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

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

3. 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

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

5. 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

6. Differential diagnosis of wheezing due to upper airway diseases

7. Differential diagnosis of wheezing due to lower airway diseases

12. 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

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

14. 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

15. 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

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

17. Laryngeal Disorders Laryngeal nerve paralysis Flaccid VC Laryngeal nerve paralysis Flaccid VC

18. Bronchiectasis / CF

19. Tracheal compression secondary to intrathoracic goiter

20. 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

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

22. 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

23. RUL Bronchus

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

25. Foreign Body Aspiration Day 3 Nut

26. Foreign Body Aspiration I and E

27. Foreign Body Aspiration FBA

28. 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

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