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  1. All That Wheezes… Andrew Lipton, MD, MPH&TM MAJ, USA, MC Chief, Pediatric Pulmonology San Antonio Military Pediatric Center

  2. What is a “wheeze” Definitions of obstructive noises • Stertor • Low-pitched, rumbling • Inspiratory • Nasopharynx, oropharynx, nasal passage • Loudest over neck, cheeks

  3. 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

  4. What is a “wheeze” Definitions of obstructive noises • Wheeze • Higher-pitched expiratory noise • Monophonic, homophonous = large airway = expiratory stridor • Polyphonic, heterophonous, musical = small airways

  5. What is a “wheeze” Definitions of obstructive noises • Secretory Noise • Gurgling, polyphonic, upper or lower airway • Highly variable

  6. 0 +5 0 0 0 0 -5 -5 Pre-Inspiration

  7. -1 0 +5 0 0 -1 -2 -3 -7 -7 Inspiration

  8. -2 0 +5 0 0 -2 -2 -3 -7 -7 Inspiration

  9. 0 +8 0 0 0 0 -8 -8 End Inspiration

  10. +5 0 +5 0 0 -10 +10 +20 +30 +38 +30 +30 Forced Expiration

  11. +1 0 +1 0 0 -20 +5 +10 +30 +38 +30 +30 Forced Expiration

  12. Stertor Causes • Choanal atresia • Mandibular hypoplasia • Macroglossia • Nasal congestion • Adenotonsillar hypertrophy • Pharyngeal insufficiency • Encephalocele • Dermoid of base of tongue • Thyroglossal duct cyst • Lingual thyroid

  13. Inspiratory Stridor Causes • Laryngomalacia • Vocal cord paralysis • Unilateral – left (recurrent laryngeal nerve) • Bilateral – brainstem • Laryngotracheoesophageal cleft • Laryngocele • Laryngeal polyp • Abscess • Hypotonia

  14. 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

  15. 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

  16. Biphasic Stridor Causes • Subglottic stenosis • Congenital • Acquired – intubation, croup • Subglottic hemangioma • Laryngeal web • GERD

  17. 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

  18. Biphasic Stridor Causes • Recurrent Croup • Consider underlying airway anomaly • GERD • Spasmodic (reactive airways)

  19. Expiratory Stridor Causes • Tracheomalacia • Bronchomalacia • Vascular Ring/Sling • Complete Tracheal Ring • Tracheoesophageal Fistula • Bronchogenic Cyst • Mediastinal Mass • Foreign Body • GERD

  20. 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

  21. Wheezing Causes • Asthma • Bronchiolitis • Pneumonia • GERD – inflammation, bronchospasm • Heart Failure – often presents around 2 mos • BPD • Other: CF, Ciliary Dykinesia, Food Allergy

  22. Congenital or acquired Acute, Chronic, or intermittent Positional? Feeding – gag/choke/cough, suck, emesis, fatigue Voice/cry quality History

  23. History • FTT – increased WOB, poor feeding • >90% - think of GERD • Cyanosis • Apnea • Fever • Cough • Nocturnal Sxs

  24. 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

  25. 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

  26. Radiographs • Lateral neck • Chest PA/Lateral • CT Head/Neck/Chest • UGI, Videofluoroscopic swallowing study • Airway fluoroscopy • MRI/MRA – chest, brainstem

  27. Other Studies • Bronchoscopy • Flexible • Rigid • Laryngoscopy • Polysomnography (sleep study) • Echocardiography • Infant PFTs • pH Probe, scan • ABG

  28. Other Studies • Allergy testing • Immunoglobulins • CBC • ABG • Sweat Cl • Ciliary Bx