Wheezy InfantWheezy Infant

ByBy

Professor Of PediatricsProfessor Of Pediatrics,, Head of Allergy & Clinical Immunology Unit Head of Allergy & Clinical Immunology Unit

Mansoura UniversityMansoura University EgyptEgypt

wheezing

Def. It is a continuous expiratory musical

sound produced by partial airway

obstruction either localized or generalized at

level of small bronchi and bronchioles (lower

airway obstruction)

Causes of wheezing

I- Acute conditions

II- Non structural causes

III- Structural

I- Acute conditions1- Bronchiolits

2- Bronchial aspiration of F.B

3- Acute congestive heart failure

4- Bronchial asthma (first episode)

5- Organo phosphorus poisoning

6- Transient bronchial hyper reactivity

II-Non structuralII-Non structural1- Gastrooesophageal reflux1- Gastrooesophageal reflux

2- F.B2- F.B

3- B.A3- B.A

4- Chronic bacterial bronchitis4- Chronic bacterial bronchitis

5- Cystic fibrosis 5- Cystic fibrosis

6- Bronchopulmonary dysplasia6- Bronchopulmonary dysplasia

III- Structural

1- Tracheomalacia

2- Bronchomalacia

3- Vascular compression (vascular

ring)

4- Tracheal stenosis

5- Cystic lesion

Key Points in Present History Key Points in Present History Differential DiagnosisDifferential Diagnosis

Useful PointersUseful PointersThink AboutThink About Intermittent,Intermittent, Self Limiting Self Limiting cough and wheezecough and wheeze Poor Poor weight gainweight gain /Wet /Wet cough/bulky offensive stoolcough/bulky offensive stool FeedingFeeding difficulties/ difficulties/ Vomiting/Vomiting/nightnight coughcough Paroxysmal coughing fitsParoxysmal coughing fits Mostly Mostly inspiratoryinspiratory wheezing wheezing or stridoror stridor

Recurrent viral infectionRecurrent viral infection

Cystic fibrosisCystic fibrosis

Reflux/aspirationReflux/aspiration

Pertussis infectionPertussis infectionLaryngomalacia Laryngomalacia

(Floppy Larynx) or Some (Floppy Larynx) or Some other narrowing of the large other narrowing of the large airwaysairways

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Key Points in Present History Differential DiagnosisKey Points in Present History Differential Diagnosis

Useful pointersUseful pointersThink aboutThink about

FebrileFebrile illnesses/ severe recurrent illnesses/ severe recurrent infectioninfection Breathlessness Breathlessness and sweety with and sweety with feeding with or without murmurfeeding with or without murmur

Symptoms since Symptoms since birthbirth

PrematurityPrematurity

Immune deficiencyImmune deficiency

Heart failureHeart failure

Unlikely to be asthma:Unlikely to be asthma:

Congenital lung problem? Congenital lung problem?

Perinatal infection Perinatal infection

(chlamydia) (chlamydia)

Ciliary dyskinesia?Ciliary dyskinesia?

Cystic fibrosis?Cystic fibrosis? Wheezes associated with preterm Wheezes associated with preterm birthbirth

Airway CompressionAirway Compression

1- Extrathoracic lesions:1- Extrathoracic lesions: Lryngeomalacia, TracheomalaciaLryngeomalacia, Tracheomalacia Subglottic hemangiomaSubglottic hemangioma

Key point:Key point: Dry irritative cough with inspiratory Dry irritative cough with inspiratory

stridor.stridor.

2- Intra thoracic airway compression:2- Intra thoracic airway compression: Vascular rings e.g. double aortic archVascular rings e.g. double aortic arch Perihilar adenopathyPerihilar adenopathy Mediastinal tumours Mediastinal tumours

Gastro Esophageal Reflux and Gastro Esophageal Reflux and Wheezy InfantWheezy Infant

GERDGERD can cause wheezing by; can cause wheezing by;

Direct aspirationDirect aspiration of acidic gastric of acidic gastric secretions or food into tracheo-bronchial secretions or food into tracheo-bronchial tree.tree.

TriggeringTriggering ParasympatheticParasympathetic reflex reflex receptors in the lower esophagus. receptors in the lower esophagus.

Bronchiolitis ObliteransBronchiolitis Obliterans

DefinitionDefinition It is It is neutrophilic inflammationneutrophilic inflammation of of

small airways including terminal small airways including terminal bronchioles and alveolar wall.bronchioles and alveolar wall.

