Wheeze in children

A wheeze is a musical and continuous sound that originates from oscillations in

narrowed airways. Wheezing is heard mostly on expiration as a result of critical
airway obstruction, caused by bronchiolitis , asthma and others conditions.
*Bronchiolitis
1-definition:is an acute, infectious, inflammatory disease of lower respiratory tract
that result in obstruction of the small airways.
2-Epidemiology : Bronchiolitis is the leading cause of hospitalization of infants.
Approximately 50 % of children experience bronchiolitis at the first 2 years of life,
The peak age at 2 to 6 months.
M:F ratio 1.5 : 1 .
3-Etiology:
RSV is the most common cause((more than50% of cases)), others include Human
metapneumovirus Parainfluenza viruses,Influenza viruses,Adenoviruses,Rhinoviruses
and Infrequently, Mycoplasma Pneumoniae.
4-risk factors:
A-LBW, particularly premature infants.
B-Low socioeconomic group.
C-Crowded living conditions"daycare" .
D-Parental smoking.
E-Chronic Lung Disease.
F-Severe congenital or acquired neurologic disease.
G-Congenital heart disease.
H-Congenital or acquired immunodeficiency disease.
I-Airway anomalies.

5-pathogensis:
Viruses penetrate terminal bronchiolar cells directly damaging and causing
inflamtion Pathologic changes begin 18-24 hours after infection
Bronchiolar cell necrosis, ciliary disruption, peribronchial lymphocytic infiltration
Edema, excessive mucus, sloughed epithelium lead to airway obstruction and
atelectasis.
6-clinical feature:
Symptoms: bronchiolitis caused by RSV has an incubation period of 4 - 6 days .
Classically begin with upper respiratory tract symptoms : Nasal
congestion,Rhinorrhea,Low grade fever,Mild cough(progress to sharp and dry)
Progress in 3-7 days to rapid respirations, chest retractions and audible
wheezing which is usually during expiration.
Feeding difficulty associated with increasing dyspnea is often the reason for
admission to hospital.
sign: Subcostal, Intercostal & supra sternal retraction.Hyperinflation of the
chest Hyper resonant on percussion Sternum prominent,Liver displaced
downwards,impaited air entry in both lung, Fine endinspiratory crackles
,Prolonged expiration,Highpitched wheezes((expiratory > inspiratory))
Tachycardia,Cyanosis and grunting.
7-investigations:
Predominantly a clinical diagnosis; routine cases do not need blood work
or a CXR.
A)Complete Blood Count: may show mild leukocytosis of 12,000 to 16,000
cells / L
B)Pulse Oximetry+ABG
C)Nasopharyngeal Swab for Antigen tests for RSV usually by
Immunofluorescence or ELISA The most sensitive test to confirm the
infection, but has little effect on management (infants should be treated for
bronchiolitis regardless of whether RSV is _ or not).
D)PCR
E) CXR may be obtained to rule out pneumonia and may show hyperinflation
of the lungs with flattened diaphragms, interstitial perihilar infiltrates, and
atelectasis.

8-complications:
Highest in high-risk children
Pnemothorax.
Apnea , Most in youngest children or those with previous apnea
Respiratory failure Around 15% overall.
Development of Asthma later.
Secondary bacterial infection Uncommon, about 1%, most in children
requiring intubation.
9- Differential Diagnosis:
A-Viral-triggered asthma
B-Bronchitis or pneumonia
C-Chronic lung disease
D-Foreign body aspiration
Gastroesophageal reflux or dysphagia leading to e-aspiration
Cystic Fibrosis
F-Congenital heart disease or heart failure
G-Vascular rings, bronchomalacia, complete tracheal rings or other
anatomical abnormalities.
10- Management:
-hospitlization:
1-< 6months
2-Moderate to severe respiratory distress (Tachypnea , Apnea , Cyanosis)
Hypoxemia 3-O2 saturation <92%
4-Inability to tolerate oral feeding
5-Lack of appropriate care at home
-Supportive Therapy :
1-Humidified Oxygen and Good Hydration with IV fluid.
2-Monitoring and Control of fever
3-Upper airway suction
4-A trial of aerosolized albuterol"B2agonist"and ipratropium may be
attempted.
5- ribavirin sometimes used in high-risk infants with underlying heart,lung, or
immune disease.
6- RSV prophylaxis with injectable poly- or monoclonal antibodies (RespiGam
or Synagis) is recommended in winter for high-risk patients 2years of age.
-RSV is highly infectious, and infection control measures, particularly good
hand hygiene, are needed to prevent cross-infection to other infants in
hospital.

