II. Pathophysiology

  1. Airway wall fluttering results from flow limitation
  2. Expiration typically occurs passively with elastic recoil of the chest wall
    1. Obstruction to outflow requires active expulsion of air
    2. Resulting positive intrapleural pressure worsens the obstruction
  3. Wheezing is more common in children than adults
    1. Inflammation of a child's smaller Bronchi has a greater impact on airway resistance
    2. Obstruction is more likely in a child's airway due to less chest elastic recoil
    3. A child's compliant airway walls collapse more easily under negative pressure

III. Causes: Infants

  1. Acute
    1. RSV or other Bronchiolitis (most common cause in infants)
    2. Asthma Exacerbation
    3. Other respiratory infection (Acute Bronchitis, Pneumonia)
    4. Foreign Body Aspiration (uncommon under age 1 year)
  2. Chronic or Recurrent: Common
    1. Asthma
    2. Gastroesophageal Reflux
  3. Chronic or Recurrent: Uncommon or Rare
    1. Aspiration Pneumonitis
    2. Bronchopulmonary Dysplasia
    3. Congenital Lobar Emphysema
    4. Congestive Heart Failure
    5. Cystic Fibrosis
    6. Diaphragmatic Hernia
    7. Extrinsic compression by tumor (Neuroblastoma)
    8. Hemosiderosis
    9. Tracheal Stenosis
    10. Tracheomalacia
    11. Tracheoesophageal Fistula
    12. Vascular Ring
    13. Visceral larval migrans

IV. Causes: Children and Adolescents

  1. Acute
    1. Asthma Exacerbation (most common cause in children)
    2. RSV or other Bronchiolitis
    3. Acute Bronchitis
    4. Pneumonia
    5. Foreign Body Aspiration
  2. Chronic or Recurrent: Common
    1. Asthma
    2. Allergic Rhinitis
    3. Gastroesophageal Reflux disease
    4. Obstructive Sleep Apnea (adenoid hypertrophy, also with craniofacial abnormalities)
  3. Chronic or Recurrent: Uncommon or rare
    1. a1-antitrypsin Deficiency
    2. Aspergillosis
    3. Cystic Fibrosis
    4. Ciliary Dysmotility Syndrome
    5. Sarcoidosis
    6. Tumors or Lymph node compression
    7. Vocal Cord Dysfunction

V. History

  1. Onset
    1. Onset as an infant: Congenital cause
    2. Sudden onset: Foreign Body Aspiration
    3. Winter onset with upper respiratory symptoms and with cluster of cases
      1. Respiratory Syncytial Virus (fall to spring)
      2. Croup (fall and winter)
      3. Human Metapneumovirus (winter to spring)
  2. Pattern
    1. Seasonal pattern
      1. Asthma
      2. Allergic Rhinitis
    2. Persistent or recurrent respiratory illnesses with Wheezing
      1. Cystic Fibrosis
      2. Bronchopulmonary Dysplasia
      3. Laryngomalacia
      4. Immunodeficiency (e.g. Primary ciliary Dyskinesia, Agammaglobulinemia)
    3. Associated cough
      1. Cough After feeding: Gastroesophageal Reflux
      2. Dry, nighttime cough
        1. Gastroesophageal Reflux
        2. Allergic Rhinitis
        3. Asthma
        4. Obstructive Sleep Apnea
  3. Modifying Factors
    1. Wheezing after feeding
      1. Gastroesophageal Reflux (most common)
      2. Tracheoesophageal fistula
      3. Laryngeal cleft
    2. Positional change
      1. Tracheomalacia
      2. Great Vessel anomalies

VI. Signs

  1. General: Signs of chronic systemic illness (e.g. Cystic Fibrosis, Immunodeficiency)
    1. Observe for ill, wan, tired appearance
    2. Review growth charts for fall in Growth Velocity
  2. Wheezing Intensity
    1. Wheezing in infant heard without stethoscope suggests Congenital Anomaly
  3. Wheezing Modifying maneuvers
    1. Worse with neck flexion and better with extension suggests Vascular Ring
  4. Severity: Asseess for outpatient versus inpatient management
    1. Observe for critical or ominous signs
      1. Altered Mental Status
      2. Diaphoresis
    2. Observe for respiratory distress
      1. Neck or intercostal retractions
      2. Tachypnea
      3. Grunting (auto-PEEP)

