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]

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) Acute - ✔ ✔ ✔ - -
  • Normal function
  • Clear chest
  • Tripod posture
  • Drooling
  • Tenderness of the anterior part of the neck
Goiter Chronic ✔ ✔ - - - -
  • Airflow limitation of the volume loop depending on the size and localization[23]
Postnasal drip syndrome Acute ✔ ✔ - - - -
  • Increase of IgE
  • Positive intradermic test[26]
  • Clear chest
  • Sinus CT may be helpful
  • Clinical diagnosis
Relapsing polychondritis 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:[28]

  • Involvement of cartilage of ears, ribs, nose, and eyes
Retropharyngeal abscess Subacute - ✔ ✔ ✔ - -
  • Normal function
  • Neck CT or presence of pus during the surgical procedure[30]
Tonsillar hypertrophy 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 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[32]
Central airway diseases

(Intrathoracic upper airway obstruction)

Mediastinal mass/lymphadenopathy 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 [34]
Respiratory papillomatosis Chronic ✔ ✔ - ✔ - -
  • Not specific
  • Not specific
Tracheobronchomalacia Chronic ✔ ✔ - - - -
  • Not specifc
  • Airway compression from other structures
Tracheal stenosis Acute - ✔ - - ✔ -
  • Not specific
  • FV loop variable
  • Extension of the narrowing observed in CT or MRI
  • Long segment stenosis incompatible with survival[39]
Tracheal and bronchial tumors Chronic ✔ ✔ - - - -
  • Not specific
  • FV loop variable
Vascular ring or aneurysm Chronic ✔ ✔ - - - -
  • Not required
  • Usually asymptomatic
  • Chest or abdominal pain appears when other structures are compressed
Lower airway obstruction Bronchiectasis Chronic ✔ ✔ - - - ✔
  • Tram lines or end-on ring shadows in chest CT [43]
Bronchiolitis Acute ✔ ✔ ✔ - ✔ - For bacterial infection in neonates:
  • Hyperinflation
  • Mosaic attenuation
  • Increased bronchial wall[44]
  • Clinical diagnosis
Carcinoid syndrome Chronic - ✔ - - - -
  • Not specific
  • Liver metastases are visualized in MRI
Heart failure Chronic ✔ ✔ - - - -
  • Not required
  • Clinical diagnosis (test are supportive)
  • High levels of BNP and pro-BNP[49]
Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) [50] 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 Acute ✔ ✔ - - ✔ -
  • Bilateral alveolar infiltration
  • Bilateral opacities in CT

According to Berlin definition:[51]

