Wheezy Child

Doç Dr Saniye Girit

 What is wheezing?
Wheeze is a continuous & musical sound that
originates from oscillations in narrowed
airways
Mostly heard in expiration due to critical
airway obstruction
Sign of lower (intra-thoracic) airway
obstruction
If there is widespread narrowing of airways
leading to various levels of obstruction to
airflow (eg. asthma), polyphonic wheeze is
heard i.e. sounds of various
Monophonic wheeze (single pitch) is
produced in larger airways during expiration
eg. Distal tracheomalacia, bronchomalacia
Causes of Wheezing in Childhood
ACUTE CHRONIC OR RECURRENT
Reactive airway disease…
Reactive airway disease : Asthma
Bronchial edema : Airway compression by mass or
blood vessel:
•Infection • Vascular ring/sling
• Bronchial or pulmonary cysts
•Inhalation •Lymph node
•Increased PVP Dynamic airway collapse:
Bronchomalacia/tracheomalacia
Aspiration : Foreign body
Bronchial hypersecretion :
GORD
• Infection Bronchial hypersecretion :
• Inhalation Bronchitis, Bonchiectasis, Cystic
• Cholinergic drugs fibrosis, Primary ciliary dyskinesia
Aspiration : Foreign body Intrinsic airway lesions:
Endobronchial tumors
Aspiration of gastric (carcinoid)
contents
 Approach to a wheezing child
Clinical History:
Patient age at onset of wheeze
Course: acute vs gradual
Pattern of wheezing?
Episodic: asthma
Persistent: congenital
Response to bronchodilators?
Is wheezing associated with multiple systemic
illnesses?
Cystic fibrosis and Immunodeficiency diseases
Wheeze associated with feeding?
Wheeze associated with cough?
Change in position? Worsening or improvement
Family hx of asthma?
 Physical Examination
•General
•Vital signs including SpO2 %
•Chest examination Inspection:

–Respiratory distress
–Chest wall deformity (increased AP diameter)
– allergic shiners/nasal polyps
–Skin: eczema
•Palpation: chest wall asymmetry with expansion, tracheal deviation
•Percussion: difference in vocal resonance
•Auscultation:

•Location of wheeze
•Character of wheeze
•Other breath sounds associated with wheeze
•Cardiac: presence of murmur
 Investigations
•CXR: AP and lateral views
–Children with new onset wheezing of undetermined etiology
–Chronic persistent wheezing not responding to treatment
–Suspected FB aspiration
•CXR findings: Hyperinflation:
Generalized: suggests diffuse air trapping Asthma/ Cystic
fibrosis/ Primary ciliary dyskinesia
Localized hyperinflation: Structural abnormalities/ FB
aspiration
Other findings: atelectasis, bronchiectasis, mediastinal
masses, enlarged LN’s, cardiomegaly, enlarged pulmonary
vessels or pulmonary edema.
Chest CT scan:
–Mediastinal masses or LN’s
–Vascular anomalies
–Bronchiectasis
Barium Swallow:
–GERD
–TEF
–Vascular rings
–Swallowing dysfunction
Pulmonary Function Tests (PFT’s) Airway obstruction
assessment
Response to bronchodilator
Other investigations:
•Sweat Chloride Test:
Cystic fibrosis screening in children with chronic lung
problems, failure to thrive and diarrhea
•Immunoglobulin levels: Screen for immunodeficiency.
•Rapid antigen testing, viral cultures, sputum gram stain and
culture.
 Bronchiolitis
It is inflammatory obstruction of small
airways.
Age: first 2 years.
2- 12 months peak 6 months.
more sever at 1-3 months.
Seasonal disease, peak during winter & early
spring.
 Etiology & Epidemiology
Predominantly viral:
RSV
Human metapeumovirus
Influenza
Adeno
Para influenza
Mumps,
Entero,
Rhino
Mycoplasma pneumonia
Chlamydia pneumonia, Chlamydia Trachomatis.
 Clinical manifestation
Mild URTI, diminished appetite, fever(38.5-39)
Respiratory distress with paroxysmal wheezy
cough, dyspnea& irritability.
Infant is tachypnic which interfere with feeding
No other systemic complain.
Apnea(in 20% of hospitalized infants)
Infant at risk for apnea:
*premature infant
*very young infant(1-4 months)
* Chronic lung disease.
 On examination
Sign of respiratory distress (nasal flaring, retraction)+ wheezing.
Auscultation :
Fine crackle or overt ronchi+ prolongation of expiratory phase.
Barely audible breath sound suggest a very sever disease
with nearly complete bronchiolar obstruction.
Hyperinflation of the lung may permit palpation of liver &spleen.
 Investigation
CXR:
•Hyperinflated lung.
•Bilateral interstitial abnormalities with
peribronchial thickening.
•Up to 20% having lobar, segmental, or sub
segmental consolidation.
 Investigation
WBC & differential count are usually normal.
Viral testing:
•Rapid immunofluorescene.
•Polymerase chain reaction
•Viral culture
Blood gas analysis: hypoxemia, hypercarbia
Treatment Supportive : mainstay of treatment. -
Respiratory distress( hospitalization, positioning, cool&humidified
oxygen).
Feeding :risk of aspiration( NG feeding) and parenteral fluids.
Bronchodilater.
Nebulized epinephrine.
Corticosteroid : (oral, inhaler, parentral).
Ribavirin .
Antibiotic.
RSV immunoglobulin.
Intubation &mechanical ventilation.
Complication
1-increasingly labored breathing
2-cyanosis
3-dehydration
4-fatigue
5-severe respiratory failure
 Case

