Wheeze differential diagnosis

Etiology on the basis of anatomy	Diseases	Clinical manifestations								Diagnosis					Other features
		Symptoms					Physical exam					Imaging
		Onset	Cough	Dyspnea	Fever	Slurred speech	Cyanosis	Clubbing	Auscultation	Labs	Pulmonary function testing	Chest imaging	Other	Gold standard
Extrathoracic upper airway diseases	Laryngeal edema (Anaphylaxis)	Acute	-	✔	-	✔	✔	-	Hoarseness Stridor	High levels of serum tryptase Incrieased levels of plasmahistamine Sking test	Not specific	Not required	Not required	Acute onset with one of them: Respiratory compromised Reduced blood pressure (BP) Two or more after the exposure to a likely allergern Respiratory compromised Reduced BP Gastrointestinalsymptoms Skin-mucosal involment BP reduced after exposure of a known allergen Adult BP systolic<90 mmHg Children: Low systolic BP	Nasal discharge, altered mental status, redness and hives of the skin Common allergens: food, insect stings, biologic materials, natural rubber latex, etc
	Cricoarytenoid arthritis	Acute	✔	✔	-	✔	-	-	Hoarseness Stridor	Test for Rheumatoid arthritis	Forced inspiratory flowdecreased Forced expiratory flowdecreased	Clear chest	Hyperdense intra-articular sclerotic cricoid and arytenoid cartilages in CT	Direct laryngoscopy	Cartilageerosion can lead on joint luxation and inmovilization of the cord
	Vocal fold edema/Hematoma/Paralysis	Acute	✔	✔	-	✔	-	-	Hoarseness Short breathing	Not specific	Variable	Clear chest	Not required	Laryngoscopy	Associated to neck surgery
	Paradoxical vocal fold motion	Acute	✔	✔	-	✔	-	-	Inspiratory stridor	Hypercapnia in Arterial blood gaseswhen distress is severe	Forced insiparatory flowdecrease but normal between episodes	Clear chest	CT and Color flow Dopplerto rule out other diseases	Abnormal adduction of vocal fold visualized inLaryngoscopy	Throat tightness, choking sensation Associated to exercise, asthma, postextubation, etc
	Laryngeal stenosis	Acute, Chronic	✔	✔	-	✔	✔	-	Glottic or supraglottic: Inspiratory stridor Glottisthrough trachea: Biphasic stridor	Not specific	FV loop variable	Clear chest	Stenosis visualized in neckx-ray	Palpation of arytenoidfor passive mobility and laryngoscopy	History of neck trauma or intubation
	Laryngocele	Chronic	✔	✔	-	-	-	-	Inspiratory stridor Hoarseness	Not specific	Normal function	Clear chest	Cyst wiht liquid or air content in ultrasound, radiography or CT	Smooth swelling visualized in laryngoscopy	Dysphagia, laryngeal discomfort Usually asymptomati
	Epiglottitis (supraglottitis)	Acute	-	✔	✔	✔	-	-	Hoarseness Stridor	Elevated white blood count Epiglottal culture	Normal function	Clear chest	More than 8 mm of size epiglottal and distend hypopharynx  in neck x-ray	Laryngoscopy where is visualizd a edematous epiglottis	Tripod posture Drooling Tenderness of the anterior part of the neck
	Goiter	Chronic	✔	✔	-	-	-	-	Stridor	Thyroid function tests: TSH, T3  and T4 Thyroid peroxide antibodies :TPO	Airflow limitation of the volume loop depend on the size and localization	Substernal Goiter causes a deviation of the trachea	CT can be performed to visualized the cervical and substernal Gotier and its extention	Physical examination	Iodine deficiency is the most common cause
	Postnasal drip syndrome	Acute	✔	✔	-	-	-	-	Stridor	Elevated eosinophils Increase of IgE Positive intradermic test	Normal response to bronchoprovocation Variable FV loop	Clear chest	Sinus CT	Clinical diagnosis	Nasal congestion Rhinorrhea
	Relapsing polychondritis	Acute	✔	✔	✔	-	-	-	Hoarseness Aphonia Inspiratory stridor	Leukocytosis or thrombocytosis Positive antinuclear antibodies ( ANA) and  ANCA	Variable  flow volume loop	Tracheal narrowing Cartilaginous calicification, bronchial Wall thickness and tracheal narrowing observed in  CT  MRI can distinguish fibrosis from inflammation	Cartilaginous calicification, bronchial wall thickness and tracheal narrowing observed in  CT  MRI can distinguish fibrosis from inflammation	Mc Adam criteria:  Ear bilateral chondritis   Seronegative inflammatory polyarthritis  Respiratory tract chondritirs Coclear or vestibular dysfunction Ocular inflamation	Involment of cartilage, ears, ribs. nose and eyes
	Retropharyngeal abscess	Subacute	-	✔	✔	✔	-	-	Stridor Tachypnea	Increased of white blood cell count Aerobic and anaerobic blood cultures	Normal function	Lateral chest x-ray to determine the extension of the abscess	Increased vertebral space in lateral neck x-ray Cervical lordosis and gas collection in retropharyngeal space in neck CT with intravenous contrast	Neck CT or presence of pus during the surgical procedure	Pain with neck extension Dysphagia Head in sniffing position
