Wheezing Wheezing is a high-pitched whistling sound during breathing. It occurs when air flows through narrowed breathing tubes.

Pathophysiology Airflow through a narrowed or compressed segment of a small airway becomes turbulent, causing vibration of airway walls; this vibration produces the sound of wheezing. Wheezes are more common during expiration because increased intrathoracic pressure during this phase narrows the airways. Wheezing during expiration alone indicates milder obstruction than wheezing during both inspiration and expiration, which suggests more severe airway narrowing. y contrast, turbulent flow of air through a narrowed segment of the large, extrathoracic airways produces a whistling inspiratory noise Etiology !mall airway narrowing may be caused by bronchoconstriction, mucosal edema, or external compression, or partial obstruction by a tumor, foreign body, or thic" secretions. #verall, the most common causes are

Asthma $#%&

ut wheezing may occur in other disorders affecting the small airways, including heart failure 'cardiac asthma(, anaphylaxis, and toxic inhalation. !ometimes, healthy patients manifest wheezing during a bout of acute bronchitis. In children, bronchiolitis and foreign body aspiration are also causes 'see )able *+ !ymptoms of %ulmonary &isorders+ !ome $auses of Wheezing(. Table 7 Some Causes of Wheezing Cause Suggestive Findings Diagnostic App oach! $linical evaluation Acute bronchitis ,-I symptoms .o "nown history of lung disease

Allergic reaction !udden onset, usually within /0 $linical evaluation min of exposure to "nown or potential allergen #ften accompanied by nasal congestion, urticaria, itchy eyes, and sneezing

Asthma

#ften "nown history of asthma $linical evaluation Wheezing arising spontaneously!ometimes pulmonary or after exposure to specific function testing, bedside pea" stimuli 'eg, allergen, ,-I, cold, flow measurement, exercise( methacholine challenge, or observation of response to empiric bronchodilators In children 1 23 mo 'usually $linical evaluation from .ovember to April in the .orthern 4emisphere( ,sually ,-I symptoms and tachypnea 5iddle-aged or elderly patient $linical evaluation #ften "nown history of $#%& !ometimes chest x-ray and 6xtensive smo"ing history A 7 measurement %oor breath sounds &yspnea %ursed lip breathing ,se of accessory muscles

ronchiolitis

$#%& exacerbation

&rugs 'eg, A$6 -ecent initiation of a new drug, $linical evaluation inhibitors,aspirin most often in a patient with a history of reactive airway disease

, 8-bloc"ers, .!AI&s( 6ndobronchial tumors 9ixed and constant inspiratory $hest x-ray or $) and expiratory wheezes, ronchoscopy especially in a patient with ris" factors for or signs of cancer 'eg, smo"ing history, night sweats, weight loss, hemoptysis( 5ay be focal rather than diffuse !udden onset in a young child $hest x-ray or $) who has no ,-I or ronchoscopy constitutional symptoms )rial of acid-suppressing drugs !ometimes esophageal p4 monitoring

9oreign body

76-& with $hronic or recurrent wheezing, chronic aspiration often with heartburn and nocturnal cough .o ,-I or allergic symptoms Inhaled irritants

!udden onset after occupational $linical evaluation exposure or inappropriate use of

cleaning agents :eft-sided heart failure with pulmonary edema 'cardiac asthma( $rac"les and signs of central or $hest x-ray peripheral volume overload 'eg, 6$7 distended nec" veins, peripheral .% measurement edema( 6chocardiography &yspnea while lying flat 'orthopnea( or appearing 2;< h after falling asleep 'paroxysmal nocturnal dyspnea(

Evaluation When patients are in significant respiratory distress, evaluation and treatment proceed at the same time. History: "isto y of p esent illness should determine whether the wheezing is new or recurrent. If recurrent, patients are as"ed the previous diagnosis and whether current symptoms are different in nature or severity. %articularly when the diagnosis is unclear, the acuity of onset 'eg, abrupt or gradual(, temporal patterns 'eg, persistent vs intermittent, seasonal variations(, and provo"ing or exacerbating factors 'eg, current ,-I, allergen exposure, cold air, exercise, feeding in infants( are noted. Important associated symptoms include shortness of breath, fever, cough, and sputum production. #evie$ of systems should see" symptoms and signs of causative disorders, including fever, sore throat, and rhinorrhea 'respiratory infection(; orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema 'heart failure(; night sweats, weight loss, and fatigue 'cancer(; nasal congestion, itching eyes, sneezing, and rash 'allergic reaction(; and vomiting, heartburn, and swallowing difficulties 'gastroesophageal reflux disease with aspiration(. Past medical histo y should as" about conditions "nown to cause wheezing, particularly asthma, $#%&, and heart failure. !ometimes the patient=s drug list may be the only indication of such diagnoses 'eg, inhaled bronchodilators and corticosteroids in $#%&; diuretics and A$6 inhibitors in heart failure(. %atients with "nown disease should be as"ed about indicators of disease severity, such as previous hospitalization, intubation, or I$, admission. Also, conditions that predispose to heart failure are identified, including atherosclerotic or congenital heart disease and hypertension. !mo"ing history and exposure to secondhand smo"e should be noted. Physical examination: >ital signs are reviewed for presence of fever, tachycardia, tachypnea, and low #< saturation.

