 Wheezing illnesses other than asthma in children

Wheezing is a common presenting symptom of respiratory disease in children. Wheezing can be divided clinically according to the acuity of its onset and the mechanism of airway narrowing.

ACUTE WHEEZING 1-asthma 2-infection 3-foreign body aspiration

INFECTION In infants younger than two years of age, the most common cause of acute wheezing is viral bronchiolitis. Respiratory syncytial virus(RSV). Parainfluenza virus and metapneumovirus.

Clinical features and diagnosis:.Runnynose,cough,fever,wheezing,tachypnea Physical examination: Nasal congestion,tachypnea,wheezing,dehydration..Chest radiographs: Normal,hyperinflatin,infiltrates,atelectasis.Rapid antigen detection,ELISA-based assays,(PCR)

Less common infection: Bacterial tracheiti,epiglottitis,bronchitis,Mycoplasma pneumonia.

Foreign body aspiration Sudden onset wheezing A history of choking FBA is more common in young children, and less commonly in infants under six months of age. Physical examination: Unilateral wheeze or unequal breath sounds. Chest radiographs: Localized hyperinflation or atelectasis Esophageal foreign body can cause acute wheezing: history of feeding and swallowing difficulties, dysphagia.

CHRONIC OR RECURRENT WHEEZING Structural causes: 1-Anomalies of the tracheobronchial tree – Congenital tracheomalacia and bronchomalacia. Noisy breathing early in life, Wheezing commonly becomes apparent in the first two to three months after birth. Stridor. Chest radiographs: nondiagnostic. Fluoroscopy of the airways: dynamic collapse during expiration. CT angiogram or (MRI). Bronchoscopy.

2-Cardiovascular disease: Large left to right shunts Left ventricular failure, pulmonary venous outflow obstruction. Congenital heart disease. Vascular rings or slings: can cause: obstruction of large airways and result in wheezing or stridor. Complete rings (double and right aortic arches) Incomplete rings (pulmonary artery sling) Signs and symptoms: commonly appear early in life (biphasic stridor, wheezing, recurrent respiratory infection,feeding difficulty,vomiting ) Physical examination: (wheezing during inspiration and expiration) Diagnoses: -chest radiograph(abnormal),right aortic arch with vascular rings. -barium swallow -(MRI) -CT

3-Mediastinal masses: Tumors,thymic lesions,bronchogenic cysts,angiomatous lesions,lymph nodes Diagnosis: chest radiographs,CT,MR, Bronchoscopy.

Functional causes 1-Aspiration syndromes: are associated with a variety of anatomic functional disorders. A- Foreign body aspiration B- Gastroesophageal reflux(GER) C- Swallowing disorders(neurologic muscular dysfunction of pharynx and/or larynx) D- Anatomic abnormalities(laryngeal clefts,vocal cord paralysis) Diagnoses: videofluoroscopic swallowing study E- Tracheoesophageal fistulae:chronic cough,recurrent pneumonia,wheezing,increased with feeding. Diagnoses : chest radiographs(infiltrates), bronchoscopy, esophagoscopy

2-Host defense abnormalities. Immune deficiency syndromes (IgG and/or IgA deficiency) 3-Primary ciliary dyskinesia: chronic cough,wheezing,recurrent severe upper respiratory infections, otitis, chronic sinusitis 4-Cystic fibrosis: the most common autosomal recessive disease(persistent pulmonary infection,pancreatic insufficiency,elevated sweat chloride levels)

5-Bronchopulmonary dysplasia(BPD)neonatal chronic lung disease : Most patients have a history of neonatal respiratory distress syndrome. 6-Paradoxical vocal cord motion: (older children and adults) -inappropriate adduction of the true vocal cords on inspiration with abduction on expiration(inspiratory stridor) Causes: psychosocial disorders,stress, exercise, perioperative airway, neurologic injury, GER PFT normal, flow-volume loops: flattening of the inspiratory loop( extrathoracic upper airway obstruction) Diagnosis: flexible fiberoptic laryngoscop.

7-Bronchiolitis obliterans(BO): chemical, infectious, immunologic injury, Idiopathic. Adenovirus is the most likely cause BO,influenza,measles,mycoplasma. Chronic lung transplant rejection,hematopoietic cell transplantation. Symptoms:tachypnea,dyspnea,cough,wheezing, Crackles. PFT:airway obstruction Chest radiograph:normal,hyperinflation, Interstitial infiltrates. Diagnoses:HRCT,lung biopsy.

8-Interstitial lung disease(ILD): progressive dyspnea,tachypnea,cyanosis,wheezing,crackles, Digital clubbing. PFT: restrictive pattern,reduced DLCO

Pulmonary artery sling