Wheeze differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Karina Zavaleta, MD [2], Iqra Qamar M.D.[3], Anmol Pitliya, M.B.B.S. M.D.[4]

Differential diagnosis of Wheezing

Etiology on the basis of anatomy Diseases Clinical manifestations Diagnosis Other features
Symptoms Physical exam Labs Pulmonary function testing Imaging
Onset Cough Dyspnea Fever Slurred speech Cyanosis Clubbing Auscultation Chest imaging Other Gold standard
Extrathoracic upper airway diseases Laryngeal edema

(Anaphylaxis)[1][2][3][4][5]

Acute - - ✔ ✔ -
  • Not specific
  • Not required
  • Not required

Acute onset with one of them:

Two or more after the exposure to a likely allergen

BP reduced after exposure of a known allergen

Cricoarytenoid arthritis[6][7] Acute ✔ ✔ - ✔ - -
  • Clear chest
Vocal fold edema/hematoma/paralysis[9] Acute ✔ ✔ - ✔ - -
  • Not specific
  • Variable
  • Clear chest
  • Not required
Paradoxical vocal fold motion[10][11] Acute ✔ ✔ - ✔ - -
  • Clear chest
  • CT and color flow doppler to rule out other diseases[13]
Laryngeal stenosis[15] Acute, Chronic ✔ ✔ - ✔ ✔ -
  • Not specific
  • FV loop variable
  • Clear chest
Laryngocele[17][18][19][20][21] Chronic ✔ ✔ - - - -
  • Not specific
  • Normal function
  • Clear chest
Epiglottitis (supraglottitis)[22][23][24][25][26] Acute - ✔ ✔ ✔ - -
  • Normal function
  • Clear chest
  • Tripod posture
  • Drooling
  • Tenderness of the anterior part of the neck
Goiter[27][28][29][30][31][32][33][34] Chronic ✔ ✔ - - - -
  • Airflow limitation of the volume loop depending on the size and localization[35]
Postnasal drip syndrome[38][39][40] Acute ✔ ✔ - - - -
  • Increase of IgE
  • Positive intradermic test[41]
  • Clear chest
  • Sinus CT may be helpful
  • Clinical diagnosis
Relapsing polychondritis [42][43][44][45][46][47][48] Acute ✔ ✔ ✔ - - -
  • Variable flow volume loop
  • Tracheal narrowing
  • Cartilaginous calcification, bronchial wall thickness, and tracheal narrowing is observed on CT 
  • MRI can distinguish fibrosis from inflammation 

Mc Adam criteria:[47]

  • Involvement of cartilage of ears, ribs, nose, and eyes
Retropharyngeal abscess[50][51][52] Subacute - ✔ ✔ ✔ - -
  • Normal function
  • Neck CT or presence of pus during the surgical procedure[54]
Tonsillar hypertrophy[55] Acute, chronic - ✔ - ✔ hyponasal speech - -
  • Not specific
  • Flow loop shows inspiratory slowing
  • Clear chest
  • Not required
  • More in children and adolescents
Tumor of pharynx/larynx/upper trachea[57][58] Chronic ✔ ✔ - - - -
  • Not specific
  • Flow loop shows inspiratory slowing
  • Not required
  • CT provide information about the grade of invasion
  • MRI can make a difference between tumors in the mucosa or bone marrow[59]
Central airway diseases

(Intrathoracic upper airway obstruction)

Mediastinal mass/lymphadenopathy[60][61] Chronic ✔ ✔ ✔ - - -
  • Size, location, and density of the mass can be observed
  • In chest CT, location, size, tissue characteristic, and relationship with other structures of the mass is observed
  • Information of posterior mediastinal mass can be provided in chest or spine MRI [63]
Respiratory papillomatosis[64][65] Chronic ✔ ✔ - ✔ - -
  • Not specific
  • Not specific
Tracheobronchomalacia[67] Chronic ✔ ✔ - - - -
  • Not specifc
  • Airway compression from other structures
Tracheal stenosis[70][71][72][73] Acute - ✔ - - ✔ -
  • Not specific
  • FV loop variable
  • Extension of the narrowing observed in CT or MRI
  • Long segment stenosis incompatible with survival[75]
Tracheal and bronchial tumors[76][77][78] Chronic ✔ ✔ - - - -
  • Not specific
  • FV loop variable
Vascular ring or aneurysm[80][81][82][83][84][85] Chronic ✔ ✔ - - - -
  • Not required
  • Usually asymptomatic
  • Chest or abdominal pain appears when other structures are compressed
Lower airway obstruction Bronchiectasis[87][88] Chronic ✔ ✔ - - - ✔
  • Tram lines or end-on ring shadows in chest CT [90]
Bronchiolitis[91][92][93][94][95] Acute ✔ ✔ ✔ - ✔ - For bacterial infection in neonates:
  • Hyperinflation
  • Mosaic attenuation
  • Increased bronchial wall[96]
  • Clinical diagnosis
Carcinoid syndrome[97][98][99] Chronic - ✔ - - - -
  • Not specific
  • Liver metastases are visualized in MRI
Heart failure[102][103] Chronic ✔ ✔ - - - -
  • Not required
  • Clinical diagnosis (test are supportive)
Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) [107] Chronic ✔ ✔ - - - -
  • Not specific
  • Mosaic pattern and nodules observed in chest CT
  • Single neuroendocrine cell and/ or linear proliferation of the cells that involves bronchial epithelium
Noncardiogenic pulmonary edema[108][109][110] Acute ✔ ✔ - - ✔ -
  • Bilateral alveolar infiltration
  • Bilateral opacities in CT

