How to manage a wheezing patient
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A brief description of few causes of wheeze and its management. Mainly for post graduates in respiratory medicine.
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How to manage a wheezing patient
- 1. How to manage a wheezing patient Thomas Kurian Thomas Kurian
- 2. Approach to a case Thomas Kurian
- 3. Asthma should be considered likely • episodic wheezing and other symptoms, such as cough and dyspnea • respond favorably to conventional asthma medications Thomas Kurian
- 4. Historical findings that may suggest that wheezing is NOT due to asthma or COPD • sore throat • hoarseness • heartburn • sour taste and regurgitation • hemoptysis Thomas Kurian
- 5. History • ●Onset - foreign body aspiration • goiter compressing the airway or endobronchial tumor • ●A history of neck or thyroid surgery – ? vocal cord paralysis • ●Prior intubation – • ? vocal fold trauma or paralysis, tracheal stenosis, or tracheomalacia Thomas Kurian
- 6. History • ●dyspnea, wheeze, intractable (often barking) cough to the point of syncope, and recurrent pulmonary infections— • tracheobronchomalacia and hyperdynamic airway collapse. • ●Cigarette smoking more than 10 pack years • COPD • laryngeal or bronchogenic cancer Thomas Kurian
- 7. History • Respiratory symptoms in the minutes or hours after a single accidental inhalation of a high concentration of irritant gas, aerosol, or smoke --- • reactive airways dysfunction syndrome (RADS) ●Wheezing associated with a chronic or recurrent cough productive of purulent sputum may suggest bronchiectasis Thomas Kurian
- 8. Physical examination • oxygen saturation, and evidence of respiratory distress • Chest and neck auscultation are used to differentiate stridor from wheezing Thomas Kurian
- 9. Acoustic characteristics of wheeze • •Polyphonic wheeze • •Monophonic wheeze Thomas Kurian
- 10. Stridor is a type of monophonic wheeze, but its intensity and occurrence during inspiration help distinguish it from lower airway monophonic wheezing Thomas Kurian
- 11. Timing • Expiratory wheezing-- neither sensitive nor specific for asthma • Inspiratory wheezing-- neither a sensitive nor a specific sign of extrathoracic upper airway disease or obstruction • In some patients with asthma, wheezing may only be heard during inspiration Thomas Kurian
- 12. Focal wheeze • persistently located in one area • foreign body in a segmental airway, endobronchial tumor Thomas Kurian
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- 14. Extrapulmonary findings • Tonsillar hypertrophy is typically visible on oral exam. • Neck - lymphadenopathy, thyroid enlargement, or a surgical scar is identified. Thomas Kurian
- 15. • Spirometry • Flow volume loop Thomas Kurian
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- 18. Bronchoprovocation challenge • A negative methacholine challenge test - strong evidence against asthma or RADS. Thomas Kurian
- 19. Gas transfer • P(A-a)O2 gradient on arterial blood gases • increased P(A-a)O2 gradient or a reduced DLCO suggest small airway disease or lung parenchymal involvement Thomas Kurian
- 20. Imaging • A conventional chest radiograph is appropriate in most adults with new onset or refractory wheezing Thomas Kurian
- 21. Chest CT • vascular rings, aneurysms of the major vessels, mediastinal masses, or lymphadenopathy that compress the trachea extrinsically • Tracheomalacia Thomas Kurian
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- 23. HRCT • bronchiectasis , mosaic ground glass attenuation Thomas Kurian
- 24. Direct visualization • At the time of visualization, biopsies can be obtained of intraluminal masses and plaques Thomas Kurian
- 25. Bronchoscopy • ●When the flow volume loop suggests extrathoracic obstruction, laryngoscopy is often the next step • ●Flexible or rigid bronchoscopy Thomas Kurian
- 26. 2 year old child • acute onset of breathlessness • Temperature, 37.4°C • respiratory rate, 40 breaths per minute • pulse, 110 beats per minute • blood pressure, 92/60 mm Hg • oxygen saturation, 80% on room air. • He had no nasal congestion, rhinorrhea, stridor, or previous history of difficulty breathing. Thomas Kurian
- 27. • Physical examination - tachypnea and suprasternal and subcostal retractions • Left sided wheeze Thomas Kurian
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- 29. • What is the probable diagnosis? Thomas Kurian
