle and back pain, and substernal tightness.
Wegener’s granulomatosis
Wegener’s granulomatosis may cause mild to moderate wheezing if it compresses major airways. Other findings include cough (possibly bloody), dyspnea, pleuritic chest pain, hemorrhagic skin lesions, and progressive renal failure. Epistaxis and severe sinusitis are common.
Nursing considerations
Prepare the patient for diagnostic tests, such as chest X-rays, arterial blood gas analysis, pulmonary function tests, and sputum culture.
Ease the patient’s breathing by placing him in semi-Fowler’s position and repositioning him frequently. Perform pulmonary physiotherapy as necessary.
Administer an antibiotic to treat infection, a bronchodilator to relieve bronchospasm and maintain a patent airway, a steroid to reduce inflammation, and a mucolytic or expectorant to increase the flow of secretions. Provide humidification to thin secretions.
Patient teaching
If appropriate, encourage increased activity to promote drainage and prevent pooling of secretions. Encourage regular deep breathing and coughing. Explain the importance of drinking fluids to liquefy secretions and prevent dehydration.
Pictures
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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