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Diseases » Wheezing » Causes
 

Causes of Wheezing

Contents
  1. Wheezing: Introduction
  2. List of Causes
  3. Drugs/substances (269 causes)
  4. Hidden causes
  5. Excerpts from book chapters
  6. Complication causes
  7. Causes of symptoms
  8. News
  9. Related cause information

List of causes of Wheezing

Following is a list of causes or underlying conditions (see also Misdiagnosis of underlying causes of Wheezing) that could possibly cause Wheezing includes:

More causes: see full list of causes for Wheezing

Wheezing Causes: Book Excerpts

Wheezing as a complication of other conditions:

Other conditions that might have Wheezing as a complication may, potentially, be an underlying cause of Wheezing. Our database lists the following as having Wheezing as a complication of that condition:

Wheezing as a symptom:

Conditions listing Wheezing as a symptom may also be potential underlying causes of Wheezing. Our database lists the following as having Wheezing as a symptom of that condition:

Medications or substances causing Wheezing:

The following drugs, medications, substances or toxins are some of the possible causes of Wheezing as a symptom. This list is incomplete and various other drugs or substances may cause your symptoms. Always advise your doctor of any medications or treatments you are using, including prescription, over-the-counter, supplements, herbal or alternative treatments.

See full list of 269 medications causing Wheezing


Medical news summaries relating to Wheezing:

The following medical news items are relevant to causes of Wheezing:

Related information on causes of Wheezing:

As with all medical conditions, there may be many causal factors. Further relevant information on causes of Wheezing may be found in:

Causes of Wheezing: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the causes of Wheezing.

Stridor & Wheezing: Differential Diagnosis
(In a Page: Signs and Symptoms)

Stridor (inspiratory)

  • Croup (laryngotracheobronchitis)
    –Viral infection with tracheal narrowing due to airway edema
    –“Bark-like” cough, hoarseness
  • Epiglottitis
    –Airway emergency most commonly due to Haemophilus influenzae or group A streptococcus infection
    –Abrupt onset of high fevers, sore throat, hoarseness, dysphagia, respiratory distress
  • Foreign body lodged in the upper airway
    • Allergic reaction/anaphylaxis
      –May have urticaria and angioedema (subcutaneous or mucosal swelling, often of the lips)
  • Trauma
  • Postendotracheal intubation
  • Psychogenic (e.g., paroxysmal vocal cord dyskinesia)
    Stridor (expiratory)
  • COPD (expiratory vocalization to prolong time to airway closure and avoid air trapping)
  • Cardiac failure (expiratory vocalization to prolong increased intrathoracic pressure and unload left ventricle)

Wheezing
  • Asthma
    –Triad of chronic cough, dyspnea, wheezing
    –Wheezing may be absent in cases of severe obstruction (insufficient air movement)
  • Pulmonary edema
    –Leakage of fluid into the interstitium and alveoli due to elevated capillary pressure (cardiogenic) or abnormal capillary permeability (noncardiogenic)
  • COPD
  • GERD
  • Respiratory infection
    –Upper respiratory infection
    –Bronchiolitis
    –“Atypical” pneumonia
    • Aspirated foreign body
      –Abrupt onset of unilateral wheezing or stridor (if lodged in the upper airway), cough, and decreased breath sounds
  • Allergic reaction/anaphylaxis
    –Urticaria, throat swelling (angioedema), and lip/tongue edema may be present

    • » READ BOOK EXCERPT ONLINE »

    Source: In a Page: Signs and Symptoms, 2004

    Stridor: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

    Nasal cavity and nasopharynx

    • Congenital
      –Piriform aperture stenosis
      –Choanal atresia
      –Lacrimal duct cyst
      –Craniofacial anomaly
      –Nasopharyngeal mass (teratoma)
      • Inflammatory/infectious
        –Rhinosinusitis
        –Adenoid hypertrophy

      Oral cavity, oropharynx, and hypopharynx
    • Congenital
      –Macroglossia
      –Glossoptosis
      –Vallecular cyst
    • Inflammatory/infectious
      –Tonsillar hypertrophy
    • Tumors
      –Lingual thyroid
      –Dermoid
      –Lymphovascular malformation
    • Foreign body

    Laryngeal
    • Congenital
      –Laryngomalacia (#1 cause in infants); usual onset is in the first 2 weeks of life, typically positional; most resolve spontaneously by age 1
      –Saccular cyst
      –Webs
      –Clefts
      –Vocal cord paralysis
    • Inflammatory/infectious
      –Epiglottitis
      –Laryngotracheitis (croup)
      –Gastroesophageal reflux
    • Tumors
      –Papillomas
      –Hemangiomas
      • Trauma
        –Subglottic stenosis
        –Foreign bodies
        –Laryngeal fracture
        –Caustic ingestion
        Tracheobronchial
      • Congenital
        –Tracheomalacia
        –Vascular rings
        –Tracheoesophageal fistula
      • Inflammatory

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    Wheezing: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

    Lower airway (expiratory, polyphonic)

    • Extraluminal compression of airways
      –Parenchymal: Pneumonia, pulmonary edema, bronchogenic cyst
      –Vascular: Ring, sling, “cardiac wheeze”
      –Lymphatics: Enlarged lymph nodes (TB, sarcoidosis, malignancy)
      –Structural: CLE, scoliosis, or chest wall deformity with airway “kinking”
    • Transluminal change in airway
      –Asthma: Inflammation, edema, hyperemia, mucus gland hypertrophy and proliferation, smooth muscle bronchospasm
      –Bronchiectasis/bronchitis
      –Cystic fibrosis
      –Ciliary disease: Primary ciliary dyskinesia, dysfunction due to ETS or hyperoxia
      –Anatomic: Hemangioma, polyps, TEF, bronchial atresia, BALT, bronchiolitis obliterans, tracheobronchomalacia
      –Immunologic disorders (e.g., IgA deficiency)
    • Intraluminal change in airway
      –Mucus (increased production or decreased clearance), pus (infected sputum), blood
      –Foreign body
      –Aspirated food or stomach contents secondary to gastroesophageal reflux
      Upper airway (usually inspiratory and monophonic)
    • Nasal (congestion, choanal atresia, FB)
    • Oropharyngeal (tonsils, adenoids, macroglossia, foreign body, decreased tone, retropharyngeal abscess)
      • Laryngeal (laryngomalacia, vocal cord dysfunction or paralysis, laryngeal web or polyp, subglottic stenosis)

