Wheeze, Stridor, Cough, and
Other Respiratory Noises
Miles Weinberger, M.D.
Professor of Pediatrics
www.uihealthcare.com/allerpulm
Wheeze
Continuous musical sounds, typically
expiratory in nature
But What Do Parents Mean by “Wheeze”
¾Less than 50% agreement between parents
and clinicians (Cane et al. Arch Dis Child 2000;82:327)
¾Wheeze most commonly used term for
respiratory sounds until imitated or shown
video (Elphick et al. Arch Dis Child 2001;84:35)
¾30% of parents used other words for wheeze
and 30% labeled other sounds as “wheeze”
(Cane et al. Arch Dis Child 2001;84)
Causes of Wheezing
¾Bronchiolitis
¾Asthma
¾Cystic fibrosis
¾Foreign body (monophonic)
¾Bronchomalacia
Causes of Wheezing
¾Bronchiolitis
¾Asthma
¾Cystic fibrosis
¾Foreign body (monophonic)
¾Bronchomalacia
Patient GH
¾5 m.o. with wheezing and retractions
¾Onset 6 weeks of age
¾No response to albuterol
Patient GH
Patient GH
Patient GH
¾BAL from RUL
n
n
n
52% neutrophils
400,000 cfu/ml Moraxella catarrhalis
400,000 cfu/ml Haemophilus influenzae
¾Coughing and wheezing resolved with
Augmentin ES600, 90 mg/kg/day divided BID
¾Stridor and retractions when excited persisted
from the mild laryngomalacia
Bronchomalacia
Bronchomalacia
Noises and Clinical Consequences
Associated with Bronchomalcia
Kompare M, Weinberger M. Protracted bacterial bronchitis in young children: association with airway malacia.
J Pediatr 2012;160:88-92).
¾ Protracted bacterial bronchitis –
most with bronchomalacia
¾ BAL for persistent presence of
cough, wheeze, or noisy breathing
n Inflammation (neutrophilia)
n
High colony counts bacteria
– S. pneumo
– H. influenza
– M. catarrhalis
¾ Improved with Augmentin, but
recurrences common
Airway Malacia
26%
41%
13%
20%
Bronchomalacia
Tracheomalacia
Both
None seen
Stridor
Continuous inspiratory musical sound of
variable pitch
Laryngomalacia
¾Common to varying degrees – about 60% of
stridor in infants
¾Represents a delay in maturation of
supporting laryngeal structures.
¾Generally resolves by 2 years of age
¾Rare cases result in pulmonary hypertension
¾Laser laryngoplasty for very occasional
severe cases affecting feeding or growth
What is “croup”?
¾ Transient inflammation of the laryngeal area
causing upper airway obstruction characterized by
inspiratory stridor - generally from viruses
¾ Commonly associated with inflammation of the
trachea and bronchi, hence the term
“laryngotracheobronchitis”
¾ Typically accompanied by harsh barking cough
from the tracheobronchitis – but a “croupy” cough
alone is not croup
¾ Responds to epinephrine aerosol with transient
relief and dexamethasone for sustatined benefit
Etiologic Agents Recovered
from Children with Croup
N = 360
Paraflu 3
18%
Paraflu 2
9%
M Pneumoniae
4%
Influenza A
Influenza B
4%
3%
Paraflu 1
47%
RSV
10%
Denny et al, Pediatr 71:871, 1983
Misc. vir.
