wheezing chest pediatrics

1. PEDIATRIC
WHEEZY
CHEST
Supervisor: Prof. Dr. Bahaa Deyaa
Seminar presentation by: 1. Mustafa Musa Asker
2. Mustafa Rafaa Muhammed
3. Mesk Emad Hussein

2. What is Wheezing?
The production of a musical continuous sound that originates
in narrowed airways, is heard on expiration as a result of
airway obstruction.
-Infants are more likely to wheeze than are older children
-Approximately(%25- %30) of infants will have at
least one wheezing episode, and nearly one half of
children have a history of wheezing by six years of age.

3. Types and Patterns of Wheeze
Inspiratory Expirartory Mixed
Low Pitch Sonorous type (rhonchi)
• Caused by airway narrowing due
to secretions:- lower pitched
vibrating sound like snoring and are
usually heard as Mixed type
High Pitch Sibilant type (wheeze- can
bemonophonic or polyphonic)
• Caused by bronchospasm-
turbulent flow increases during
passive exhalation, hence mostly
expiratory
Types and
Mechanisms

4. Confirm if it is a wheeze or other upper or lower
airway noise (e.g. stridor, rattle). Parents can differ in
their understanding and definition of wheeze,
Understanding the pathophysiology of wheeze helps
differentiation of causes; intrathoracic airway
obstruction leads to wheeze, more prominent in
expiration, whereas extrathoracic airway obstruction
leads to inspiratory stridor
Its important to:

5. Causes of Wheezing in Children and Infants

Common:
Allergies
Asthma or reactive airway disease
Gastroesophageal reflux disease
Infections
Bronchiolitis
Bronchitis
Pneumonia
Upper respiratory infection
Obstructive sleep apnea

Uncommon:
Bronchopulmonary dysplasia
Foreign body aspiration

Rare:
Bronchiolitis obliterans
Congenital vascular abnormalities
Congestive heart failure
Cystic fibrosis
Immunodeficiency diseases
Mediastinal masses
Primary ciliary dyskinesia
Tracheobronchial anomalies
Tumor or malignancy
Vocal cord dysfunction

6. CLINICAL GRADING OF WHEEZING
Grade I (Wheezing only)
Prolonged expiration and expiratory wheezing are the only findings.
No respiratory distress or diminished air entry.
Grade I (Wheezing and tachypnea)
Prolonged expiration and expiratory wheezing.
Rapid respiration (tachypnea) and slightly diminished air entry.
Grade III (Wheezing and retractions)
Prolonged expiration and expiratory wheezing.
Rapid respiration, retractions (intercostal, suprasternal) and moderately
diminished air entry.
Grade IV (Wheezing and cyanosis)
Rapid respiration, marked retractions and cyanosis.
Markedly diminished air entry.
Wheezing is minimal or even absent, "silent chest" or "tight chest"
• Infants and children with wheezing and respiratory distress should be hospitalized.

7. Approach
to a wheezing child

8. Clinical History:
Questions to Distinguish the Etiology of Wheezing in Children:
- How old was the patient when the wheezing started?
Distinguishes congenital from noncongenital causes
- Did the wheezing start suddenly?
Foreign body aspiration
- Is there a pattern to the wheezing?
Episodic: asthma Persistent: congenital or genetic cause
- Is the wheezing associated with a cough? GERD, sleep apnea, asthma, allergies
- Is the wheezing associated with feeding? GERD

9. - Is the wheezing associated with multiple respiratory illnesses?
Cystic fibrosis, immunodeficiency
- Is the wheezing associated with a specific season? Allergies: fall and spring
Croup: fall to winter
Human bocavirus
Human metapneumovirus:
December through April
RSV: fall to spring
- Does the wheezing get better or worse when the patient changes position?
Tracheomalacia, anomalies of the great vessels
- Is there a family history of wheezing?
Infections, allergic triad

10. Physical Examination

11. Differential Diagnosis of Wheezing According to Characteristic
Signs and Symptoms
Signs and symptoms Presumptive diagnosis

Associated with feeding, cough, and vomiting Gastroesophageal reflux disease

Associated with positional changes Tracheomalacia; anomalies of the great vessels

Auscultatory crackles, fever, cough Bronchopneumonia

Episodic pattern, cough; patient responds to bronchodilators Asthma

Exacerbated by neck flexion; relieved by neck hyperextension Vascular ring

Heart murmurs or cardiomegaly, cyanosis without respiratory distress Cardiac disease

History of multiple respiratory illnesses; failure to thrive Cystic fibrosis
or immunodeficiency

12. Differential Diagnosis of Wheezing According to Characteristic
Signs and Symptoms
Signs and symptoms Presumptive diagnosis

Seasonal pattern, nasal flaring, intercostal retractions Bronchiolitis (RSV), croup, allergies