      Central nervous system
    • Structural disease (e.g., Arnold-Chiari malformation leading to vocal cord paralysis)
    • Functional (e.g., vocal cord dysfunction, chronic aspiration)

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    Respirations, stertorous: Medical causes
    (Handbook of Signs & Symptoms (Third Edition))

    Airway obstruction

    Regardless of its cause, partial airway obstruction may lead to stertorous respirations accompanied by wheezing, dyspnea, tachypnea and, later, intercostal retractions and nasal flaring. If the obstruction becomes complete, the patient abruptly loses his ability to talk and displays diaphoresis, tachycardia, and inspiratory chest movement but absent breath sounds. Severe hypoxemia rapidly ensues, resulting in cyanosis, loss of consciousness, and cardiopulmonary collapse.

    Obstructive sleep apnea

    Loud and disruptive snoring is a major characteristic of obstructive sleep apnea, which commonly affects people who are obese. Typically, the snoring alternates with periods of sleep apnea, which usually end with loud gasping sounds. Alternating tachycardia and bradycardia may occur.

    Episodes of snoring and apnea recur in a cyclic pattern throughout the night. Sleep disturbances, such as somnambulism and talking during sleep, may also occur. Some patients display hypertension and ankle edema. Most awaken in the morning with a generalized headache, feeling tired and unrefreshed. The most common complaint is excessive daytime sleepiness. Lack of sleep may cause depression, hostility, and decreased mental acuity.

    Other causes

    Endotracheal (ET) intubation, suction, or surgery

    ET intubation, suction, or surgery may cause significant palatal or uvular edema, resulting in stertorous respirations.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Stridor: Medical causes
    (Handbook of Signs & Symptoms (Third Edition))

    Airway trauma

    Local trauma to the upper airway commonly causes acute obstruction, resulting in the sudden onset of stridor. Accompanying this sign are dysphonia, dysphagia, hemoptysis, cyanosis, accessory muscle use, intercostal retractions, nasal flaring, tachypnea, progressive dyspnea, and shallow respirations. Palpation may reveal subcutaneous crepitation in the neck or upper chest.

    Anaphylaxis

    With a severe allergic reaction, upper airway edema and laryngospasm cause stridor and other signs and symptoms of respiratory distress: nasal flaring, wheezing, accessory muscle use, intercostal retractions, and dyspnea. The patient may also develop nasal congestion and profuse, watery rhinorrhea. Typically, these respiratory effects are preceded by a feeling of impending doom or fear, weakness, diaphoresis, sneezing, nasal pruritus, urticaria, erythema, and angioedema. Common associated findings include chest or throat tightness, dysphagia and, possibly, signs of shock, such as hypotension, tachycardia, and cool, clammy skin.

    Anthrax (inhalation)

    Initial signs and symptoms are flulike and include a fever, chills, weakness, a cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by stridor, a fever, dyspnea, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

    Aspiration of a foreign body

    Sudden stridor is characteristic in foreign body aspiration, a life-threatening situation. Related findings include an abrupt onset of dry, paroxysmal coughing; gagging or choking; hoarseness; tachycardia; wheezing; dyspnea; tachypnea; intercostal muscle retractions; diminished breath sounds; cyanosis; and shallow respirations. The patient typically appears anxious and distressed.

    Hypocalcemia

    With hypocalcemia, laryngospasm can cause stridor. Other findings include paresthesia, carpopedal spasm, and positive Chvostek’s and Trousseau’s signs.

    Inhalation injury

    Within 48 hours after inhalation of smoke or noxious fumes, the patient may develop laryngeal edema and bronchospasms, resulting in stridor. Associated signs and symptoms include singed nasal hairs, orofacial burns, coughing, hoarseness, sooty sputum, crackles, rhonchi, wheezes, and other signs and symptoms of respiratory distress, such as dyspnea, accessory muscle use, intercostal retractions, and nasal flaring.

    Mediastinal tumor

    Commonly producing no symptoms at first, a mediastinal tumor may eventually compress the trachea and bronchi, resulting in stridor. Its other effects include hoarseness, a brassy cough, a tracheal shift or tug, dilated neck veins, swelling of the face and neck, stertorous respirations, and suprasternal retractions on inspiration. The patient may also report dyspnea, dysphagia, and pain in the chest, shoulder, or arm.

    Retrosternal thyroid

    Retrosternal thyroid is an anatomic abnormality that causes stridor, dysphagia, a cough, hoarseness, and tracheal deviation. It can also cause signs of thyrotoxicosis.

    Other causes

    Diagnostic tests

    Bronchoscopy or laryngoscopy may precipitate laryngospasm and stridor.

    Treatments

    After prolonged intubation, the patient may exhibit laryngeal edema and stridor when the tube is removed. Aerosol therapy with epinephrine may reduce stridor. Reintubation may be necessary in some cases. Neck surgery, such as thyroidectomy, may cause laryngeal paralysis and stridor.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Wheezing [Sibilant rhonchi]: Medical causes
    (Handbook of Signs & Symptoms (Third Edition))

    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.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Respirations, stertorous: Medical causes
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Airway obstruction

    Regardless of its cause, partial airway obstruction may lead to stertorous respirations accompanied by wheezing, dyspnea, tachypnea and, later, intercostal retractions and nasal flaring. If the obstruction becomes complete, the patient abruptly loses his ability to talk and displays diaphoresis, tachycardia, and inspiratory chest movement but absent breath sounds. Severe hypoxemia rapidly ensues, resulting in cyanosis, loss of consciousness, and cardiopulmonary collapse.

