Stridor & Wheezing

Stridor & Wheezing: Excerpt from In a Page: Signs and Symptoms

Stridor is characterized by a high-pitched grating sound on inhalation or exhalation, but it is caused by narrowing or obstruction of the upper airway. Wheezing is a high-pitched musical sound on inhalation or exhalation that is due to oscillations of narrowed lower airway walls. The age of the patient is important in determining the specific etiology: Younger patients are much more likely than older patients to have symptoms of respiratory infections or a foreign body; older patients are more likely to suffer from pulmonary edema, COPD, and cancers.

Differential Diagnosis

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)

• 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)

• Aspirated foreign body
  –Abrupt onset of unilateral wheezing or stridor (if lodged in the upper airway), cough, and decreased breath sounds

Workup and Diagnosis

• History and physical examination
• Initial labs may include CBC with differential, pulse oximetry, electrolytes, BUN/creatinine, calcium, and glucose
• Consider blood and/or sputum cultures if infectious cause is suspected
• Chest X-ray helps to differentiate respiratory infection from pulmonary edema, diagnose radiopaque foreign bodies, and shows “steeple sign” in cases of croup
• Lateral neck X-ray may reveal swelling of the epiglottis in cases of epiglottitis or abscess
• Chest CT with contrast provides excellent views of the lung parenchyma and helps to identify tumors and bronchiectasis
• Bronchoscopy may be diagnostic and therapeutic in cases of obstruction due to foreign body
• Lung biopsy or bronchoalveolar lavage can be performed in cases of suspected malignancy
• Echocardiogram may be indicated to evaluate for structural heart disease, valve disease, and left ventricular function

Treatment

• Attention to airway, breathing, and circulation
• Administer supplemental O₂
• Asthma: Avoid triggers; bronchodilation with inhaled β ₂ agonists (e.g., albuterol) and anticholinergics (e.g., ipratropium); inhaled, oral and/or IV steroids
  • Epiglottitis: Emergent airway intervention (endotracheal intubation or tracheostomy); cephalosporin antibiotics
  • Respiratory infection: Appropriate antibiotics if bacterial cause is suspected; βagonists
  • Anaphylaxis: Patients in extremis require immediate subcutaneous epinephrine injection; antihistamines (e.g., diphenhydramine); inhaled β ₂ agonists (e.g., albuterol); steroids
• Croup: Supportive care; nebulized steroids; epinephrine

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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