NeutrophilsNeutrophils release oxidative and release oxidative and proteolytic enzymes (myleo peroxidase proteolytic enzymes (myleo peroxidase and collagenase) that cause and collagenase) that cause lung damagelung damage and and obliteration obliteration of bronchiolar lumen.of bronchiolar lumen.

Conditions Associated with Development Conditions Associated with Development of Bronchiolitis Obliteransof Bronchiolitis Obliterans

1- Viral infections:1- Viral infections: Especially adenovirus type 3,7,21Especially adenovirus type 3,7,21 Also RSV, Measles, influenza and herpes zoster Also RSV, Measles, influenza and herpes zoster

also have been implicatedalso have been implicated

2- Bacterial infections:2- Bacterial infections: Staph aureousStaph aureous Mycoplasma PneumoniaMycoplasma Pneumonia KlepsiellaKlepsiella

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Conditions Associated with Development Conditions Associated with Development of Bronchiolitis Obliteransof Bronchiolitis Obliterans

3- Connective tissue diseases3- Connective tissue diseases Rheumatoid arthritisRheumatoid arthritis Ulcerative colitisUlcerative colitis SLESLE SclerodermaScleroderma

4- Toxic exposures4- Toxic exposures Nitrous oxide is a common causeNitrous oxide is a common cause

5- Others5- Others Foreign body aspirationForeign body aspiration Bronchopulmonary dysplasiaBronchopulmonary dysplasia cystic fibrosis cystic fibrosis

Features of Bronchiolitis ObliteransFeatures of Bronchiolitis Obliterans

Cough and wheeze with exertional dyspneaCough and wheeze with exertional dyspnea HRCT shows:-HRCT shows:-

Ground glass opacityGround glass opacity Multi focal atelectasisMulti focal atelectasis Mosaic oligemiaMosaic oligemia

PFT shows :PFT shows : Fixed air flow obstruction Fixed air flow obstruction

Pathology Pathology BAL BAL Neutrophils and lymphocytesNeutrophils and lymphocytes Biopsies:Biopsies:

Fibrosis, Bronchiectasis,Mucus stain, Alveolar Fibrosis, Bronchiectasis,Mucus stain, Alveolar overinflation overinflation

Differential Diagnosis of Chronic and Differential Diagnosis of Chronic and Recurrent BronchitisRecurrent Bronchitis

Phase I: Specific EtiologiesPhase I: Specific Etiologies

AsthmaAsthma Preexisting lung diseasePreexisting lung disease

Respiratory distress syndrome and bronchopulmonary Respiratory distress syndrome and bronchopulmonary dysplasia dysplasia

Postinfectious bronchiectasisPostinfectious bronchiectasis

Cystic fibrosisCystic fibrosis

Foreign body aspirationForeign body aspirationIntrathoracic or extrathoracic airwayIntrathoracic or extrathoracic airway

EsophagusEsophaguscontinuecontinue

Differential Diagnosis of Chronic and Differential Diagnosis of Chronic and Recurrent BronchitisRecurrent Bronchitis

Aspiration syndromesAspiration syndromes Abnormal enteropulmonary communicationsAbnormal enteropulmonary communications (e.g., Laryngeal cleft) (e.g., Laryngeal cleft) Dysfunction of swallowingDysfunction of swallowing Gastroesophageal refluxGastroesophageal reflux

Airway compressionAirway compression Weakened wall (e.g., tracheomalacia)Weakened wall (e.g., tracheomalacia)

Extrinsic compression (e.g., vascular ring)Extrinsic compression (e.g., vascular ring)

Congenital heart diseaseCongenital heart disease ImmunodeficiencyImmunodeficiency Primary cilliary abnormalitiesPrimary cilliary abnormalities

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Phase II:Phase II: Nonspecific Airway IrritationNonspecific Airway IrritationExposure to recurrent respiratory tract infections Exposure to recurrent respiratory tract infections

in day-care centersin day-care centers

Cigarette smokeCigarette smokePassive smoke exposurePassive smoke exposure

Active smokingActive smoking

Air pollutionAir pollutionOutdoor secondary to particulate matter, automobile Outdoor secondary to particulate matter, automobile

exhaust, and other pollutantsexhaust, and other pollutants

Indoor secondary to Wood burning, irritants, and Indoor secondary to Wood burning, irritants, and chemicalschemicals