    Obstructive sleep apnea

    Loud and disruptive snoring is a major characteristic of this syndrome, which commonly affects the obese. Typically, the snoring alternates with periods of sleep apnea, which usually end with loud gasping sounds. Alternating tachycardia and bradycardia may occur.

    Episodes of snoring and apnea recur in a cyclic pattern throughout the night. Sleep disturbances, such as somnambulism and talking during sleep, may also occur. Some patients display hypertension and ankle edema. Most awaken in the morning with a generalized headache, feeling tired and unrefreshed. The most common complaint is excessive daytime sleepiness. Lack of sleep may cause depression, hostility, and decreased mental acuity.

    Other causes

    Endotracheal intubation, suction, or surgery

    These procedures may cause significant palatal or uvular edema, resulting in stertorous respirations.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Stridor: Medical causes
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Airway trauma

    Local trauma to the upper airway commonly causes acute obstruction, resulting in the sudden onset of stridor. Accompanying this sign are dysphonia, dysphagia, hemoptysis, cyanosis, accessory muscle use, intercostal retractions, nasal flaring, tachypnea, progressive dyspnea, and shallow respirations. Palpation may reveal subcutaneous crepitation in the neck or upper chest.

    Anaphylaxis

    With a severe allergic reaction, upper airway edema and laryngospasm cause stridor and other signs and symptoms of respiratory distress: nasal flaring, wheezing, accessory muscle use, intercostal retractions, and dyspnea. The patient may also develop nasal congestion and profuse, watery rhinorrhea. Typically, these respiratory effects are preceded by a feeling of impending doom or fear, weakness, diaphoresis, sneezing, nasal pruritus, urticaria, erythema, and angioedema. Common associated findings include chest or throat tightness, dysphagia and, possibly, signs of shock, such as hypotension, tachycardia, and cool, clammy skin.

    Anthrax, inhalation

    Initial signs and symptoms are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by stridor, fever, dyspnea, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

    Aspiration of a foreign body

    Sudden stridor is characteristic in this life-threatening situation. Related findings include abrupt onset of dry, paroxysmal coughing, gagging or choking, hoarseness, tachycardia, wheezing, dyspnea, tachypnea, intercostal muscle retractions, diminished breath sounds, cyanosis, and shallow respirations. The patient typically appears anxious and distressed.

    Epiglottiditis

    With this inflammatory condition, stridor is caused by an erythematous, edematous epiglottis that obstructs the upper airway. Stridor occurs along with fever, sore throat, and a croupy cough.

    Hypocalcemia

    With this disorder, laryngospasm can cause stridor. Other findings include paresthesia, carpopedal spasm, and positive Chvostek’s and Trousseau’s signs.

    Inhalation injury

    Within 48 hours after inhalation of smoke or noxious fumes, the patient may develop laryngeal edema and bronchospasms, resulting in stridor. Associated signs and symptoms include singed nasal hairs, orofacial burns, coughing, hoarseness, sooty sputum, crackles, rhonchi, wheezes, and other signs and symptoms of respiratory distress, such as dyspnea, accessory muscle use, intercostal retractions, and nasal flaring.

    Laryngeal tumor

    Stridor is a late sign and may be accompanied by dysphagia, dyspnea, enlarged cervical nodes, and pain that radiates to the ear. Typically, stridor is preceded by hoarseness, minor throat pain, and a mild, dry cough.

    Laryngitis (acute)

    This disorder may cause severe laryngeal edema, resulting in stridor and dyspnea. Its chief sign, however, is mild to severe hoarseness, perhaps with transient voice loss. Other findings include sore throat, dysphagia, dry cough, malaise, and fever.

    Mediastinal tumor

    Commonly producing no symptoms at first, this type of tumor may eventually compress the trachea and bronchi, resulting in stridor. Its other effects include hoarseness, brassy cough, tracheal shift or tug, dilated neck veins, swelling of the face and neck, stertorous respirations, and suprasternal retractions on inspiration. The patient may also report dyspnea, dysphagia, and pain in the chest, shoulder, or arm.

    Retrosternal thyroid

    This anatomic abnormality causes stridor, dysphagia, cough, hoarseness, and tracheal deviation. It can also cause signs of thyrotoxicosis.

    Thoracic aortic aneurysm

    If this aneurysm compresses the trachea, it may cause stridor accompanied by dyspnea, wheezing, and a brassy cough. Other findings include hoarseness or complete voice loss, dysphagia, jugular vein distention, prominent chest veins, tracheal tug, paresthesia or neuralgia, and edema of the face, neck, and arms. The patient may also complain of substernal, lower back, abdominal, or shoulder pain.

    Other causes

    Diagnostic tests

    Bronchoscopy or laryngoscopy may precipitate laryngospasm and stridor.

    Treatments

    After prolonged intubation, the patient may exhibit laryngeal edema and stridor when the tube is removed. Aerosol therapy with epinephrine may reduce stridor. Reintubation may be necessary in some cases. Neck surgery, such as thyroidectomy, may cause laryngeal paralysis and stridor.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Wheezing [Sibilant rhonchi]: Medical causes
    (Professional Guide to Signs & Symptoms (Fifth Edition))

    Anaphylaxis

    This allergic reaction can cause tracheal edema or bronchospasm, resulting in severe wheezing and stridor. Initial signs and symptoms include apprehension, 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

    In this disorder, wheezing may accompany tachypnea, marked dyspnea, cyanosis, tachycardia, fever, a productive (eventually purulent) cough, and frothy pink 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.

