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Wheezing

Wheezing is a high-pitched musical soundthat is usually produced by narrowing of the segmental bronchi andbronchioles. May be heard during inspiration, expiration, or both.

Principal Causes of Wheezing

1. Asthma
2. Bronchiolitis
3. Pneumonia
4. Foreign body
5. Bronchopulmonary dysplasia
6. Cystic fibrosis
7. Cardiac failure
8. Bronchial obstruction
9. Anaphylaxis
10. Gastroesophageal reflux
11. Allergic bronchopulmonary aspergillosis
12. Psychogenic

Clinical Features and Diagnosis

Asthma

Inflammatorydisorder of smaller airways produces recurrent wheezing, which isreversible with bronchodilator therapy or spontaneously. Wheezingis heard on expiration and often on inspiration.

Cough, tachypnea, and dyspnea are commonfindings.

Episodes may be triggered by viralinfections, allergens (pollens, molds, house dust mite, dog or catdander), exercise, cold air, emotional stress, noxious irritants(tobacco smoke, chemical fumes), and drugs (aspirin, propranolol).

Clinical or family history of atopicdisease is common.

Chest radiography often shows hyperinflationand peribronchial thickening. Peripheral eosinophilia may occurin some cases.

Clinical findings and positive responseto bronchodilators confirm diagnosis.

Bronchiolitis

Inflammationof bronchioles that is usually caused by respiratory syncytial virus (RSV)and occasionally by parainfluenza viruses, influenza viruses, andadenoviruses. Peak incidence is in infants 2–18 mos ofage during winter months.

Usual presentation is rhinorrhea andcough for 1–2 days followed by tachypnea and expiratorywheezing. Fever and crackles are variable findings.

Chest radiography usually shows hyperinflationand peribronchial thickening.

Detection of RSV antigen can be accomplishedby enzyme immunoassay using secretions from nasal wash. Other virusesmay be detected by polymerase chain reaction or by nasal wash culture.

Pneumonia

Is an inflammationor infection of lung parenchyma.

Clinical findings include fever, cough,some degree of respiratory distress, and occasionally expiratorywheezing. Crackles and decreased breath sounds may be heard overinvolved lung field.

Chest radiography confirms presenceof lung infiltrate but not the specific cause.

See further discussion of pneumoniain Chap. 10, Cough.

Foreign Body

Aspiration of foreign body in airway mayproduce choking, gagging, coughing, and wheezing (see Chap. 10, Cough).

Bronchopulmonary Dysplasia

Wheezing is frequent finding in this disorder,which can occur following prolonged mechanical ventilation for treatmentof neonatal respiratory distress syndrome (see Chap. 10, Cough, and Chap. 56, Respiratory Distress and Apnea).

Cystic Fibrosis

Most common manifestation of respiratorydisease in cystic fibrosis is cough that is intermittent and oftenproductive. Wheezing also may occur, especially with acute pulmonaryexacerbations. This disorder is discussed in Chap. 10, Cough.

Cardiac Failure

Severe cardiac failure may cause pulmonaryedema and wheezing (see Chap.7, Cardiac Failure).

Bronchial Obstruction

Intrinsicor extrinsic tracheal or bronchial obstruction may cause wheezing.

Intrinsic lesions include tracheomalacia,tracheal or bronchial stenosis, and endobronchial tumors.

Extrinsic lesions include enlargedlymph nodes (tuberculosis, histoplasmosis), cardiovascular disorders(enlarged pulmonary arteries from large left-to-right shunt lesionsor enlarged left atrium of any cause), and mediastinal masses.

In evaluation, chest radiography, bronchoscopy,chest CT, and MRI are useful diagnostic tools.

Anaphylaxis

Can produceacute onset of urticaria, wheezing, and hypotension. There is usually historyof exposure to specific allergen (foods, drugs, hymenoptera stings).

History and physical exam are usuallydiagnostic.

Gastroesophageal Reflux

Gastroesophagealreflux disease may cause respiratory disturbances including wheezingand apnea. Often there is history of persistent regurgitation andpoor weight gain.

Esophageal pH monitoring for 24 hrscan confirm presence of pathologic reflux.

