Wheezing From PCO

7/26/2019 Wheezing From PCO

1/23

Wheezing

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Definition / Supporting InformationWheezing is a whistling sound that occurs as a result of bronchospasm (airwayconstriction). It is usually more prominent during expiration but may also be present ininspiration.

Essential HistoryAsk about:

Age at onset

Frequency of wheezing

Intermittent or constant wheezing

ecent upper respiratory tract illness

Fe!er

Association with !igorous acti!ity" changing weather" exposure to allergens

Acute onset

Accompanying coughing" cho#ing


2/23

Frequent !omiting

$ositional wheezing

Worsening with agitation or crying

%ifficulty in swallowing

Allergies" anaphylaxis

Faltering growth (re!iew &ed 'oo#& charts)

aemoptysis

ecent surgical procedure intubation

$oor response to con!entional therapy

Family history of wheeze and or cystic fibrosis

*ight time symptoms


3/23

+mo#ing in the house

%amp and or mould in the house

'Red Flag' Symptoms and SignsAsk about:

Allergies especially to food animals and specifically about pre!ious anaphylacticreactions

$oor feeding and respiratory distress in acute wheeze

Faltering growth in chronic wheeze

'reathlessness

,oo breathless to spea# full sentences-

$anic anxiety

Is the patient frightened-


4/23

$re!ious admissions

$re!ious admission to intensi!e care unit

$re!ious need for intra!enous therapies to support respiration

$re!ious intubation" e!en as a neonate (thin# of subglottic stenosis)

Look for:

+igns of respiratory distress

,achypnoea

ecessions

%ecreased or absent breath sounds &silent chest&

/nilateral wheezing

0ost often associated with aspiration of a foreign body

Differential Diagnosis / Conditions


5/23

1iral bronchiolitis" !iral lower respiratory tract infections and asthma account for mostwheezing

Wheezing after a recent surgical procedure or intubation suggests acquiredobstruction

2xpiratory wheeze can result from3

4arge airway obstruction (ie" trachea or mainstem bronchi) or

$eripheral small airway obstruction (ie" asthma)

$resence or absence of expiratory wheeze does not reliably indicate location of

obstruction

Asthma

Worse with exercise or respiratory infections

5ther triggers include3


6/23

o

6ontact with animals

o

+tress or emotional disturbances

o

Weather conditions

esponds to bronchodilators and steroids

e!ersible obstruction on pulmonary function testing

$olyphonic musical expiratory wheeze

Family history

,racheomalacia

Worse with acti!ity or agitation

$oor response to bronchodilators and steroids

0onophonic usually inspiratory noise


7/23

Inspiratory airway collapse

o

%etectable by fluoroscopy

6ollapsing trachea on inspiration

o

%etectable by bronchoscopy

'ronchomalacia

Worse with acti!ity or agitation

$oor response to bronchodilators and steroids

0onophonic usually inspiratory noise

Airway collapse

o


8/23

%etectable by fluoroscopy

6ollapsing bronchus

o

%etectable by bronchoscopy

Foreign body

+udden onset

0ay be associated with history of cho#ing

0any patients with foreign body aspiration do not ha!e an ob!ious history ofcho#ing

o

6ho#ing should be suspected e!en in a child whose wheezing has been presentfor days or wee#s

%ifferential breath sounds

%ifferential hyperinflation or collapse on radiography


9/23

eart failure or pulmonary oedema

$oor response to salbutamol

$oor growth

epatomegaly

adiography showing enlarged heart and or pulmonary oedema (increased fluid)

esponds to diuresis

'ronchiolitis

Infant

o

/pper respiratory tract infection symptoms

0ost usual pattern3
http://www.pcouk.org/drug.aspx?gbosId=200278http://www.pcouk.org/drug.aspx?gbosId=200278


10/23

o

2xpiratory wheeze

o

Inspiratory and expiratory crac#les

$ositi!e !iral studies

Wheezing caused by !iral bronchiolitis3

Is usually preceded by upper respiratory tract symptoms and fe!er

Worsens within the first few days of onset

,ends to impro!e slowly thereafter

1ocal cord dysfunction (see +tridor)

0ore common in older children

$oor response to all bronchodilators


11/23

0ay ha!e inspiratory as well as expiratory component

%istress may be se!ere

$ulmonary function tests may be normal" may ha!e reduced pea# expiratory flowrate ($2F) and with abnormal inspiratory loop

5xygen saturation in air usually normal

4aryngoscopy shows paradoxical !ocal cord adduction during inspiration

6ystic fibrosis

$oor growth" gastrointestinal (7I) symptoms

ecurrent pneumonia

Frequent fruity moist cough

$ositi!e sweat test


12/23

0ay be finger clubbing

7astro8oesophageal reflux and aspiration

istory of frequent !omiting

1ariable response to bronchodilators

5ften worse after meals

$oor growth" 7I symptoms

ecurrent pneumonia

6onfirmation of reflux by upper 7I endoscopy" nuclear scan" or p probe

$ulmonary haemosiderosis

are disorder causing anaemia and recurrent wheezing from blood irritating theperipheral airways