    Blast lung injury

    Wheezing is a common symptom of this condition, which is characterized by hypoxia and respiratory difficulty. The forceful blast wave that follows an explosive detonation can cause serious lung injury, including hemorrhage, contusion, edema, and tearing. In addition to wheezing, patients may exhibit chest pain, dyspnea, cyanosis, and hemoptysis. The diagnosis is confirmed by chest X-rays that show a classic “butterfly” pattern.

    Bronchial adenoma

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

    Bronchiectasis

    In this disorder, excessive mucus commonly causes intermittent and localized or diffuse wheezing. Characteristic findings include a chronic cough that produces copious amounts of foul-smelling, mucopurulent sputum; hemoptysis; rhonchi; and coarse crackles. Weight loss, fatigue, weakness, exertional dyspnea, fever, malaise, halitosis, and late-stage clubbing may also occur.

    Bronchitis (chronic)

    This disorder 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 in this 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

    Early findings include hoarseness and coughing, singed nasal hairs, orofacial burns, and soot-stained sputum. Later effects may include wheezing, crackles, rhonchi, and respiratory distress.

    Pneumothorax (tension)

    This 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

    This disorder may cause wheezing and rhonchi along with cough, fever, chills, pleuritic chest pain, headache, weakness, malaise, anorexia, and macular rash.

    Pulmonary edema

    This life-threatening disorder may cause wheezing, 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 a thready pulse.

    Pulmonary embolus

    Diffuse, mild wheezing rarely occurs in this disorder, which 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. Examination reveals dullness on percussion, increased tactile fremitus, and amphoric breath sounds.

    Respiratory syncytial virus (RSV)

    Infected individuals commonly develop wheezing and other symptoms within 4 to 6 days of exposure to this virus. Healthy adults and children older than age 3 usually have mild cases of RSV and experience wheezing along with other common cold-like symptoms of runny nose, cough, and low-grade fever. In children ages 3 and younger, high-pitched expiratory wheezing can accompany a severe cough, rapid breathing, and high-grade fever. RSV is the primary cause of lower respiratory tract infection in infants, who may develop pneumonia or bronchiolitis. Infection-control practices help prevent the spread of this virus, which can be inactivated by disinfectants or soap and water. A vaccine is being researched for this common condition that affects most children by age 2.  

    Thyroid goiter

    This disorder may produce no symptoms, 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 a cough, a slight fever, sudden chills, muscle and back pain, and substernal tightness.

    Wegener’s granulomatosis

    This disorder 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.

    » READ BOOK EXCERPT ONLINE »

    Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

    Wheezing: Differential Overview
    (Field Guide to Bedside Diagnosis)

    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

    » READ BOOK EXCERPT ONLINE »

    Source: Field Guide to Bedside Diagnosis, 2007

    Respirations, stertorous: Medical causes
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    Airway obstruction

    Regardless of its cause, partial airway obstruction may lead to stertorous respirations accompanied by wheezing, dyspnea, tachypnea and, later, intercostal retractions and nasal flaring. If the obstruction becomes complete, the patient abruptly loses his ability to talk and displays diaphoresis, tachycardia, and inspiratory chest movement but absent breath sounds. Severe hypoxemia rapidly ensues, resulting in cyanosis, loss of consciousness, and cardiopulmonary collapse.

    Obstructive sleep apnea

    Loud and disruptive snoring is a major characteristic of obstructive sleep apnea, which commonly affects the obese. Typically, snoring alternates with periods of sleep apnea, which usually end with loud gasping sounds. Alternating tachycardia and bradycardia may occur.

    Episodes of snoring and apnea recur in a cyclic pattern throughout the night. Sleep disturbances, such as somnambulism and talking during sleep, may also occur. Some patients display hypertension and ankle edema. Most awaken in the morning with a generalized headache, feeling tired and unrefreshed. The most common complaint is excessive daytime sleepiness. Lack of sleep may cause depression, hostility, and decreased mental acuity.

    Other causes

    Endotracheal intubation, suction, or surgery

    These procedures may cause significant palatal or uvular edema, resulting in stertorous respirations.

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Stridor: Medical causes
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    Airway trauma

    Local trauma to the upper airway commonly causes acute obstruction, resulting in the sudden onset of stridor. Accompanying this sign are dysphonia, dysphagia, hemoptysis, cyanosis, accessory muscle use, intercostal retractions, nasal flaring, tachypnea, progressive dyspnea, and shallow respirations. Palpation may reveal subcutaneous crepitation in the neck or upper chest.

    Anaphylaxis

    With a severe allergic reaction, upper airway edema and laryngospasm cause stridor and other signs and symptoms of respiratory distress — nasal flaring, wheezing, accessory muscle use, intercostal retractions, and dyspnea. The patient may also develop nasal congestion and profuse, watery rhinorrhea. Typically, these respiratory effects are preceded by a feeling of impending doom or fear, weakness, diaphoresis, sneezing, nasal pruritus, urticaria, erythema, and angioedema. Common associated findings include chest or throat tightness, dysphagia and, possibly, signs of shock, such as hypotension, tachycardia, and cool, clammy skin.

    Anthrax (inhalation)

    Initial signs and symptoms of inhalation anthrax are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by stridor, fever, dyspnea, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

    Aspiration of a foreign body

    Sudden stridor is characteristic in this life-threatening situation. Related findings include an abrupt onset of dry, paroxysmal coughing, gagging or choking, hoarseness, tachycardia, wheezing, dyspnea, tachypnea, intercostal muscle retractions, diminished breath sounds, cyanosis, and shallow respirations. The patient typically appears anxious and distressed.

    Epiglottiditis

    With epiglottiditis, an inflammatory condition, stridor is caused by an erythematous, edematous epiglottis that obstructs the upper airway. Stridor occurs along with fever, sore throat, and a croupy cough.