5%
Epiglottitis
¾Bacterial infection
n
n
H. influenza group B
S. pyogenes (beta hemolytic streptococcus, group A)
¾Life threatening
¾Medical emergency
¾Treatment
n
n
Establish an airway
Antibiotics
Jennifer J 15 Y.O. Girl With 3 Weeks of recurrent stridor and dyspnea
¾First episode while detasseling - Rx with
epinephrine in ER successful
¾2nd episode next day while detasseling same treatment with same result
¾Then daily episodes without detasseling and
without response to epinephrine
¾Respiratory sound called wheezing
¾Rx with inhaled bronchodilators, prednisone,
and hospitalization without response
Jennifer J - Spirometry Before
and After Treadmill Exercise
¾ Treadmill exercise
induced “wheezing”
(actually a high pitched
stridor)
post-exercise
pre-exercise
¾ Normal pre-exercise;
decreased flow only on
inspiration postexercise
¾ Diagnostic of
extrathoracic airway
obstruction
Sarah J - 15 Y.O. Girl With 1.5 Year History
Recurrent Severe “Wheezing” and Dyspnea
¾ Multiple paramedic calls for ER Rx because of
severe respiratory distress
¾ Rx with bronchodilators, inhaled and oral
corticosteroids
¾ Several hospitalizations
¾ No consistent response to any treatment
Sarah J - spirometry before and after
preparing to perform bronchoprovocation
¾ “Wheezing” (actually a high
before
pitched inspiratory stridor and a
monophonic expiratory wheeze)
after
and dyspnea began while
preparing to perform
bronchoprovocation
¾ Initially normal; then severe
airflow obstruction
apparent on both
inspiration and expiration
Vocal Cord Dysfunction Syndrome
¾Commonly mis-diagnosed as asthma
¾May be present along with asthma
¾Two clinical patterns (Doshi D. Weinberger M. Long-term outcome of
vocal cord dysfunction. Ann Allergy Asthma Immunol 2006;96;794-799)
n
Exercise induced (can be blocked with anti-cholinergic aerosol)
n
Spontaneous
¾Treatment of spontaneous VCD – vocal cord
training by a speech therapist familiar with
the disorder
History of D.D.
¾17 m.o. girl with 8 months of harsh
nocturnal stridor and coughing
¾Rx with albuterol and corticosteroids
¾No response to treatment
¾Flexible bronchoscopy showed
intermittent paradoxical vocal cord
movement
MRI of D.D.
Chiari 1 malformation with herniation of cerebellar tonsil
below foramen magnum
Causes of Stridor
¾Croup
¾Epiglottitis
¾Laryngomalacia
¾Chiari malformation
¾Vocal cord paralysis
¾Laryngeal foreign body
¾Vocal cord dysfunction syndrome
Cough
Forceful exhalation after quickly raising
thoracoabdominal pressure, often to > 100 cm H20
Pertussis
Whooping Cough
¾Most dangerous in unimmunized infants
¾Occurs in immunized adolescents and adults
n
n
26% of 130 college students with persistent cough
> 6 days (Mink et al, Clin infect Dis 1992;14:464-71)
21% of 75 adults with cough > 2 weeks (Wright et al,
JAMA 1994;273:1044-6)
n
12% of 153 adults with cough > 2 weeks (Nennig et al,
JAMA 1996;275:1672-4)
Nasal Swab for Pertussis PCR
Habit Cough Syndrome
Clinical Characteristics
¾Loud, repetitive, dry, barking cough
¾Duration of weeks or months
¾Irritating and disturbing to others prevents school attendance
¾Commonly misdiagnosed as asthma
¾No response to medication
¾Absent once asleep
Habit Cough
Rx With Suggestion Therapy - Outcome
Lockshin, Lindgren, Weinberger, Koviach. Ann Allergy
1991;67:405 (from U of IA Ped All/Pulm Clinic)
¾8/9 patients treated successfully with 15
minute session, 1/9 required 30 minutes
¾Minor relapses controlled with
autosuggestion technique
¾1 required a 2nd session 9 days later
¾All remained asymptomatic for median
of 2.2 years
Habit Cough Syndrome
Natural History
Rojas, Sachs, Yunginger, O’Connell. Annals of Allergy
1991;66:106 (from the Mayo Clinic)
¾Follow-up of 62 pts (34 m & 26 f) for mean
length of 7.9 years
¾Ages 4.6-15.6 (mean 10.5)
¾Mean duration till Dx - 7.6 months
¾Mean duration till resolution 6.1 months
¾16 pts still coughing for mean of 5.9 years
from time of Dx
Habit Cough Syndrome
Rx With Suggestion Therapy - Method
¾Physician must have confidence in success
¾Focus patient’s attention on suppressing cough
¾Explain cough
¾Reinforce even brief successes
¾Emphasize that patient, not physician, is
controlling cough
¾Success usual in about 15 minutes
¾Emphasize autosuggestion for minor relapses
Donna E 9 Y.O. Girl With Cough for 2 Years
¾Treated as asthma
¾Oral corticosteroids
n
n
n
Growth retarded
Cushingoid
Hirsute
¾Several hospitalizations with IV
antibiotics and corticosteroids
¾No response to any of the therapy
Patient MW
¾14 m.o. coughing day and night
¾4-5 spasms of coughing a day lasting 4-5
minutes
¾Interferes with activity
¾Coughing disturbs sleep, especially when
lying on her back
Patient MW
Patient MW
Patient MW
¾No inflammation on BAL
¾Referred to pediatric surgery
¾Aortopexy performed
Tracheomalacia - treatment
¾Behaviorally – successful for some mild
cases (Wood RE. Localized tracheomalacia or
bronchomalacia in children with intractable cough. J
Pediatr 1990;116:404-406)
¾Aortopexy – stenting the trachea using a
stitch between the sternum and the aorta to
place tension on the connective tissue
between the aorta and anterior wall of the
trachea
Aortopexy
Patient MW
¾Cough now not troublesome
¾She now sleeps well at night on her back
History of A.K.
