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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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slide1

All That Wheezes…

Andrew Lipton, MD, MPH&TM

MAJ, USA, MC

Chief, Pediatric Pulmonology

San Antonio Military Pediatric Center

what is a wheeze
What is a “wheeze”

Definitions of obstructive noises

  • Stertor
    • Low-pitched, rumbling
    • Inspiratory
    • Nasopharynx, oropharynx, nasal passage
    • Loudest over neck, cheeks
what is a wheeze4
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
what is a wheeze5
What is a “wheeze”

Definitions of obstructive noises

  • Wheeze
    • Higher-pitched expiratory noise
    • Monophonic, homophonous = large airway

= expiratory stridor

    • Polyphonic, heterophonous, musical = small airways
what is a wheeze6
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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-7

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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

stertor
Stertor

Causes

  • Choanal atresia
  • Mandibular hypoplasia
  • Macroglossia
  • Nasal congestion
  • Adenotonsillar hypertrophy
  • Pharyngeal insufficiency
  • Encephalocele
  • Dermoid of base of tongue
  • Thyroglossal duct cyst
  • Lingual thyroid
inspiratory stridor
Inspiratory Stridor

Causes

  • Laryngomalacia
  • Vocal cord paralysis
    • Unilateral – left (recurrent laryngeal nerve)
    • Bilateral – brainstem
  • Laryngotracheoesophageal cleft
  • Laryngocele
  • Laryngeal polyp
  • Abscess
  • Hypotonia
inspiratory stridor16
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
inspiratory stridor18
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
biphasic stridor
Biphasic Stridor

Causes

  • Subglottic stenosis
    • Congenital
    • Acquired – intubation, croup
  • Subglottic hemangioma
  • Laryngeal web
  • GERD
biphasic stridor20
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
biphasic stridor21
Biphasic Stridor

Causes

  • Recurrent Croup
    • Consider underlying airway anomaly
    • GERD
    • Spasmodic (reactive airways)
expiratory stridor
Expiratory Stridor

Causes

  • Tracheomalacia
  • Bronchomalacia
  • Vascular Ring/Sling
  • Complete Tracheal Ring
  • Tracheoesophageal Fistula
  • Bronchogenic Cyst
  • Mediastinal Mass
  • Foreign Body
  • GERD
expiratory stridor23
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
wheezing
Wheezing

Causes

  • Asthma
  • Bronchiolitis
  • Pneumonia
  • GERD – inflammation, bronchospasm
  • Heart Failure – often presents around 2 mos
  • BPD
  • Other: CF, Ciliary Dykinesia, Food Allergy
history
Congenital or acquired

Acute, Chronic, or intermittent

Positional?

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

Voice/cry quality

History
history29
History
  • FTT – increased WOB, poor feeding
    • >90% - think of GERD
  • Cyanosis
  • Apnea
  • Fever
  • Cough
  • Nocturnal Sxs
history30
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

slide31
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
radiographs
Radiographs
  • Lateral neck
  • Chest PA/Lateral
  • CT Head/Neck/Chest
  • UGI, Videofluoroscopic swallowing study
  • Airway fluoroscopy
  • MRI/MRA – chest, brainstem
other studies
Other Studies
  • Bronchoscopy
    • Flexible
    • Rigid
  • Laryngoscopy
  • Polysomnography (sleep study)
  • Echocardiography
  • Infant PFTs
  • pH Probe, scan
  • ABG
other studies34
Other Studies
  • Allergy testing
  • Immunoglobulins
  • CBC
  • ABG
  • Sweat Cl
  • Ciliary Bx