A 13 month old child has a runny nose, mild cough,

and a low grade fever for several days. The cough
got worse and sounded like “barking”.
The child made a wheezing sound when agitated.
The child appeared well except for the cough.
A lateral X-ray examination of the neck showed a
subglottic narrowing.
Background information
Parainfluenza virus (PIV)
Negative sense, single-stranded RNA virus
Varies in size and shape
Averaging in diameters of nm
Account for a large percentage of pediatric respiratory infections,
second to respiratory syncitial virus.
Major cause of croup
Divided into 4 types
Type 1 is the most frequent in children, followed by type 3 and type
2.
Type 4 is less likely to cause a severe illness.
Self- limited infection
Can manifest repeatedly throughout life
 Described Symptoms

Coryza :
Symptoms of a common head cold
nasal congestion
runny nose
Sore throat
cough
Inflammation of nasal cavity mucous membrane, affecting upper
respiratory tract
Viral croup:
Inflammation of the larynx and upper airway
Results in narrowing of the airway
Characterized by a barking cough, inspiratory stridor, and a variable
amount of respiratory distress that develops over a brief period.
Stridor:
A high pitched, breathing sound caused by turbulent flow of air, usually
caused by a blockage in breathing.
Inspiratory stridor (a sound heard in inspiration through a spasmodically
closed glottis)
 Described Symptoms Retractions
Intercostal retractions: retractions of the chest cavity
The inward movement of the chest due to
decreased pressure in the chest cavity.
Usually an indicator for difficulty in breathing
The virus will cause a diffused inflammation with
erythema and edema in the tracheal walls that will
affect the mobility of the vocal cords.
The subglottic region of the child’s upper airway is
narrow. So, a small amount of edema will significantly
restrict airflow.
Other causative agents
Viruses from the Paramyxoviridae family
Mumps, measles, and respiratory syncitial virus
(RSV)
Can also cause sporadic cases of croup
Adenovirus Infection of the respiratory tract, as well
as eyes, intestines, and urinary tract
Pneumonia Inflammation of the lungs caused by
bacteria, viruses, or other microorganisms Leading
cause of death in children world wide Influenza A
and B
Both caused by viruses in the family
Orthomyxoviridae