  • 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) Acute ✔ ✔ ✔ - - -
  • Not specific
  • Bilateral peribronchial infiltration
  • Parenchymal infiltration
  • Subpleural nodules, ground-glass opacities observed on chest CT [53]
  • Larve on biopsy
Pulmonary thromboembolism  Acute, subacute, Chronic ✔ ✔ - - - -
  • Not required
Reactive airways dysfunction syndrome 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[57]
  • 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.
  7. ↑ Geterud A, Ejnell H, Månsson I, Sandberg N, Bake B, Bjelle A (October 1986). "Severe airway obstruction caused by laryngeal rheumatoid arthritis". J. Rheumatol. 13 (5): 948–51. PMID 3820205.
  8. ↑ 8.0 8.1 Greco A, Fusconi M, Macri GF, Marinelli C, Polettini E, Benincasa AT, de Vincentiis M (2012). "Cricoarytenoid joint involvement in rheumatoid arthritis: radiologic evaluation". Am J Otolaryngol. 33 (6): 753–5. doi:10.1016/j.amjoto.2012.06.004. PMID 22884484.
  9. ↑ Ishman SL, Halum SL, Patel NJ, Kerschner JE, Merati AL (October 2006). "Management of vocal paralysis: a comparison of adult and pediatric practices". Otolaryngol Head Neck Surg. 135 (4): 590–4. doi:10.1016/j.otohns.2006.04.014. PMID 17011423.
  10. ↑ Morris MJ, Christopher KL (November 2010). "Diagnostic criteria for the classification of vocal cord dysfunction". Chest. 138 (5): 1213–23. doi:10.1378/chest.09-2944. PMID 21051397.
  11. ↑ Tilles SA, Ayars AG, Picciano JF, Altman K (November 2013). "Exercise-induced vocal cord dysfunction and exercise-induced laryngomalacia in children and adolescents: the same clinical syndrome?". Ann. Allergy Asthma Immunol. 111 (5): 342–346.e1. doi:10.1016/j.anai.2013.07.025. PMID 24125138.
  12. ↑ Forrest LA, Husein T, Husein O (April 2012). "Paradoxical vocal cord motion: classification and treatment". Laryngoscope. 122 (4): 844–53. doi:10.1002/lary.23176. PMID 22434681.
  13. ↑ Nastasi KJ, Howard DA, Raby RB, Lew DB, Blaiss MS (June 1997). "Airway fluoroscopic diagnosis of vocal cord dysfunction syndrome". Ann. Allergy Asthma Immunol. 78 (6): 586–8. doi:10.1016/S1081-1206(10)63220-6. PMID 9207723.
  14. ↑ Chiang T, Marcinow AM, deSilva BW, Ence BN, Lindsey SE, Forrest LA (March 2013). "Exercise-induced paradoxical vocal fold motion disorder: diagnosis and management". Laryngoscope. 123 (3): 727–31. doi:10.1002/lary.23654. PMID 23097011.
  15. ↑ Nair S, Nilakantan A, Sood A, Gupta A, Gupta A (September 2016). "Challenges in the Management of Laryngeal Stenosis". Indian J Otolaryngol Head Neck Surg. 68 (3): 294–9. doi:10.1007/s12070-015-0936-2. PMC 4961642. PMID 27508129.
  16. ↑ Bogdasarian RS, Olson NR (1980). "Posterior glottic laryngeal stenosis". Otolaryngol. Head Neck Surg. 88 (6): 765–72. PMID 7208045.
  17. ↑ Crelin ES (1976). "Development of the upper respiratory system". Clin Symp. 28 (3): 1–30. PMID 1053096.
  18. ↑ Pennings RJ, van den Hoogen FJ, Marres HA (March 2001). "Giant laryngoceles: a cause of upper airway obstruction". Eur Arch Otorhinolaryngol. 258 (3): 137–40. PMID 11374255.
  19. ↑ Sniezek JC, Johnson RE, Ramirez SG, Hayes DK (April 1996). "Laryngoceles and saccular cysts". South. Med. J. 89 (4): 427–30. PMID 8614888.
  20. ↑ 20.0 20.1 Chu L, Gussack GS, Orr JB, Hood D (April 1994). "Neonatal laryngoceles. A cause for airway obstruction". Arch. Otolaryngol. Head Neck Surg. 120 (4): 454–8. PMID 8166980.
  21. ↑ Civantos FJ, Holinger LD (March 1992). "Laryngoceles and saccular cysts in infants and children". Arch. Otolaryngol. Head Neck Surg. 118 (3): 296–300. PMID 1554451.
  22. ↑ Glynn F, Fenton JE (May 2008). "Diagnosis and management of supraglottitis (epiglottitis)". Curr Infect Dis Rep. 10 (3): 200–4. PMID 18510881.
  23. ↑ Al-Bazzaz F, Grillo H, Kazemi H (May 1975). "Response to exercise in upper airway obstruction". Am. Rev. Respir. Dis. 111 (5): 631–40. doi:10.1164/arrd.1975.111.5.631. PMID 1130755.