Stridor with drooling Epiglottitis

Sudden onset of wheezing and choking Foreign body aspiration

13. Investigations:
-CXR: AP and lateral views:
-Children with new onset wheezing of undetermined etiology
-Chronic persistent wheezing not responding to treatment
-Suspected FB aspiration
CXR findings:
Hyperinflation:
Generalized: suggests diffuse air trapping
Asthma/ Cystic fibrosis/ Primary ciliary dyskinesia
Localized hyperinflation:
Structural abnormalities/ FB aspiration
Other findings:
atelectasis, bronchiectasis, mediastinal masses, enlarged LN's, cardiomegaly,
enlarged pulmonary vessels or pulmonary edema

14. FB aspiration case

15. Generalized Hyperinflation case
PA

16. -Chest CT scan
-Mediastinal masses or LN's
-Vascular anomalies
-Bronchiectasis
-Barium Swallow:
-GERD
-TEF
-Vascular rings
-Swallowing dysfunction
-Pulmonary Function Tests (PFT's)
In assessing airway obstruction, is helpful in determining the
presence, degree, and location of airway obstruction
-Response to bronchodilator

17. -flexible fibreoptic bronchoscopy
Endoscopy is a diagnostic tool used in
patients with suspected FBA, Flexible
bronchoscopy can identify structural
airway abnormality.
-24hour esophageal pH monitoring
suggested in infants and children with
recurrent wheezing

18. Other investigations:
*Sweat Chloride Test: Cystic fibrosis screening in children with
chronic lung problems, failure to thrive and diarrhea
•Immunoglobulin levels: Screen for immunodeficiency.
*Rapid antigen testing, PCR, sputum gram stain and cultures.

19. Mangment

20. Treatment
• 1) Comfort the child -Try to keep the baby
calm. Having cough and noisy wheeze
frightens children and breathing is more
difficult when they are upset.
• 2) Offer frequent liquids, Drinking less but
more often may be easier
• 3) Treatment for wheezing depends on its
underlying cause. If wheezing is severe
or interfering with breathing, the patient
need to be hospitalized.

21. 4) Bronchodilators:
- administer inhaled short acting beta-2 agonist
(eg.salbutamol) & observe the response.
- Children < 3 yrs: inhaled medications by MDI with
mask & spacer.
- response is unpredictable
- Therapy to be continued in all asthma patients
with exacerbations with viral illness

22. 5) Ipratropium bromide:
- can be used as adjunct therapy
- also useful in patients with significant tracheal or
bronchomalacia
- Anticholinergic agent
6) Oral/ IV steroids:
- used for atopic wheezing infants thought to
have asthma i.e. refractory to other medications

23. 7) Inhaled steroids:
- appropriate for maintenance therapy in
known reactive airways but not useful in
acute illness
- to be used if significant h/o atopy (food
allergy, eczema) present
- maintenance treatment with inhaled
steroids is recommended for multiple-trigger
wheeze.

24. 8) In acute bronchiolitis:
- hospitalize the patient
- mainstay of treatment is supportive
- hypoxemic child: cool humidified oxygen
- avoid sedatives
- keep head & chest elevated at 30 degree angle
- NG tube feeds to avoid aspiration
- respiratory decompensation > tracheal intubation
- Bronchodilators show modest short term
improvement in clinical features
- Nebulized epinephrine more effective

25. 9) Montelukast
is recommended for the treatment of episodic
(viral) wheeze, to be started when symptoms
of a viral cold develop
10)Ribavarine: antiviral administered by
aerosol
- Used for children with CHD/CLD
11) No role of antibiotics unless secondary
bacterial infection

26. Prevention
1) Reduction in severity & incidence of acute bronchiolitis due to Rota virus is possible through
administration of pooled Hyper immune RSV Intravenous Immunoglobulin (RSV IVlg,
Respigam) and Palivizumab, which is monoclonal antibody to the RSV F protein, its
recommended before and during RSV season for children < 2yrs age with chronic lung
disease (BPD) or prematurity
2) Inhaled corticosteroids and montelukast may be considered in preschool child with
recurrent wheeze.
www.traditionalmedicine.com

27. Prevention
3) Avoid smoking -Smoking in the home or car
increases the risk of respiratory problems in
children
4) Educating parents regarding causative factors
and treatment is useful.
5) Allergen avoidance may be considered when
sensitization has been established
6) handwashing is the best measure to prevent
nosocomial infection
www.traditionalmedicine.com

28. • Approx 60% of infants who wheeze, will stop wheezing.
• Acute Bronchiolitis: highest risk in 1st 2-3 days;
Fatality Rate <1%
-Death > apnea, severe dehydration, uncompensated
respiratory acidosis
Mean duration of symptoms - 12 days
High incidence of wheezing & asthma in children with h/o
bronchiolitis
• Coronery heart disease /Bronchopulmonary
dysplasia/Immuno-deficiency:
More severe disease, higher morbidity & mortality
Prognosis

29. RESOURCES
1) -Nelson Essentials of Pediatrics, 6th Edition
2) -Nelson textbook of pediatrics 21th edition
3) The Diagnosis of Wheezing in Children:
https://www.aafp.org/pubs/afp/issues/2008/0415/p1109.html#afp20080415p110
9-tfn4
4) Evaluation of wheezing in infants and children – UpToDate:
https://www.uptodate.com/contents/evaluation-of-wheezing-in-infants-and-childr
en#H12
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30. Thank you
for listening