VII. Evaluation

  1. Full Vital Signs including Oxygen Saturation, Respiratory Rate and Peak Flows (if possible)
    1. V-Q Mismatch in Asthma or Bronchiolitis is typically mild to moderate
    2. Severe V-Q Mismatch with significant Hypoxemia (O2 Sat <90%) suggests other underlying cause
      1. Example: Pneumonia
  2. Consider specific testing or empiric therapy in common conditions
    1. Asthma (e.g. Spirometry)
    2. Allergic Rhinitis (e.g. Allergy Testing)
    3. Gastroesophageal Reflux (e.g. barium swallow)
  3. Consider testing for uncommon conditions
    1. Cystic Fibrosis (e.g. Sweat Chloride)
    2. Immunodeficiency (e.g. Serum Immunoglobulins)

VIII. Imaging: Chest XRay

  1. Consider inspiratory and expiratory films (detects airway foreign bodies)

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Ontology: Wheezing (C0043144)

Definition (NCI) A symptom and a finding during physical examination, characterized by a high-pitched, whistling sound during breathing. It results from the narrowing or obstruction of the respiratory airways. The most common causes of wheezing are asthma, chronic obstructive pulmonary disease, tracheobronchitis, and pulmonary edema.
Definition (NCI_CTCAE) A disorder characterized by a high-pitched, whistling sound during breathing. It results from the narrowing or obstruction of the respiratory airways.
Concepts Sign or Symptom (T184)
MSH D012135
ICD9 786.07
ICD10 R06.2
SnomedCT 207058001, 139199004, 161944004, 158380003, 56018004
LNC MTHU013532
English Wheezings, WHEEZES, [D]Wheezing, [D]Wheezing (context-dependent category), wheezing [as a symptom], reported wheezing, wheezing, reported wheezing (symptom), Wheezes, wheezes, wheezy, wheeze, [D]Wheezing (situation), Wheeze, Wheezy, Wheezing (finding), Wheezing, NOS, Wheezing
Italian Sibilo, Sibilante, Sibili
Dutch gepiep, piept, piepend, Piepende ademhaling, Wheezing, piepen, Piepen
French Présentant une respiration sifflante, Sifflements, Wheezing, SIBILANCE, Sibilances, Respiration sifflante
German pfeifendes Atmen, pfeifende Atemgeraeusche, pfeifend, Giemen, KEUCHEN, Ziehende Atmung
Portuguese Sibilo, Sibilos, Sibilante, Chiado, PIEIRA, Síbilo
Spanish Sibilante, Pitidos, [D]sibilancias (categoría dependiente del contexto), SIBILANTES, Sibilancias, [D]sibilancias (situación), [D]sibilancias, sibilancias (hallazgo), sibilancias, silbido, Sibilancia
Japanese 喘鳴, 喘鳴性, ゼンメイ, ゼンメイセイ
Czech Sípot, Sípání, Sípoty, Dýchavičný, sípání
Korean 쌕쌕거림
Hungarian Sípolások, Sípolás, Sípoló
Norwegian Hveselyder, Hvesing

Ontology: Expiratory wheezing (C0231875)

Concepts Sign or Symptom (T184)
SnomedCT 301275009, 9763007
English WHEEZING EXPIRATORY, auscultation wheezing expiratory, expiratory wheezing, expiratory wheezes, expiratory wheezes (physical finding), wheezing only when breathing out, wheezing only when breathing out (symptom), expiratory wheezing was heard, Wheezing expiratory, expiratory wheeze, Expiratory wheeze (finding), Expiratory wheezing, Expiratory wheeze, Expiratory wheezing (finding), expiratory; wheezing
Dutch piepende uitademing, expiratoir; piepen
French Sifflement expiratoire, SIFFLEMENT EXPIRATOIRE
German pfeifende Atemgeraeusche beim Ausatmen, STRIDOR EXSPIRATORISCH
Italian Sibilo espiratorio
Portuguese Pieira expiratória, SILVO RESPIRATORIO
Spanish Sibilancia expiratoria, SIBILANTES ESPIRATORIOS, sibilancias espiratorias (hallazgo), sibilancias espiratorias
Japanese 呼気性喘鳴, コキセイゼンメイ
Czech Expirační sípot
Hungarian Kilégzési sípolás