II. Pathophysiology
- Airway wall fluttering results from flow limitation
- Expiration typically occurs passively with elastic recoil of the chest wall
- Obstruction to outflow requires active expulsion of air
- Resulting positive intrapleural pressure worsens the obstruction
- Wheezing is more common in children than adults
- Inflammation of a child's smaller Bronchi has a greater impact on airway resistance
- Obstruction is more likely in a child's airway due to less chest elastic recoil
- A child's compliant airway walls collapse more easily under negative pressure
III. Causes: Infants
- Acute
- RSV or other Bronchiolitis (most common cause in infants)
- Asthma Exacerbation
- Other respiratory infection (Acute Bronchitis, Pneumonia)
- Foreign Body Aspiration (uncommon under age 1 year)
- Chronic or Recurrent: Common
- Chronic or Recurrent: Uncommon or Rare
- Aspiration Pneumonitis
- Anomalous innominate artery
- Anomalous left common Carotid Artery
- Bronchopulmonary Dysplasia
- Bronchomalacia
- Choanal Atresia
- Congenital Lobar Emphysema
- Congestive Heart Failure
- Cystic Fibrosis or ciliary Dyskinesia
- Double aortic arch
- Diaphragmatic Hernia
- Extrinsic compression by tumor (Neuroblastoma)
- Hemosiderosis
- Tracheal Stenosis
- Tracheomalacia
- Tracheoesophageal Fistula
- Vascular Ring
- Visceral larval migrans
IV. Causes: Children and Adolescents
- Acute
- Asthma Exacerbation (most common cause in children)
- RSV or other Bronchiolitis
- Acute Bronchitis
- Pneumonia
- Foreign Body Aspiration (uncommon after preschool age, if no Developmental Delay)
- Chronic or Recurrent: Common
- Asthma
- Allergic Rhinitis
- Gastroesophageal Reflux disease
- Obstructive Sleep Apnea (adenoid hypertrophy, also with craniofacial abnormalities)
- Chronic or Recurrent: Uncommon or rare
- a1-antitrypsin Deficiency
- Aspergillosis
- Cystic Fibrosis
- Ciliary Dysmotility Syndrome
- Sarcoidosis
- Tumors or Lymph Node compression
- Vocal Cord Dysfunction
V. History
- Onset
- Onset as an infant: Congenital cause
- Sudden onset: Foreign Body Aspiration
- Winter onset with upper respiratory symptoms and with cluster of cases
- Respiratory Syncytial Virus (fall to spring)
- Croup (fall and winter)
- Human Metapneumovirus (winter to spring)
- Pattern
- Seasonal pattern
- Persistent or recurrent respiratory illnesses with Wheezing
- Cystic Fibrosis
- Bronchopulmonary Dysplasia
- Laryngomalacia
- Immunodeficiency (e.g. Primary ciliary Dyskinesia, Agammaglobulinemia)
- Associated cough
- Cough After feeding: Gastroesophageal Reflux
- Dry, nighttime cough
- Modifying Factors
- Wheezing after feeding
- Gastroesophageal Reflux (most common)
- Tracheoesophageal fistula
- Laryngeal cleft
- Positional change
- Tracheomalacia
- Great Vessel anomalies
- Wheezing after feeding
VI. Signs
-
General: Signs of chronic systemic illness (e.g. Cystic Fibrosis, Immunodeficiency)
- Observe for ill, wan, tired appearance
- Review growth charts for fall in Growth Velocity
- Wheezing Intensity
- Wheezing in infant heard without stethoscope suggests Congenital Anomaly
- Wheezing Modifying maneuvers
- Worse with neck flexion and better with extension suggests Vascular Ring
- Severity: Asseess for outpatient versus inpatient management
- Observe for critical or ominous signs
- Altered Mental Status
- Diaphoresis
- Observe for respiratory distress
- Observe for critical or ominous signs
VII. Imaging: Chest XRay
- Consider inspiratory and expiratory films (detects airway foreign bodies)
VIII. Evaluation
- Full Vital Signs including Oxygen Saturation, Respiratory Rate and Peak Flows (if possible)