According to Berlin definition:[111]

  • One week of new or worse respiratory symptoms or clinical insult
  • Symptoms can not be explain by cardiac disease
  • Bilateral opacities in chest X-Ray or CT
  • Compromised oxygenation
  • High altitute pulmonary edema (HAPE)
  • Neurogenic pulmonary edema
Parasitic infection with VLM (eg, Ascaris, Strongyloides, filaria)[112][113][114][115] Acute ✔ ✔ ✔ - - -
  • Not specific
  • Bilateral peribronchial infiltration
  • Parenchymal infiltration
  • Subpleural nodules, ground-glass opacities observed on chest CT [117]
  • Larve on biopsy
Pulmonary thromboembolism [118][119] Acute, subacute, Chronic ✔ ✔ - - - -
  • Not required
Reactive airways dysfunction syndrome[123][124][125][126] Acute ✔ ✔ - - - -
  • Normal or hyperinflation
  • CT to rule out other diseases
 Clinical diagnosis:
  • History of exposure
  • Acute onset with sympotoms in 24h
  • Airway obstruction > 3 months[124]
  • Burning sensation in the throat
  • Chest pain
  • High dose of inhalation of the irritant

References

  1. ↑ Sampson HA, Muñoz-Furlong A, Campbell RL, Adkinson NF, Bock SA, Branum A, Brown SG, Camargo CA, Cydulka R, Galli SJ, Gidudu J, Gruchalla RS, Harlor AD, Hepner DL, Lewis LM, Lieberman PL, Metcalfe DD, O'Connor R, Muraro A, Rudman A, Schmitt C, Scherrer D, Simons FE, Thomas S, Wood JP, Decker WW (February 2006). "Second symposium on the definition and management of anaphylaxis: summary report--Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium". J. Allergy Clin. Immunol. 117 (2): 391–7. doi:10.1016/j.jaci.2005.12.1303. PMID 16461139.
  2. ↑ Sampson HA, Muñoz-Furlong A, Bock SA, Schmitt C, Bass R, Chowdhury BA, Decker WW, Furlong TJ, Galli SJ, Golden DB, Gruchalla RS, Harlor AD, Hepner DL, Howarth M, Kaplan AP, Levy JH, Lewis LM, Lieberman PL, Metcalfe DD, Murphy R, Pollart SM, Pumphrey RS, Rosenwasser LJ, Simons FE, Wood JP, Camargo CA (March 2005). "Symposium on the definition and management of anaphylaxis: summary report". J. Allergy Clin. Immunol. 115 (3): 584–91. doi:10.1016/j.jaci.2005.01.009. PMID 15753908.
  3. ↑ Kemp SF, Lockey RF (September 2002). "Anaphylaxis: a review of causes and mechanisms". J. Allergy Clin. Immunol. 110 (3): 341–8. PMID 12209078.
  4. ↑ Ewan PW, Dugué P, Mirakian R, Dixon TA, Harper JN, Nasser SM (January 2010). "BSACI guidelines for the investigation of suspected anaphylaxis during general anaesthesia". Clin. Exp. Allergy. 40 (1): 15–31. doi:10.1111/j.1365-2222.2009.03404.x. PMID 20205694.
  5. ↑ Simons FE (February 2010). "Anaphylaxis". J. Allergy Clin. Immunol. 125 (2 Suppl 2): S161–81. doi:10.1016/j.jaci.2009.12.981. PMID 20176258.
  6. ↑ Kelly CA (February 1993). "Rheumatoid arthritis: other rheumatoid lung problems". Baillieres Clin Rheumatol. 7 (1): 17–29. PMID 8519073.
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  53. ↑ Knorr TL, Sinha V. PMID 28722903. Missing or empty |title= (help)
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  73. ↑ Stephens KE, Wood DE (February 2000). "Bronchoscopic management of central airway obstruction". J. Thorac. Cardiovasc. Surg. 119 (2): 289–96. doi:10.1016/S0022-5223(00)70184-X. PMID 10649204.
  74. ↑ Altman KW, Wetmore RF, Mahboubi S (June 1998). "Comparison of endoscopy and radiographic fluoroscopy in the evaluation of pediatric congenital airway abnormalities". Int. J. Pediatr. Otorhinolaryngol. 44 (1): 43–6. PMID 9720679.
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