7/24/2013
What’s the reason for the wheezing?
Danielle M. Goetz, MD
Pediatric Pulmonology
Pediatric Grand Rounds
July 26, 2013
All that wheezes is not asthma!
Chevalier Jackson
Objectives
• Distinguish stridor from wheeze
• Distinguish the classic history for vocal cord dysfunction compared to that for asthma
• Develop a relevant differential diagnosis and management plan for an infant or child with wheeze
Case 1 History
• 15 year old female presents to the ED with difficulty breathing and “wheezing”
• “Difficulty getting the air in”
• Dyspnea Dyspnea
• Tightness in the throat for the past 15 minutes
Physical Examination
• Similar symptoms starting 3 months ago with gym class and soccer • Symptoms are becoming more frequent • In between episodes she is asymptomatic
In between episodes she is asymptomatic
• Albuterol does not prevent her symptoms
What noise is heard?
Weinberger M, Pediatrics 2007
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Stridor
Wheeze
Usually inspiratory, can be biphasic
Expiratory, can be biphasic
Upper (extrathoracic) airway
Lower (intrathoracic) airway
Continuous noise
Discontinuous noise; Monophonic or polyphonic
Not responsive to bronchodilator
May or may not be responsive to bronchodilator
Vocal Cord Dysfunction
(VCD)
Variable Upper Airway Obstruction
Persistent Adduction of the Vocal Cords
VCD
• History
– Dyspnea (76‐95%)
• More trouble getting air “in”
– Cough
– Noise breathing in (stridor)
– Tightness in the throat and chest
– Neck pain
– Hoarseness
– Dysphonia
– Numbness or tingling in hands, feet or lips
– Lightheaded or dizzy
• Physical Examination
– Stridor during an attack
– If present, wheezing is biphasic and loudest over the larynx and large airways
– Pulse oximetryy is normal
Weinberger M, Pediatrics 2007
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VCD
Asthma
• Extrathoracic obstruction
• Rapid onset and rapid resolution
• Refractory to asthma Rx
• Anxiety preceding
• Can hold breath
• Resolution in sleep
• Normal ABG/pulse oximetry
• Normal CXR
• Intrathoracic obstruction
• Insidious onset and slower to resolve
• Bronchodilators help
• Anxiety following
• Can’t hold breath
• Symptomatic in sleep
• Abnormal ABG/pulse oximetry
• Hyperinflated, peribronchial
thickening or atelectasis on CXR
Etiology
• Athletes
• Laryngeal hyperresponsiveness
– Irritant induced
– GERD
– Post‐nasal drip
• Psychologic (functional) causes
– Depression, Anxiety, Obsessive compulsive disorder, conversion disorder
• Comorbidity with Asthma or GERD
Noyes B. Ped Resp Reviews 2007
Hoyte F. Immunol Allergy Clin A Am 2013
Acute Management
Long‐term Management
• Common:
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Reassurance
Relaxed breathing techniques: panting, pursed lips, sniffing
Anxiolytics (Benzodiazepines)
Heliox (20‐40%)
Inhaled saline as placebo
Inhaled lidocaine
Inhaled lidocaine
Inhaled atrovent (if exercise induced)
• Psychologic counseling
• Speech therapy
– Resistive breathing
– “Relaxed throat” breathing or diaphragmatic breathing
p g
g
– Relaxation techniques
– Biofeedback
– Self‐hypnosis
• Less common:
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CPAP
Anesthesia (Propofol)
Injection of Botulinum toxin
Intubation or tracheostomy (historical, not indicated!)
Discontinue unnecessary asthma medications
Kenn K. Eur Respir J 2011
Lessons Learned from Case 1
• VCD can be easily confused with asthma and is often a comorbid condition
• Differentiating VCD from asthma relies on good clinical history and PE
good clinical history and PE
• Recognizing the difference can prevent needless hospitalizations, testing and medication side effects!
Case 2
8 month old male with wheeze
Noisy breathing and cough x 3 months
Worse when awake Possible response to albuterol
Trial of inhaled budesonide x 6 weeks: no improvement
• No history of foreign body aspiration or choking
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• Pediatrician heard inspiratory stridor
• Clinically diagnosed with laryngomalacia near full term birth
Normal Larynx
Congenital Anomalies:
Tracheomalacia
Differential Diagnosis of Wheezing in Infants
Large airways (Monophonic)
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Tracheal
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Subglottic stenosis
Tracheomalacia
Repaired TEF
Complete tracheal rings
Vascular rings
Hemangioma
Tumor
Bronchial
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Bronchomalacia or bronchial stenosis
Foreign body
Hilar lymphadenopathy (eg. Tb)
Vascular slings
Bronchogenic cysts
Cardiomegaly
Pulmonary artery dilatation
Tumor (rare)
Small airways (Polyphonic)
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Asthma
Bronchiolitis
y
Cystic fibrosis
GERD
BPD
PCD
Bronchiolitis obliterans
Normal Trachea
Tracheomalacia
Finder JF. Curr Probl Pediatri March 1999
Tracheal Stenosis
Extrinsic Airway Compression
• Suspected External Compression – enlarged lymph nodes
– vascular structures
– lung abscess
– cysts
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Foreign Bodies
Vascular Rings
• Aberrant Right Subclavian – esophageal compression
• Right aortic arch
• Double aortic arch
• Food Products are frequent culprits
• Nuts cause many problems
– Small, easy to aspirate
– Nut oil, irritant
– Break apart causing airway obstruction
Anomalous Innominate Artery
Pulmonary Artery Sling (Aberrant L pulmonary artery)
Vascular Compression of the Airways
Tracheal
Obstruction of airflow
Impaired mucus clearance
Reflex apnea
Esophageal
Dysphagia
Regurgitation
Aspiration
Plan
• Referred to ENT for laryngoscopy, procedure to be coordinated with flexible bronchoscopy
to assess lower airway dynamics
• Seen 4 weeks later by ENT
Seen 4 weeks later by ENT
• Rigid bronchoscopy performed 7 weeks after Pulmonology appointment (at 8 months of age)
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Normal larynx
Normal subglottis and trachea (not pictured)
Physical Exam on admission POD #1 after rigid bronchoscopy
• Gen : Playful, Afebrile, RR 28, Pulse oximetry
97% on RA.
