Pediatrics notes about "Wheezy chest". These notes were published in 2018. You can download them also from - Telegram: https://t.me/pediatric_notes_2018 - Mediafire: http://www.mediafire.com/folder/u5u60m184t9z7/Pediatric_Notes_2018

1. Wheezy Chest
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Chest 2018
Kareem Alnakeeb
Wheezy Chest
- Continuous musical sound
- It is produced by partial lower airway narrowing
- usually heard on expiration
- If wheezes extend to inspiration → this indicates severe respiratory distress.
- High-pitched sound
- It is produced by partial upper airway narrowing
- usually heard on inspiration → this indicates obstruction above the glottis (extrathoracic)
- If Stridor heard on expiration → this indicates intrathoracic obstruction.
 Laryngomalacia:
• the most common cause of chronic extrathoracic airway obstruction in infants
• Worse in  supine position & during exertion (feeding and crying).
• improve in  prone position
Acute Chronic or recurrent
• Asthma
• Bronchiolitis
• Bronchitis
• Laryngotracheobronchitis
• Bacterial tracheitis
• Foreign body aspiration
• Esophageal foreign body
Structural abnormalities Functional abnormalities
• Tracheo-bronchomalacia
• Vascular
compression/rings
• Tracheal stenosis/webs
• Cystic lesions/masses
• Tumors/lymphadenopathy
• Cardiomegaly
• Asthma
• Gastroesophageal reflux
• Recurrent aspiration
• Cystic fibrosis
• Immunodeficiency
• Primary ciliary dyskinesia
• Bronchopulmonary
dysplasia
• Retained foreign body
(trachea or esophagus)
• Bronchiolitis obliterans
• Pulmonary edema
• Vocal cord dysfunction
• Interstitial lung disease
Wheezes:
Stridor:
Causes of wheezing in children:

2. Wheezy Chest
P a g e | 2
Chest 2018
Kareem Alnakeeb
Bronchial Asthma
Symptoms:
- Recurrent.
- Variable presentation (dyspnea, chest tightness, wheezes, cough)
- Reversible: BA is diagnosed by ↑ of FEV1 ˃ 12% after using inhaled short acting ß2 agonists
"Cardinal sign".
- Precipitated by exposure to specific allergens.
- ↑ by night (nocturnal cough).
- Common cold will last for 10-14 days.
- +ve family history of atopy: asthma, eczema, allergic rhinitis.
- Increase by exercise.
- Drug-induced → aspirin intake
Investigation:
- CBC → increase eosinophilic count.
- Increase serum IgE.
- Skin test: to detect the causative allergen.
- Pulmonary function test ”spirometry” : ↓ FEV1 & ↓ PEF
Acute Bronchiolitis
 can be diagnosed by: (special course - wheezes with obstructive emphysema).
- Special course of the disease: “ 10 days in 3 phases “
1. It starts with flu-like symptoms (for 3-4 days).
2. It is followed by severe respiratory distress (for 2-3 days)
3. Then the course will be ended with resolution (within 3 days)
- Obstructive emphysema which is manifested by:
1- Hyper-resonance on percussion.
2- Prolonged expiration “due to loss of elastic recoil of the lung”.
3- Palpable liver & spleen (ptosed).
4- CXR:
- Depressed cupola of diaphragm
- Attenuation of BVMs
- Bulging of intercostal spaces in lateral view

3. Wheezy Chest
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Chest 2018
Kareem Alnakeeb
Acute bronchiolitis Bronchial asthma
Type of
disturbance
infection Type I Hypersensitivity ( IgE Mediated )
“ Airway hyper-responsiveness “
Type of cell Neutrophils Mast cells + Eosinophils
Type of airway
obstruction
obstructive emphysema (ball & valve) No emphysema but airway
hyperactivity (No ball & valve)
Cause Viral infection (RSV) ❖Reversible bronchoconstriction with
chronic inflammation
❖ Precipitating factors e.g.
- viral infection
- inhaled smoke, dust, pollens
- food allergens
- Exercise & aspirin-induced
Timing Winter • All year
• Most with URI in winter
Family history Negative Positive
Age Infants (especially <1 year) Most start age <5 years
Course ❖Specific course of the disease:
 flu-like symptoms for 3-4 days.
 Severe respiratory distress for 2-3 days
Resolution within 3 days.
1. Recurrent
2. Variable
3. Reversible (cardinal)
(good response to β2 agonists)
Pneumonia- like
signs
Non-consonating crepitations
may be heard “due to alveolar collapse”
No crepitations
IgE level RSV- specific IgE ↑ IgE
Eosinophilic
count
Normal Increased
Recurrence Usually not recurrent Recurrent
Bronchodilator
response
Minimal (controversial) Good (diagnostic)
Treatment 1. Oxygen
2. IV fluids
3. Ribavirin
1. Rescue (O2 – SABA)
2. Controller (ICS – LABA – LTRA)

