All That Wheezes Is Not Asthma
A Wheeze Is Not Always What It Seems To Be
Wheezing =
Continuous musical sound
High pitched advantitia
Bronchospasm
Asthma
COPD
Bronchitis
Wheezing
Poly-phonic
Multiple notes
Whale call
Small airway
Mono-phonic
Single note
Stridor
Large airway
Wheezing
Inspiratory
Expiratory
Focal/Local
Bronchial tumors, lymph anomolies, cysts
Stridor or Wheeze
Stridor
Harsh noise caused by turbulent flow
Inspiratory = larynx
Expiratory = trachea
Biphasic = fixed lesion in periglottic region
Stidor heard as a wheeze
Differential diagnosis of wheezing due to
upper airway diseases
Differential diagnosis of wheezing due to
lower airway diseases
Physical Findings to Consider
 Onset of Symptoms
 Clearing of throat
 Discharge/secretions
 Pain
 Response to BD
 PFT results
 FLOW VOLUME I & E
 Heart burn
 Changes in weight
 SOB w/ exertion
 Clubbing/Sx hypoxia
 Smoking Hx
 Short neck
 Wheezing / Stridor/
Stertor
Quality
Location
Type
Lower Airway Obstruction
Asthma
COPD
Pulm Edema
Aspiration
PE
Bronchiolitis
CF
Tumor
Infection
Intrathoracic Large Airway Obstruction
Tracheal Stenosis
FBA
Tumors
Cysts
Goiter
Tracheo/bronchomegaly
Tracheal malacia
R aortic arch
Extrathoracic Upper Airway Obstruction
Sinus drip
Vocal cord
dysfunction
Arytenoid dysfuction
Tonsils
Supraglottitis
Laryngeal edema /
stenosis
Granuloma
2 Intubation
Wegener’s
Tumors
Anaphylaxis
Obesity
Laryngocele
Laryngeal Disorders
dilatation of right laryngeal ventricle (white arrow, C) and ante-rior positioning of right arytenoid cartilage (black arrow, C)
Laryngeal Disorders
Laryngeal nerve paralysis
Flaccid VC
Bronchiectasis / CF
Tracheal compression secondary to
intrathoracic goiter
Previously Healthy
Episodic wheezing
Progressive exercise intolerance
Bilateral expir wheezes
Treated for asthma
No response
 Spirometry
 Bronch
 90%
blockage
distal
trachea
 Vascular
Mass
 CT Scan
 Improved Post-op
Spirometry
 No symptoms
 Free of wheezes
Inderpal Randhawa, M.D., and Eliezer Nussbaum, M.D. N Engl J Med 2010; 363:e1,July 1, 2010
RUL Bronchus
Foreign Body Aspiration
Initial Xray
Hyperinflation
Very subtle
Which side has
the foreign
object?
Foreign Body Aspiration
Day 3
Nut
Foreign Body Aspiration
I and E
Foreign Body Aspiration
FBA
Neuromuscular Bulbar Weakness
I < E flow volume
Jagged lines (on insp)
Inability to perform
FIVC
Neuromuscular Bulbar Weakness
 Initial visit
 Unable to perform FIVC
 NIF difficult
 6 mo follow up