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All That Wheezes… PowerPoint PPT Presentation


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All That Wheezes…. Andrew Lipton, MD, MPH&TM MAJ, USA, MC Chief, Pediatric Pulmonology San Antonio Military Pediatric Center. What is a “wheeze”. Definitions of obstructive noises Stertor Low-pitched, rumbling Inspiratory Nasopharynx, oropharynx, nasal passage Loudest over neck, cheeks.

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All That Wheezes…

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All That Wheezes…

Andrew Lipton, MD, MPH&TM

MAJ, USA, MC

Chief, Pediatric Pulmonology

San Antonio Military Pediatric Center


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What is a “wheeze”

Definitions of obstructive noises

  • Stertor

    • Low-pitched, rumbling

    • Inspiratory

    • Nasopharynx, oropharynx, nasal passage

    • Loudest over neck, cheeks


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What is a “wheeze”

Definitions of obstructive noises

  • Stridor

    • Harsh noise caused by turbulent flow

    • Inspiratory = larynx

    • Expiratory = trachea

    • Biphasic = fixed lesion in subglottic region


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What is a “wheeze”

Definitions of obstructive noises

  • Wheeze

    • Higher-pitched expiratory noise

    • Monophonic, homophonous = large airway

      = expiratory stridor

    • Polyphonic, heterophonous, musical = small airways


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What is a “wheeze”

Definitions of obstructive noises

  • Secretory Noise

    • Gurgling, polyphonic, upper or lower airway

    • Highly variable


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Pre-Inspiration


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Inspiration


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Inspiration


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End Inspiration


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Forced Expiration


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Forced Expiration


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Stertor

Causes

  • Choanal atresia

  • Mandibular hypoplasia

  • Macroglossia

  • Nasal congestion

  • Adenotonsillar hypertrophy

  • Pharyngeal insufficiency

  • Encephalocele

  • Dermoid of base of tongue

  • Thyroglossal duct cyst

  • Lingual thyroid


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Inspiratory Stridor

Causes

  • Laryngomalacia

  • Vocal cord paralysis

    • Unilateral – left (recurrent laryngeal nerve)

    • Bilateral – brainstem

  • Laryngotracheoesophageal cleft

  • Laryngocele

  • Laryngeal polyp

  • Abscess

  • Hypotonia


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Inspiratory Stridor

Laryngomalacia

  • 60% of insp. stridor

  • 90% require no intervention

  • Improves when prone

  • Worsens with activity

  • Worsens over first 1-6mos, then improves

  • Watch for FTT, apnea, cyanosis


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Inspiratory Stridor

Causes

  • Laryngomalacia

  • Vocal cord paralysis

    • Unilateral – left (recurrent laryngeal nerve)

    • Bilateral – brainstem

    • Not positional

  • Laryngotracheoesophageal cleft

  • Laryngocele

  • Laryngeal polyp - ? Maternal history

  • Abscess

  • Hypotonia


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Biphasic Stridor

Causes

  • Subglottic stenosis

    • Congenital

    • Acquired – intubation, croup

  • Subglottic hemangioma

  • Laryngeal web

  • GERD


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Biphasic Stridor

Causes

  • Croup – acute barky cough, stridor, resp. distress

    • Low grade fever

    • Rhinorrhea

    • Worse at night

    • 3mos-3yrs

    • Parinfluenza 1-3, RSV, Influenza

    • Fall/Winter


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Biphasic Stridor

Causes

  • Recurrent Croup

    • Consider underlying airway anomaly

    • GERD

    • Spasmodic (reactive airways)


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Expiratory Stridor

Causes

  • Tracheomalacia

  • Bronchomalacia

  • Vascular Ring/Sling

  • Complete Tracheal Ring

  • Tracheoesophageal Fistula

  • Bronchogenic Cyst

  • Mediastinal Mass

  • Foreign Body

  • GERD


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Expiratory Stridor

Causes

  • Tracheobronchomalacia

    • Deficient cartilage rings

    • Worse with exertion, agitation

    • Prolonged expiratory phase

    • Narrow trachea on expiratory lateral films

    • Primary vs. Secondary

      • BPD, TEF, vascular anomalies


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Wheezing

Causes

  • Asthma

  • Bronchiolitis

  • Pneumonia

  • GERD – inflammation, bronchospasm

  • Heart Failure – often presents around 2 mos

  • BPD

  • Other: CF, Ciliary Dykinesia, Food Allergy


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Congenital or acquired

Acute, Chronic, or intermittent

Positional?

Feeding – gag/choke/cough, suck, emesis, fatigue

Voice/cry quality

History


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History

  • FTT – increased WOB, poor feeding

    • >90% - think of GERD

  • Cyanosis

  • Apnea

  • Fever

  • Cough

  • Nocturnal Sxs


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History

  • Birth/Neonatal History

  • Other anomalies: cardiac, hemangiomas, eczema, CHARGE, VACTERL, Arnold-Chiari, hypotonia, etc.

  • Family Hx – anomalies, CF, immunodeficiency, asthma, GERD, atopy

  • Exposure – smoke, pollutants, irritants,

    Foreign body: toys, foods, older sibs


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Exam

  • Nose

  • Pharynx, tonsils, tongue, face, mandible, palate

  • Neck

  • Cardiac

  • Chest

  • Respiration:

    • Pattern, rate,accessory muscle use, sounds, change with position, oxygenation

  • Abdomen – hepatomegaly, masses

  • Tone

  • Skin – eczema, hemangiomas, cyanosis


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Radiographs

  • Lateral neck

  • Chest PA/Lateral

  • CT Head/Neck/Chest

  • UGI, Videofluoroscopic swallowing study

  • Airway fluoroscopy

  • MRI/MRA – chest, brainstem


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Other Studies

  • Bronchoscopy

    • Flexible

    • Rigid

  • Laryngoscopy

  • Polysomnography (sleep study)

  • Echocardiography

  • Infant PFTs

  • pH Probe, scan

  • ABG


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Other Studies

  • Allergy testing

  • Immunoglobulins

  • CBC

  • ABG

  • Sweat Cl

  • Ciliary Bx


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