Wheezy Infant By Professor Of Pediatrics, Head of Allergy & Clinical Immunology Unit Mansoura University Egypt

wheezing Def. It is a continuous expiratory musical sound produced by partial airway obstruction either localized or generalized at level of small bronchi and bronchioles (lower airway obstruction)

Causes of wheezing I- Acute conditions II- Non structural causes III- Structural

I- Acute conditions 1- Bronchiolits 2- Bronchial aspiration of F.B 3- Acute congestive heart failure 4- Bronchial asthma (first episode) 5- Organo phosphorus poisoning 6- Transient bronchial hyper reactivity

II-Non structural 1- Gastrooesophageal reflux 2- F.B 3- B.A 4- Chronic bacterial bronchitis 5- Cystic fibrosis 6- Bronchopulmonary dysplasia

III- Structural 1- Tracheomalacia 2- Bronchomalacia 3- Vascular compression (vascular ring) 4- Tracheal stenosis 5- Cystic lesion

Key Points in Present History Differential Diagnosis Think About Useful Pointers  Recurrent viral infection  Cystic fibrosis  Reflux/aspiration  Pertussis infection  Laryngomalacia (Floppy Larynx) or Some other narrowing of the large airways (Floppy Larynx) or Some other narrowing of the large airways Continue Continue  Intermittent, Self Limiting cough and wheeze  Poor weight gain /Wet cough/bulky offensive stool  Feeding difficulties/ Vomiting/night cough  Paroxysmal coughing fits  Mostly inspiratory wheezing or stridor

Key Points in Present History Differential Diagnosis Think about Useful pointers  Immune deficiency  Heart failure  Unlikely to be asthma: Congenital lung problem? Congenital lung problem? Perinatal infection Perinatal infection (chlamydia) (chlamydia) Ciliary dyskinesia? Ciliary dyskinesia? Cystic fibrosis? Cystic fibrosis?  Wheezes associated with preterm birth  Febrile illnesses/ severe recurrent infection  Breathlessness and sweety with feeding with or without murmur  Symptoms since birth  Prematurity

Airway Compression 1- Extrathoracic lesions:  Lryngeomalacia, Tracheomalacia  Subglottic hemangioma Key point:  Dry irritative cough with inspiratory stridor. 2- Intra thoracic airway compression:  Vascular rings e.g. double aortic arch  Perihilar adenopathy  Mediastinal tumours

Gastro Esophageal Reflux and Wheezy Infant GERD can cause wheezing by;  Direct aspiration of acidic gastric secretions or food into tracheo-bronchial tree.  Triggering Parasympathetic reflex receptors in the lower esophagus.

Bronchiolitis Obliterans Definition It is neutrophilic inflammation of small airways including terminal bronchioles and alveolar wall. It is neutrophilic inflammation of small airways including terminal bronchioles and alveolar wall. Neutrophils release oxidative and proteolytic enzymes (myleo peroxidase and collagenase) that cause lung damage and obliteration of bronchiolar lumen. Neutrophils release oxidative and proteolytic enzymes (myleo peroxidase and collagenase) that cause lung damage and obliteration of bronchiolar lumen.

Conditions Associated with Development of Bronchiolitis Obliterans 1- Viral infections: 1- Viral infections:  Especially adenovirus type 3,7,21  Also RSV, Measles, influenza and herpes zoster also have been implicated 2- Bacterial infections: 2- Bacterial infections:  Staph aureous  Mycoplasma Pneumonia  Klepsiella continue

Conditions Associated with Development of Bronchiolitis Obliterans 3- Connective tissue diseases  Rheumatoid arthritis  Ulcerative colitis  SLE  Scleroderma 4- Toxic exposures  Nitrous oxide is a common cause 5- Others  Foreign body aspiration  Bronchopulmonary dysplasia  cystic fibrosis

Features of Bronchiolitis Obliterans  Cough and wheeze with exertional dyspnea  HRCT shows:-  Ground glass opacity  Multi focal atelectasis  Mosaic oligemia  PFT shows : Fixed air flow obstruction Fixed air flow obstruction Pathology Pathology  BAL Neutrophils and lymphocytes Neutrophils and lymphocytes  Biopsies: Fibrosis, Bronchiectasis,Mucus stain, Alveolar overinflation Fibrosis, Bronchiectasis,Mucus stain, Alveolar overinflation

Differential Diagnosis of Chronic and Recurrent Bronchitis Phase I: Specific Etiologies Asthma Preexisting lung disease Preexisting lung disease Respiratory distress syndrome and bronchopulmonary dysplasia Postinfectious bronchiectasis Cystic fibrosis Cystic fibrosis Foreign body aspiration Foreign body aspiration Intrathoracic or extrathoracic airway Esophaguscontinue