4. Wheezy Chest
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Chest 2018
Kareem Alnakeeb
Foreign Body Aspiration
- Positive history of inhalation of FB
- Sudden onset without preceding illness
- History of severe shocking before the wheezes
- Fixed unilateral wheezes (sometimes bilateral)
- Wheezes NOT responding to bronchodilators
- Recurrent lobar pneumonia involving the same lobe
- CXR:
1- Normal
2- Obstructive emphysema
3- Radiopaque FB
- Bronchoscope is diagnostic & therapeutic
- Most seen in children age 3–4 years
- Most common foreign body is peanuts
- Larynx is the most common site of foreign body aspiration in children age <1 year.
- In children age >1 year, think trachea or right mainstem bronchus.
Congenital Heart disease (with↑PBF) e.g. VSD
- Feeding difficulty + cold sweating on forehead
- Murmur & abnormal heart sounds
- Cardiomegaly & ↑ PVMs (by CXR) & confirmed by ECHO
Gastroesophageal reflux (GERD)
- GIT symptoms: vomiting
- Esophagitis (Arching back during feeding)
- Confirmed by barium study & PH metry
Vascular ring
- Symptoms change by changing position
- Symptoms dating since birth
- Persistent wheezes with NO response to bronchodilators

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Chest 2018
Kareem Alnakeeb
Mediastinal mass
- Other manifestations of mediastinal syndrome e.g. dysphagia & hoarseness of voice
- CXR  Broad mediastinum
- Confirmed by CT chest & MRI
Cystic fibrosis
- Poor weight gain with recurrent sinus infection & sometimes with chronic diarrhea
- Bilateral crepitations
- CXR  Bronchiectasis
- Confirmed by sweat chloride test
1. History
Age at onset
• Since Birth:
- Congenital airway obstruction:
(Laryngomalacia, Tracheomalacia, laryngotracheomalacia, bronchomalacia)
- The sound is transmitted from stridor
• > 3 years: Bronchial asthma
Course of wheezes
1- Sudden onset of persistent wheezes:
- FB aspiration (Confirmed by bronchoscope)
2- Slowly progressive wheezes:
- Extraluminal obstruction
- GERD (with GIT symptoms & Barium study)
3- Persistent wheezes without change:
- Congenital structural anomaly e.g. vascular ring
Approach for a case of wheezy infant:

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Chest 2018
Kareem Alnakeeb
Clinical diagnosis
Clues Diagnosis
GIT symptoms
“ vomiting, arching back during feeding”
- GERD
Poor weight gain with recurrent sinus infection - Cystic fibrosis
(Confirmed by: Sweat chloride test)
- Immune deficiency
(Confirmed by: Immune profile e.g. T&B
cell function)
- Ciliary dyskinesia
(Confirmed by: Pulmonary function test +
Bronchoscope +Biopsy (EM)
Symptoms changes by changing position - Laryngomalacia
- Vascular ring
Wheezes with little or no cough - Mechanical obstruction e.g. FB
aspiration
Feeding difficulty + cold sweating on forehead
+ Murmur
- CHD
(Confirmed by: ECHO)
Good response to selective B2 agonist - Bronchial asthma
2. Examination
Clues Diagnosis
Clubbing - Chronic disease
Added sounds e.g. crackles - Parenchymatous lung disease
- Pulmonary edema d.2 CHD
Allergic rhinitis or skin allergy - Atopy e.g. BA
Murmur - CHD
arching back during feeding - GERD

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3. Investigations
Radiography
1- CXR:
• Cardiomegaly  CHD with CHF “pulmonary congestion”
• Broad mediastinum  Mediastinal mass
• Homogenous opacity  Parenchymatous lung disease
• Dilatation “mainly Basal”  Bronchiectasis
2- CT chest: for dilated anatomy of “mediastinum, airway, parenchyma”
3- MRA: for vascular ring
4- Barium study: for GERD & Vascular ring ”indentation of esophagus”
Pulmonary function tests
- To differentiate intrathoracic from extrathoracic causes
- To differentiate upper from lower airway causes
Laboratory studies
1- CBC: Eosinophilia  Allergy
2- Allergic workup  BA
3- Sweat chloride test  cystic fibrosis
4- Viral studies
5- Sputum cultures  TB
6- Immunological workup  Immunodeficiency e.g. T & B cell deficiency
Bronchoscopy:
• Endoscopy is a diagnostic tool used in patients with
suspected FBA, persistent symptoms, or inadequate response to therapy
• Rigid bronchoscopy: In sudden onset of wheezing & suspected FBA.
• Flexible bronchoscopy: In tracheomalacia “ diameter of trachea >75% in expiration”
PH metry: for GERD