Wheezing [Sibilant rhonchi]

Wheezes are adventitious breath sounds with a high-pitched, musical, squealing, creaking, or groaning quality. They are 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, as in tension pneumothorax or goiter. With airway obstruction, wheezing occurs during inspiration.

Emergency interventions

Help the patient relax, administer humidified oxygen by face mask, and encourage him to take slow, deep breaths. 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.

History and physical examination

If the patient isn’t in respiratory distress, obtain a 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 any 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?

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, distended jugular veins, 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 599.) Percuss for dullness or hyperresonance, and auscultate for crackles, rhonchi, or pleural friction rubs. Note absent or hypoactive breath sounds, abnormal heart sounds, gallops, or murmurs. Also note arrhythmias, bradycardia, or tachycardia. (See Evaluating breath sounds.)  

Medical causes

Anaphylaxis

Anaphylaxis is an allergic reaction that 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; profuse, watery rhinorrhea; chest or throat tightness; and dysphagia. Cardiac effects include arrhythmias and hypotension.

Aspiration of a foreign body

Partial obstruction by a foreign body produces 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, 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

Bronchial adenoma, an insidious disorder, 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)

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.

Emphysema

Mild to moderate wheezing may occur with emphysema, a form of chronic obstructive pulmonary disease. Related findings include dyspnea, malaise, 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.

Pulmonary coccidioidomycosis

Pulmonary coccidioidomycosis may cause wheezing and rhonchi along with cough, fever, chills, pleuritic chest pain, headache, weakness, malaise, anorexia, and 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; diffuse crackles; a productive cough with frothy, bloody sputum; arrhythmias; cold, clammy, cyanotic skin; hypotension; and thready pulse.

Tracheobronchitis

Auscultation may detect wheezing, rhonchi, and crackles. The patient also has a 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 a cough (possibly bloody), dyspnea, pleuritic chest pain, hemorrhagic skin lesions, and progressive renal failure. Epistaxis and severe sinusitis are common.

Special 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 a 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 patent airways, a steroid to reduce inflammation, and a mucolytic or expectorant to increase the flow of secretions. Provide humidification to thin secretions.

Pediatric pointers

Children are especially susceptible to wheezing because their small airways allow rapid obstruction. Primary causes of wheezing include bronchospasm, mucosal edema, and accumulation of secretions. These may occur with such disorders as cystic fibrosis, aspiration of a foreign body, acute bronchiolitis, and pulmonary hemosiderosis.

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Book Source Details

• Book Title: Handbook of Signs & Symptoms (Third Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Dry cough: Introduction (review 189 causes)
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More About This Book: Title: Handbook of Signs & Symptoms (Third Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-402-1

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