wheezing
TRANSCRIPT
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All That Wheezes…All That Wheezes…
Andrew Lipton, MD, MPH&TMAndrew Lipton, MD, MPH&TMMAJ, USA, MCMAJ, USA, MC
Chief, Pediatric PulmonologyChief, Pediatric PulmonologySan Antonio Military Pediatric CenterSan Antonio Military Pediatric Center
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What is a “wheeze”
Definitions of obstructive noises Stertor
• Low-pitched, rumbling• Inspiratory• Nasopharynx, oropharynx, nasal passage• Loudest over neck, cheeks
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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
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What is a “wheeze”
Definitions of obstructive noises Wheeze
• Higher-pitched expiratory noise• Monophonic, homophonous = large airway
= expiratory stridor• Polyphonic, heterophonous, musical =
small airways
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What is a “wheeze”
Definitions of obstructive noises Secretory Noise
• Gurgling, polyphonic, upper or lower airway
• Highly variable
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-5 -5
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Pre-Inspiration
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-7 -7
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-1
-1
Inspiration
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-7 -7
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Inspiration
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-8 -8
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End Inspiration
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Forced Expiration
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+30 +30
+38
-20
+30
+1
+10
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Forced Expiration
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Stertor
Causes Choanal atresia Mandibular hypoplasia Macroglossia Nasal congestion Adenotonsillar hypertrophy Pharyngeal insufficiency Encephalocele Dermoid of base of tongue Thyroglossal duct cyst Lingual thyroid
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Inspiratory Stridor
Causes Laryngomalacia Vocal cord paralysis
• Unilateral – left (recurrent laryngeal nerve)• Bilateral – brainstem
Laryngotracheoesophageal cleft Laryngocele Laryngeal polyp Abscess Hypotonia
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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
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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
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Biphasic Stridor
Causes Subglottic stenosis
• Congenital • Acquired – intubation, croup
Subglottic hemangioma Laryngeal web GERD
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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
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Biphasic Stridor
Causes Recurrent Croup
• Consider underlying airway anomaly• GERD• Spasmodic (reactive airways)
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Expiratory Stridor
Causes Tracheomalacia Bronchomalacia Vascular Ring/Sling Complete Tracheal Ring Tracheoesophageal Fistula Bronchogenic Cyst Mediastinal Mass Foreign Body GERD
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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
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Wheezing
Causes Asthma Bronchiolitis Pneumonia GERD – inflammation, bronchospasm Heart Failure – often presents around 2 mos BPD Other: CF, Ciliary Dykinesia, Food Allergy
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History
Congenital or acquired Acute, Chronic, or intermittent Positional? Feeding – gag/choke/cough, suck,
emesis, fatigue Voice/cry quality
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History
FTT – increased WOB, poor feeding• >90% - think of GERD
Cyanosis Apnea Fever Cough Nocturnal Sxs
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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
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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
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Radiographs
Lateral neck Chest PA/Lateral CT Head/Neck/Chest UGI, Videofluoroscopic swallowing study Airway fluoroscopy MRI/MRA – chest, brainstem
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Other Studies
Bronchoscopy• Flexible• Rigid
Laryngoscopy Polysomnography (sleep study) Echocardiography Infant PFTs pH Probe, scan ABG
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Other Studies
Allergy testing Immunoglobulins CBC ABG Sweat Cl Ciliary Bx