11-prognosis:Most infants recover from the acute infection within 2 weeks.
However, as many as half will have recurrent episodes of cough and wheeze.
Rarely, usually following adenovirus infection, the illness may result in
permanent damage to the airways (bronchiolitis obliterans)

12-prevention:
Avoiding contact with individuals with viral illnesses and Good hand washing.
Avoidance of cigarette smoke.
Influenza vaccine for children > 6 months and household contacts of those
children.

Asthma *
1-definition: Reversible airway obstruction 2 to bronchial hyperreactivity, airway
inflammation, mucous plugging, and smooth muscle hypertrophy.
2-Epidemiology: It affects 10% of the population and can develop at any age,
but typically half of pediatric cases present before the age of 10 years ,and is
a leading cause of office and emergency department visits, hospitalizations,
and school absenteeism. Asthma mortality nearly doubled between1980and
1993, with more than 5500 fatalities annually.
3-pathophysiology:
Three major pathologic events.. 1-mucosal edema 2-smooth muscle
contraction 3- production of mucus .
Asthma associated with elevation serum IgE
An allergic-type inflammatory response , resulting in bronchial hyperactivity
and Bronchial hyperactivity has been linked to a chromosomal locus.
4-Childhood risk factors(asthma triggers):
1-Parental asthma (inherited factors)(risk of about 1 in 5)
2-Allergy ( like Food allergy)
3-Severe lower RTI
4-Wheezing apart from cold
5-Male
6-Low birth weight
7-Environmental (Outdoor pollution , tobacco & Cigarette smoke exposure )

5-classification:

6-dignosis:
History A)
Cough , episodic wheezing ,dyspnea, and/or cheast tighiness.
Sputum production, limitation of exercise performance.
Symptoms often worsen at night or early morning

Examination B)
Normal between attacks
The child with chronic problem consistent finding include:
Barrel-shaped chest
Hyperinflation, Wheeze and prolonged expiration.
Tachypnea and tachycardia chest retraction,nasal flare , impaired air entry
C)I nvestigation
1-ABGs: mild hypoxia and respiratory alkalosis
2-peak expirtory flow meter: decrease FEV1

Used to: assess severity ,predict attacks and assess response to ttt.

3-Spirometry :FEV1/FVCpeak fl ow is diminished acutely; RV
and total lung capacity (TLC).
4-CBC: Possible esonophilia.
5-Allergy skin testing should be a part of the evaluation of all children with
persistent asthma
6-chest radiograph: should be performed with the first episode of asthma or
with recurrent episodes of undiagnosed cough or wheeze or both to exclude