13/23

0ay present with haemoptysis or in association with iron deficiency anaemia

1ascular abnormalities or compression

0ay be inspiratory as well as expiratory noise

5ften present from birth or soon after birth

*o bronchodilator response

5esophageal indentation on barium swallow

6hest 98ray may show right8sided aortic arch

Anatomy shown on thoracic magnetic resonance imaging

Abnormality (eg" stenosis" complete rings" compression) of large airways3

*o response to therapy

Worse with acti!ity


14/23

+tridor noted at times

Flattened or square flow!olume loop

5bstruction !isible on imaging or bronchoscopy

6ongenital airway abnormalities

Wheezing that appears at birth or soon afterward should prompt an e!aluation for3

o

,racheomalacia

o

6omplete tracheal rings

Investigations,o be underta#en by non8specialist practitioners (eg" 7eneral $ractitioner (7$) ,eam)3

0easure !ital signs including oxygen saturation" $2F

*asopharyngeal aspirate in younger children (below : years of age) for !iral studies(if a!ailable)


15/23

6hest 98ray

,horacic masses

Foreign body aspiration

,o be underta#en by specialist practitioners (eg" 2mergency %epartment $aediatric $aediatric espiratory ,eam(s))3

4aboratory testing may be indicated to diagnose specific clinical entities

+weat test for cystic fibrosis

1iral studies can identify respiratory syncytial !irus or influenza

Airway fluoroscopy

6an confirm diagnosis and help to quantify the se!erity of tracheobronchomalacia

'arium swallow or upper 7I series


16/23

/seful if a !ascular abnormality is suspected

6omputed tomography or magnetic resonance imaging

6onfirmation of !ascular abnormality or other intrathoracic lesions

%iagnostic procedures

$ulmonary function testing (spirometry) can help to3

o

5btain ob;ecti!e data on wheezing in patients aged < years and older

o

%istinguish re!ersible airways disease from fixed obstruction

o

%istinguish small airway from large airway obstruction

Flexible bronchoscopy3


17/23

o

7i!es !isualisation of airways

o

/sually in!ol!es a general anaesthetic

o

/seful to characterise dynamic lesions (ie" tracheobronchomalacia)

igid bronchoscopy

o

6an be useful in diagnosis and treatment of3

+uspected inhaled foreign body

arer conditions such as tracheal stenosis

reatment !pproa"hIn general" when e!aluating and managing the wheezy child3

'e aware of the !arious clinical entities that can produce wheezing

'e able to recognise by history or physical examination patients who require furtherin!estigation or inter!ention (see Anaphylaxis and +tridor)


18/23

,o be underta#en by non8specialist practitioners (eg" 7$ ,eam)3

For acute management of wheeze in asthma and !iral induced wheeze see 'ritish

guideline on the management of asthma = +I7* clinical guideline >?>@.

Asthma

+albutamol> microgrammetered inhalation3 ?B puffs !ia a spacer de!ice" e!ery

? hours as needed. 7i!e up to > puffs in mild to moderate acute asthma

5ral prednisolone>8: mg#g (max. ? mg) once daily for three days

1iral bronchiolitis

Inhaled beta : agonist bronchodilators" ipratorium bromide" adrenaline" hypertonicsaline are not recommended for the treatment of acute bronchiolitis in infants('ronchiolitis in children = +I7* clinical guideline C>" +ection B.D.>@and = *I62clinical guideline *7C" +ection >.?@).

+ome children require hospital admission for3

+e!ere respiratory distress
https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/http://www.pcouk.org/drug.aspx?gbosId=200278http://www.pcouk.org/drug.aspx?gbosId=200586http://www.sign.ac.uk/pdf/sign91.pdfhttp://www.sign.ac.uk/pdf/sign91.pdfhttp://www.nice.org.uk/guidance/NG9/chapter/1-recommendations#management-of-bronchiolitishttp://www.nice.org.uk/guidance/NG9/chapter/1-recommendations#management-of-bronchiolitishttps://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/http://www.pcouk.org/drug.aspx?gbosId=200278http://www.pcouk.org/drug.aspx?gbosId=200586http://www.sign.ac.uk/pdf/sign91.pdfhttp://www.nice.org.uk/guidance/NG9/chapter/1-recommendations#management-of-bronchiolitishttp://www.nice.org.uk/guidance/NG9/chapter/1-recommendations#management-of-bronchiolitis


19/23

ypoxaemia

$oor feeding

%ehydration

,o be underta#en by specialist practitioners (eg" 2mergency %epartment $aediatric $aediatric espiratory ,eam(s))3

For the acute management of asthma and !iral wheeze see 'ritish guideline on themanagement of asthma = +I7* clinical guideline >?>@.

