wheezing from pco
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Wheezing
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Definition / Supporting InformationWheezing is a whistling sound that occurs as a result of bronchospasm (airwayconstriction). It is usually more prominent during expiration but may also be present ininspiration.
Essential HistoryAsk about:
Age at onset
Frequency of wheezing
Intermittent or constant wheezing
ecent upper respiratory tract illness
Fe!er
Association with !igorous acti!ity" changing weather" exposure to allergens
Acute onset
Accompanying coughing" cho#ing
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Frequent !omiting
$ositional wheezing
Worsening with agitation or crying
%ifficulty in swallowing
Allergies" anaphylaxis
Faltering growth (re!iew &ed 'oo#& charts)
aemoptysis
ecent surgical procedure intubation
$oor response to con!entional therapy
Family history of wheeze and or cystic fibrosis
*ight time symptoms
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+mo#ing in the house
%amp and or mould in the house
'Red Flag' Symptoms and SignsAsk about:
Allergies especially to food animals and specifically about pre!ious anaphylacticreactions
$oor feeding and respiratory distress in acute wheeze
Faltering growth in chronic wheeze
'reathlessness
,oo breathless to spea# full sentences-
$anic anxiety
Is the patient frightened-
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$re!ious admissions
$re!ious admission to intensi!e care unit
$re!ious need for intra!enous therapies to support respiration
$re!ious intubation" e!en as a neonate (thin# of subglottic stenosis)
Look for:
+igns of respiratory distress
,achypnoea
ecessions
%ecreased or absent breath sounds &silent chest&
/nilateral wheezing
0ost often associated with aspiration of a foreign body
Differential Diagnosis / Conditions
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1iral bronchiolitis" !iral lower respiratory tract infections and asthma account for mostwheezing
Wheezing after a recent surgical procedure or intubation suggests acquiredobstruction
2xpiratory wheeze can result from3
4arge airway obstruction (ie" trachea or mainstem bronchi) or
$eripheral small airway obstruction (ie" asthma)
$resence or absence of expiratory wheeze does not reliably indicate location of
obstruction
Asthma
Worse with exercise or respiratory infections
5ther triggers include3
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o
6ontact with animals
o
+tress or emotional disturbances
o
Weather conditions
esponds to bronchodilators and steroids
e!ersible obstruction on pulmonary function testing
$olyphonic musical expiratory wheeze
Family history
,racheomalacia
Worse with acti!ity or agitation
$oor response to bronchodilators and steroids
0onophonic usually inspiratory noise
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Inspiratory airway collapse
o
%etectable by fluoroscopy
6ollapsing trachea on inspiration
o
%etectable by bronchoscopy
'ronchomalacia
Worse with acti!ity or agitation
$oor response to bronchodilators and steroids
0onophonic usually inspiratory noise
Airway collapse
o
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%etectable by fluoroscopy
6ollapsing bronchus
o
%etectable by bronchoscopy
Foreign body
+udden onset
0ay be associated with history of cho#ing
0any patients with foreign body aspiration do not ha!e an ob!ious history ofcho#ing
o
6ho#ing should be suspected e!en in a child whose wheezing has been presentfor days or wee#s
%ifferential breath sounds
%ifferential hyperinflation or collapse on radiography
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eart failure or pulmonary oedema
$oor response to salbutamol
$oor growth
epatomegaly
adiography showing enlarged heart and or pulmonary oedema (increased fluid)
esponds to diuresis
'ronchiolitis
Infant
o
/pper respiratory tract infection symptoms
0ost usual pattern3
http://www.pcouk.org/drug.aspx?gbosId=200278http://www.pcouk.org/drug.aspx?gbosId=200278 -
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o
2xpiratory wheeze
o
Inspiratory and expiratory crac#les
$ositi!e !iral studies
Wheezing caused by !iral bronchiolitis3
Is usually preceded by upper respiratory tract symptoms and fe!er
Worsens within the first few days of onset
,ends to impro!e slowly thereafter
1ocal cord dysfunction (see +tridor)
0ore common in older children
$oor response to all bronchodilators
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0ay ha!e inspiratory as well as expiratory component
%istress may be se!ere
$ulmonary function tests may be normal" may ha!e reduced pea# expiratory flowrate ($2F) and with abnormal inspiratory loop
5xygen saturation in air usually normal
4aryngoscopy shows paradoxical !ocal cord adduction during inspiration
6ystic fibrosis
$oor growth" gastrointestinal (7I) symptoms
ecurrent pneumonia
Frequent fruity moist cough
$ositi!e sweat test
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0ay be finger clubbing
7astro8oesophageal reflux and aspiration