Differential Diagnosis of Chronic and Recurrent Bronchitis Aspiration syndromes Aspiration syndromes Abnormal enteropulmonary communications Abnormal enteropulmonary communications (e.g., Laryngeal cleft) (e.g., Laryngeal cleft) Dysfunction of swallowing Dysfunction of swallowing Gastroesophageal reflux Gastroesophageal reflux Airway compression Airway compression Weakened wall (e.g., tracheomalacia) Weakened wall (e.g., tracheomalacia) Extrinsic compression (e.g., vascular ring) Extrinsic compression (e.g., vascular ring) Congenital heart disease Congenital heart disease Immunodeficiency Immunodeficiency Primary cilliary abnormalities Primary cilliary abnormalities continue continue

Phase II: Nonspecific Airway Irritation Phase II: Nonspecific Airway Irritation Exposure to recurrent respiratory tract infections in day-care centers Cigarette smoke Passive smoke exposure Active smoking Air pollution Outdoor secondary to particulate matter, automobile exhaust, and other pollutants Indoor secondary to Wood burning, irritants, and chemicals

DDBronchiolitsHistory - The patient usually has an antecedent history of coryza and may be fever for 3-5 days -Age most common between 1-6 months of age -The patient usually has wheezing for first time

Examination - Cough is prominent - Cough is prominent - RR is elevated 50-60/minute - RR is elevated 50-60/minute - Chest retraction - Chest retraction - Chest auscultation - Chest auscultation. Expiratory wheezing. Expiratory wheezing. Fine inconstant crepitations. Fine inconstant crepitations. Diminished intensity of B.S in severe cases. Diminished intensity of B.S in severe cases

Investigation Hyperinflated chest (areas of segmental collapse may be present) Hyperinflated chest (areas of segmental collapse may be present)Course Rapid improvement within few days,no recurrence Rapid improvement within few days,no recurrence

2-Foreign Body Inhalation History The possibility should be considered in every case of acute wheezing especially when the onset is sudden, associated with chocking and not preceded by any illness Age is older than 9 month the possibility becomes greater when wheezing is not responding to therapy The possibility should be considered in every case of acute wheezing especially when the onset is sudden, associated with chocking and not preceded by any illness Age is older than 9 month the possibility becomes greater when wheezing is not responding to therapy

Examination  Localized wheezing  Unequal breath sound  Severe chest retraction not explained by physical finding on chest

Investigation X-Ray Chest X-Ray Chest. Localized hyperinfalation. Localized hyperinfalation. Ateleclasis or localized air traping. Ateleclasis or localized air traping on chest radiographs obtained on chest radiographs obtained during inspiration and expiration during inspiration and expiration Bronchoscope Bronchoscope F.B inside bronchus

3-Bronchial Asthma History History. Episodic symptoms of airflow obstruction. Episodic symptoms of airflow obstruction are present that worse at night and early morning. are present that worse at night and early morning.. History of atopy or eczema.. History of atopy or eczema.. Positive family history of asthma.. Positive family history of asthma. Examination Examination Severe resp. distress partially or completely Severe resp. distress partially or completely reversed with bronchodilator. reversed with bronchodilator.

Investigation  Increased serum IgE level  Oesinophilia in peripheral blood  Skin test positive in older childern  FEV1< 80% of expected and reversability is more than 12% after bronchodilator Course Recurrent episodic attacks of chest symptoms which may be ppt.by specific allergen or URTI that usually respond to B.D Recurrent episodic attacks of chest symptoms which may be ppt.by specific allergen or URTI that usually respond to B.D

4- Transient Infant Wheeze: History   Persistent or recurrent wheeze from early infancy.   No history of atopy.   Cease wheezing either late in first year or early in their second year.   No history of hospital admission.   Unresponsive to bronchodilator.

Examination A well baby (thriving child) No significant respiratory distress Generalized wheezes No undercurrent febrile illness Investigation Normal X ray chest   Pulmonary function airflow rate are abnormally low

5- Gastroesophageal Reflux - It is a retrograde passage of stomach contents into esophagus secondary to relaxation of esophageal sphincter. - wheezing from GER results either from reflex bronchospasm after esophageal irritation or from aspiration of gastric content.

History - Symptoms worsen after meal or when they are supine presence of GIT symptoms: - Symptoms worsen after meal or when they are supine presence of GIT symptoms:  vomiting.  Arching of back during feeding.  Crying during feeding irritability during feeding. - Recurrent chest infection

Examination - Failure to thrive if GIT manifestation are severe. - Failure to thrive if GIT manifestation are severe. - Multiple chest auscultatory signs. - Multiple chest auscultatory signs.Investigation - A barium study (evaluate anatomy). - A barium study (evaluate anatomy). - Radionuclide scintigraphy (GER scan). - Radionuclide scintigraphy (GER scan). - PH probe monitoring. - PH probe monitoring.

