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Revision as of 19:05, 20 September 2011

Wheeze
ICD-10 R06.2
ICD-9 786.07

Wheeze Microchapters

Home

Patient Information

Overview

Pathophysiology

Causes

Differentiating Wheeze from other Conditions

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Laboratory Findings

Chest X Ray

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editor-In-Chief: John Fani Srour, M.D.

Overview

A wheeze is a continuous, coarse, whistling sound produced in the respiratory airways during breathing. For wheezes to occur, some part of the respiratory tree must be narrowed or obstructed, or airflow velocity within the respiratory tree must be heightened. Wheezing is commonly experienced by persons with a lung disease; the most common cause of recurrent wheezing is asthma, a form of reactive airway disease.

Pathophysiology

Wheezes occupy different portions of the respiratory cycle depending on the site of airway obstruction and its nature. The proportion of the respiratory cycle occupied by the wheeze roughly corresponds to the degree of airway obstruction.Template:Rf,Template:Rf Bronchiolar disease usually causes wheezing that occurs in the expiratory phase of respiration. The presence of expiratory phase wheezing signifies that the patient's peak expiratory flow rate is less than 50% of normal.Template:Rf Wheezing heard in the inspiratory phase on the other hand is often a sign of a stiff stenosis, usually caused by tumors, foreign bodies or scarring. This is especially true if the wheeze is monotonal, occurs throughout the inspiratory phase (ie. is "holoinspiratory"), and is heard more distally, in the trachea. Inspiratory wheezing also occurs in hypersensitivity pneumonitis.Template:Rf Wheezes heard at the end of both expiratory and inspiratory phases usually signify the periodic opening of deflated alveoli, as occurs in some diseases that lead to collapse of parts of the lungs.

The location of the wheeze can also be an important clue to the diagnosis. Diffuse processes that affect most parts of the lungs are more likely to produce wheezing that may be heard throughout the chest via a stethoscope. Localized processes, such as the occlusion of a portion of the respiratory tree, are more likely to produce wheezing at that location, whence the sound will be loudest and radiate outwardly. The pitch of a wheeze does not reliably predict the degree of narrowing in the affected airway.Template:Rf

Wheezing can also occur in people who are deconditioned.

Differentiating wheezing from the more serious condition of stridor

A special type of wheeze is stridor. Stridor — the word is from the Latin, strīdorTemplate:Rf — is a harsh, high-pitched, vibrating sound that is heard in respiratory tract obstruction. Stridor heard solely in the expiratory phase of respiration usually indicates a lower respiratory tract obstruction, "as with aspiration of a foreign body (such as the fabled pediatric peanut)."Template:Rf Stridor in the inspiratory phase is usually heard with obstruction in the upper airways, such as the trachea, epiglottis, or larynx; because a block here means that no air may reach either lung, this condition is a medical emergency.

Differential diagnosis of wheezing: Common causes

The differential diagnosis of wheezing is wide, and the cause of wheezing in a given patient is determined by considering the characteristics of the wheezes and the historical and clinical findings made by the examining physician. The most common cases in clinical practice are:

Medication-induced bronchoconstriction

Complete Differential Diagnosis of the Causes of Wheeze

(In alphabetical order)



Complete Differential Diagnosis of the Causes of Wheeze

(By organ system)

Cardiovascular Cardiac asthma ( pulmonary edema), Cardiomegaly, Descending aortic aneurysm, Pulmonary edema

Pulmonary embolism, Right sided aortic arch, Vascular compression/ rings, Heart failure

Chemical / poisoning Dialyzer hypersensitivity syndrome, Food allergies, Peanut Allergy, Chemical poisoning
Dermatologic No underlying causes
Drug Side Effect Medication-induced bronchoconstriction, ACE inhibitors, Sotalol

,Adenosine, Beta blockers, Dipyridamole, Protamine, NSAIDs, Aspirin, Marijuana

Ear Nose Throat Aspiration(foreign particles or foods), Bilateral vocal cord paralysis, Hypertrophied tonsils, Intrathoracic goiter, Laryngeal edema, Laryngocele, Laryngostenosis, Laryngotracheobronchitis, Mobile supraglottic soft tissue, Paroxysmal vocal cord motion, Postextubation granuloma, Postlobectomy bronchial torsion, Postnasal drip syndrome, Postradiation stenosis, Retropharyngeal abscess, Supraglottitis, Vocal cord dysfunction, Vocal cord hematoma, Sinusitis
Endocrine Intrathoracic goiter, Obesity,
Environmental asthma, Byssinosis, Hay fever
Gastroenterologic Gastroesophageal Reflux Disease
Genetic Cystic fibrosis, Milk allergy, Obesity, Primary ciliary dyskinesia, Vascular compression/ rings, Alpha 1-Antitrypsin Deficiency, Ciliary dyskinesia-bronchiectasis,
Hematologic Lymphadenopathy
Iatrogenic Aspiration(foreign particles or foods), Esophageal foreign body, Mendelson's syndrome (aspiration pneumonitis),
Infectious Disease Allergic bronchopulmonary aspergillosis, Cold induced wheezing, Bronchitis, Bronchiolitis, pneumonia, Lymphadenopathy, Retropharyngeal abscess, Tuberculosis, Ascariasis, Hookworm, Paragonimiases - lung infection, Strongyloidiasis, Toxocariasis, Aspergillosis
Musculoskeletal / Ortho Cricoarytenoid arthritis,
Neurologic No underlying causes
Nutritional / Metabolic Obesity
Obstetric/Gynecologic No underlying causes
Oncologic Carcinoid syndrome, Lymphadenopathy, Lymphangitic carcinomatosis, Malignancy (bronchogenic tumors), Bronchial adenomata syndrome, Mastocytosis
Opthalmologic No underlying causes
Overdose / Toxicity chemical poisoning
Psychiatric Psychogenic wheezing
Pulmonary Bronchiectasis, Bronchiolitis, Bronchiolitis obliterans, Bronchitis, Bronchopulmonary dysplasia, Carcinoid syndrome, Chronic obstructive pulmonary disease: Chronic bronchitis and Emphysema, Cold induced wheezing, Cystic fibrosis, Pulmonary hemorrhage, pneumonia, Interstitial lung disease, Postlobectomy bronchial torsion, Postradiation stenosis, Primary ciliary dyskinesia, Pulmonary edema, Pulmonary embolism, Tracheal stenosis, Tracheobronchitis, Tracheobronchomegaly, Tracheomalacia, Wegener's granulomatosis, Pulmonary eosinophilia, Tuberculosis, Alpha 1-Antitrypsin Deficiency, Extrinsic allergic alveolitis, Bronchial adenomata syndrome, Ciliary dyskinesia-bronchiectasis, Tracheobronchopathia osteoplastica, Aspergillosis
Renal / Electrolyte No underlying causes
Rheum / Immune / Allergy Allergic bronchopulmonary aspergillosis, Anaphylaxis, Angioedema, Asthma, Cricoarytenoid arthritis, Immunodeficiency, Interstitial lung disease, Lymphadenopathy, Milk allergy, Relapsing polychondritis, Wegener's granulomatosis, Pulmonary eosinophilia, Extrinsic allergic alveolitis, Graft-versus-host disease, Hay fever, Mastocytosis,
Sexual No underlying causes
Trauma No underlying causes
Urologic No underlying causes
Miscellaneous Amyloid deposition, Tracheobronchopathia osteochondroplastica


