Professional Documents
Culture Documents
Samah Awad
29 - 11 - 2013
Wheezing in Preschool Children
- If in the small airways there would be diffuse narrowing then it would be polyphonic
Stridor. Is a sound the is produced due to obstruction in upper airway (extra thoracic)
mainly during inspiration.
- Position affects its intensity so it is worse if lying supine and flexed position
But usually the position does not affect the wheezing, despite that sometimes when the
baby gets irritable the wheeze may show up
Examples of diseases that cause srtidor are, croup, infection, laryngomalacia and many
other DDx that are beyond our scope for this lecture.
** epiglottitis, cause upper airway obstruction but does not cause stridor
** laryngomalacia,
- it is the most common congenital anomaly of stidor,
- it is an abnormality in larynx cartilage where softening of it may predispose the
larynx to collapse during breathing,
- it stars after birth but subside by time so usually it does not need intervention or
surgical repair unless sever
-interfere with feeding and growth causing apparent life threatening event as cyanosis
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Pathophysiology of Wheezing:
As we said, wheezing result from Partial obstruction of airways due to single or multiple
points of airway narrowing, where there would be critical airflow velocity (reduced),
together these would cause the flow to be turbulenced so wheeze is produced.
Differential Diagnosis:
• Congenital Anomalies
1. Tracheoesophageal Fistula,
4 or 5 types,
The most common type is proximal esophageal atresia with distal
fistula, where the esophagus is atretic (has no continuation) while the
fistula is connecting the distal part of the esophagus with the trachea. It
could be detected very early since baby start to vomit immediately after
feeding, if NG tube is inserted then it would coil and won’t pass into the
stomach
H type fistula, which usually present as wheezing but could be missed
until later age 2 or 4 after recurrent wheezing, pneumonia, misdiagnosed
to have asthma
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2. Tracheomalacia/Bronchomalacia
3. Vascular ring
4. Bronchogenic Cyst
5. Bronchial/tracheal stenosis
1. Swallowing dysfunction
If laryngomalacia, where the larynx could not protect the air way properly
Cleft palate
CNS disease
Neuromuscular disease
Structural lesions
2. GERD, where they may aspirate the gastric content from below
3. Foreign body aspiration
Here the Dr talked about a 4 months baby who was referred to hospital as FTT, his first presentation was
wheezing, then he was diagnosed to have laryngomalacia, was operated, first the mother complained that
her baby is not gaining weight (2.4 kg) and do not like the milk, by observing his feeding process, it was
found that baby starts to cough and wheeze once the bottle is put in his mouth. He ended to have a
gastrestomy tube because they were not able to establish a safe oral route of feeding, and so now he is
gaining weight interestingly
• Cardiogenic causes:
1. Heart failure,
kids with congenital heart disease, acyanotic CHD, like VSD or PDA, they could
present with wheezing (mainly due to the interstitial edema formation in the lungs
which cause airway narrowing), where by good examination you could hear the
gallop rhythm and feel the hepatomegaly, but unfortunately those patients could
be missed
2. Airway compression due to cardiomegaly, where the baby is known to have a
cardiac problem but even with treatment of it he persist to wheeze all the time
(usually inspiratory expiratory wheeze) due to the compression on the airways
Tumors
1. Benign, malignant
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Tracheobronchomalacia:
Patients having this are usually called the happy wheezers since they live normally,
complaining of nothing but the wheeze that develop due to the malacia (not an inflammation).
It is mild that usually does not need intervention unless respiratory failure is present
because of this, so we should do the surgery to fix it, but usually it disapper by itself with
time due to development of the cartilage
- Laryngomalacia, it is an upper airway problem where the larynx is very soft and the
epiglottis is collapsed so cannot close the airway appropriately; sometimes we need
surgery by ENT Drs for that to be corrected by laser therapy to strengthen the
connective tissue or the cartilage.
- Both of them have the same pathophysiology, where softening of the cartilage is present
- Both could be present together so patient have stridor and wheezing
- Both could be mild or severe according to the degree of malformation.
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Vascular Ring:
Case Discussion:
A previously healthy boy, 2 years 10 months of age, was brought by his parents to a pediatric emergency
department (ED) with fever up to 103°F for 3 days and intermittent violent coughing episodes. His
mother had brought him to the ED 10 days earlier because he was experiencing wheezing and cough. The
patient was afebrile at that time and had no history of asthma. He was administered albuterol in the ED
for bilateral wheezing in the lung bases, after which he showed some improvement. Because the
wheezing was not focal and the boy seemed to be well, he was discharged with a prescription for
albuterol and instructions for close follow-up with his pediatrician. The patient's parents administered the
albuterol to him intermittently, and he continued to have episodes of coughing and gagging. During the
past 3 days, he developed an increasingly harsh, productive cough and has had emesis 1-2 times per day.
At this visit, the patient’s father recalled that the child had choked on a plastic peg from a
Lite-Brite toy approximately 3 weeks earlier.
The patient was afebrile, his respiratory rate was 28 breaths per minute, his pulse was 118
beats/min, and his room air oxygen saturation was 96%. He appeared to be comfortable and
had clear rhinorrhea. Respiratory effort was normal, with markedly decreased aeration on
the left. He had no wheezing or crepitations
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The patient underwent bronchoscopy, and a red plastic peg was removed from the left main-stem
bronchus. The foreign body was surrounded by large amounts of purulent secretions. The patient
recovered well and had no complications
• Majority of cases will be below age 3 years, peak incidence in 1-2 years of age.