• Cough; intermittent, Brassy in nature. Lungs with expiratory wheeze, intermittent,
with expiratory wheeze, intermittent, bilateral. No improvement with albuterol. Worse with activity.
• Neck: Posterior cervical lymphadenopathy 2 cm bilaterally. RUL bronchus compressed
Left main bronchus significantly compressed
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Tuberculosis Evaluation
• Quantiferon gold test positive
• NG aspirates x 3 smear negative
• Sent home on 4 drug therapy: Lymph node pathology ‐ multiple focally caseating
granulomas
DDX Mycobacterium TB, NTM, Fungal infection
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Isoniazid
Rifampin
f
Pyrazinamide
Ethambutol
• BAL cultures, NG aspirates, and brush cultures ultimately grew Mycobacterium tuberculosis‐
sensistive to isoniazid
Lessons Learned from Case 2
• Don’t forget mediastinal lymphadenopathy as a cause of wheeze in infants
• Anyone can get TB
– And in this case the index case was never found
A d i thi
th i d
f
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• Directly observed therapy is a good thing
– Patients rarely take the medications prescribed to them exactly as prescribed ☺
Case 3
2 year old male previously healthy
Placed in his toddler bed at 9pm
One of the bottom dresser drawers was open
Mother observed him to have choking and difficulty breathing
• ED physicians heard inspiratory stridor and expiratory wheezing
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Foreign Body Aspiration
WHAT IS YOUR TOP DIAGNOSIS UNLESS PROVED OTHERWISE?
FOREIGN BODY ASPIRATION
Appropriate history
• Vulnerable age
– (95% ages 1‐4 years)
• Witnessed aspiration event (choking in 80‐90%)
(choking in 80‐90%)
• Respiratory distress (acute)
• Recurrent pneumonia
• Sx: drooling, stridor, dysphonia, cough, wheeze
Exam
• Relentless stridor/cough
• Wheeze (unilateral or bilateral)
D
d/ b
b
h
• Decreased/absent breath sounds
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Possible Chest Radiograph Findings
Bronchoscopy
Lessons Learned from Case 3
Take Home Points
• Pediatricians can help prevent accidental foreign body aspiration, which is quite common!
• Foreign body removal is not always an easy Foreign body removal is not always an easy
thing
• I am supported by the evidence in chopping up foods into tiny pieces for my kids ☺
• Differentiate stridor from wheeze
• Think of other causes of wheezing
– Tracheobronchomalacia
– Mediastinal
di i l lymphadenopathy
l
h d
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– Foreign body aspiration
• VCD can often be differentiated from asthma
– History, PE and flow volume loops
• We are happy to consult for help!
Thank you!!
References
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Cane RS, Ranganathan SC, McKenzie SA. What do parents of wheezy children understand by “wheeze”? Arch Dis Child 2000; 82: 327‐32. Finder JD. Understanding airway disease in infants. Curr Probl Pediat, March 1999.
Gimenez L. Vocal cord dysfunction: an update. Ann Allergy Asthma Immunol 2011; 106: 267‐75.
Hoyte F. Vocal Cord Dysfunction. Immunol Allergy Clin N Am 2013; 33: 1‐22.
K
Kenn
K & B lki
K & Balkissoon
R V lC dD f
R. Vocal Cord Dysfunction: what do we know? European i
h d
k
? E
Respiratory Journal 2011; 37: 194‐200.
Noyes B. & Kemp J. Vocal cord dysfunction in children. Paediatric Respiratory Reviews 2007; 8: 155‐63. Toka B. et al. Tracheobronchial foreign bodies in children; Clinical Radiology; 2004; 609‐15.
Weinberger M and Abu‐Hasan M. Pseudo‐asthma: when cough, wheezing and dyspnea are not asthma. Pediatrics 2007; 120:855‐64.
For additional information: National Jewish Medical and Research Center http://www.njc.org/disease‐info/diseases/vcd/index. aspx
Allergy and Asthma Network: Mothers of Asthmatics http://www.aanma.org/2009/02/vocal‐cord‐dysfunction‐something‐to‐talk‐about
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