Allergic Bronchopulmonary Aspergillosis

Rare butcan be complication of asthma.

Usual pathogen is A. fumigatus.

Inhalation of spores and shedding ofantigens into respiratory tract lead to inflammatory response ofairways.

Almost all affected individuals haverecurrent wheezing and dyspnea. Less frequent are chronic cough,fever, and pleuritic chest pain. Crackles may be heard over involvedlung segments.

Chest radiography usually shows patchydensities or consolidation that usually occurs in upper lobes. Peripheralblood eosinophilia is usual feature.

Serum immunoglobulin E level may beas high as 2,500 mg/dL. There is immunologic evidence ofexposure allergy to Aspergillus antigens (immediate skin reactivityor serum precipitins to these antigens). Sputum culture may revealA. fumigatus organisms.

Most serious complication is saccularbronchiectasis, which usually begins centrally. Can be demonstratedby chest CT.

Psychogenic

Normally,vocal cords abduct during inspiration and adduct slightly, if atall, during expiration.

In vocal cord dysfunction, cords adductduring inspiration, narrowing airway. Throat tightness, wheezing,and dyspnea, especially on exertion, can occur.

Direct visualization of cords throughfiberoptic laryngoscope, when patient is symptomatic, establishesdiagnosis. History of psychologic disturbance (e.g., anxiety ordepression) may be found in some cases.

Diagnostic Approach

History,physical exam, and chest radiograph are diagnostic in most casesof wheezing.

Age of child; timing and duration ofwheezing; presence of fever, stridor, or cough; and family historyof asthma or other atopic disorders help distinguish various causesof wheezing.

Asthma, bronchiolitis, and pneumoniaare most frequent causes of acute wheezing, whereas asthma is mostcommon cause of recurrent or persistent wheezing.

Other useful tests in children withhistory of wheezing are sweat test (cystic fibrosis), pH probe andendoscopy (gastroesophageal reflux disease), video swallowing study(swallowing disorders with aspiration), bronchoscopy (foreign bodyaspiration, tracheal or bronchial stenosis, tracheomalacia), andflexible laryngoscopy (vocal cord dysfunction). Further investigationsdepend on suspected diagnosis.

References

1. Barnes SD, et al. Psychogenic upper airwayobstruction presenting as refractory wheezing. J Pediatr 1986;109:1067–1070.
2. Behrman RE, et al, eds. Nelson textbook of pediatrics,16th ed. Philadelphia: WB Saunders, 2000.
3. Chernick V, Boat TF, eds. Kendig's disordersof the respiratory tract in children, 6th ed. Philadelphia: WB Saunders,1998.
4. Christopher KL, et al. Vocal-cord dysfunction presentingas asthma. N Engl J Med 1983;308:1566–1570.
5. Fireman P. The wheezing infant. Pediatr Rev 1986;7:247–254.
6. Landwehr LP, et al. Vocal cord dysfunction mimickingexercise-induce bronchospasm in adolescents. Pediatrics 1996;98:971–974.
7. Long SA, et al. Principles and practice of pediatricinfectious diseases. New York: Churchill Livingstone, 1997.
8. Martinati LC, Boner AL. Clinical diagnosis of wheezingin early childhood. Allergy 1995;50:701–710.
9. Rosenthal B. Wheezing. In: Fleisher GR, Ludwig S, eds.Textbook of pediatric emergency medicine, 4th ed. Philadelphia:Lippincott Williams & Wilkins, 2000:643–649.
10. Rudolph AM, ed. Rudolph's pediatrics, 20thed. Stamford, CT: Appleton & Lange, 1996.

Book Source Details

• Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
• Author(s): Paul S. Bellet
• Year of Publication: 2006
• Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.

Other Book Chapters Related to Breathlessness on exertion

Read excerpts from these other book chapters related to Breathlessness on exertion:

Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2008 Williams & Wilkins.

More About Causes of Breathlessness on exertion

• Back to symptom: Breathlessness on exertion: Introduction (review 6 causes)
• Next Book Extract About Breathlessness on exertion: Respiratory Distress and Apnea (The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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More About This Book: Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics Authors: Paul S. Bellet Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 0-78172-899-1

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