  24. ↑ Bashist B, Ellis K, Gold RP (March 1983). "Computed tomography of intrathoracic goiters". AJR Am J Roentgenol. 140 (3): 455–60. doi:10.2214/ajr.140.3.455. PMID 6600532.
  25. ↑ Knudsen N, Perrild H, Christiansen E, Rasmussen S, Dige-Petersen H, Jørgensen T (March 2000). "Thyroid structure and size and two-year follow-up of solitary cold thyroid nodules in an unselected population with borderline iodine deficiency". Eur. J. Endocrinol. 142 (3): 224–30. PMID 10700715.
  26. ↑ Yu L, Xu X, Lv H, Qiu Z (May 2015). "Advances in upper airway cough syndrome". Kaohsiung J. Med. Sci. 31 (5): 223–8. doi:10.1016/j.kjms.2015.01.005. PMID 25910556.
  27. ↑ Behar JV, Choi YW, Hartman TA, Allen NB, McAdams HP (January 2002). "Relapsing polychondritis affecting the lower respiratory tract". AJR Am J Roentgenol. 178 (1): 173–7. doi:10.2214/ajr.178.1.1780173. PMID 11756115.
  28. ↑ McAdam LP, O'Hanlan MA, Bluestone R, Pearson CM (May 1976). "Relapsing polychondritis: prospective study of 23 patients and a review of the literature". Medicine (Baltimore). 55 (3): 193–215. PMID 775252.
  29. ↑ Knorr TL, Sinha V. PMID 28722903. Missing or empty |title= (help)
  30. ↑ Lazor JB, Cunningham MJ, Eavey RD, Weber AL (December 1994). "Comparison of computed tomography and surgical findings in deep neck infections". Otolaryngol Head Neck Surg. 111 (6): 746–50. doi:10.1177/019459989411100608. PMID 7991254.
  31. ↑ Jazi SM, Barati B, Kheradmand A (December 2011). "Treatment of adenotonsillar hypertrophy: A prospective randomized trial comparing azithromycin vs. fluticasone". J Res Med Sci. 16 (12): 1590–7. PMC 3434901. PMID 22973368.
  32. ↑ "CDC - Head and Neck Cancers".
  33. ↑ Shamberger RC, Holzman RS, Griscom NT, Tarbell NJ, Weinstein HJ, Wohl ME (September 1995). "Prospective evaluation by computed tomography and pulmonary function tests of children with mediastinal masses". Surgery. 118 (3): 468–71. PMID 7652680.
  34. ↑ Juanpere S, Cañete N, Ortuño P, Martínez S, Sanchez G, Bernado L (February 2013). "A diagnostic approach to the mediastinal masses". Insights Imaging. 4 (1): 29–52. doi:10.1007/s13244-012-0201-0. PMC 3579993. PMID 23225215.
  35. ↑ "Laryngotracheobronchial papillomatosis: findings on computed tomography scans of the chest".
  36. ↑ Aquino SL, Shepard JA, Ginns LC, Moore RH, Halpern E, Grillo HC, McLoud TC (2001). "Acquired tracheomalacia: detection by expiratory CT scan". J Comput Assist Tomogr. 25 (3): 394–9. PMID 11351189.
  37. ↑ Majid A, Gaurav K, Sanchez JM, Berger RL, Folch E, Fernandez-Bussy S, Ernst A, Gangadharan SP (July 2014). "Evaluation of tracheobronchomalacia by dynamic flexible bronchoscopy. A pilot study". Ann Am Thorac Soc. 11 (6): 951–5. doi:10.1513/AnnalsATS.201312-435BC. PMID 24960030.
  38. ↑ 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.
  39. ↑ Chiu PP, Rusan M, Williams WG, Caldarone CA, Kim PC (February 2006). "Long-term outcomes of clinically significant vascular rings associated with congenital tracheal stenosis". J. Pediatr. Surg. 41 (2): 335–41. doi:10.1016/j.jpedsurg.2005.11.034. PMID 16481247.
  40. ↑ 40.0 40.1 Stevic R, Milenkovic B (November 2016). "Tracheobronchial tumors". J Thorac Dis. 8 (11): 3401–3413. doi:10.21037/jtd.2016.11.24. PMC 5179373. PMID 28066620.
  41. ↑ Miller WT (October 2001). "Thoracic aortic aneurysms: plain film findings". Semin Roentgenol. 36 (4): 288–94. PMID 11715324.
  42. ↑ Polverino E, Goeminne PC, McDonnell MJ, Aliberti S, Marshall SE, Loebinger MR, Murris M, Cantón R, Torres A, Dimakou K, De Soyza A, Hill AT, Haworth CS, Vendrell M, Ringshausen FC, Subotic D, Wilson R, Vilaró J, Stallberg B, Welte T, Rohde G, Blasi F, Elborn S, Almagro M, Timothy A, Ruddy T, Tonia T, Rigau D, Chalmers JD (September 2017). "European Respiratory Society guidelines for the management of adult bronchiectasis". Eur. Respir. J. 50 (3). doi:10.1183/13993003.00629-2017. PMID 28889110.
