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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
Differential Diagnosis
Common conditions
Bronchiolitis
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
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
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
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
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
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?
CHF
Chemical pneumonitis
Anaphylaxis
Physical Examination
Distinguish wheeze from other noisy
breathing
Stridor
Stertor
Rhonchi
Crackles
Diagnostic Tests
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