anatomic abnormalities. Children with a history of asthma do not need repeat
chest radiograph with each episode, unless there is fever that suggests
pneumonia, or if there are localized findings on physical examination.
7-Methacholine challenge: Tests for bronchial hyperresponsiveness; useful when PFTs are
normal but asthma is still suspected.
7- Management:
-in general:
1- Regular assessment
2- Control of factors contribute to asthma
a-eliminate environmental exposure
b-treat co-morbid conditions
c-annual influenza vaccination
3- Asthma pharmacotherapy
4- Patient education
5- Prevention.
Management of acute attack: -
Moderate asthma
Oxygen saturation > 92%
Peak flow > 50%
No signs of severe asthma
Treatment: oxygen, short acting B2 agonist by nebulizer(every 2h)
Sever asthma
Tachycardia and Tachypnea
Use of accessory neck muscles
Oxygen saturation <92%
Peak flow < 50%
Treatment: oxygen, B2 agonist nebulizer, steroid, ipratropium nebulizer
Life threatening Asthma Also Called (Status asthmaticus )
Silent chest
Poor respiratory effort
Altered conscious
Cyanosis
Oxygen saturation < 92%
Peak flow < 33%
Treatment: oxygen , B2 agonist nebulizer(every 20mins), IV steroid,Mg sulphate
admission in PICU
Management of Chronic Asthma: -
1- Mild intermittent asthma
Days with symptoms :< or = 2/W
Nights with symptoms: < 2/Mo
Treatment:No daily medication,B2agonist as needed
2- Mild persistent
Days with symptoms :>2/W but <1/day
Night with symptoms :>2/Mo
Treatment:Low dose inhaled corticosteroid ,OR Leukotriene antagonist and B2 agonist
3- Moderate persistent
Days with symptoms: daily
Night with symptoms: >1/W
Treatment:Low dose inhaled steroid and long acting inhaled B2 agonist ,OR medium
dose inhaled steroid
4- Severe persistent
Days with symptoms :continual
Night with symptoms :frequent
Treatment:High dose inhaled steroid and long acting B2 agonist if needed oral steroid
-Exercise induced asthma: sabutamol befor exercise and salmetrol prophylaxsis
8-prognosis:
60% of children improve in adulthood depending on presence of risk factors



*Foreign body aspiration
Children younger than 3 yr of age account for 73% of cases,and most deaths are in
the patient younger than 4 years old.
The right main bronchus is the most site. Some foreign bodies, especially nuts or
seeds, may migrate from place to place in the airways and lodge in the larynx on
coughing, totally occluding the airway and often are not associated with
radiographic abnormalities and are difficult to detect.
Younger children most commonly aspirate food, small toys, balloons, and other
small objects. Coins tend to go down the esophagus, although they rarely are found
in the trachea.
-diagnosis:
A)History: in most cases there is a history of choking or witnessed aspiration or
nuts eating.
B)Examination: cough, localized wheezing, unilateral absence of breath sounds,
stridor, and rarely bloody sputum.
The late diagnosis may come to medical attention because of symptoms of fever,
cough, sputum production, or chest pain. In patients with persistent wheezing
unresponsive to bronchodilator therapy, persistent atelectasis, recurrent or
persistent pneumonia, or persistent cough without other explanation, the presence
of a foreign body should be suspected.
Dysphagia with stridor or wheezing : esophageal foreign body.
C)investigations:
1-CXR: expiratory or lateral decubitus chest film, may show a radiopaque object
(rare) or evidence of air trapping on exhalation.
2-Fluoroscopy may also be helpful.
3-Bronchoscopy: Rigid bronchoscopy is curative, flexible bronchoscopy may be a
useful diagnostic technique when the presentation is not straightforward; however,
foreign body removal should not be attempted during flexible bronchoscopy.
Prevention: -
The best approach to foreign body aspiration is to educate parents and caregivers in
preventing the event.
Before molar teeth have developed, infants and children should not have nuts,
uncooked carrots, and other foods that may be easily broken into small pieces and
aspirated and to give them tiny toys which are at risk for being aspirated by young
children.
-Treatment:
Respiratory support with O2,B2 agonist and corticosteroid in acute cases.
The treatment of choice for airway foreign bodies is prompt endoscopic removal
with rigid instruments
*GASTROESOPHAGEAL REFLUX
-Physiological GER: up to 9 to 12 month, without complication.
-C/P: heartburn, cough, , wheezing,respiratory distress, aspiration pneumonia,
hoarse voice, failure to thrive, and recurrent otitis media or sinusitis. After food
-Investigation: 24-hour esophageal pH probe monitoring.
there may be laboratory evidence of anemia and hypoalbuminemia secondary to
esophageal bleeding and inflammation.
-Treatment: proton pump inhibitor, Metoclopramide surgical: fundoplication for
the life threatening case, Feeding jejunostomy if unable to tolerate oral or gastric
feeding tube.