  43. ↑ Milliron B, Henry TS, Veeraraghavan S, Little BP (2015). "Bronchiectasis: Mechanisms and Imaging Clues of Associated Common and Uncommon Diseases". Radiographics. 35 (4): 1011–30. doi:10.1148/rg.2015140214. PMID 26024063.
  44. ↑ 44.0 44.1 Devakonda A, Raoof S, Sung A, Travis WD, Naidich D (April 2010). "Bronchiolar disorders: a clinical-radiological diagnostic algorithm". Chest. 137 (4): 938–51. doi:10.1378/chest.09-0800. PMID 20371529.
  45. ↑ 45.0 45.1 Mota JM, Sousa LG, Riechelmann RP (2016). "Complications from carcinoid syndrome: review of the current evidence". Ecancermedicalscience. 10: 662. doi:10.3332/ecancer.2016.662. PMC 4990058. PMID 27594907.
  46. ↑ Mota JM, Sousa LG, Riechelmann RP (2016). "Complications from carcinoid syndrome: review of the current evidence". Ecancermedicalscience. 10: 662. doi:10.3332/ecancer.2016.662. PMC 4990058. PMID 27594907.
  47. ↑ Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WH, Tsai EJ, Wilkoff BL (October 2013). "2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines". Circulation. 128 (16): 1810–52. doi:10.1161/CIR.0b013e31829e8807. PMID 23741057.
  48. ↑ Weintraub NL, Collins SP, Pang PS, Levy PD, Anderson AS, Arslanian-Engoren C, Gibler WB, McCord JK, Parshall MB, Francis GS, Gheorghiade M (November 2010). "Acute heart failure syndromes: emergency department presentation, treatment, and disposition: current approaches and future aims: a scientific statement from the American Heart Association". Circulation. 122 (19): 1975–96. doi:10.1161/CIR.0b013e3181f9a223. PMID 20937981.
  49. ↑ Doust JA, Glasziou PP, Pietrzak E, Dobson AJ (October 2004). "A systematic review of the diagnostic accuracy of natriuretic peptides for heart failure". Arch. Intern. Med. 164 (18): 1978–84. doi:10.1001/archinte.164.18.1978. PMID 15477431.
  50. ↑ Davies SJ, Gosney JR, Hansell DM, Wells AU, du Bois RM, Burke MM, Sheppard MN, Nicholson AG (March 2007). "Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia: an under-recognised spectrum of disease". Thorax. 62 (3): 248–52. doi:10.1136/thx.2006.063065. PMC 2117154. PMID 17099078.
  51. ↑ Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, Camporota L, Slutsky AS (June 2012). "Acute respiratory distress syndrome: the Berlin Definition". JAMA. 307 (23): 2526–33. doi:10.1001/jama.2012.5669. PMID 22797452.
  52. ↑ Rubinsky-Elefant G, Hirata CE, Yamamoto JH, Ferreira MU (January 2010). "Human toxocariasis: diagnosis, worldwide seroprevalences and clinical expression of the systemic and ocular forms". Ann Trop Med Parasitol. 104 (1): 3–23. doi:10.1179/136485910X12607012373957. PMID 20149289.
  53. ↑ Sakai S, Shida Y, Takahashi N, Yabuuchi H, Soeda H, Okafuji T, Hatakenaka M, Honda H (June 2006). "Pulmonary lesions associated with visceral larva migrans due to Ascaris suum or Toxocara canis: imaging of six cases". AJR Am J Roentgenol. 186 (6): 1697–702. doi:10.2214/AJR.04.1507. PMID 16714661.
  54. ↑ Stein PD, Goldhaber SZ, Henry JW, Miller AC (January 1996). "Arterial blood gas analysis in the assessment of suspected acute pulmonary embolism". Chest. 109 (1): 78–81. PMID 8549223.
  55. ↑ Pipavath SN, Godwin JD (September 2008). "Acute pulmonary thromboembolism: a historical perspective". AJR Am J Roentgenol. 191 (3): 639–41. doi:10.2214/AJR.07.3989. PMID 18716087.
  56. ↑ 56.0 56.1 Remy-Jardin M, Pistolesi M, Goodman LR, Gefter WB, Gottschalk A, Mayo JR, Sostman HD (November 2007). "Management of suspected acute pulmonary embolism in the era of CT angiography: a statement from the Fleischner Society". Radiology. 245 (2): 315–29. doi:10.1148/radiol.2452070397. PMID 17848685.
  57. ↑ 57.0 57.1 Brooks SM, Weiss MA, Bernstein IL (September 1985). "Reactive airways dysfunction syndrome (RADS). Persistent asthma syndrome after high level irritant exposures". Chest. 88 (3): 376–84. PMID 4028848.

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