istory of frequent !omiting
1ariable response to bronchodilators
5ften worse after meals
$oor growth" 7I symptoms
ecurrent pneumonia
6onfirmation of reflux by upper 7I endoscopy" nuclear scan" or p probe
$ulmonary haemosiderosis
are disorder causing anaemia and recurrent wheezing from blood irritating theperipheral airways
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0ay present with haemoptysis or in association with iron deficiency anaemia
1ascular abnormalities or compression
0ay be inspiratory as well as expiratory noise
5ften present from birth or soon after birth
*o bronchodilator response
5esophageal indentation on barium swallow
6hest 98ray may show right8sided aortic arch
Anatomy shown on thoracic magnetic resonance imaging
Abnormality (eg" stenosis" complete rings" compression) of large airways3
*o response to therapy
Worse with acti!ity
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+tridor noted at times
Flattened or square flow!olume loop
5bstruction !isible on imaging or bronchoscopy
6ongenital airway abnormalities
Wheezing that appears at birth or soon afterward should prompt an e!aluation for3
o
,racheomalacia
o
6omplete tracheal rings
Investigations,o be underta#en by non8specialist practitioners (eg" 7eneral $ractitioner (7$) ,eam)3
0easure !ital signs including oxygen saturation" $2F
*asopharyngeal aspirate in younger children (below : years of age) for !iral studies(if a!ailable)
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6hest 98ray
,horacic masses
Foreign body aspiration
,o be underta#en by specialist practitioners (eg" 2mergency %epartment $aediatric $aediatric espiratory ,eam(s))3
4aboratory testing may be indicated to diagnose specific clinical entities
+weat test for cystic fibrosis
1iral studies can identify respiratory syncytial !irus or influenza
Airway fluoroscopy
6an confirm diagnosis and help to quantify the se!erity of tracheobronchomalacia
'arium swallow or upper 7I series
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/seful if a !ascular abnormality is suspected
6omputed tomography or magnetic resonance imaging
6onfirmation of !ascular abnormality or other intrathoracic lesions
%iagnostic procedures
$ulmonary function testing (spirometry) can help to3
o
5btain ob;ecti!e data on wheezing in patients aged < years and older
o
%istinguish re!ersible airways disease from fixed obstruction
o
%istinguish small airway from large airway obstruction
Flexible bronchoscopy3
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o
7i!es !isualisation of airways
o
/sually in!ol!es a general anaesthetic
o
/seful to characterise dynamic lesions (ie" tracheobronchomalacia)
igid bronchoscopy
o
6an be useful in diagnosis and treatment of3
+uspected inhaled foreign body
arer conditions such as tracheal stenosis
reatment !pproa"hIn general" when e!aluating and managing the wheezy child3
'e aware of the !arious clinical entities that can produce wheezing
'e able to recognise by history or physical examination patients who require furtherin!estigation or inter!ention (see Anaphylaxis and +tridor)
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,o be underta#en by non8specialist practitioners (eg" 7$ ,eam)3
For acute management of wheeze in asthma and !iral induced wheeze see 'ritish
guideline on the management of asthma = +I7* clinical guideline >?>@.
Asthma
+albutamol> microgrammetered inhalation3 ?B puffs !ia a spacer de!ice" e!ery
? hours as needed. 7i!e up to > puffs in mild to moderate acute asthma
5ral prednisolone>8: mg#g (max. ? mg) once daily for three days
1iral bronchiolitis
Inhaled beta : agonist bronchodilators" ipratorium bromide" adrenaline" hypertonicsaline are not recommended for the treatment of acute bronchiolitis in infants('ronchiolitis in children = +I7* clinical guideline C>" +ection B.D.>@and = *I62clinical guideline *7C" +ection >.?@).
+ome children require hospital admission for3
+e!ere respiratory distress
https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/http://www.pcouk.org/drug.aspx?gbosId=200278http://www.pcouk.org/drug.aspx?gbosId=200586http://www.sign.ac.uk/pdf/sign91.pdfhttp://www.sign.ac.uk/pdf/sign91.pdfhttp://www.nice.org.uk/guidance/NG9/chapter/1-recommendations#management-of-bronchiolitishttp://www.nice.org.uk/guidance/NG9/chapter/1-recommendations#management-of-bronchiolitishttps://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/http://www.pcouk.org/drug.aspx?gbosId=200278http://www.pcouk.org/drug.aspx?gbosId=200586http://www.sign.ac.uk/pdf/sign91.pdfhttp://www.nice.org.uk/guidance/NG9/chapter/1-recommendations#management-of-bronchiolitishttp://www.nice.org.uk/guidance/NG9/chapter/1-recommendations#management-of-bronchiolitis -
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ypoxaemia
$oor feeding
%ehydration
,o be underta#en by specialist practitioners (eg" 2mergency %epartment $aediatric $aediatric espiratory ,eam(s))3
For the acute management of asthma and !iral wheeze see 'ritish guideline on themanagement of asthma = +I7* clinical guideline >?>@.