    Hypocalcemia

    With hypocalcemia, laryngospasm can cause stridor. Other findings include paresthesia, carpopedal spasm, and positive Chvostek’s and Trousseau’s signs.

    Inhalation injury

    Within 48 hours after inhalation of smoke or noxious fumes, the patient may develop laryngeal edema and bronchospasms, resulting in stridor. Associated signs and symptoms include singed nasal hairs, orofacial burns, coughing, hoarseness, sooty sputum, crackles, rhonchi, wheezes, and other signs and symptoms of respiratory distress, such as dyspnea, accessory muscle use, intercostal retractions, and nasal flaring.

    Laryngeal tumor

    Stridor is a late sign and may be accompanied by dysphagia, dyspnea, enlarged cervical nodes, and pain that radiates to the ear. Typically, stridor is preceded by hoarseness, minor throat pain, and a mild, dry cough.

    Laryngitis (acute)

    Acute laryngitis may cause severe laryngeal edema, resulting in stridor and dyspnea. Its chief sign, however, is mild to severe hoarseness, perhaps with transient voice loss. Other findings include sore throat, dysphagia, dry cough, malaise, and fever.

    Mediastinal tumor

    Commonly producing no symptoms at first, this type of tumor may eventually compress the trachea and bronchi, resulting in stridor. Its other effects include hoarseness, brassy cough, tracheal shift or tug, jugular vein distention, face and neck swelling, stertorous respirations, and suprasternal retractions on inspiration. The patient may also report dyspnea, dysphagia, and pain in the chest, shoulder, or arm.

    Retrosternal thyroid

    An anatomic abnormality, retrosternal thyroid causes stridor, dysphagia, cough, hoarseness, and tracheal deviation. It can also cause signs of thyrotoxicosis.

    Thoracic aortic aneurysm

    If this aneurysm compresses the trachea, it may cause stridor accompanied by dyspnea, wheezing, and a brassy cough. Other findings include hoarseness or complete voice loss, dysphagia, jugular vein distention, prominent chest veins, tracheal tug, paresthesia or neuralgia, and edema of the face, neck, and arms. The patient may also complain of substernal, lower back, abdominal, or shoulder pain.

    Other causes

    Diagnostic tests

    Bronchoscopy or laryngoscopy may precipitate laryngospasm and stridor.

    Medical treatments

    After prolonged intubation, the patient may exhibit laryngeal edema and stridor when the tube is removed. Aerosol therapy with epinephrine may reduce stridor. Reintubation may be necessary in some cases. Neck surgery, such as thyroidectomy, may cause laryngeal paralysis and stridor.

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Wheezing: Medical causes
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    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.

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    Respirations, stertorous: Medical causes
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Airway obstruction

    Partial airway obstruction may lead to stertorous respirations accompanied by wheezing, dyspnea, tachypnea and, later, intercostal retractions and nasal flaring. If the obstruction becomes complete, the patient abruptly loses his ability to talk and displays diaphoresis, tachycardia, and inspiratory chest movement but absent breath sounds. Severe hypoxemia rapidly ensues, resulting in cyanosis, loss of consciousness, and cardiopulmonary collapse.

    Obstructive sleep apnea

    Loud and disruptive snoring is a major characteristic of obstructive sleep apnea, which commonly affects the obese. Typically, the snoring alternates with periods of sleep apnea, which usually end with loud gasping sounds. These episodes occur in a cyclic pattern throughout the night. Alternating tachycardia and bradycardia may occur as well as such sleep disturbances as somnambulism and talking during sleep. Some patients display hypertension and ankle edema. Most awaken in the morning with a generalized headache, feeling tired and unrefreshed. The most common complaint is excessive daytime sleepiness. Lack of sleep may cause depression, hostility, and decreased mental acuity.

    Other causes

    Procedures

    Endotracheal intubation, suction, or surgery may cause significant palatal or uvular edema, resulting in stertorous respirations.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Stridor: Medical causes
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    Airway trauma

    Local trauma to the upper airway commonly causes acute obstruction, resulting in the sudden onset of stridor. Accompanying this sign are dysphonia, dysphagia, hemoptysis, cyanosis, accessory muscle use, intercostal retractions, nasal flaring, tachypnea, progressive dyspnea, and shallow respirations. Palpation may reveal subcutaneous crepitation in the neck or upper chest.

    Anaphylaxis

    With a severe allergic reaction (anaphylaxis), upper airway edema and laryngospasm cause stridor and other signs and symptoms of respiratory distress: nasal flaring, wheezing, accessory muscle use, intercostal retractions, and dyspnea. The patient may also develop nasal congestion and profuse, watery rhinorrhea. Typically, these respiratory effects are preceded by a feeling of impending doom or fear, weakness, diaphoresis, sneezing, nasal pruritus, urticaria, erythema, and angioedema. Common associated findings of anaphylaxis include chest or throat tightness, dysphagia and, possibly, signs of shock, such as hypotension, tachycardia, and cool, clammy skin.

    Anthrax (inhalation)

    Initial signs and symptoms of inhalation anthrax are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by stridor, fever, dyspnea, and hypotension generally leading to death within 24 hours.

    Aspiration of a foreign body

    Sudden stridor is characteristic in this life-threatening situation. Related findings include abrupt onset of dry, paroxysmal coughing, gagging or choking, hoarseness, tachycardia, wheezing, dyspnea, tachypnea, intercostal muscle retractions, diminished breath sounds, cyanosis, and shallow respirations. The patient typically appears anxious and distressed.

    Epiglottiditis

    With epiglottiditis, a life-threatening inflammatory condition, stridor is caused by an erythematous, edematous epiglottis that obstructs the upper airway. Stridor occurs along with fever, sore throat, and a croupy cough. The cough may progress to severe respiratory distress with sternal and intercostal retractions, nasal flaring, cyanosis, and tachycardia.

