Wheezing in Children
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Transcript Wheezing in Children
Wheezing in
Children
Mona Massoud, MD
Emory University School of Medicine
Family Medicine Residency
9/22/11
Introduction
Common presenting symptom of respiratory
disease in children
Could benign and self limiting or presenting
symptom of significant respiratory disease
Common problems presented to PCP
Incidence
25-30% of infants will have one episode of
wheezing.
By six years of age approximately half of
children will have had at least one episode of
wheezing
Overview
Wheezing: Continuous coarse whistling
sound produced by oscillation of narrowed or
compressed respiratory airway. Inspiratory or
expiratory/ High or low pitched.
Crackles (rales): Popping sound created
when air is forced through respiratory
passages.
Stridor: high-pitched harsh sound heard
during inspiration, due to obstruction of upper
airway.
Wheezing type in childhood
Transient wheezer: One episode or few
episodes of wheezing. No further episodes
beyond 6 years.
Non-atopic wheezer: Wheeze during viral
infections and continue to have recurrent
airway obstruction during early school years.
IgE associated wheeze/asthma: Start to have
symptoms later in life which continues into
adulthood.
Wheezing Type in Childhood
Why do Children tend to wheeze more
than Adults?
Children have smaller airway passages,
therefore higher resistance
Less chest compliance
Elastic tissue recoil is lower than adults and
fewer collateral airways-prone to obstruction
and atelectasis
Differential Diagnosis
Acute
Asthma
Bronchitis
Bronchiolitis
Laryngeotracheobronchitis (Croup)
Bacterial Tracheitis
FB aspiration
Esophageal FB
Chronic or Recurrent Causes
Asthma
GERD
Retained foreign body
Cystic Fibrosis
Recurrent Aspiration
Primary ciliary dyskinesia
ILD
Immunodeficiency
Structural Causes:
Tracheo-bronchomalacia
Vascular rings
Tracheal web
Cystic lesions/lymphadenopathy/mediastinal masses
Asthma
Affects approximately 5 million children in US
Chronic and reversible inflammatory disorder
that produces airway hyper-responsiveness,
airway inflammation and airflow limitation.
Immediate and delayed inflammatory
response
Classification of Asthma
Asthma Control assessment
Bronchiolitis
Children less than 2 yo, usually 3-6 m
Viruses-RSV (most common), adenovirus,
influenza or parainfluenza
Fall and winter months
Begins as mild URI which can progress to
increase respiratory distress
Rx:
Supportive therapy
Ribavirin in extremely ill children
Croup vs Epiglottitis
Approach to a wheezing child
Clinical History:
Wheeze description from parents
Snoring, snoring, rattling or gargling noises
Patient age at onset of wheeze
Distinguishes congenital vs non-congenital
Course: acute vs gradual
Acute onset- FB aspiration
Cont’d Q’s
Pattern of wheezing?
Episodic: asthma
Persistent: congenital
Response to bronchodilators?
Improvement: Asthma
Is Wheezing associated with multiple
respiratory illnesses?
Cystic fibrosis and Immunodeficiency diseases
Cont’d Q’s
Wheeze associated with feeding?
GERD
Wheeze associated with cough?
GERD, asthma, allergies
Change in position? Worsening or
improvement
Tracheomalacia
Family hx of asthma?
Features that favors diagnosis of
Asthma
Intermittent episodes of asthma
Presence of a trigger
URI
Allergens
Exercise
Seasonal variation
Family hx of asthma and/or atopy
Response to bronchodilators
Clinical features that suggest a
diagnosis other than asthma:
Hx of wheezing since birth or neonatal
respiratory problems.
Hx of choking associated with SOB and
coughing.
Symptoms that change with position.
Poor weight gain and recurrent infections.
Hx of progressive dyspnea, tachypnea,
exercise intolerance.
Poor response to broncholdilators.
Physical Examination
Vital signs including Sa02 %
Inspection:
Respiratory distress/ tachypnea/ cyanosis
Retractions or structural abnormalities (increased
AP diameter, pectus excavatum, scoliosis)
HENT: allergic shiners/nasal polyps
Skin: eczema
Cont’d PE
Palpation: chest wall asymmetry with expansion,
tracheal deviation or supratracheal lymphadenopathy
Percussion: difference in vocal resonance and define
position of diaphragm
Auscultation:
Location of wheeze
Character of wheeze
Other breath sounds associated with wheeze
Cardiac: presence of murmur or gallops
Diagnostic Evaluation
CXR: AP and lateral views
Children with new onset wheezing of
undetermined etiology
Chronic persistent wheezing not responding to
treatment
Lateral decubitus views: FB aspiration
Chest radiography is not performed with
every asthma exacerbation unless there is a
specific indication
CXR findings:
Hyperinflation:
Generalized: suggests diffuse air trapping
Asthma/ Cystic fibrosis/ Primary ciliary dyskinesia
Localized hyperinflation:
Structural abnormalities/ FB aspiration
Other findings: atelectasis, bronchiectasis,
mediastinal masses, enlarged LN’s,
cardiomegaly, enlarged pulmonary vessels or
pulmonary edema.
Status Asthmaticus
Croup (Steeple Sign):
FB aspiration
FB occludes middle
lobe bronchus
Atelectasis of Rt middle
lobe
Hyperinflation of upper
and lower lobes
Other radiological studies:
Chest CT scan:
Mediastinal masses or LN’s
Vascular anomalies
Bronchiectasis
Barium Swallow:
GERD
TEF
Vascular rings
Swallowing dysfunction
Vascular ring
TEF
Pulmonary Function Tests (PFT’s)
Airway obstruction assessment
PFT’s with inspiratory and expiratory flow-
volume loops is is important in determining
the degree, location of airway obstruction in
addition to response to bronchodilators.
Response to Treatment
Trial of inhaled bronchodilators
Improvement: reversible airway disease
Partial or negative response: asthma or other
causes
Combination of inhaled CST
+bronchodilators: if asthma is suspected in a
patient with chronic or persistent symptoms
Bronchodilator response
Other Investigations
Sweat Chloride Test: Cystic fibrosis screening
in children with chronic lung problems, failure
to thrive and diarrhea
Immunoglobulin levels: Screen for
immunodeficiencies.
Rapid antigen testing, viral cultures, sputum
gram stain and culture. PPD in suspected
cases.
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References
http://www.aafp.org
http://www.uptodate.com/contents
http://emedicine.medscape.com
http://www.essentialevidenceplus.com
http://www.acaai.org/patients/resources/asthma/Docu
ments/AZnhlbiGuidelines
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001
970/
http://www.medcyclopaedia.com/library/radiology
http://pediatrics.aappublications.org/content/123/3/e5
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