- V-Q Mismatch in Asthma or Bronchiolitis is typically mild to moderate
- Severe V-Q Mismatch with significant Hypoxemia (O2 Sat <90%) suggests other underlying cause
- Example: Pneumonia
- Consider specific testing or empiric therapy in common conditions
- Asthma (e.g. Spirometry)
- Allergic Rhinitis (e.g. Allergy Testing)
- Gastroesophageal Reflux (e.g. barium swallow)
- Consider testing for uncommon conditions
- Cystic Fibrosis (e.g. Sweat Chloride)
- Immunodeficiency (e.g. Serum Immunoglobulins)
IX. References
- Claudius and Brown (2017) Crit Dec Emerg Med 31(12): 13-20
- Majoewsky (2012) EM:Rap-C3 2(5):2
- Bush (2007) Prim Care Respir J 16:7-15 [PubMed]
- Martinati (1995) Allergy 50:701-10 [PubMed]
- Weiss (2008) Am Fam Physician 77: 1109-14 [PubMed]
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Related Studies
| Definition (NCI) | A symptom and a finding during physical examination, characterized by a high-pitched, whistling sound during breathing. It results from the narrowing or obstruction of the respiratory airways. The most common causes of wheezing are asthma, chronic obstructive pulmonary disease, tracheobronchitis, and pulmonary edema. |
| Definition (NCI_CTCAE) | A disorder characterized by a high-pitched, whistling sound during breathing. It results from the narrowing or obstruction of the respiratory airways. |
| Concepts | Sign or Symptom (T184) |
| MSH | D012135 |
| ICD9 | 786.07 |
| ICD10 | R06.2 |
| SnomedCT | 207058001, 139199004, 161944004, 158380003, 56018004 |
| LNC | MTHU013532 |
| English | Wheezings, WHEEZES, [D]Wheezing, [D]Wheezing (context-dependent category), wheezing [as a symptom], reported wheezing, wheezing, reported wheezing (symptom), Wheezes, wheezes, wheezy, wheeze, [D]Wheezing (situation), Wheeze, Wheezy, Wheezing (finding), Wheezing, NOS, Wheezing |
| Italian | Sibilo, Sibilante, Sibili |
| Dutch | gepiep, piept, piepend, Piepende ademhaling, Wheezing, piepen, Piepen |
| French | Présentant une respiration sifflante, Sifflements, Wheezing, SIBILANCE, Sibilances, Respiration sifflante |
| German | pfeifendes Atmen, pfeifende Atemgeraeusche, pfeifend, Giemen, KEUCHEN, Ziehende Atmung |
| Portuguese | Sibilo, Sibilos, Sibilante, Chiado, PIEIRA, Síbilo |
| Spanish | Sibilante, Pitidos, [D]sibilancias (categoría dependiente del contexto), SIBILANTES, Sibilancias, [D]sibilancias (situación), [D]sibilancias, sibilancias (hallazgo), sibilancias, silbido, Sibilancia |
| Japanese | 喘鳴, 喘鳴性, ｾﾞﾝﾒｲ, ｾﾞﾝﾒｲｾｲ |
| Czech | Sípot, Sípání, Sípoty, Dýchavičný, sípání |
| Korean | 쌕쌕거림 |
| Hungarian | Sípolások, Sípolás, Sípoló |
| Norwegian | Hveselyder, Hvesing |
Ontology: Expiratory wheezing (C0231875)
| Concepts | Sign or Symptom (T184) |
| SnomedCT | 301275009, 9763007 |
| English | WHEEZING EXPIRATORY, auscultation wheezing expiratory, expiratory wheezing, expiratory wheezes, expiratory wheezes (physical finding), wheezing only when breathing out, wheezing only when breathing out (symptom), expiratory wheezing was heard, Wheezing expiratory, expiratory wheeze, Expiratory wheeze (finding), Expiratory wheezing, Expiratory wheeze, Expiratory wheezing (finding), expiratory; wheezing |
| Dutch | piepende uitademing, expiratoir; piepen |
| French | Sifflement expiratoire, SIFFLEMENT EXPIRATOIRE |
| German | pfeifende Atemgeraeusche beim Ausatmen, STRIDOR EXSPIRATORISCH |
| Italian | Sibilo espiratorio |
| Portuguese | Pieira expiratória, SILVO RESPIRATORIO |
| Spanish | Sibilancia expiratoria, SIBILANTES ESPIRATORIOS, sibilancias espiratorias (hallazgo), sibilancias espiratorias |
| Japanese | 呼気性喘鳴, ｺｷｾｲｾﾞﾝﾒｲ |
| Czech | Expirační sípot |
| Hungarian | Kilégzési sípolás |