6-Bronchopulmonary Dysplasia History of neonatal problem History of neonatal problem Low birth weight under 2.5 KgLow birth weight under 2.5 Kg Persistent or recurrent wheezingPersistent or recurrent wheezing wheezes usually associated with intercurrent viral respiratory infectionwheezes usually associated with intercurrent viral respiratory infection Continue

7- Tracheomalacia or Bronchomalacia History Causing wheezes from birth but more commonly in first 2-3 months of life. Wheezes are loud during activity but are quit at rest ( because the degree of air way narrowing depends on the amount of collapsing pressure applied,wheezes is loudest during periods of increased expiratory effort, crying and agitation) in contrast wheezing may disappear during sleep when expiration is unlabored.Wheezes are loud during activity but are quit at rest ( because the degree of air way narrowing depends on the amount of collapsing pressure applied,wheezes is loudest during periods of increased expiratory effort, crying and agitation) in contrast wheezing may disappear during sleep when expiration is unlabored.

High pitched inspiratory stridor may be present High pitched inspiratory stridor may be present Investigation. Bronchoscopy during spontaneous expiration, the trachea and bronchi narrow by more than 50%of their resting caliber Fluoroscopy of air way can demonstrate collapse during exhalation

8-Acute Congestive Heart Failure History Feeding difficulties (interrupted feeding, cold sweat on forehead following feeding, tachypnea after feeding ) Recurrent chest infection Frank history of congenital heart disease (VSD,PDA,ECD)

Examination   Failure to thrive (usually under weight due to CHD   Hyper dynamic pericordium with cardiomegaly   Murmurs of specific cardiac lesion   Wheezes diffuse with fine basal cons. Crepitation   Tender hepatomegaly, abnormality of peripheral pulses. Investigations   Chest X-ray Cardiomegaly, pulmonary congestion   ECG, ECHO diagnosis specific cardiac lesion

8- Immune deficiency 8- Immune deficiencyHistory Recurrent wheezes with fever Recurrent wheezes with fever Recurrent pulmonary and extra pulmonary infection (Skin Abscesses) Recurrent pulmonary and extra pulmonary infection (Skin Abscesses) Chest infection usually has a prolonged course Chest infection usually has a prolonged course Failure to gain weight Failure to gain weight + VE consanguinity + VE consanguinityExamination Bad general condition Bad general condition High fever ē wheezes High fever ē wheezes Many chest auscultatory finding Many chest auscultatory finding Involvement of other system as well Involvement of other system as well

Investigations CBC CBC Leucopenia or granulocytosis T cell function CD 4, CD 8 T cell function CD 4, CD 8 Immunoglobulin assay IgA,E,M,G Immunoglobulin assay IgA,E,M,G

Cystic Fibrosis Cystic fibrosis (CF) is an AR disorder. There is abnormal function of exocrine glands due to defect in cystic fibrosis transmembrane regulator (CFTR) results in production of abnormally thick mucus.Cystic fibrosis (CF) is an AR disorder. There is abnormal function of exocrine glands due to defect in cystic fibrosis transmembrane regulator (CFTR) results in production of abnormally thick mucus. Bronchial mucus is poorly cleared with resulting airway obstruction which causes dyspnea. Hyperinflation, a prolonged inspiratory, exp.ratio and expiratory wheezes.Bronchial mucus is poorly cleared with resulting airway obstruction which causes dyspnea. Hyperinflation, a prolonged inspiratory, exp.ratio and expiratory wheezes. In some children mucus stasis predisposes to chronic bacterial infection and chronic bronchiactasis and pulmonary scaring In some children mucus stasis predisposes to chronic bacterial infection and chronic bronchiactasis and pulmonary scaring

History - History of chronic cough - History of chronic cough - History of recurrent bronchopulmonary infection - History of recurrent bronchopulmonary infection - Failure to thrive - Failure to thrive - Production of large greasy stool (steatorhea) - Production of large greasy stool (steatorhea)Examination - Clubbing - Clubbing - Nasal polyps - Nasal polyps - Barrel chest appearance - Barrel chest appearance - Prominent abdomen - Prominent abdomenInvestigation - Sweat chloride test - Sweat chloride test

Clues to the Cause of wheeze in infants with Failure to thrive Cystic fibrosis Cystic fibrosis Severe gastro cesophageal reflux Severe gastro cesophageal reflux Chronic lung disease 0f prematurity Chronic lung disease 0f prematurity