All That Wheezes…

Andrew Lipton, MD, MPH&TM MAJ, USA, MC Chief, Pediatric Pulmonology San Antonio Military Pediatric Center

What is a “wheeze”

Definitions of obstructive noises

 Stertor • Low-pitched, rumbling • • • Inspiratory Nasopharynx, oropharynx, nasal passage Loudest over neck, cheeks

What is a “wheeze”

Definitions of obstructive noises

 Stridor • Harsh noise caused by turbulent flow • • • Inspiratory = larynx Expiratory = trachea Biphasic = fixed lesion in subglottic region

What is a “wheeze”

Definitions of obstructive noises

 Wheeze • Higher-pitched expiratory noise • Monophonic, homophonous = large airway = expiratory stridor • Polyphonic, heterophonous, musical = small airways

What is a “wheeze”

Definitions of obstructive noises

 Secretory Noise • Gurgling, polyphonic, upper or lower airway • Highly variable

-5 0 0 0 0 0 +5 -5 Pre-Inspiration

-1 -7 0 0 -1 -2 0 +5 -3 -7 Inspiration

-2 -7 0 0 -2 -2 0 +5 -3 -7 Inspiration

-8 0 0 0 0 0 +8 -8 End Inspiration

+5 +30 0 0 +5 +10 +20 +30 +38 0 +30 -10 Forced Expiration

+1 +30 0 0 +1 +5 +10 +30 +38 0 +30 -20 Forced Expiration

Stertor

Causes

 Choanal atresia    Mandibular hypoplasia Macroglossia Nasal congestion       Adenotonsillar hypertrophy Pharyngeal insufficiency Encephalocele Dermoid of base of tongue Thyroglossal duct cyst Lingual thyroid

Inspiratory Stridor

Causes

  Laryngomalacia Vocal cord paralysis • Unilateral – left (recurrent laryngeal nerve) • Bilateral – brainstem     Laryngotracheoesophageal cleft Laryngocele Laryngeal polyp Abscess  Hypotonia

Inspiratory Stridor

Laryngomalacia

      60% of insp. stridor 90% require no intervention Improves when prone Worsens with activity Worsens over first 1-6mos, then improves Watch for FTT, apnea, cyanosis

Inspiratory Stridor

Causes

 Laryngomalacia  Vocal cord paralysis • Unilateral – left (recurrent laryngeal nerve) • • Bilateral – brainstem Not positional      Laryngotracheoesophageal cleft Laryngocele Laryngeal polyp Abscess Hypotonia ? Maternal history

Biphasic Stridor

Causes

 Subglottic stenosis • Congenital • Acquired – intubation, croup    Subglottic hemangioma Laryngeal web GERD

Biphasic Stridor

Causes

 Croup – acute barky cough, stridor, resp. distress • • • • • • Low grade fever Rhinorrhea Worse at night 3mos-3yrs Parinfluenza 1-3, RSV, Influenza Fall/Winter

Biphasic Stridor

Causes

 Recurrent Croup • Consider underlying airway anomaly • • GERD Spasmodic (reactive airways)

Expiratory Stridor

Causes

   Tracheomalacia Bronchomalacia Vascular Ring/Sling      Complete Tracheal Ring Tracheoesophageal Fistula Bronchogenic Cyst Mediastinal Mass Foreign Body  GERD

Expiratory Stridor Causes

 Tracheobronchomalacia • • • • • Deficient cartilage rings Worse with exertion, agitation Prolonged expiratory phase Narrow trachea on expiratory lateral films Primary vs. Secondary  BPD, TEF, vascular anomalies

Wheezing

Causes

       Asthma Bronchiolitis Pneumonia GERD – inflammation, bronchospasm Heart Failure – often presents around 2 mos BPD Other: CF, Ciliary Dykinesia, Food Allergy

History

  Congenital or acquired Acute, Chronic, or intermittent   Positional?

Feeding – gag/choke/cough, suck, emesis, fatigue  Voice/cry quality

History

 FTT – increased WOB, poor feeding • >90% - think of GERD  Cyanosis  Apnea  Fever  Cough  Nocturnal Sxs

History

    Birth/Neonatal History Other anomalies: cardiac, hemangiomas, eczema, CHARGE, VACTERL, Arnold-Chiari, hypotonia, etc.

Family Hx – anomalies, CF, immunodeficiency, asthma, GERD, atopy Exposure – smoke, pollutants, irritants, Foreign body: toys, foods, older sibs

Exam

         Nose Pharynx, tonsils, tongue, face, mandible, palate Neck Cardiac Chest Respiration: • Pattern, rate,accessory muscle use, sounds, change with position, oxygenation Abdomen – hepatomegaly, masses Tone Skin – eczema, hemangiomas, cyanosis

Radiographs

      Lateral neck Chest PA/Lateral CT Head/Neck/Chest UGI, Videofluoroscopic swallowing study Airway fluoroscopy MRI/MRA – chest, brainstem

Other Studies

       Bronchoscopy • Flexible • Rigid Laryngoscopy Polysomnography (sleep study) Echocardiography Infant PFTs pH Probe, scan ABG

Other Studies

      Allergy testing Immunoglobulins CBC ABG Sweat Cl Ciliary Bx