Wheezing

Differential Overview

Wheezing

❑ Asthma

❑ Reactive airways disease

❑ Pulmonary edema

❑ Pulmonary embolism

❑ Emphysema

❑ Gastroesophageal reflux

❑ Drug/toxin reaction

❑ Vocal cord dysfunction

❑ Foreign body aspiration

❑ Mediastinal mass

❑ Carcinoid syndrome

Stridor

❑ Mucus plug

❑ Laryngeal trauma

❑ Angioedema

❑ Acute epiglottitis

❑ Retropharyngeal abscess

Diagnostic Approach

A wheeze is a continuous musical sound produced by vibration of airway walls when they are near closure. A wheeze consisting of a single musical note indicates small airways disease, usually asthma. Polyphonic wheezes (multiple musical notes) are produced by dynamic compression of large central airways.

Stridor signifies central airway obstruction, and is an ominous portent of impending complete airway closure. Causes such as an aspirated foreign body or bronchogenic cancer should be suspected when the onset of wheezing is sudden and focal, allergic markers and specific triggers are absent, and response to bronchodilator is poor. A history of aspiration, or smoking and clubbing are also helpful.

Nocturnal wheezing could be the result of congestive heart failure (paroxysmal nocturnal dyspnea) or gastric aspiration with reflux.

Dyspnea on exertion correlates with an FEV1 below 50% predicted, and dyspnea at rest with FEV1 below 25% predicted. Forced expiratory time (FET) is measured by ausculting over the trachea, and timing until airflow is no longer heard. FET of 9 seconds predicts an FEV1/FVC ratio of 70%. Stridor indicates that the airway diameter is less than 5 mm.

Clinical Findings

Asthma  Diffuse expiratory wheezing and a subjective tightness in breathing are cardinal signs. An asthma exacerbation with absence of wheeze and marked dyspnea signals severe airflow obstruction with little air movement.

Reactive airways disease  Self-limited wheezing occurs in the setting of a viral respiratory infection. The patient usually has a prior history of atopy or allergy.

Pulmonary edema  Rales are characteristic, but may be obscured by wheezes. Elevation of jugular venous pressure is usually found.

Pulmonary embolism  Diffuse or localized wheezing may be caused by the release of mediators of inflammation. Sudden-onset pleuritic chest pain, a swollen leg, and hemoptysis are important clues.

Emphysema  In chronic obstructive pulmonary disease the course is protracted and progressive rather than episodic, and dyspnea is a hallmark. The patient is a heavy smoker with a barrel chest.

Gastroesophageal reflux  Nocturnal cough and wheeze coincide with heartburn and an acidic taste in the mouth.

Drug/toxin reaction  Beta blockers, aspirin (in a triad with nasal polyps and asthma), metabisulfate, iodinated contrast, and monosodium glutamate are common ingested precipitants. Toluene and sulfur dioxide are inhalant precipitants.

Vocal cord dysfunction  Upper airway inspiratory wheeze is associated with an abnormal voice.

Foreign body aspiration  Aspiration is suggested by focal wheezing and onset that occurs after loss of consciousness or dental manipulation.

Mediastinal mass  Mediastinal compression produces a superior vena cava syndrome with facial plethora, jugular venous engorgement, and prominent veins over the anterior chest.

Carcinoid syndrome  Carcinoid syndrome is recognized by brief, episodic flushing, and wheezing.

Mucus plug  Acute stridor occurs in a dehydrated patient with a productive but weak cough.

Laryngeal trauma  There is a history of external neck trauma or inhalation of hot or caustic substances.

Angioedema  Focal swelling of the tongue, lips, or periorbital region is coincident with stridor.

Acute epiglottitis  Severe sore throat without visible findings, thick muffled voice, and dysphagia are accompanied by stridor.

Retropharyngeal abscess  Severe pain occurs with swallowing, leading to drooling, neck swelling, fever, and a toxic appearance.

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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