Wheezing in
Children
Mona Massoud, MD
Emory University School of Medicine
Family Medicine Residency
9/22/11
Introduction
 Common presenting symptom of respiratory
disease in children
 Could benign and self limiting or presenting
symptom of significant respiratory disease
 Common problems presented to PCP
Incidence
 25-30% of infants will have one episode of
wheezing.
 By six years of age approximately half of
children will have had at least one episode of
wheezing
Overview
 Wheezing: Continuous coarse whistling
sound produced by oscillation of narrowed or
compressed respiratory airway. Inspiratory or
expiratory/ High or low pitched.
 Crackles (rales): Popping sound created
when air is forced through respiratory
passages.
 Stridor: high-pitched harsh sound heard
during inspiration, due to obstruction of upper
airway.
Wheezing type in childhood
 Transient wheezer: One episode or few
episodes of wheezing. No further episodes
beyond 6 years.
 Non-atopic wheezer: Wheeze during viral
infections and continue to have recurrent
airway obstruction during early school years.
 IgE associated wheeze/asthma: Start to have
symptoms later in life which continues into
adulthood.
Wheezing Type in Childhood
Why do Children tend to wheeze more
than Adults?
 Children have smaller airway passages,
therefore higher resistance
 Less chest compliance
 Elastic tissue recoil is lower than adults and
fewer collateral airways-prone to obstruction
and atelectasis
Differential Diagnosis
 Acute
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Asthma
Bronchitis
Bronchiolitis
Laryngeotracheobronchitis (Croup)
Bacterial Tracheitis
FB aspiration
Esophageal FB
Chronic or Recurrent Causes
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Asthma
GERD
Retained foreign body
Cystic Fibrosis
Recurrent Aspiration
Primary ciliary dyskinesia
ILD
Immunodeficiency
Structural Causes:
 Tracheo-bronchomalacia
 Vascular rings
 Tracheal web
 Cystic lesions/lymphadenopathy/mediastinal masses
Asthma
 Affects approximately 5 million children in US
 Chronic and reversible inflammatory disorder
that produces airway hyper-responsiveness,
airway inflammation and airflow limitation.
 Immediate and delayed inflammatory
response
Classification of Asthma
Asthma Control assessment
Bronchiolitis
 Children less than 2 yo, usually 3-6 m
 Viruses-RSV (most common), adenovirus,
influenza or parainfluenza
 Fall and winter months
 Begins as mild URI which can progress to
increase respiratory distress
 Rx:

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Supportive therapy
Ribavirin in extremely ill children
Croup vs Epiglottitis
Approach to a wheezing child
 Clinical History:
Wheeze description from parents
Snoring, snoring, rattling or gargling noises
 Patient age at onset of wheeze
Distinguishes congenital vs non-congenital
 Course: acute vs gradual
Acute onset- FB aspiration

Cont’d Q’s
 Pattern of wheezing?

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Episodic: asthma
Persistent: congenital
 Response to bronchodilators?

Improvement: Asthma
 Is Wheezing associated with multiple
respiratory illnesses?

Cystic fibrosis and Immunodeficiency diseases
Cont’d Q’s
 Wheeze associated with feeding?
GERD
 Wheeze associated with cough?
GERD, asthma, allergies
 Change in position? Worsening or
improvement
Tracheomalacia
 Family hx of asthma?
Features that favors diagnosis of
Asthma
 Intermittent episodes of asthma
 Presence of a trigger

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URI
Allergens
Exercise
 Seasonal variation
 Family hx of asthma and/or atopy
 Response to bronchodilators
Clinical features that suggest a
diagnosis other than asthma:
 Hx of wheezing since birth or neonatal
respiratory problems.
 Hx of choking associated with SOB and
coughing.
 Symptoms that change with position.
 Poor weight gain and recurrent infections.
 Hx of progressive dyspnea, tachypnea,
exercise intolerance.
 Poor response to broncholdilators.
Physical Examination
 Vital signs including Sa02 %
 Inspection:
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Respiratory distress/ tachypnea/ cyanosis
Retractions or structural abnormalities (increased
AP diameter, pectus excavatum, scoliosis)
HENT: allergic shiners/nasal polyps
Skin: eczema
Cont’d PE
 Palpation: chest wall asymmetry with expansion,
tracheal deviation or supratracheal lymphadenopathy
 Percussion: difference in vocal resonance and define
position of diaphragm
 Auscultation:
 Location of wheeze
 Character of wheeze
 Other breath sounds associated with wheeze
 Cardiac: presence of murmur or gallops
Diagnostic Evaluation
 CXR: AP and lateral views
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Children with new onset wheezing of
undetermined etiology
Chronic persistent wheezing not responding to
treatment
Lateral decubitus views: FB aspiration
 Chest radiography is not performed with
every asthma exacerbation unless there is a
specific indication
CXR findings:
 Hyperinflation:
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Generalized: suggests diffuse air trapping
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Asthma/ Cystic fibrosis/ Primary ciliary dyskinesia
Localized hyperinflation:
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Structural abnormalities/ FB aspiration
 Other findings: atelectasis, bronchiectasis,
mediastinal masses, enlarged LN’s,
cardiomegaly, enlarged pulmonary vessels or
pulmonary edema.
Status Asthmaticus
Croup (Steeple Sign):
FB aspiration
 FB occludes middle
lobe bronchus
 Atelectasis of Rt middle
lobe
 Hyperinflation of upper
and lower lobes
Other radiological studies:
 Chest CT scan:
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Mediastinal masses or LN’s
Vascular anomalies
Bronchiectasis
 Barium Swallow:
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GERD
TEF
Vascular rings
Swallowing dysfunction
Vascular ring
TEF
Pulmonary Function Tests (PFT’s)
 Airway obstruction assessment
 PFT’s with inspiratory and expiratory flow-
volume loops is is important in determining
the degree, location of airway obstruction in
addition to response to bronchodilators.
Response to Treatment
 Trial of inhaled bronchodilators
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Improvement: reversible airway disease
Partial or negative response: asthma or other
causes
 Combination of inhaled CST
+bronchodilators: if asthma is suspected in a
patient with chronic or persistent symptoms
Bronchodilator response
Other Investigations
 Sweat Chloride Test: Cystic fibrosis screening
in children with chronic lung problems, failure
to thrive and diarrhea
 Immunoglobulin levels: Screen for
immunodeficiencies.
 Rapid antigen testing, viral cultures, sputum
gram stain and culture. PPD in suspected
cases.
 http://www.youtube.com/watch?v=VA9C_aC
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 http://www.youtube.com/watch?v=EMKxnyPs
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 http://www.youtube.com/watch?v=Qbn1Zw5C
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References
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http://www.aafp.org
http://www.uptodate.com/contents
http://emedicine.medscape.com
http://www.essentialevidenceplus.com
http://www.acaai.org/patients/resources/asthma/Docu
ments/AZnhlbiGuidelines
 http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001
970/
 http://www.medcyclopaedia.com/library/radiology
 http://pediatrics.aappublications.org/content/123/3/e5
19.long