Wheeze

Wheeze
ICD-10	R06.2
ICD-9	786.07

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

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

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.

Characteristics

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 not in shape. Wheezing is not a severe problem. The more often you run, the easier breathing gets.

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.

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.

Complete Differential Diagnosis of the Causes of Wheeze

(In alphabetical order)

• Abnormal arytenoid movement
• Allergic bronchopulmonary aspergillosis
• Alpha 1-Antitrypsin Deficiency
• Amyloid deposition
• Anaphylaxis
• Angioedema
• Aspergillosis
• Aspiration(foreign particles or foods)
• Asthma including status asthmaticus
• Benign airway tumors including:
  • Bronchial adenomata syndrome
  • Unknown (hamartoma, clear cell, teratoma)
  • Epithelial (papilloma, polyps)
  • Mesodermal (fibroma, lipoma, leiomyoma, chondroma, granular cell tumor, sclerosing hemangioma)
  • Other (myofibroblastic tumor, xanthoma, amyloid, mucosa-associated lymphoid tumor)
• Bronchiectasis
• Bronchiolitis
• Bronchiolitis obliterans
• Bronchitis (usually viral, bacterial only in patients with tracheostomy or endotracheal intubation)
  • influenza A and B
  • parainfluenza
  • coronavirus (types 1-3)
  • rhinovirus
  • respiratory syncytial virus
  • human metapneumovirus
  • Other:
    • Mycoplasma pneumoniae
    • Chlamydophila pneumoniae
    • Pertussis
• Bronchopulmonary dysplasia
• Byssinosis - cotton duct
• Carcinoid syndrome
• Cardiac asthma ( pulmonary edema)
• Cardiomegaly
• Chemical poisoning ( more than 50 substances have been linked to wheezing )
• Chondromalacia
• Chronic obstructive pulmonary disease: Chronic bronchitis and Emphysema
• Cold induced wheezing (Paediatrics)
• Ciliary dyskinesia-bronchiectasis
• Congenital abnormalities
• Cricoarytenoid arthritis
• Cystic fibrosis
• Descending aortic aneurysm
• Dialyzer hypersensitivity syndrome
• Esophageal foreign body
• Exercise-induced asthma
• Extrinsic allergic alveolitis
• Food allergies
  • Peanut Allergy
• Gastroesophageal Reflux Disease (with aspiration)
• Graft-versus-host disease
• Hay fever
• Heart failure (see pulmonary edema)
• Hemorrhage, pulmonary
• Hypertrophied tonsils
• Immunodeficiency
• Infection ( pneumonia )
• Interstitial lung disease
• Intrathoracic goiter
• Klebsiella rhinoscleroma
• Laryngeal edema
• Laryngocele
• Laryngostenosis
• Laryngotracheobronchitis
• Lymphadenopathy
• Lymphangitic carcinomatosis
• Malignancy (bronchogenic)
  • Squamous cell carcinoma with variants: papillary, clear cell, small cell, basaloid
  • Small cell carcinoma
  • Adenocarcinoma
    • Acinar
    • Papillary
    • Bronchioloalveolar carcinoma
      • Non-mucinous (Clara cell/type II pneumocyte type)
      • Mucinous (Goblet cell type)
      • Mixed mucinous and non-mucinous (Clara cell/type II pneumocyte/goblet cell type) or indeterminate
    • Solid adenocarcinoma with mucin formation
    • Mixed
    • Variants: well-differentiated fetal adenocarcinoma, mucinous ("colloid"), mucinous cystadenocarcinoma, signet ring, clear cell
  • Large cell carcinoma with variants: large cell neuroendocrine carcinoma, combined large cell neuroendocrine carcinoma, basaloid carcinoma, lymphoepithelioma-like carcinoma, clear cell carcinoma, large cell carcinoma with rhaboid phenotype
  • Adenosquamous carcinoma
  • Carcinomas with pleomorphic, sarcomatoid, or sarcomatous elements
    • Carcinomas with spindle and/or giant cells
    • Pleomorphic carcinoma
    • Spindle cell carcinoma
    • Giant cell carcinoma
    • Carcinosarcoma
    • Blastoma (Pulmonary blastoma)
  • Carcinoid tumor
    • Typical carcinoid
    • Atypical carcinoid
  • Carcinomas of salivary gland type
    • Mucoepidermoid carcinoma
    • Adenoid cystic carcinoma
  • Unclassified carcinoma
  • Mastocytosis
  • Mendelson's syndrome (aspiration pneumonitis)
• Medication-induced bronchoconstriction
  • ACE inhibitors ( cough or rarely Angioneurotic edema and wheeze)
  • Sotalol
  • Adenosine
  • Beta blockers: Common; usually occurs in patients with asthma or COPD; 1-selective agents, labetalol, esmolol, and pindolol are better tolerated than nonselective agents.
  • Dipyridamole (IV form only)
  • Protamine
  • NSAIDs includign aspirin
  • Marijuana (chronic use)
• Milk allergy
• Mobile supraglottic soft tissue
• Obesity
• Parasitic infections
  • Ascariasis
  • Hookworm
  • Paragonimiases - lung infection
  • Strongyloidiasis
  • Toxocariasis
• Paroxysmal vocal cord motion
• Postextubation granuloma
• Postlobectomy bronchial torsion
• Postnasal drip syndrome
• Postradiation stenosis
• Primary ciliary dyskinesia
• Psychogenic wheezing
• Pulmonary edema (cardiogenic or non-cardiogenic)
• Pulmonary embolism
• Pulmonary eosinophilia
• Relapsing polychondritis
• Retained foreign body (trachea or esophagus)
• Retropharyngeal abscess
• Right sided aortic arch
• Sinusitis ( chronic sinusitis )
• Supraglottitis
• Tracheal stenosis
• Tracheobronchitis
• Tracheobronchomegaly
• Tracheobronchopathia osteoplastica : a rare, benign condition and is characterized by the presence of bony and cartilaginous nodules in the tracheal and bronchial mucosa.
• Tracheomalacia
• Tuberculosis, Pulmonary
• Vascular compression and rings ( Aberrant subclavian artery abnormality )
• Vocal cord dysfunction
• Vocal cord hematoma
• Vocal cord paralysis (bilateral paralysis)
• Wegener's granulomatosis

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

:

See also

• Rales
• Rhonchi

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