    Hypocalcemia

    With hypocalcemia, laryngospasm can cause stridor. Other findings include paresthesia, carpopedal spasm, hyperactive deep tendon reflexes, muscle twitching and cramping, and positive Chvostek’s and Trousseau’s signs.

    Inhalation injury

    Within 48 hours after inhalation of smoke or noxious fumes, the patient may develop laryngeal edema and bronchospasms, resulting in stridor. Associated signs and symptoms include singed nasal hairs, orofacial burns, coughing, hoarseness, sooty sputum, crackles, rhonchi, wheezes, and other signs and symptoms  of respiratory distress, such as dyspnea, accessory muscle use, intercostal retractions, and nasal flaring.

    Laryngeal tumor

    Stridor is a late sign of laryngeal tumor and may be accompanied by dysphagia, dyspnea, enlarged cervical nodes, and pain that radiates to the ear. Typically, stridor is preceded by hoarseness, minor throat pain, and a mild, dry cough.

    Laryngitis (acute)

    Acute laryngitis may cause severe laryngeal edema, resulting in stridor and dyspnea. Its chief sign, however, is mild to severe hoarseness, perhaps with transient voice loss. Other findings include sore throat, dysphagia, dry cough, malaise, and fever.

    Mediastinal tumor

    Commonly producing no symptoms at first, a mediastinal tumor may eventually compress the trachea and bronchi, resulting in stridor. Its other effects include hoarseness, brassy cough, tracheal shift or tug, dilated neck veins, swelling of the face and neck, stertorous respirations, and suprasternal retractions on inspiration. The patient may also report dyspnea, dysphagia, and pain in the chest, shoulder, or arm.

    Thoracic aortic aneurysm

    If a thoracic aortic aneurysm compresses the trachea, it may cause stridor accompanied by dyspnea, wheezing, and a brassy cough. Other findings include hoarseness or complete voice loss, dysphagia, jugular vein distention, prominent chest veins, tracheal tug, paresthesia or neuralgia, and edema of the face, neck, and arms. The patient may also complain of substernal, lower back, abdominal, or shoulder pain.

    Other causes

    Diagnostic tests

    Bronchoscopy or laryngoscopy may precipitate laryngospasm and stridor.

    Treatments

    After prolonged intubation, the patient may exhibit laryngeal edema and stridor when the tube is removed. Aerosol therapy with epinephrine may reduce stridor. Reintubation may be necessary in some cases. Neck surgery, such as thyroidectomy, may cause laryngeal paralysis and stridor.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Wheezing: Medical causes
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    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.

    » READ BOOK EXCERPT ONLINE »

    Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

    Wheezing: Principal Causes of Wheezing
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    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

    » READ BOOK EXCERPT ONLINE »

    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Stertor, Stridor, and Airway Obstruction: Principal Causes of Airway Obstruction
    (The Diagnostic Approach to Symptoms and Signs in Pediatrics)

    1. Noseand nasopharynx
      1. Congenital
        1. Choanal atresia
        2. Craniofacial anomalies
        3. Midline masses
      2. Infection/inflammation
        1. Rhinitis
        2. Adenoid hypertrophy
        3. Polyps
      3. Trauma
      4. Neoplasm
    2. Oropharynx and hypopharynx
      1. Congenital
        1. Micrognathiaand other skull base abnormalities
        2. Macroglossia
        3. Decreased pharyngeal muscle tone
      2. Infection/inflammation
        1. Tonsillarhypertrophy
        2. Abscess
      3. Foreign body
      4. Trauma
      5. Neoplasm
    3. Supraglottic
      1. Congenital
        1. Laryngomalacia
        2. Laryngeal cyst and laryngocele
      2. Infection/inflammation
        1. Supraglottitis
        2. Gastroesophageal reflux
        3. Hereditary angioedema
      3. Trauma
      4. Neoplasm
    4. Glottic
      1. Congenital
        1. Laryngeal web
        2. Laryngeal cleft
        3. Vocal cord paralysis
      2. Infection/inflammation
        1. Laryngitis
        2. Laryngeal spasm
      3. Foreign body
      4. Trauma
      5. Neoplasm
    5. Subglottic
      1. Congenital
        1. Subglottic stenosis
        2. Cysts
      2. Infection/inflammation
        1. Croup
        2. Bacterial tracheitis
      3. Trauma
      4. Neoplasm
    6. Tracheobronchial
      1. Congenital
        1. Tracheomalacia
        2. Tracheal web
        3. Tracheal cysts
        4. Tracheal stenosis
        5. Vascular anomalies
      2. Infection/inflammation
      3. Foreign body
      4. Trauma
      5. Neoplasm
        1. Tracheal
        2. Thyroid
        3. Mediastinal masses
    7. Psychogenic

    » READ BOOK EXCERPT ONLINE »

    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Respirations, stertorous: Medical causes
    (Nursing: Interpreting Signs and Symptoms)

    Airway obstruction.Regardless of its cause, partial airway obstruction may lead to stertorous respirations accompanied by wheezing, dyspnea, tachypnea and, later, intercostal retractions and nasal flaring. If the obstruction becomes complete, the patient abruptly loses his ability to talk and displays diaphoresis, tachycardia, and inspiratory chest movement but absent breath sounds. Severe hypoxemia rapidly ensues, resulting in cyanosis, loss of consciousness, and cardiopulmonary collapse.

    Obstructive sleep apnea.Loud and disruptive snoring is a major characteristic of obstructive sleep apnea, which commonly affects people who are obese. Typically, the snoring alternates with periods of sleep apnea, which usually end with loud gasping sounds. Alternating tachycardia and bradycardia may occur.