When they start the mouthing and they develop a good motor skills to walk
around and pick the foreign body, they could aspirate the food, peanuts
especially, or they could aspirate the small batteries, coins …
They may even get the FB lodged in the esophagus, in a way that would compress the airways, where
patient may come with wheezing and then after the lateral x-rays the coin is found in the esophagus
>> usual course that they would choke, cough slightly and then that will be subside, it
can passed as minor event, even that some parents do not recall the choking event
>> sometimes it is hard to remove the FB, so they leave it, which may cause granuloma
Evaluation of Wheezing:
Any evaluation starts with good history then physical examination then take the lab you
want
History:
1) Birth History:
Gestational age
Respiratory difficulties in neonatal period
Length for assisted ventilation
Oxygen supplementation
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2) History of onset of wheezing
Age of onset
Other symptoms associated with the wheezing episode as cough or difficulty
breathing
Also ask about swallowing problems, difficulty breathing or SOB, previous attacks,
cyanosis, steatorrhea, diurnal variation, relation to position, exacerbating and
relieving factors, triggering factors, sweating, pattern of the attack and if symptom
free between the attacks
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Physical Examination:
1. General Status
Well-nourished
Failure to thrive
Clubbing
2. Respiratory Rate
Normal or elevated for age
3. Characteristics of Wheezing
Generalized or unilateral
Monophonic or polyphonic
Inspiratory, expiratory or both
Other adventitial lung sounds by auscultation
Also exam the chest expansion, chest symmetry, tracheal deviation, presence of fever
or not, growth parameters and pain
Laboratory Studies:
You should pick what you want, do not ask for every test, because the history will guide
you. So It would vary depending on the suspected etiology of wheezing.
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X-rays:
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** we also ask for the decubitus film if pleural effusion
Barium Swallow
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this is a barium swallow that detected a vascular ring , here we see a
posterior indentation of the esophagus caused by compression , when you
find a vascular ring you should do a “MRI” or “MRA”, that is important
because we need details for the anatomy , in order to help the sergeant
when he operates because he will need the exact anatomy . and it Is the
gold standard for diagnosis .
so in this case the CT is asked for after we see the abnormality in the X-ray
that suggests a mass or a cyst or other abnormality.
Bronchoscopy :
When do I do a bronchoscopy ???
1) Foreign body , we have two types of bronchoscopes the rigid and the flexible , in the case of a
foreign body we will use the rigid bronchoscope , because the rigid bronchoscope has a pipe
shape.
We actually can pass the forceps within the bronchoscope , an it can be used to ventilate the
baby .
The flexible bronchoscope has a very tiny suction channel , in adults they
can pass forceps but not for the case of foreign body retrieval .
Other laboratory studies , u can pick what ever you want according to the
suspected etiology or disease , sweat chloride of we are thinking of CF , upper gi
studies or 24 ph probe if you are thinking about GERD , echocardiogram if you are
thinking of a cardiac etiology .
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So we do not have to order all the tests . only select those that you need to perform .
*A common question is :
Does my child have asthma ???
A common early presentation of asthma is wheezing and cough that follows a URTI “a viral
infection” , it is unknown wither the infection triggered the asthma or if that the child has a
predisposition of wheezing after the infection .
• It is difficult to distinguish an initial episode of asthma triggered by viral RTI from wheezing due
to viral bronchiolitis
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This figure is very important
When a healthy baby becomes infected with RSV , that happens to about 90% of infants most
get symptoms of common cold
Minority experience Bronchiolitis which is the most common cause of hospitalization in first
year of life
25-50% will have intermittent pattern of asthma manifested as recurrent wheezing associated
with viral RTI , remission is common in later in childhood , this pattern is known as intermittent
asthma and episodic asthma and transient , those children are symptom free between the
attacks , so the mother would complain of wheezing and cough that starts with a runny nose .
Some would continue to have persistent symptoms throughout childhood and may continue
until adulthood even between the attacks and it is called a chronic or persistent asthma , those
Children have atopy (IgE mediated inflammation) , they react showing hyper responsiveness to
certain allergens .
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*Who Gets Asthma?
• Genetic Factors
Some evidence that supports the presence of genetic attributuin
-Asthma presents in 25% of the offspring of a parent with asthma
-Higher concordance in MZ twins compared to DZ twins
• Environmental Factors
-Children who are exposed to certain allergens , cats , dogs , dust mite and so on , increase the
risk of developing asthma
-Tobacco smoke has synergistic effect with inhalant allergens , passive smoker kids are more
likely to develop asthma .
• Remission of symptoms by school age ( most likely) , by 5-6 years these patients wont have
symptoms .
• Poor response to anti-inflammatory agents , inhaled steroids will not prevent the attacks , it
could minimize the severity and the duration of the attack but it doesn’t remove it
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• The bronchodialators usually relief the attack but the controller does not prevent an attack
***note: the determining of the pattern is very important to the finding of the proper
treatment
• History of chocking
• Failure to thrive
Four or more episodes of wheezing in the past year that lasted for more than one day and affected
sleep
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One of the following: Two of the following:
AND
• Parenteral history of asthma • Food allergy
it to the package .
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