DDDDBronchiolitsBronchiolits

HistoryHistory -The patient usually has an antecedent

history of coryza and may be fever for

3-5 days

-Age most common between 1-6 months of age

-The patient usually has wheezing for first time

ExaminationExamination

- Cough is prominent- Cough is prominent

- RR is elevated 50-60/minute- RR is elevated 50-60/minute

- Chest retraction- Chest retraction

- Chest auscultation - Chest auscultation

. Expiratory wheezing. Expiratory wheezing

. Fine inconstant crepitations . Fine inconstant crepitations

. Diminished intensity of B.S . Diminished intensity of B.S in severe casesin severe cases

InvestigationInvestigation

Hyperinflated chest (areas of segmental Hyperinflated chest (areas of segmental collapse may be present)collapse may be present)

CourseCourse Rapid improvement within few Rapid improvement within few

days ,no days ,no recurrencerecurrence

2-Foreign Body Inhalation2-Foreign Body Inhalation

HistoryHistory The possibility should be considered in every case of The possibility should be considered in every case of

acute wheezing especially when the onset is sudden, acute wheezing especially when the onset is sudden,

associated with chocking and not preceded by any associated with chocking and not preceded by any

illness Age is older than 9 month the possibility illness Age is older than 9 month the possibility

becomes greater when wheezing is not responding to becomes greater when wheezing is not responding to

therapytherapy

Examination Examination Localized wheezingLocalized wheezing

Unequal breath soundUnequal breath sound

Severe chest retraction not Severe chest retraction not

explained by explained by physical finding on chestphysical finding on chest

InvestigationInvestigation

X-Ray Chest X-Ray Chest . Localized hyperinfalation. Localized hyperinfalation

. Ateleclasis or localized air traping . Ateleclasis or localized air traping

on chest radiographs obtained on chest radiographs obtained

during inspiration and expiration during inspiration and expiration

BronchoscopeBronchoscope F.B inside bronchusF.B inside bronchus

3-Bronchial Asthma3-Bronchial Asthma HistoryHistory . Episodic symptoms of airflow obstruction . Episodic symptoms of airflow obstruction are present that worse at night and early morning. are present that worse at night and early morning. . History of atopy or eczema. . History of atopy or eczema. . Positive family history of asthma.. Positive family history of asthma.

ExaminationExamination Severe resp. distress partially or completely Severe resp. distress partially or completely reversed with bronchodilator.reversed with bronchodilator.

Investigation Increased serum IgE levelIncreased serum IgE level Oesinophilia in peripheral bloodOesinophilia in peripheral blood Skin test positive in older childern Skin test positive in older childern FEV1< 80% of expected and reversability is FEV1< 80% of expected and reversability is

more than 12% after bronchodilatormore than 12% after bronchodilator

CourseCourse• Recurrent episodic attacks of chest symptoms Recurrent episodic attacks of chest symptoms

which may be ppt.by specific allergen or URTI that which may be ppt.by specific allergen or URTI that usually respond to B.D usually respond to B.D

4- Transient Infant Wheeze: History

Persistent or recurrent wheeze from early infancy.

No history of atopy. Cease wheezing either late in first year or

early in their second year. No history of hospital admission. Unresponsive to bronchodilator.

Examination • A well baby (thriving child)• No significant respiratory distress • Generalized wheezes • No undercurrent febrile illness

Investigation Normal X ray chest Pulmonary function airflow rate are abnormally

low

5- Gastroesophageal Reflux

- It is a retrograde passage of stomach contents into esophagus secondary to relaxation of esophageal sphincter.

- wheezing from GER results either from reflex bronchospasm after esophageal irritation or from aspiration of gastric content.

HistoryHistory - Symptoms worsen after meal or when - Symptoms worsen after meal or when

they are supine presence of GIT they are supine presence of GIT symptoms: symptoms: vomiting.vomiting. Arching of back during feeding.Arching of back during feeding. Crying during feeding irritability during feeding. Crying during feeding irritability during feeding.

- Recurrent chest infection- Recurrent chest infection

ExaminationExamination - Failure to thrive if GIT manifestation - Failure to thrive if GIT manifestation

are severe. are severe.

- Multiple chest auscultatory signs.- Multiple chest auscultatory signs.

InvestigationInvestigation - A barium study (evaluate anatomy).- A barium study (evaluate anatomy).

- Radionuclide scintigraphy (GER scan).- Radionuclide scintigraphy (GER scan).

- PH probe monitoring.- PH probe monitoring.

