Wheezing [Sibilant rhonchi]

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

Wheezes are adventitious breath sounds with a high-pitched, musical, squealing, creaking, or groaning quality. 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. In airway obstruction, wheezing occurs during inspiration.

Emergency interventions

Help the patient 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 and physical examination

If the patient isn’t in respiratory distress, obtain a history. What provokes his wheezing? Does he have asthma or allergies? Does he smoke or have a history of a pulmonary, cardiac, or circulatory disorder? Does he have cancer? Ask about recent surgery, illness, or trauma and recent changes in appetite, weight, exercise tolerance, or sleep patterns. Obtain a drug history. Ask about exposure to toxic fumes or any respiratory irritants. If he has a cough, ask how it sounds, when it starts, and how often it occurs. Does he have paroxysms of coughing? Is his cough dry, sputum producing, or bloody?

Ask the patient about chest pain. If he reports pain, determine its quality, onset, duration, intensity, and radiation. Does it increase with breathing, coughing, or certain positions?

Examine the patient’s nose and mouth for congestion, drainage, or signs of infection such as halitosis. If he produces sputum, obtain a specimen 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 766.) Percuss for dullness or hyperresonance, and auscultate for crackles, rhonchi, or pleural friction rub. Note absent or hypoactive breath sounds, abnormal heart sounds, gallops, or murmurs. Also note arrhythmias, bradycardia, or tachycardia. (See Evaluating breath sounds. See also Differential diagnosis: Wheezing, pages 826 and 827.)

Medical causes

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.

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 an 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: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

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