+albutamol!ia an inhaler de!ice

Ipratropium bromide

5ral prednisolone

5xygen to #eep saturations E C:

,reatment of other causes of wheeze depends on the underlying cause.

When to Referefer to specialist practitioners (eg" 2mergency %epartment $aediatric $aediatricespiratory ,eam(s)) if3
https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/http://www.pcouk.org/drug.aspx?gbosId=200278http://www.pcouk.org/drug.aspx?gbosId=200987http://www.pcouk.org/drug.aspx?gbosId=200586https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/http://www.pcouk.org/drug.aspx?gbosId=200278http://www.pcouk.org/drug.aspx?gbosId=200987http://www.pcouk.org/drug.aspx?gbosId=200586


20/23

Acute wheeze

espiratory distress unresponsi!e to inhaled salbutamol

ypoxaemia

,achypnoea interfering with ability to eat or drin#

Altered mental status or signs of fatigue

efer children with unusual presentations or poor response to con!entional therapiesto appropriate subspecialty physicians

$resence of finger clubbing

$resence of arrison&s sulcus (horizontal groo!e along lower end of rib cage)3

o

0ay represent exaggerated suction of diaphragm on inspiration

o
http://www.pcouk.org/drug.aspx?gbosId=200278http://www.pcouk.org/drug.aspx?gbosId=200278


21/23

+uggests longstanding problem

$ersistent or recurrent wheezing in an infant G > year

Apparent paradoxical response to bronchodilators

$oor weight gain or growth associated with chronic or recurrent wheezing

epeated hospital admission or multiple courses of oral corticosteroid

$ersistent asymmetrical wheezing

'Safety #etting' !dvi"e+ee 'ritish guideline on the management of asthma = +I7* clinical guideline >?>"+ection H.H.:@.

$arents carers should see# urgent medical attention3

If an acute asthma attac# occurs in a child at home and

+ymptoms are not controlled by up to > puffs of +albutamol!ia pressurisedmetered dose inhaler and spacer

$atient / Carer Information
https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/http://www.pcouk.org/drug.aspx?gbosId=200278https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/http://www.pcouk.org/drug.aspx?gbosId=200278


22/23

*Please note: whilst these resources have been developed to a high standardthey may not be specific tochildren.

Asthma(Web page)" *+ 6hoices

'ronchiolitis(Web page)" *+ 6hoices

Wheeze(Web page)" $atient.co.u#

Resour"esNational Clinical Guidance

'ritish guideline on the management of asthma(pdf)" +I7* clinical guideline >?>"+cottish Intercollegiate 7uidelines *etwor#.

'ronchiolitis in children(Web page)" +I7* clinical guideline C>" +cottish Intercollegiate7uidelines *etwor#.

'ronchiolitis in children(Web page)" *I62 clinical guideline *7C" *ational Institute forealth and 6are 2xcellence.

Asthma(Web page)" *I62 quality standard +:D>" *ational Institute for ealthand 6are 2xcellence.

Inhaled corticosteroids for the treatment of chronic asthma in children aged >: yearsand o!er(Web page)" *I62 technology appraisal ,A>DH" *ational Institute for ealthand 6are 2xcellence.

!"%no&ledgementsContent Editor: %r +rini 'andi

Clinical Expert Reviewer: %r +imon 4angton ewer

GP Reviewer: %r Kanice Allister
http://www.nhs.uk/conditions/asthma/Pages/Introduction.aspx#closehttp://www.nhs.uk/Conditions/Bronchiolitis/Pages/Introduction.aspxhttp://patient.info/health/wheezehttp://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/http://www.sign.ac.uk/guidelines/fulltext/91/http://www.nice.org.uk/guidance/NG9/chapter/1-recommendationshttp://www.nice.org.uk/guidance/qs25http://www.nice.org.uk/guidance/ta278http://www.nice.org.uk/guidance/ta131http://www.nice.org.uk/guidance/ta131http://www.nice.org.uk/guidance/ta138http://www.nice.org.uk/guidance/ta138http://www.nhs.uk/conditions/asthma/Pages/Introduction.aspx#closehttp://www.nhs.uk/Conditions/Bronchiolitis/Pages/Introduction.aspxhttp://patient.info/health/wheezehttp://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/http://www.sign.ac.uk/guidelines/fulltext/91/http://www.nice.org.uk/guidance/NG9/chapter/1-recommendationshttp://www.nice.org.uk/guidance/qs25http://www.nice.org.uk/guidance/ta278http://www.nice.org.uk/guidance/ta131http://www.nice.org.uk/guidance/ta131http://www.nice.org.uk/guidance/ta138http://www.nice.org.uk/guidance/ta138


23/23

AAP Reviewer: %r Lelly K Lelleher

Paediatric Trainee Reviewer 3 %r Ahtzaz assan

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Wheezing From PCO