Any signs of respiratory distress 'eg, accessory muscle use, intercostal retractions, pursed lip breathing, agitation, cyanosis, decreased level of consciousness( should be immediately noted. 6xamination focuses on the lungs, particularly ade?uacy of air entry and exit, symmetry of breath sounds, and localization of wheezing 'diffuse vs localized; inspiratory, expiratory, or both(. Any signs of consolidation 'eg, egophony, dullness to percussion( or crac"les should be noted. )he cardiac examination should focus on findings that might indicate heart failure, such as murmurs, a /rd heart sound '!/ gallop(, and @ugular venous distention. )he nose and throat examination should note appearance of the nasal mucosa 'eg, color, congestion(, swelling of the face or tongue, and signs of rhinitis, sinusitis, or nasal polyps. )he extremities are examined for clubbing and edema, and the s"in is examined for signs of allergic reactions 'eg, urticaria, rash( or atopy 'eg, eczema(. )he patient=s general appearance is noted for constitutional signs, such as the cachexia and barrel chest of severe $#%&. Red flags: )he following findings are of particular concern+

Accessory muscle use, clinical signs of tiring, or decreased level of consciousness 9ixed inspiratory and expiratory wheezing !welling of the face and tongue 'angioedema(

Interpretation of findings: #ecu ent wheezing in a patient with a "nown history of disorders such as asthma, $#%&, or heart failure is usually presumed to represent an exacerbation. In patients who have both lung and heart disease, manifestations may be similar 'eg, nec" vein distention and peripheral edema in cor pulmonale due to $#%& and in heart failure(, and testing is often re?uired. When the cause is "nown asthma or $#%&, a history of cough, postnasal drip, or exposure to allergens or to toxic or irritant gases 'eg, cold air, dust, tobacco smo"e, perfumes( may suggest a trigger. $linical findings help suggest a cause of wheezing in patients without a "nown history 'see)able *+ !ymptoms of %ulmonary &isorders+ !ome $auses of Wheezing (. Acute 'sudden-onset( wheezing in the absence of ,-I symptoms suggests an allergic reaction or impending anaphylaxis, especially if urticaria or angioedema is present. 9ever and ,-I symptoms suggest infection+ acute bronchitis in older children and adults and bronchiolitis in children 1 < yr. $rac"les, distended nec" veins, and peripheral edema suggest heart failure. Association of wheezing with feeding or vomiting in infants can be a result of gastroesophageal reflux.

%atients with asthma usually have paroxysmal or intermittent bouts of acute wheezing. Pe sistent, localized wheezing suggests focal bronchial obstruction by a tumor or foreign body. %ersistent wheezing manifesting very early in life suggests a congenital or structural abnormality. %ersistent wheezing with sudden onset is consistent with foreign body aspiration, whereas the slowly progressive onset of wheezing may be a sign of extraluminal bronchial compression by a growing tumor or lymph node. Testing: )esting see"s to assess severity, determine diagnosis, and identify complications.

%ulse oximetry $hest x-ray 'if diagnosis unclear( !ometimes A 7 !ometimes pulmonary function testing

