Definition

• A wheeze is a high-pitched, musical, adventitious lung sound produced by airflow through an abnormally partially narrowed or compressed lower airway

• A wheeze is synonymous with a high-pitched or sibilant rhonchus.

• Wheezes are heard more commonly during expiration

• Wheezing during expiration alone = milder obstruction

• Wheezing during both inspiration and expiration = more severe airway narrowing.

• Wheezing may be acute or chronic /recurrent

Differential Diagnosis

Acute bronchiolitis

Foreign body aspiration

GERD

Bronchial asthmaVascular ring

Pneumonia

Cardiac asthma

ACUTE BRONCHIOLITI

S

Clinical syndrome

Characterized by pulmonary hyperinflation and wheezing

Due to acute, infectious, inflammatory obstruction of small airways (bronchioles)*

* With no muscle layer

Definition

Etiology

Parainfluenza,Adenovirus,Influenza,Mycoplasma etc

Respiratory Syncytial Virus

75%

Viral invasion of small bronchi &

bronchioles

Complete bronchiolar obstruction

Atelectasis

Incomplete obstruction (Ball

valve)

Early air trapping during expiration

Over inflation of lung

Pathogenesis

Accumulation of mucus,

Edema, Cellular debris

Incidence

Sex

• Male is 1.25 times more frequently than female

Age

• First 2 years of life

• Peak at 2-8 months

Food

• Non-breastfed

Season

• Winter and early spring

SYMPTOMS OF PNEUMONIA

Fever, toxic ill, cough, dyspnea and grunting

SIGNS OF ASTHMAretractionHyperinflation, decrease TVFDiminish airway, Harsh V breathing, Decrease VR, Wheeze

SymptomsMild Upper Respiratory Tract Infection for 2-3 daysGradual onset of Respiratory Distress Paroxysmal Spasmodic CoughWheezesDyspnea Irritability+- Feeding difficulty due to tachypnea

CLINICAL PICTURES

SIGN

Tachypnea

Hyperinflation

Wheezes

Respiratory Distress

Respiration fast & shallow.Labored breathing (chest indrawing, flaring alae nasi, IC retraction)Air hungerRestlessnessCyanosis

Hyper resonant note due to over inflated lungs

Decrease air entryHarsh vesicular breathing + prolonged expirationInspiratory + expiratory wheezesInspiratory widespread fine crackles

Differences between bronchiolitis and bronchial asthma

• 1-Asthma is not common in the first year.• 2-The following may favors the diagnosis of

asthma which are: -positive family history, repeated attacks,

markedly prolonged expiration, onset may be sudden, without preceeding URT infection., there will be eosinophilia and favourable response to bronchodilators.

Course of the disease

• -A critical phase in first 48-72 hours by which the patient is desperately ill and apneic spells occur in the very young infants and the followed by rapid improvement.

• - In the outcome of the long term, some children may develop persistent airway hyperactivity later in childhood.

Complications:• 1-Bacterial superinfections e.g-

bronchopneumonia.• 2-Cardiac failure: rare, mainly in patients with

underlying cardiopulmonary disease example congenital heart disease, cystic fibrosis, bronchopulmonary dysplasia.

• 3-Death due to severe course with prolonged apneic spells, severe uncompensated respiratory acidosis and profound dehydration due to tachypnea and inability to drink due to respiratory distress.

•

MANAGEMENTOF ACUTE

BRONCHIOLITIS

Investigations

• Laboratory studies• Imaging studies• Other tests

Laboratory studies

. X ray ( or CT chest)• A CBC is seldom useful since the white blood

cell count is usually within normal limits.• Arterial blood gases (ABG).

Imaging studies

• These are not routinely necessary.• Hyperinflation and patchy infiltrates may be seen; but these

are non - specific• Focal atelectasis• Air trapping• Flattened diaphragm• Increased anteroposterior diameter• Peribronchial cuffing• Chest radiographs may also reveal evidence of alternative

diagnoses, such as lobar pneumonia, congestive heart failure, or foreign body aspiration.

• A chest X-ray demonstrating lung hyperinflation with a flattened diaphragm and bilateral atelectasis in the right apical and left basal regions in a 16-day-old infant with severe bronchiolitis

Other tests

• Antigen tests of nasal washings provide rapid and accurate detection of RSV.

• A positive culture or direct fluorescent antibody test result can confirm the diagnosis of RSV infection.

• Cultures of RSV are considerably less sensitive (60%) but are 100% specific.

