All That Wheezes… Andrew Lipton, MD, MPH&TM MAJ, USA, MC Chief, Pediatric Pulmonology San Antonio Military Pediatric Center

What is a “wheeze” Definitions of obstructive noises  Stertor Low-pitched, rumbling Inspiratory Nasopharynx, oropharynx, nasal passage Loudest over neck, cheeks

What is a “wheeze” Definitions of obstructive noises  Stridor Harsh noise caused by turbulent flow Inspiratory = larynx Expiratory = trachea Biphasic = fixed lesion in subglottic region

What is a “wheeze” Definitions of obstructive noises  Wheeze Higher-pitched expiratory noise Monophonic, homophonous = large airway = expiratory stridor Polyphonic, heterophonous, musical = small airways

What is a “wheeze” Definitions of obstructive noises  Secretory Noise Gurgling, polyphonic, upper or lower airway Highly variable

Pre-Inspiration

Inspiration

Inspiration

End Inspiration

Forced Expiration

Forced Expiration

Stertor Causes  Choanal atresia  Mandibular hypoplasia  Macroglossia  Nasal congestion  Adenotonsillar hypertrophy  Pharyngeal insufficiency  Encephalocele  Dermoid of base of tongue  Thyroglossal duct cyst  Lingual thyroid

Inspiratory Stridor Causes  Laryngomalacia  Vocal cord paralysis Unilateral – left (recurrent laryngeal nerve) Bilateral – brainstem  Laryngotracheoesophageal cleft  Laryngocele  Laryngeal polyp  Abscess  Hypotonia

Inspiratory Stridor Laryngomalacia  60% of insp. stridor  90% require no intervention  Improves when prone  Worsens with activity  Worsens over first 1-6mos, then improves  Watch for FTT, apnea, cyanosis

Inspiratory Stridor Causes  Laryngomalacia  Vocal cord paralysis Unilateral – left (recurrent laryngeal nerve) Bilateral – brainstem Not positional  Laryngotracheoesophageal cleft  Laryngocele  Laryngeal polyp - ? Maternal history  Abscess  Hypotonia

Biphasic Stridor Causes  Subglottic stenosis Congenital Acquired – intubation, croup  Subglottic hemangioma  Laryngeal web  GERD

Biphasic Stridor Causes  Croup – acute barky cough, stridor, resp. distress Low grade fever Rhinorrhea Worse at night 3mos-3yrs Parinfluenza 1-3, RSV, Influenza Fall/Winter

Biphasic Stridor Causes  Recurrent Croup Consider underlying airway anomaly GERD Spasmodic (reactive airways)

Expiratory Stridor Causes  Tracheomalacia  Bronchomalacia  Vascular Ring/Sling  Complete Tracheal Ring  Tracheoesophageal Fistula  Bronchogenic Cyst  Mediastinal Mass  Foreign Body  GERD

Expiratory Stridor Causes  Tracheobronchomalacia Deficient cartilage rings Worse with exertion, agitation Prolonged expiratory phase Narrow trachea on expiratory lateral films Primary vs. Secondary  BPD, TEF, vascular anomalies

Wheezing Causes  Asthma  Bronchiolitis  Pneumonia  GERD – inflammation, bronchospasm  Heart Failure – often presents around 2 mos  BPD  Other: CF, Ciliary Dykinesia, Food Allergy

History  Congenital or acquired  Acute, Chronic, or intermittent  Positional?  Feeding – gag/choke/cough, suck, emesis, fatigue  Voice/cry quality

History  FTT – increased WOB, poor feeding >90% - think of GERD  Cyanosis  Apnea  Fever  Cough  Nocturnal Sxs

History  Birth/Neonatal History  Other anomalies: cardiac, hemangiomas, eczema, CHARGE, VACTERL, Arnold-Chiari, hypotonia, etc.  Family Hx – anomalies, CF, immunodeficiency, asthma, GERD, atopy  Exposure – smoke, pollutants, irritants, Foreign body: toys, foods, older sibs

Exam  Nose  Pharynx, tonsils, tongue, face, mandible, palate  Neck  Cardiac  Chest  Respiration: Pattern, rate,accessory muscle use, sounds, change with position, oxygenation  Abdomen – hepatomegaly, masses  Tone  Skin – eczema, hemangiomas, cyanosis

Radiographs  Lateral neck  Chest PA/Lateral  CT Head/Neck/Chest  UGI, Videofluoroscopic swallowing study  Airway fluoroscopy  MRI/MRA – chest, brainstem

Other Studies  Bronchoscopy Flexible Rigid  Laryngoscopy  Polysomnography (sleep study)  Echocardiography  Infant PFTs  pH Probe, scan  ABG

Other Studies  Allergy testing  Immunoglobulins  CBC  ABG  Sweat Cl  Ciliary Bx