!everity is assessed by pulse oximetry and, in patients with respiratory distress or clinical signs of tiring, A 7 testing. %atients "nown to have asthma usually have bedside pea" flow measurements 'or, when available, forced expiratory volume in 2 sec A96>2B(. %atients with new-onset or undiagnosed persistent wheezing should have a chest x-ray. C-ray can be deferred in patients with asthma who are having a typical exacerbation and in patients having an obvious allergic reaction. $ardiomegaly, pleural effusion, and fluid in the ma@or fissure suggest heart failure. 4yperinflation and hyperlucency suggest $#%&. !egmental or subsegmental atelectasis or infiltrate suggests an obstructing endobronchial lesion. -adiopacity in the airways or focal areas of hyperinflation suggest a foreign body. If the diagnosis is unclear in patients with recurrent wheezing, pulmonary function testing can confirm airflow limitation and ?uantify its reversibility and severity. 5ethacholine challenge testing and exercise testing can confirm airway hyperreactivity in patients for whom the diagnosis of asthma is in ?uestion. T eatment &efinitive treatment of wheezing is treatment of underlying disorders. Wheezing itself can be relieved with inhaled bronchodilators 'eg, albuterol <.D mg nebulized solution or 230 mg metered dose inhalation(. :ong-term control of persistent asthmatic wheezing may re?uire inhaled corticosteroids and leu"otriene inhibitors. Intravenous 4< bloc"ers 'diphenhydramine(, corticosteroids 'methylprednisolone(, and subcutaneous and inhaled racemic epinephrine are indicated in cases of anaphylaxis. %ey Points Asthma is the most common cause, but not all wheezing is asthma.

Acute onset of wheezing in a patient without a lung disorder may be due to aspiration, allergic reaction, or heart failure. -eactive airway disease can be confirmed via spirometry. Inhaled bronchodilators are the mainstay of acute treatment.

Ch onic b onchitis Ch onic b onchitis is a chronic inflammation of the bronchi 'medium-size airways( in the lungs. It is generally considered one of the two forms of chronic obstructive pulmonary disease '$#%&(.It is defined clinically as a persistent cough that produces sputum 'phlegm( and mucus, for at least three months per year in two consecutive years. Sign and symptomps ronchitis may be indicated by a cough 'also "nown as a productive cough, i.e. one that produces sputum(, shortness of breath 'dyspnea( and wheezing. #ccasionally chest pains, fever, and fatigue or malaise may also occur. 5ucus is often green or yellowish green and also may be orange or pin", depending on the pathogen causing the inflammation.

Causes )obacco smo"ing is the most common cause. %neumoconiosis and long-term fume inhalation are other causes. Allergies can also cause mucus hypersecretion, thus leading to symptoms similar to asthma or bronchitis. Diagnosis A physical examination will often reveal diminished breath sounds, wheezing and prolonged exhalation. 5ost doctors rely on the presence of a persistent dry or wet cough as evidence of bronchitis. A variety of tests may be performed in patients presenting with cough and shortness of breath+

%ulmonary 9unction )ests '%9)( 'or spirometry( must be performed in all patients presenting with chronic cough. An 96>2E9>$ratio below 0.* that is not fully reversible after bronchodilator therapy indicates the presence of $#%&, that re?uires more aggressive therapy and carries a more severe prognosis than simple chronic bronchitis. A chest C-ray that reveals hyperinflation; collapse and consolidation of lung areas would support a diagnosis of pneumonia. !ome conditions that predispose to bronchitis may be indicated by chest radiography. A sputum sample showing neutrophil granulocytes 'inflammatory white blood cells( and culture showing that has pathogenic microorganisms such as !treptococcus spp. A blood test would indicate inflammation 'as indicated by a raised white blood cell count and elevated $-reactive protein(. .eutrophils infiltrate the lung tissue, aided by damage to the airways caused by irritation. &amage caused by irritation of the airways leads to inflammation and leads to neutrophils being present 5ucosal hypersecretion is promoted by a substance released by neutrophils 9urther obstruction to the airways is caused by more goblet cells in the small airways. )his is typical of chronic bronchitis Although infection is not the reason or cause of chronic bronchitis it is seen to aid in sustaining the bronchitis. 4igh -esolution $omputed )omography '4-$)( F )his is a special type of $) scan that provides your doctor with high-resolution images of your lungs. 4aving a 4-$) is

no different than having a regular $) scan; they both are performed on an open-air table and ta"e only a few minutes. T eatments !mo"ing cessation is of benefit. Antibiotics #nly about D-20G of bronchitis cases are caused by a bacterial infection. 5ost cases of bronchitis are caused by a viral infection and are Hself-limitedH and resolve themselves in a few wee"s. 9or acute exacerbations of chronic bronchitis, if antibiotics are used,amoxicillin or doxycycline is recommended. & onchodilato s Ipratropium is an example of a bronchodilator that may be useful for people suffering from chronic obstructive pulmonary disease, such as chronic bronchitis. Albuterol is also a common drug for this disease.