Treatment and medications

• General supportive measures are the mainstay of treatment for patients with bronchiolitis.

Oxygen

NutritionFluids

• Avoid sedatives!

Medications

• Antiviral drugs – only to those have severe RSV infections or high risk infants (Ribavirin)

• Antibiotics – Of no values• Corticosteroids – their use is controversial• Nebulized B2 – agonists – their use are also

controversial• Aerosolized racemic epinephrine – may have

some benefits as they have a vasoconstrictor effect

Prevention:

• Exclusive breastfeeding for the first 6 months decrease the risk of acquiring the RSV infection.

• -Avoid exposure to viral URTI during respiratory illness season.

• -Passive immune-prophylaxis with intravenous anti-RSV immune globulin or intramuscular anti RSV monoclonal antibodies, this is given to selected small infants with underlying cardio-pulmonary disorders.

• -Vaccination is not yet available and preventive vaccines are currently being studied.

FOREIGN BODY

Foreign body aspiration

• very serious, often life-threatening condition• Ninety percent of deaths occur in patients

who are younger than 5 years, and two thirds of these deaths occur in infants.

Why?

exploration of their

environment by putting

objects into their mouths

learning to walk and run

inadequate dentition

immature swallowing

coordination

What?

Pathophysiology

Complete airway obstruction

airway at levels above the carina

acute onset of respiratory distress in which the

patient is unable to speak or cough

Partial airway obstruction

partially occluded or if the obstruction occurs

distal to the carina

recurrent pneumonia, persistent cough,

hemoptysis, wheezing, or atelectasis

Diagnosis

• History– Positive history can be obtained – but often complicated by the fact that the event

may be unwitnessed in 90% of the case, witnessed by a person not present for history taking, or witnessed by an older sibling who may have had a role in the aspiration and chooses not to say anything.

Clinical picture

First phase

• immediately following the incident

• choking, gagging, coughing, wheezing, and/or stridor

• associated temporary cyanotic episode

Second phase

• asymptomatic period

• can last from minutes to months following the incident

Third phase

• renewed symptomatic period

• Airway inflammation or infection occurs

• of cough, wheezing (maybe unilateral) , fever, sputum production, and occasionally, hemoptysis.

• Imaging– most foreign bodies are not radiopaque– findings suggestive of the presence of a foreign

body such as

• Other test:– Bronchoscopy : diagnostic and therapeutic

mediastinal shift atelectasis

hyperinflation

Expiratory chest radiograph in a 12-month-old boy with a 2-month history of wheezing demonstrates continued hyperlucency and hyperexpansion of the right hemithorax. A greater mediastinal shift is noted toward the left lung field. A corn kernel was removed from the patient's right mainstem bronchus during bronchoscopy

Treatment

• No response to bronchodilators• Bronchoscopy

GERD

GERD in infant

• Most of the time, reflux in infants is due to a poorly coordinated gastrointestinal tract.

• Many infants with the condition are otherwise healthy; however, some infants can have problems affecting their nerves, brain or muscles.

• Certain factors also may contribute to GERD, including: obesity, overeating, certain foods, some beverages, and specific medications.

• There also appears to be an inherited component to GERD, as it is more common in some families than in others

GERD and wheezes?

GERD

Aspiration

Signs and symptoms

• Frequent or recurrent vomiting• Frequent or persistent cough• Heartburn, gas, abdominal pain, or colicky behavior

(frequent crying and fussiness)• Regurgitation and re-swallowing• Colic (frequent crying and fussiness)• Feeding problems wet burp or frequent hiccups

• Recurrent choking or gagging • poor sleep habits typically with frequent waking• arching their necks and back during or after eating• frequent ear infections or sinus congestion• Poor growth• Breathing problems• Recurrent wheezing

Investigations

• Ultrasound• Barium swallow• Esophageal pH monitoring• Scintigraphy (isotope scan)• Endoscopy

Ultrasound

Barium swallow

Esophageal pH monitoring

Scintigraphy

• Caloric liquid or solid meal appropriate to the patient’s age were used: 200 to 250 mL of formula or breast milk for small infants was labeled with isotope

• After the ingestion of the radiolabeled test meal at lunchtime, the patient was given a small portion of the unlabeled meal to wash out all previously ingested radioactivity from the esophagus

• Images then taken with the gamma camera.

Endoscopy

BRONCHIAL

ASTHMA

VASCULAR

RING

BRONCHO

PNEUMONIA

CONGESTIVEHEART

FAILURE

T H E E N DT H A N K Y O U