Inflamed airways and bronchoconstriction in asthma. Airways narrowed as a result of the inflammatory response cause wheezing.

Treatment of Wheeze

Management of chronic obstructive pulmonary disease (COPD)

All patients with COPD should be on a short-acting bronchodilator to be used on as-needed basis for intermittent increases in dyspnea. The purpose of the short-acting bronchodilator is to reduce symptoms and improve lung function. It is recommended to use a short-acting beta agonist plus a short-acting anticholinergic, rather than either alone, to achieve greater benefit. However, monotherapy with either is acceptable. For patients in whom intermittent short-acting bronchodilators are insufficient to control symptoms, a regularly scheduled long-acting inhaled bronchodilator is recommended. The purpose of the long-acting inhaled bronchodilator is to improve symptoms, improve lung function, and reduce the frequency of exacerbations. The effects of the currently available once daily long acting anticholinergic are superior to the effects of the twice daily long acting beta agonists that are available. Theophylline is the least preferred long-acting bronchodilator option because its effects are modest and toxicity is a concern. For patients who continue to have symptoms or repeated exacerbations despite an optimal long-acting inhaled bronchodilator regimen, adding an inhaled glucocorticoid is recommended.

All patients with COPD should be advised to quit smoking, educated about COPD, and given a yearly influenza vaccination. In addition, the pneumococcal polysaccharide vaccine should be given to patients who are ≥65 years old, or who are younger than 65 years with a forced expiratory volume in one second (FEV1) less than 40 percent.

Management of asthma

The optimal treatment of asthma involves the following steps:

  1. Monitoring of symptoms and lung function by formal periodic pulmonary function testing
  2. Patient education
  3. Controlling environmental and trigger factors and co-morbid conditions that contribute to asthma
  4. Pharmacologic therapy in a step wise fashion depending on the severity of asthma: intermittent (Step 1), mild persistent (Step 2, moderate persistent (Step 3), and severe persistent (Step 4 or 5).

Asthma severity is based upon current level of symptoms, FEV1 or PEFR values, and the number of exacerbations requiring oral glucocorticoids per year. Medications include: quick-acting inhaled beta-2-selective adrenergic agonists, long-acting inhaled beta agonists, inhaled glucocorticoids, leukotriene receptor antagonists, theophylline, cromoglycates, anti-IgE therapy (omalizumab), and oral glucocorticoids on a daily or alternate-day basis.


[1] [2]:


See also

References

  1. ↑ Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
  2. ↑ Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X

Additional Resources

Template:Ent Baughman RP, Loudon RG. Quantitation of wheezing in acute asthma. Chest. 1984;86:718–722. PMID 6488909 Template:Ent Pasterkamp H, Asher T, Leahy F, et al. The effect of anticholinergic treatment on postexertional wheezing in asthma studied by phonopneumography and spirometry. Am Rev Respir Dis. 1985;132:16–21. PMID 3160273 Template:Ent Shim CS, Williams MH. Relationship of wheezing to the severity of obstruction in asthma. Arch Intern Med. 1983;143:890–892. PMID 6679232 Template:Ent Earis J, Marsh K, Pearson M, et al. The inspiratory squawk in extrinsic allergic alveolitis and other pulmonary fibrosis. Thorax. 1982;37:923–926. PMID 7170682 Template:Ent Meslier N, Charbonneau G, Racineux JL. Wheezes. Eur Respir J. 1995;8(11):1942-8. PMID 8620967 Template:Ent Simpson JA, Weiner ESC (eds). "stridor, n. 2." Oxford English Dictionary 2nd ed. Oxford: Clarendon Press, 1989. OED Online Oxford University Press. Accessed September 10, 2005. http://dictionary.oed.com. Template:Ent Orient JM. Sapira's Art & Science of Bedside Diagnosis 2nd ed. Philadelphia: Lippincott William Wilkins, 2000. ISBN 0-683-30714-2

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