    Episodes of snoring and apnea recur in a cyclic pattern throughout the night. Sleep disturbances, such as somnambulism and talking during sleep, may also occur. Some patients display hypertension and ankle edema. Most awaken in the morning with a generalized headache, feeling tired and unrefreshed. The most common complaint is excessive daytime sleepiness. Lack of sleep may cause depression, hostility, and decreased mental acuity.

    Other causes

    Endotracheal (ET) intubation, suction, or surgery.ET intubation, suction, or surgery may cause significant palatal or uvular edema, resulting in stertorous respirations.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Stridor: Medical causes
    (Nursing: Interpreting Signs and Symptoms)

    Airway trauma.Local trauma to the upper airway commonly causes acute obstruction, resulting in the sudden onset of stridor. Accompanying this sign are dysphonia, dysphagia, hemoptysis, cyanosis, accessory muscle use, intercostal retractions, nasal flaring, tachypnea, progressive dyspnea, and shallow respirations. Palpation may reveal subcutaneous crepitation in the neck or upper chest.

    Anaphylaxis.With a severe allergic reaction, upper airway edema and laryngospasm cause stridor and other signs and symptoms of respiratory distress: nasal flaring, wheezing, accessory muscle use, intercostal retractions, and dyspnea. The patient may also develop nasal congestion and profuse, watery rhinorrhea. Typically, these respiratory effects are preceded by a feeling of impending doom or fear, weakness, diaphoresis, sneezing, nasal pruritus, urticaria, erythema, and angioedema. Common associated findings include chest or throat tightness, dysphagia and, possibly, signs of shock, such as hypotension, tachycardia, and cool, clammy skin.

    Anthrax (inhalation).Initial signs and symptoms of anthrax are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial symptoms. The second stage develops abruptly with rapid deterioration marked by stridor, fever, dyspnea, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

    Hypocalcemia.With hypocalcemia, laryngospasm can cause stridor. Other findings include paresthesia, carpopedal spasm, and positive Chvostek's and Trousseau's signs.

    Inhalation injury.Within 48 hours after inhalation of smoke or noxious fumes, the patient may develop laryngeal edema and bronchospasms, resulting in stridor. Associated signs and symptoms include singed nasal hairs, orofacial burns, coughing, hoarseness, sooty sputum, crackles, rhonchi, wheezes, and other signs and symptoms of respiratory distress, such as dyspnea, accessory muscle use, intercostal retractions, and nasal flaring.

    Mediastinal tumor.Commonly producing no symptoms at first, a mediastinal tumor may eventually compress the trachea and bronchi, resulting in stridor. Its other effects include hoarseness, a brassy cough, a tracheal shift or tug, dilated neck veins, swelling of the face and neck, stertorous respirations, and suprasternal retractions on inspiration. The patient may also report dyspnea, dysphagia, and pain in the chest, shoulder, or arm.

    Retrosternal thyroid.Retrosternal thyroid causes stridor, dysphagia, cough, hoarseness, and tracheal deviation. It can also cause signs of thyrotoxicosis.

    Other causes

    Diagnostic tests.Bronchoscopy or laryngoscopy may precipitate laryngospasm and stridor.

    Foreign body aspiration.Sudden stridor is characteristic in foreign body aspiration, a life-threatening situation. Related findings include an abrupt onset of dry, paroxysmal coughing; gagging or choking; hoarseness; tachycardia; wheezing; dyspnea; tachypnea; intercostal muscle retractions; diminished breath sounds; cyanosis; and shallow respirations. The patient typically appears anxious and distressed.

    Treatments.After prolonged intubation, the patient may exhibit laryngeal edema and stridor when the tube is removed. Aerosol therapy with epinephrine may reduce stridor. Reintubation may be necessary in some cases. Neck surgery, such as thyroidectomy, may cause laryngeal paralysis and stridor.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Wheezing [Sibilant rhonchi]: Medical causes
    (Nursing: Interpreting Signs and Symptoms)

    Anaphylaxis.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; profuse, watery rhinorrhea; chest or throat tightness; and dysphagia. Cardiac effects include arrhythmias and hypotension.

    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.

    Blast lung injury.Wheezing is a common symptom of blast lung injury, which is characterized by hypoxia and respiratory difficulty. The forceful blast wave that follows an explosive detonation can cause serious lung injury, including hemorrhage, contusion, edema, and tearing. In addition to wheezing, patients may exhibit chest pain, dyspnea, cyanosis, and hemoptysis. The diagnosis is confirmed by chest X-rays that show a classic “butterfly” pattern.

    Bronchial adenoma.Bronchial adenoma 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. 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 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.

    Emphysema.Mild to moderate wheezing may occur with emphysema. 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.

    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.

    Respiratory syncytial virus (RSV).Individuals infected with RSV commonly develop wheezing and other symptoms within 4 to 6 days of exposure to this virus. Healthy adults and children older than age 3 usually have mild cases of RSV and experience wheezing along with other common cold-like symptoms of runny nose, cough, and low-grade fever. In children ages 3 and younger, high-pitched expiratory wheezing can accompany a severe cough, rapid breathing, and high-grade fever.

    Tracheobronchitis.With 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.

    Other causes

    Foreign body aspiration. 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.

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    Wheezing - Case 1-1: 8-Month-Old Girl: I. Differential Diagnosis
    (Pediatric Complaints and Diagnostic Dilemmas)

    The causes of recurrent or persistent wheezing in the infant are diverse. Common causes of recurrent wheezing in infancy include bronchiolitis, reactive airways disease, and GER with microaspiration. Less commonly, recurrent wheezing is caused by congenital abnormalities of the lung or respiratory tract (cystic adenomatous malformations, TEF), diaphragmatic abnormalities (paralysis of the diaphragm, diaphragmatic hernia), cystic fibrosis, or immunologic defects (congenital absence of thymus, DiGeorge syndrome, chronic granulomatous disease, gammaglobulin deficiencies). Rarely, anomalies of the major arterial branches of the aorta or pulmonary blood vessels compress the trachea and bronchi of the infant, causing acute or progressive respiratory distress. The features of this case that prompted additional evaluation included recurrent episodes of wheezing, incomplete resolution of wheezing despite prolonged β-agonist therapy, and episodes of cyanosis.

