the

^
h

Adam Vukovic
PEM Fellow
Resident Lecture Series,
1/24/13

W(h)eezers
A little epidemiology (only a
little)
Most common bronchiolitis & asthma
20% of infants < 1 yo will wheeze once
50% of children < 6 yo will wheeze once
< 15% of children will develop asthma

W(h)eezers
Pathophysiology
Common denominator?
Obstruction to air flow
Typically at bronchiolar level
Can be tracheal/bronchial, but less common

Can be anatomic or physiologic

Can be intrinsic narrowing or compression
Intrinsic airway constriction, inflammation
and/or luminal blockage; think predominantly
expiratory
Extrinsic think inspiratory and expiratory

Differential Diagnosis
Common conditions
Bronchiolitis

RSV*, HMPV, parainfluenza, adeno, flu, corona, rhino

Epidemics between November & March
Think 2-12 mos, but can see in 2-3 yo
Older children/adults usually are URI Sx, but can
wheeze, too
Why wheeze?
Proliferation of cells & submucosal edema obstruction

Accompanied with staccato-like cough & variable degree

of RD; rhinorrhea; variable fever
Factors influencing maternal smoking, prematurity,
CHD, RAD

Differential Diagnosis
Common Conditions
Asthma
Chronic inflammatory condition recurrent
obstruction
Cough and/or wheeze
Attacks allergens, resp. infection, irritants
Atopic kiddos
Think in FHx
Typically dont diagnose before age 2, though most
asthmatics have wheezed before then
Why?
60% of wheezers < 3 yo will not wheeze by grade school

Differential Diagnosis
Less Common Conditions
Viral/Bacterial Pneumonia
Most common?
Viral RSV, HMPV, paraflu, flu, adeno
Bacterial Strep. Pneumoniae, M. pneumoniae, C.
pneumoniae, GAS, and Staph. aureus

Differential Diagnosis
Less Common Conditions
Pulmonary aspiration
Think abrupt onset associated with
cough/gag/choke
Think toddler, although anyone can
aspirate
Aspiration event may be unwitnessed
Can go unrecognized

Think with persistent symptoms despite

presumably appropriate treatment
CXR might show post-obstructive
collapse/consolidation

Differential Diagnosis
Less Common Conditions
Recurrent Aspiration of Food/Gastric
Contents

Typically < 1 yo
Think developmental delay or NMD
Think GERD or esophageal motility
Think structural anomaly
May develop wheezing/RD in absence of choking
Think microaspiration or silent aspiration

Often can develop fever

Chemical inflammation
Infection of tracheobronchial tree

Differential Diagnosis
Less Common Conditions
Allergic Reaction/Anaphylaxis
Usually after an exposure
W/ wheezing alone, think allergic if a/w
Hymenoptera envenomation, medication or food
ingestion

A/w urticaria, angioedema, stridor &

hypotension

Differential Diagnosis
Less Common Conditions
BPD/CLD
H/o prematurity, ventilatory support, O2
dependence
Chronic respiratory patterns that develop in
neonatal period
Often described as COPD of childhood
Varied degrees of structural damage and
airway inflammation
May show gradual improvement through
childhood
Varied degree of bronchial hyperactivity &
wheeze

Differential Diagnosis
Rare Conditions
Cardiovascular Anomalies
Why the wheeze?
Small airway edema 2/2 CHF or airway
impingement from enlarged cardiovascular
structures

Typically have associated symptoms

Cyanosis, murmur, pulse changes, perfusion
Exception?
Congenital vascular ring though may have
esophageal issues related to compression

Differential Diagnosis
Rare Conditions
Cystic Fibrosis
Respiratory stuff
H/o steatorrhea & FTT secondary to
pancreatic insufficiency and malabsorption
NBS isnt 100% sensitive

Kartageners Syndrome
Immotile cilia syndrome
Repeated sinusitis/OM
A/w situs inversus and bronchiectasis

Differential Diagnosis
Rare Conditions
Pulmonary Edema

Cardiovascular/CHF
Pneumonia
ARDS
Hypoalbuminemia (nephrotic syndrome &
liver failure)
Hydrocarbon aspiration

Differential Diagnosis
Rare Conditions
Extrinsic tracheobronchial compression
Enlarged LN or tumor think leukemia, lymphoma, histo,
sarcoid, TB, or fungal infections
Tumors neuroblastoma, pheochromocytoma,
ganglioneuromia, thymoma, teratoma, or thyroid
carcinoma

Congenital structura anomalies

Bronchogenic cyst, CPAM, congenital lobar emphysema,
intrinsic stenosis, & webs
Neonatal period
Larnygeal stridor & croupy cough
Bronchial wheezing & recurrent PNA
Sx exacerbated with crying/activity or respiratory infection

Differential Diagnosis
Rare Conditions
Psychogenic Wheeze

Think in child/adolescent
Moderate to severe respiratory distress
Unresponsive to inhaled B-agonist
Wheezing noises generated from larynx
Start asking yourself why?

Wang, V. J. (2010). Wheezing. In G. R. Fleisher & S. Ludwig (Eds.),

Textbook of Pediatric Emergency Medicine (635-642). Philadelphia, PA:
Lippincott Williams, Inc.

Evaluation & Decision

What are my life threats?
Was it acute?
Has this happened before?
FHx or personal Hx of asthma?
Life-threatening Causes of
URI Sx?
Wheeze
Choking spell?
Asthma
Bronchiolitis
Cyanotic
Foreign-body aspiration
Pulmonary Hemorrhage
Cardiac Hx or FTT?
Mediastinal tumor

CHF
Chemical pneumonitis
Anaphylaxis

Physical Examination
Distinguish wheeze from other noisy
breathing
Stridor
Stertor
Rhonchi
Crackles

Also, think about listening to the neck

in the B-unresponsive patient could
be a laryngeal source of wheeze

Diagnostic Tests

What do you think is most important?

Pulse oximetry
Consider ETCO2
CXR?
What views?

RSV?
EKG?
Four-point BPs?

Approach
Should be guided by degree of
respiratory distress
Supportive measures while sorting out
source of wheeze
Supplemental O2
AAP recommendations suggest that in
bronchiolitis, 90% or above is acceptable

Bronchodilator if suspect reversible

obstruction

Wang, V. J. (2010). Wheezing. In G. R. Fleisher & S. Ludwig (Eds.),

Textbook of Pediatric Emergency Medicine (635-642). Philadelphia, PA:

Wang, V. J. (2010). Wheezing. In G. R. Fleisher & S. Ludwig (Eds.),

Textbook of Pediatric Emergency Medicine (635-642). Philadelphia, PA: