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anomalies
ETIOLOGY
Wheezing occurs during the prolonged expiratory phase by the rapid passage of
air through airways that are narrowed to the point of closure. Infants' and young
children's bronchi are small, resulting in higher peripheral airway resistance. As
a result, diseases that affect the small airways have a proportionately greater
impact on total airway resistance in these patients. Infants also have less elastic
tissue recoil and fewer collateral airways, resulting in easier obstruction and
Atelectasis. The rib cage, trachea, and bronchi are also more compliant in
infants and young children, and the diaphragm inserts horizontally instead of
obliquely.
DIFFERENTIAL DIAGNOSIS
The most common diagnoses in children with wheezing are Asthma, Allergies,
Gastroesophageal Reflux Disease (GERD), Infections, and Obstructive
Sleep Apnea (OSA)
Common
Allergies
Uncommon
Rare
Bronchopulmonary
dysplasia
Bronchiolitis obliterans
Foreign body
aspiration
Congenital vascular
abnormalities
Congestive heart
failure
Indications
GERD
Cystic fibrosis
Immunodeficiency
Human Bocavirus*
Bronchitis
Trial of Albuterol
(Proventil)
Exacerbated by
neck flexion;
relieved by neck
hyperextension
Vascular ring
Angiography
Barium swallow
Bronchoscopy
Chest radiography
* Although the prevalence of Human Bocavirus in the United States has not been well
studied, it is most common in the first, second, and fourth quarters of the year in Canada
PHYSICAL EXAMINATION
This table lists history and physical examination findings that suggest specific
causes of wheezing:
SIGNS AND
SYMPTOMS
PRESUMPTIVE
DIAGNOSIS
Associated with
feeding, cough, and
vomiting
Gastroesophageal reflux
disease
24-hour pH monitoring
Barium swallow
Associated with
positional changes
Tracheomalacia;
anomalies of the great
vessels
Angiography
CT or MRI
Heart murmurs or
cardiomegaly,
cyanosis without
respiratory distress
Cardiac disease
Chest radiography
Echocardiography
FURTHER EVALUATION
Bronchoscopy
CT Chest radiographyor
MRI
Echocardiography
Auscultatory
crackles, fever
Pneumonia
Chest radiography
Episodic pattern,
cough; patient
responds to
bronchodilators
Asthma
Allergy testing
Angiography
History of multiple
respiratory
illnesses; failure to
thrive
Cystic fibrosis or
immunodeficiency
Seasonal pattern,
nasal flaring,
intercostal
retractions
Bronchiolitis (RSV),
croup, allergies
Chest radiography
Stridor with
drooling
Epiglottitis
Neck radiography
Sudden onset of
wheezing and
choking
Bronchoscopy
References:
http://www.aafp.org/afp/2008/0415/p1109.html#afp20080415p1109-t2
WHEEZING IN ASTHMA
Wheezing may result from localized or diffuse airway narrowing or obstruction
from the level of the larynx to the small bronchi. The airway narrowing may be
caused by bronchoconstriction, mucosal edema, external compression, or partial
obstruction by a tumor, foreign body, or tenacious secretions . Wheezes are
believed to be generated by oscillations or vibrations of nearly closed airway
walls . Air passing through a narrowed portion of an airway at high velocity
produces decreased gas pressure and flow in the constricted region (according
CONCLUSION
In the mildest form, wheezing is only end expiratory. As severity increases, the
wheeze lasts throughout expiration. In a more severe asthmatic episode,
wheezing is also present during inspiration. During a most severe episode,
wheezing may be absent because of the severe limitation of airflow associated
with airway narrowing and respiratory muscle fatigue. Asthma can occur without
wheezing when obstruction involves predominantly the small airways. Thus,
wheezing is not necessary for the diagnosis of asthma. Furthermore, wheezing
can be associated with other causes of airway obstruction,
References:
http://www.ncbi.nlm.nih.gov/books/NBK358/
http://emedicine.medscape.com/article/296301-clinical