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- 31. What should be done next? Thomas Kurian
- 32. Treatment • Rigid bronchoscopy Thomas Kurian
- 33. What are the DD of wheezing in a child 1) INFECTION 2) ASTHMA: • i) Transient wheezer • ii) Persistent wheezers • iii) Late onset wheezer Thomas Kurian
- 34. 3) Anatomic abnormalities a) Central airway abnormalities b) Extrinsic airway anomalies c) Intrinsic airway anomalies: 4) Immunodeficiency states 5) Mucociliary clearance disorders Thomas Kurian
- 35. 6) Aspiration Syndromes 7) Heart Failure 8) Anaphylaxis 9) WALRI 10) Drugs: Ibuprofen, Aspirin Thomas Kurian
- 36. Clinical Manifestations • HISTORY & PHYSICAL EXAMINATION - Birth history - Infection Thomas Kurian
- 37. RISKS OF FAMILY HISTORY OF ATOPY Single parent atopy : 22% Maternal Atopy : 32 % Both parents atopic : 50% Thomas Kurian
- 38. Diagnostic evaluation Initial evaluation depends on likely etiology 1. Chest Xray 2. Trial of bronchodilators Thomas Kurian
- 39. Exclude other conditions 3) Structural problems: bronchoscopy 4) Esophageal disease 5) Primary ciliary dyskinesia 6) TB 7) Bronchiectasis 8) CF 9) Systemic immune deficiency 10) Cardiovascular disease Thomas Kurian
- 40. Treatment 1. Comfort the child 2. Offer frequent liquids 3. Bronchodilators 4. Ipratropium bromide 5. Oral/ IV steroids 6. Inhaled steroids 7. Montelukast 8. No role of antibiotics Thomas Kurian
- 41. 36 year old obese female , came with history of shortness of breath, cough x 2 months Her symptoms were worse in the early morning Her symptoms vary over time and in intensity Her symptoms are triggered by laughter Thomas Kurian
- 42. What is the probable diagnosis? Thomas Kurian
- 43. These are typical of asthma- True / False Chest pain Shortness of breath associated with dizziness, light headedness or peripheral tingling Chronic production of sputum Symptoms triggered by exercise, irritants such as car exhaust fumes, smoke Thomas Kurian
- 44. These are typical of asthma- True / False Chest pain Shortness of breath associated with dizziness, light headedness or peripheral tingling Chronic production of sputum Symptoms triggered by exercise, irritants such as car exhaust fumes, smoke Thomas Kurian
- 45. What are the phenotypes of Asthma? Allergic asthma Non allergic asthma Late onset asthma Asthma with fixed airflow limitation Asthma with obesity Thomas Kurian
- 46. How do you confirm the diagnosis? PFT with reversibility Thomas Kurian
- 47. For how long should SABA be withheld ? 4 hours Thomas Kurian
- 48. For how long should LABA be withheld ? 15 hours Thomas Kurian
- 49. In our patient the PFT revealed Thomas Kurian
- 50. Pre-bronchodilator spirograph shows : FEV1/FVC : 38.39(Very low ) FVC : 2.24 (72 % pred.) FET : 6.12 sec. Diagnosis ? Obstructive airway disease Post- bronchodilatation spirograph shows: Δ FEV1 : 290 ml (34%) What is your final diagnosis ? Reversible airway obstruction- Bronchial Asthma Thomas Kurian
- 51. Which is the other way in which Asthma may be diagnosed? Excessive variability in twice daily PEF over 2 weeks Positive exercise challenge test Significant increase in lung function after 4 weeks of anti inflammatory treatment Positive bronchial challenge test Thomas Kurian
- 52. What is stepwise management in a case of asthma? Thomas Kurian
- 53. Our patient was started on Med to high dose ICS / LABA Thomas Kurian
- 54. When do you say asthma is well controlled? Day time symptoms not more than twice/week No night time waking Reliever needed not more than twice/week No activity limitation due to asthma Thomas Kurian
- 55. How to step down treatment? Once asthma control is achieved and maintained for 3 months Stepping down ICS doses by 25-50% at 3 month intervals is feasible and safe Thomas Kurian
- 56. What are the non pharmacological interventions? Thomas Kurian
- 57. Non pharmacological interventions Cessation of smoking and ETS Physical activity Avoidance of occupational exposures Avoid Medicines that make asthma worse Breathing techniques Thomas Kurian
- 58. Non pharmacological interventions Healthy diet Weight reduction Bronchial thermoplasty Allergen immunotherapy Avoidance of outdoor and indoor allergens Thomas Kurian
- 59. Inhaler technique No 2 devices Choose Check Correct Confirm Thomas Kurian
- 60. Comorbidities Obesity GERD Rhinitis , Sinusitis , Nasal polyps Thomas Kurian
