All That Wheezes Is Not Asthma A Wheeze Is Not Always What It Seems To Be.

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Presentation transcript:

All That Wheezes Is Not Asthma A Wheeze Is Not Always What It Seems To Be

Wheezing = Continuous musical sound High pitched advantitia Bronchospasm Asthma COPD Bronchitis Continuous musical sound High pitched advantitia Bronchospasm Asthma COPD Bronchitis

WheezingWheezing Poly-phonic Multiple notes Whale call Small airway Mono-phonic Single note Stridor Large airway Poly-phonic Multiple notes Whale call Small airway Mono-phonic Single note Stridor Large airway

WheezingWheezing Inspiratory Expiratory Focal/Local Bronchial tumors, lymph anomolies, cysts Inspiratory Expiratory Focal/Local Bronchial tumors, lymph anomolies, cysts

Stridor or Wheeze Stridor Harsh noise caused by turbulent flow Inspiratory = larynx Expiratory = trachea Biphasic = fixed lesion in periglottic region Stidor heard as a wheeze Stridor Harsh noise caused by turbulent flow Inspiratory = larynx Expiratory = trachea Biphasic = fixed lesion in periglottic region Stidor heard as a wheeze

Differential diagnosis of wheezing due to upper airway diseases

Differential diagnosis of wheezing due to lower airway diseases

Physical Findings to Consider Onset of Symptoms Clearing of throat Discharge/secretions Pain Response to BD PFT results FLOW VOLUME I & E Heart burn Changes in weight SOB w/ exertion Clubbing/Sx hypoxia Smoking Hx Short neck Wheezing / Stridor/ Stertor Quality Location Type Onset of Symptoms Clearing of throat Discharge/secretions Pain Response to BD PFT results FLOW VOLUME I & E Heart burn Changes in weight SOB w/ exertion Clubbing/Sx hypoxia Smoking Hx Short neck Wheezing / Stridor/ Stertor Quality Location Type

Lower Airway Obstruction Asthma COPD Pulm Edema Aspiration PE Bronchiolitis CF Tumor Infection Asthma COPD Pulm Edema Aspiration PE Bronchiolitis CF Tumor Infection

Intrathoracic Large Airway Obstruction Tracheal Stenosis FBA Tumors Cysts Goiter Tracheo/bronchomegaly Tracheal malacia R aortic arch Tracheal Stenosis FBA Tumors Cysts Goiter Tracheo/bronchomegaly Tracheal malacia R aortic arch

Extrathoracic Upper Airway Obstruction Sinus drip Vocal cord dysfunction Arytenoid dysfuction Tonsils Supraglottitis Laryngeal edema / stenosis Granuloma 2 Intubation Wegener’s Tumors Anaphylaxis Obesity Laryngocele Sinus drip Vocal cord dysfunction Arytenoid dysfuction Tonsils Supraglottitis Laryngeal edema / stenosis Granuloma 2 Intubation Wegener’s Tumors Anaphylaxis Obesity Laryngocele

Laryngeal Disorders dilatation of right laryngeal ventricle (white arrow, C) and ante-rior positioning of right arytenoid cartilage (black arrow, C)

Laryngeal Disorders Laryngeal nerve paralysis Flaccid VC Laryngeal nerve paralysis Flaccid VC

Bronchiectasis / CF

Tracheal compression secondary to intrathoracic goiter

Previously Healthy Episodic wheezing Progressive exercise intolerance Bilateral expir wheezes Treated for asthma No response Previously Healthy Episodic wheezing Progressive exercise intolerance Bilateral expir wheezes Treated for asthma No response

Spirometry Bronch 90% blockage distal trachea Vascular Mass CT S can Spirometry Bronch 90% blockage distal trachea Vascular Mass CT S can

Inderpal Randhawa, M.D., and Eliezer Nussbaum, M.D. N Engl J Med 2010; 363:e1,July 1, 2010 Improved Post-op Spirometry No symptoms Free of wheezes Improved Post-op Spirometry No symptoms Free of wheezes

RUL Bronchus

Foreign Body Aspiration Initial Xray Hyperinflation Very subtle Which side has the foreign object?

Foreign Body Aspiration Day 3 Nut

Foreign Body Aspiration I and E

Foreign Body Aspiration FBA

Neuromuscular Bulbar Weakness I < E flow volume Jagged lines (on insp) Inability to perform FIVC I < E flow volume Jagged lines (on insp) Inability to perform FIVC

Neuromuscular Bulbar Weakness 6 mo follow up Initial visit Unable to perform FIVC NIF difficult