Wheezing

Wheezes are adventitious breath sounds with a high-pitched, musical, squealing, creaking, or groaning quality. Also known as sibilant rhonchi, 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, as in tension pneumothorax or goiter. With airway obstruction, wheezing occurs during inspiration. (See Associated disorder: Asthma.)

Emergency Actions

Examine 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 use of accessory muscles; 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 him relax, 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.

History

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?

Physical assessment

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 655.) 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, pages 720 and 721.)

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 of anaphylaxis 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 is an insidious disorder that produces unilateral, possibly severe wheezing. Common features are chronic cough and recurring hemoptysis. Symptoms of airway obstruction may occur later.

Bronchiectasis

With bronchiectasis, excessive mucus commonly causes intermittent and localized or diffuse wheezing. A copious, foul-smelling, mucopurulent cough is classic. The cough is 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 from bronchogenic carcinoma 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)

With acute chemical pneumonitis, 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, 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.

Inhalation injury

Wheezing may eventually occur with inhalation injury. 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)

Tension pneumothorax, a life-threatening disorder, causes respiratory distress with possible wheezing, dyspnea, tachycardia, tachypnea, and sudden, severe, sharp chest pain (often 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 coccidioidomycosis may cause wheezing and rhonchi along with cough, fever, chills, pleuritic chest pain, headache, weakness, fatigue, sore throat, backache, malaise, anorexia, and an itchy, macular rash.

Pulmonary edema

Wheezing may occur with pulmonary edema , a life-threatening disorder. Other signs and symptoms of pulmonary edema 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.

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 to percussion, increased tactile fremitus, and amphoric breath sounds.

CULTURAL CUE:Those living in Appalachian regions have a 50% higher mortality from tuberculosis than the national average. They also have a higher incidence of pneumonia, influenza, and black lung disease. The higher rate of respiratory tract diseases may be related to the high-risk occupations of the region, such as those in the mining, timber, and textile industries.

Thyroid goiter

Thyroid goiter may not produce symptoms, or it may cause wheezing, dysphagia, and respiratory difficulty related to a compressed airway. The neck will appear swollen and distended.

Tracheobronchitis

Auscultation of the patient with tracheobronchitis may detect wheezing, rhonchi, and moist or coarse crackles. The patient also has a cough, slight fever, sudden chills, muscle and back pain, and substernal tightness.

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 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.

Patient counseling

If appropriate, encourage increased activity to promote drainage and prevent pooling of secretions. Encourage regular deep breathing and coughing. Also encourage the patient to drink fluids to liquefy secretions and prevent dehydration.

Pictures

Book Source Details

• Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Mild cough: Introduction (review 6 causes)
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More About This Book: Title: Signs & Symptoms: A 2-in-1 Reference for Nurses Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-318-1

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