	Tonsillar hypertrophy	Acute, chronic	-	✔	-	✔ hyponasal speech	-	-	Stridor	Not specific	Flow loop shows inspiratory slowing	Clear chest	Not required	Direct visualization of enlarged tonsils in oropharyngeal exam	More in children and adolescents
	Tumor of pharynx/larynx/upper trachea	Chronic	✔	✔	-	-	-	-	Stridor Hoarseness	Not specific	Flow loop shows inspiratory slowing	Not requered	CT provide information of the grade of invation MRI can make a difference between tumors in the mucos or bone marrow	Fine needle aspiration biopsy	Risk factor: Tobacco and HPV infections
Central airway diseases (Intrathoracic upper airway obstruction)	Mediastinal mass/lymphadenopathy	Chronic	✔	✔	✔	-	-	-	Stridor Hoarseness	Anti-acetylcholine receptor antibodies present in thymic tumors High levels of AFP and beta-hCG present in germ cell tumors Increased lactate dehydrogenase in Seminomas	Expiratory flow rate decreased	Size, location and density of the mass can be observed	In chest CT is observed location, size, tissue characteristic and relationship with other structures of the mass Information of posterior mediastinal mass can be provided in chest or spine MRI	Chest CT	Hemoptysis Superior vena cava syndrome Surgical resection
	Respiratory papillomatosis	Chronic	✔	✔	-	✔	-	-	Hoarseness Stridor	Not specific	Not specific	Solid or cavitated pulmonary nodules	Nodules which involves mucosal surface observed in CT	Polypoid lesions observed in bronchoscopy	Etiology: HPV 6 and 11 Biopsy to determine the type of virus
	Tracheobronchomalacia	Chronic	✔	✔	-	-	-	-	Stridor Forced expiration	Not specifc	Low expiratory flow in flow volume loop	Airway compression from other structures	Airway colalpsed observed in Images at the end of inspiration in dynamic CT	Airway collapsed observed in bronchoscopy	Sputum retention Barking cough
	Tracheal stenosis	Acute	-	✔	-	-	✔	-	Stridor Monophonic expiratory	Not specific	FV loop variable	Narrowing of the trachea	Extension of the narrowing observed in CT or MRI	Narrowing of the trachea observed in bronchoscopy	Long segment stenosis incompatible with survival
	Tracheal and bronchial tumors	Chronic	✔	✔	-	-	-	-	Hoarseness	Not specific	FV loop variable	Narrowing of the trachea	Foca lesionsl, polypoid and narrowing observed in CT	Biopsy obtained by bronchoscopy	Squamous cell carcinoma Adenoid cystic carcinoma Benign tumors
	Vascular ring or aneurysm	Chronic	✔	✔	-	-	-	-	Hoarseness	D-dimer Blood urea Blood nitrogen Anemia point acute loss blood	Not required	Aortic knob enlarged Displacement to the trachea	ECG to rule out myocardial infarction	CT or angiography MR to determine the aortic diameter or any change	Usually asymptomatic Chest or abdominal pain appears when other structures are compressed
Lower airway obstruction	Bronchiectasis	Chronic	✔	✔	-	-	-	✔	Crackles Shortness of breath	Neutrophilia Levels of IgM, IgG and IgA Sputum culture for fungi, bacteria and mycobacteria	FEV1/FVC <70% Normal FVC Low levels of FEV1	Linar atelectasis Dilated airways	Tram lines or end-on ring shadows in chest CT	Chest CT	Hemoptysis Chest pleuritic pain
	Bronchiolitis	Acute	✔	✔	✔	-	✔	.	Crackles Increased respiratory rate	For bacterial infection in neonates: CBC Urinalysis Urine culture	Normal function or obstructive changes (FEV1/FVC<70%) Air trapping in Lung volumes Reduced Diffusing capacity of carbon monoxide ( DLCO)	Hyperinflation Mosaic attenuation Increased bronchial wall	Bronchoscopy to rule out other diseases	Clinical diagnosis	Etiology: Respiratory syncytial virus, Rhinovirus
	Carcinoid syndrome
	Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH)
	Heart failure
	Noncardiogenic pulmonary edema
	Parasitic infection with VLM (eg, Ascaris Strongyloides, filaria)
	Pulmonary thromboembolism	Acute, subacute, Chronic	✔	✔	-	-	-	-	Tachypnea Decreased breath sounds	Leukocytosis Elevated erythrocyte sedimentation  High levels of lactic acid in complete blood count Hypoxemia in arterial blood gas  D-dimer to rule out other diseases Troponin I or T			Computed tomography pulmonary angiogram (CTPA) or catheter based pulmonary angiography
	Reactive airways dysfunction syndrome

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