    » READ BOOK EXCERPT ONLINE »

    Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

    Wheezing - Case 1-3: 5-Week-Old Boy: I. Differential Diagnosis
    (Pediatric Complaints and Diagnostic Dilemmas)

    In this 5-week-old boy with respiratory distress and lobar consolidation, the most likely diagnosis is bacterial pneumonia with pleural empyema. Etiologic organisms in this age group include group B Streptococcus, Listeria monocytogenes, and gram-negative enteric bacilli. The radiographic appearance of the lung may suggest a congenital lung malformation such as pulmonary sequestration, bronchogenic cyst, or cystic adenomatoid malformation. Infantile lobar emphysema is unlikely because the lung, despite causing a mediastinal shift, does not appear to be overinflated. Other congenital considerations include enterogenic cysts and CDH. Acquired causes include mediastinal neoplasm (e.g., neuroblastoma) and chronic pulmonary infection distal to an aspirated foreign body or an area of bronchiectasis. Chronic pulmonary infection may result in neovascularization of the infected tissue by ingrowth of systemic arteries. Such acquired systemic vascularization typically consists of several small arteries rather than one or two large arteries that typically supply a pulmonary sequestration. It may be impossible to make the distinction between true pulmonary sequestration and so-called pseudosequestration secondary to chronic infection preoperatively.

    » READ BOOK EXCERPT ONLINE »

    Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

    Wheezing - Case 1-4: 15-Month-Old Girl: I. Differential Diagnosis
    (Pediatric Complaints and Diagnostic Dilemmas)

    The most common cause of recurrent wheezing in a young infant is GER with pulmonary aspiration. Other causes of recurrent aspiration include cricopharyngeal incoordination, submucosal cleft palate, seizures, neuromuscular disorders, and TEF. Esophageal obstruction due to webs or strictures may also predispose to recurrent aspiration.
    Although bronchiolitis and poorly controlled reactive airways disease remain a consideration, the frequency of wheezing episodes and the recurrent pneumonia warrant further investigation. Cystic fibrosis should be excluded, particularly in light of the family history. The differential diagnosis also includes extrinsic obstructing lesions such as mediastinal lymphadenopathy, diaphragmatic hernia, and vascular ring. Intraluminal obstructing lesions can occur in this age group and include aspirated foreign body, bronchial papilloma or lipoma, and segmental bronchomalacia. The history of recurrent pneumonia may be a sign of underlying primary immunodeficiency —for example, an agammaglobulinemia, a dysgammaglobulinemia, or a phagocytic defect such as chronic granulomatous disease, which occasionally exhibits autosomal recessive inheritance. Infectious causes of recurrent or persistent pneumonia, such as Coxiella burnetii (Q fever), Histoplasma capsulatum, and Mycobacterium tuberculosis, are less likely in this age group.

    » READ BOOK EXCERPT ONLINE »

    Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

    Wheezing - Case 1-5: 5-Week-Old Boy: I. Differential Diagnosis
    (Pediatric Complaints and Diagnostic Dilemmas)

    In an infant with cyanosis and respiratory distress, bacterial or viral sepsis must be considered. Children with either viral bronchiolitis or pertussis may present with cyanosis, respiratory symptoms, and rapid deterioration. In this child, the history of periodic cyanosis with crying since birth provided a clue to the diagnosis. The differential diagnosis includes a large ventricular septal defect, patent ductus arteriosus, truncus arteriosus, atrioventricular canal, single ventricle without pulmonary stenosis, and total anomalous pulmonary venous connection (TAPVC). Except for TAPVC, these cardiac anomalies typically produce electrocardiographic evidence of left atrial or left ventricular hypertrophy. Children with TAPVC have right ventricular hypertrophy. The severity of illness warranted an echocardiogram, which provided the definitive diagnosis.

    » READ BOOK EXCERPT ONLINE »

    Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

    Wheezing - Case 1-6: 4-Month-Old Boy: I. Differential Diagnosis
    (Pediatric Complaints and Diagnostic Dilemmas)

    The most common cause of progressive respiratory distress during infancy is bronchiolitis, which is most often caused by respiratory syncytial virus; adenovirus; influenza viruses A and B; or parainfluenza viruses types 1, 2, and 3. The differential diagnosis of perihilar or diffuse infiltrates includes B. pertussis, C. trachomatis, and M. pneumoniae. Herpes simplex virus and cytomegalovirus (CMV) can cause pneumonia in the young infant. CMV pneumonia is frequently associated with hepatosplenomegaly, thrombocytopenia, and lymphocytosis. PCP should be considered, particularly if there are maternal risk factors for HIV infection. Other conditions predisposing to PCP include primary B-cell defects, primary T-cell defects, and combined defects. The immune disorders most likely to result in PCP are severe combined immunodeficiency, DiGeorge anomaly, Wiskott-Aldrich syndrome, X-linked agammaglobulinemia, and hyper-IgM syndrome.
    Noninfectious causes of pneumonia include GER associated with pulmonary aspiration. Occasionally, an anatomic defect such as TEF may predispose to aspiration. Primary cardiac abnormalities (e.g., ventricular septal defect), pulmonary vascular abnormalities, and impaired lymphatic flow (e.g., congenital lymphangiectasia) can cause tachypnea and progressive respiratory distress in a 4-month-old child. Cystic fibrosis can masquerade as any of these conditions.

    » READ BOOK EXCERPT ONLINE »

    Source: Pediatric Complaints and Diagnostic Dilemmas, 2003


     » Next page: Risk Factors for Wheezing

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