¾ 4 y.o. with harsh barking cough
¾ Present since infancy
¾ Dx as asthma
¾ Allergy skin testing negative
¾ Rx with cromolyn, Singulair, prn albuterol, and
multiple courses of steroids
¾ Equivocal response to all treatment
Upper Airway of A.K. Through
Flexible Bronchoscope
Najada A, Weinberger M. Unusual cause of chronic cough in a four-year-old cured by uvulectomy.
Pediatr Pulmonol 2002;34;144-146.
3.y.o. girl with chronic cough
Gurgel RK, Brookes JT, Weinberger MM, Smith RJ. Chronic cough and tonsillar hypertrophy.
Ped Pulmonol 2008;43:1147–1149.
¾ No response to
bronchodilators
¾ No response to
prednisolone
¾ No response to
antibiotic
¾ No airway
inflammation on BAL
¾ No bacteria on BAL
epiglottis
Tonsillar tissue
Other Causes of Cough
¾Acute viral bronchitis (or
tracheobronchitis)
¾Asthma (1215 tomorrow)
¾Protracted bacterial bronchitis
¾M. Or C. Pneumoniae
¾Aspiration
¾Cystic fibrosis
¾Primary ciliary dyskinesia
¾Habit cough syndrome (Saturday at 1300)
What about GERD and Cough???
Chang et al. Cough and reflux esophagitis in children: their co-existence and
airway cellularity. BMC Pediatr 2006 Feb 27;6:4.
Chang et al. An objective study of acid reflux and cough in
children using an ambulatory pHmetry–cough logger. Arch Dis Child. 2011
May;96(5):468-72.
Chang et al. Gastro-oesophageal reflux treatment for prolonged non-specific
cough in children and adults. Cochrane Database Syst Rev. 2011 Jan 19;(1)
Controlled clinical tirals have not shown PPIs to improve
cough associated with GERD symptoms in infants,
children, or adults.
What About Post-Nasal Drip?
Morice AH. Post-nasal drip syndrome – a symptom to be sniffed at?
Pulmonary Pharmacology & Therapeutics 2004;17:343-5.
Kemp A. Does post-nasal drip cause cough in childhood?
Paediatr Resp Rev 2006;7:31-35.
¾A diagnostic label that is unhelpful
¾No accepted definition
¾Mucus dripping down the back of the throat
not consistently associated with cough
¾Presence of post-nasal drainage with cough
likely indicates inflammation of lower airway
in addition to the upper airway
Other Respiratory Noises
¾Crackles – interrupted sounds
n
n
Fine crackles – inspiratory opening of
alveoli that closed on previous exhalation(s)
Coarse crackles (preferred terminology over
rhonchi) – movements of fluids in bronchi or
bronchioles
¾Pleural rubs
¾Increased transmission of voice sounds
n
n
Bronchophony and egophony
Whispering pectoriloquy
Describing Respiratory Sounds
¾Inspiratory or expiratory
¾Continuous or
interrupted
¾Pitch
¾Volume
¾Location
¾Duration and frequency