6-Bronchopulmonary Dysplasia6-Bronchopulmonary Dysplasia

History of neonatal problemHistory of neonatal problem• Low birth weight under 2.5 KgLow birth weight under 2.5 Kg

• Persistent or recurrent wheezingPersistent or recurrent wheezing

• wheezes usually associated with intercurrent viral wheezes usually associated with intercurrent viral respiratory infectionrespiratory infection

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7- Tracheomalacia or Bronchomalacia

HistoryCausing wheezes from birth but more commonly in first

2-3 months of life.

• Wheezes are loud during activity but are quit at Wheezes are loud during activity but are quit at rest ( because the degree of air way narrowing rest ( because the degree of air way narrowing depends on the amount of collapsing pressure depends on the amount of collapsing pressure applied ,wheezes is loudest during periods of applied ,wheezes is loudest during periods of increased expiratory effort, crying and increased expiratory effort, crying and agitation) in contrast wheezing may disappear agitation) in contrast wheezing may disappear during sleep when expiration is unlabored.during sleep when expiration is unlabored.

High pitched inspiratory stridor may be High pitched inspiratory stridor may be presentpresent

Investigation.• Bronchoscopy during spontaneous expiration,

the trachea and bronchi narrow by more than 50%of their resting caliber

• Fluoroscopy of air way can demonstrate collapse during exhalation

8-Acute Congestive Heart Failure

History Feeding difficulties (interrupted feeding, cold sweat

on forehead following feeding, tachypnea after feeding )

Recurrent chest infection Frank history of congenital heart disease

(VSD,PDA,ECD)

Examination Failure to thrive (usually under weight due to

CHD Hyper dynamic pericordium with cardiomegaly Murmurs of specific cardiac lesion Wheezes diffuse with fine basal cons. Crepitation Tender hepatomegaly, abnormality of peripheral

pulses.

Investigations Chest X-ray Cardiomegaly, pulmonary congestion ECG, ECHO diagnosis specific cardiac lesion

8- Immune deficiency8- Immune deficiency

HistoryHistory Recurrent wheezes with feverRecurrent wheezes with fever Recurrent pulmonary and extra pulmonary Recurrent pulmonary and extra pulmonary

infection (Skin Abscesses)infection (Skin Abscesses) Chest infection usually has a prolonged courseChest infection usually has a prolonged course Failure to gain weightFailure to gain weight + VE consanguinity+ VE consanguinity

ExaminationExamination Bad general conditionBad general condition High fever ē wheezesHigh fever ē wheezes Many chest auscultatory findingMany chest auscultatory finding Involvement of other system as wellInvolvement of other system as well

InvestigationsInvestigations CBCCBC

Leucopenia or granulocytosisLeucopenia or granulocytosis T cell function CDT cell function CD4 4 , CD, CD88

Immunoglobulin assay IgA,E,M,GImmunoglobulin assay IgA,E,M,G

Cystic FibrosisCystic Fibrosis• Cystic fibrosis (CF) is an AR disorder. There is abnormal Cystic fibrosis (CF) is an AR disorder. There is abnormal

function of exocrine glands due to defect in cystic fibrosis function of exocrine glands due to defect in cystic fibrosis transmembrane regulator (CFTR) results in production of transmembrane regulator (CFTR) results in production of abnormally thick mucus.abnormally thick mucus.

• Bronchial mucus is poorly cleared with resulting airway Bronchial mucus is poorly cleared with resulting airway obstruction which causes dyspnea. Hyperinflation, a obstruction which causes dyspnea. Hyperinflation, a prolonged inspiratory, exp.ratio and expiratory wheezes.prolonged inspiratory, exp.ratio and expiratory wheezes.

• In some children mucus stasis predisposes to chronic In some children mucus stasis predisposes to chronic

bacterial infection and chronic bronchiactasis and bacterial infection and chronic bronchiactasis and

pulmonary scaring pulmonary scaring

HistoryHistory - - History of chronic coughHistory of chronic cough

- History of recurrent bronchopulmonary infection- History of recurrent bronchopulmonary infection - Failure to thrive- Failure to thrive - Production of large greasy stool (steatorhea)- Production of large greasy stool (steatorhea)

ExaminationExamination - Clubbing- Clubbing - Nasal polyps- Nasal polyps - Barrel chest appearance- Barrel chest appearance - Prominent abdomen- Prominent abdomenInvestigationInvestigation - Sweat chloride test- Sweat chloride test

Clues to the Cause of wheeze in infants Clues to the Cause of wheeze in infants with Failure to thrivewith Failure to thrive

Cystic fibrosisCystic fibrosis

Severe gastro cesophageal refluxSevere gastro cesophageal reflux

Chronic lung disease 0f prematurityChronic lung disease 0f prematurity