+albutamol!ia an inhaler de!ice
Ipratropium bromide
5ral prednisolone
5xygen to #eep saturations E C:
,reatment of other causes of wheeze depends on the underlying cause.
When to Referefer to specialist practitioners (eg" 2mergency %epartment $aediatric $aediatricespiratory ,eam(s)) if3
https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/http://www.pcouk.org/drug.aspx?gbosId=200278http://www.pcouk.org/drug.aspx?gbosId=200987http://www.pcouk.org/drug.aspx?gbosId=200586https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/http://www.pcouk.org/drug.aspx?gbosId=200278http://www.pcouk.org/drug.aspx?gbosId=200987http://www.pcouk.org/drug.aspx?gbosId=200586 -
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Acute wheeze
espiratory distress unresponsi!e to inhaled salbutamol
ypoxaemia
,achypnoea interfering with ability to eat or drin#
Altered mental status or signs of fatigue
efer children with unusual presentations or poor response to con!entional therapiesto appropriate subspecialty physicians
$resence of finger clubbing
$resence of arrison&s sulcus (horizontal groo!e along lower end of rib cage)3
o
0ay represent exaggerated suction of diaphragm on inspiration
o
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+uggests longstanding problem
$ersistent or recurrent wheezing in an infant G > year
Apparent paradoxical response to bronchodilators
$oor weight gain or growth associated with chronic or recurrent wheezing
epeated hospital admission or multiple courses of oral corticosteroid
$ersistent asymmetrical wheezing
'Safety #etting' !dvi"e+ee 'ritish guideline on the management of asthma = +I7* clinical guideline >?>"+ection H.H.:@.
$arents carers should see# urgent medical attention3
If an acute asthma attac# occurs in a child at home and
+ymptoms are not controlled by up to > puffs of +albutamol!ia pressurisedmetered dose inhaler and spacer
$atient / Carer Information
https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/http://www.pcouk.org/drug.aspx?gbosId=200278https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/http://www.pcouk.org/drug.aspx?gbosId=200278 -
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*Please note: whilst these resources have been developed to a high standardthey may not be specific tochildren.
Asthma(Web page)" *+ 6hoices
'ronchiolitis(Web page)" *+ 6hoices
Wheeze(Web page)" $atient.co.u#
Resour"esNational Clinical Guidance
'ritish guideline on the management of asthma(pdf)" +I7* clinical guideline >?>"+cottish Intercollegiate 7uidelines *etwor#.
'ronchiolitis in children(Web page)" +I7* clinical guideline C>" +cottish Intercollegiate7uidelines *etwor#.
'ronchiolitis in children(Web page)" *I62 clinical guideline *7C" *ational Institute forealth and 6are 2xcellence.
Asthma(Web page)" *I62 quality standard +:D>" *ational Institute for ealthand 6are 2xcellence.
Inhaled corticosteroids for the treatment of chronic asthma in children aged >: yearsand o!er(Web page)" *I62 technology appraisal ,A>DH" *ational Institute for ealthand 6are 2xcellence.
!"%no&ledgementsContent Editor: %r +rini 'andi
Clinical Expert Reviewer: %r +imon 4angton ewer
GP Reviewer: %r Kanice Allister
http://www.nhs.uk/conditions/asthma/Pages/Introduction.aspx#closehttp://www.nhs.uk/Conditions/Bronchiolitis/Pages/Introduction.aspxhttp://patient.info/health/wheezehttp://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/http://www.sign.ac.uk/guidelines/fulltext/91/http://www.nice.org.uk/guidance/NG9/chapter/1-recommendationshttp://www.nice.org.uk/guidance/qs25http://www.nice.org.uk/guidance/ta278http://www.nice.org.uk/guidance/ta131http://www.nice.org.uk/guidance/ta131http://www.nice.org.uk/guidance/ta138http://www.nice.org.uk/guidance/ta138http://www.nhs.uk/conditions/asthma/Pages/Introduction.aspx#closehttp://www.nhs.uk/Conditions/Bronchiolitis/Pages/Introduction.aspxhttp://patient.info/health/wheezehttp://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/http://www.sign.ac.uk/guidelines/fulltext/91/http://www.nice.org.uk/guidance/NG9/chapter/1-recommendationshttp://www.nice.org.uk/guidance/qs25http://www.nice.org.uk/guidance/ta278http://www.nice.org.uk/guidance/ta131http://www.nice.org.uk/guidance/ta131http://www.nice.org.uk/guidance/ta138http://www.nice.org.uk/guidance/ta138 -
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AAP Reviewer: %r Lelly K Lelleher
Paediatric Trainee Reviewer 3 %r Ahtzaz assan
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