- 61. Our patient came for follow up and is pregnant In what percent asthma worsens? Poor symptom control and exacerbations are associated with worse outcomes for both the baby and the mother Thomas Kurian
- 62. After 6 months of delivery , she had worsening asthma, and was put on high dose ICS Thomas Kurian
- 63. During this treatment patient had a fracture of femur after a fall from bike What is the precaution? Why? Thomas Kurian
- 64. After surgery , she was prescribed regular controller therapy, antibiotics and analgesics She developed nasal congestion , anosmia, conjunctival ingestion What is the clinical picture resembling? Thomas Kurian
- 65. AERD Aspirin challenge test is the gold standard Should avoid NSAIDs. When NSAIDS are indicated substitute with COX- 2 inhibitors ICS are the mainstay Desensitization Thomas Kurian
- 66. Male 30 year old cough, breathlessness, wheezing and chest pain Fever , weight loss were also present Symptoms are mostly nocturnal He had hepato splenomegaly Thomas Kurian
- 67. There was eosinophilia 4200 /um ESR 70 Thomas Kurian
- 68. What is the relevance of place of residence? Thomas Kurian
- 69. Thomas Kurian
- 70. What are the investigations to confirm TPE? High serum levels of IgE filarial-specific IgE and IgG are found Thomas Kurian
- 71. TPE (i) history suggestive of nocturnal symptoms mainly cough and dyspnoea (ii) pulmonary infiltrates on chest radiograph (iii) leukocytosis with peripheral eosinophilia > 3000/µm (iv) elevated serum IgE and filarial specific IgG and IgE (v) clinical improvement with DEC Thomas Kurian
- 72. What is the treatment? DEC Steroids Thomas Kurian
- 73. Prevention Albendazole DEC Thomas Kurian
- 74. An 83 year old female presents episode of weakness, breathlessness orthopnoea Thomas Kurian
- 75. Initial Clinical Findings Airway – clear & patent Breathing – tachypnoeic Circulation – Pulse present, irregular, tachycardic; skin colour normal, cap refill normal Disability – No LOC before ambulance arrival, patient responding to verbal stimuli Thomas Kurian
- 76. What is AMPLE history? AMPLE, Allergies, Medications, Past Medical History, Last Eaten, Events Leading AMPLE History A – Allergic to penicillin M – Currently taking Warfarin, Furosemide P – History of CVA x 1 year, CHF L – Last oral intake 7pm the evening previous E – Son stated patient became very weak before going to bed Thomas Kurian
- 77. On examination Pulse rate 110bpm Pulse rhythm Irregular Resp rate 24 per minute, regular, shallow Wheeze + , basal crackles Thomas Kurian
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- 79. SpO2% 89% @ room air Cap Refill <2secs BP 178/112 RBS normal Thomas Kurian
- 80. Thomas Kurian
- 81. What is the treatment to be given? GTN SL Furosemide 40mg O2 CPAP Urinary catheter CPAP Therapy Thomas Kurian
- 82. Investigations 3 Lead ECG 12 Lead ECG CXR Blood tests – to identify any electrolyte imbalances etc. Urinary catheter Thomas Kurian
- 83. Assessment Excessive sweatiness/clamminess Tachycardia Hypertension/hypotension in extremis Raised JVP Central cyanosis Tachypnea Basal respiratory crackles Wheeze Pitting ankle oedema ECG changes (old MI, ischaemic changes, indicative of previous myocardial damage) Thomas Kurian
- 84. 15-year-old girl history of ‘poorly controlled asthma’ dyspnoea on exertion and wheeze Her symptoms started after she was pushed over while playing football She had been treated with inhaled corticosteroids, short-acting and long-acting β2-agonists and a leukotriene receptor antagonist without improvement. Thomas Kurian
- 85. Inspiratory stridor was noted on clinical examination Thomas Kurian
- 86. Thomas Kurian
- 87. Speech and language therapy Thomas Kurian
- 88. A 58-year-old woman was referred with ‘poorly controlled asthma’ She reported prolonged wheeze and chronic cough, was unresponsive to a range of inhaled therapies prescribed by her general practitioner She worked as a hairdresser and was a non-smoker She had no history of atopy. She had been treated for asthma for 4 years and had never been intubated. Thomas Kurian
- 89. Inspiratory stridor was noted on clinical examination Thomas Kurian
- 90. Thomas Kurian
- 91. The spirometric flow-volume loop showed truncation of inspiratory as well as expiratory flow-volume loops consistent with fixed upper airway obstruction Bronchoscopy revealed fixed subglottic stenosis She was referred to an otorhinolaryngologist for endoscopic repair. Thomas Kurian
- 92. A 75-year-old man with a 20 smoking pack-years was referred with a 6-week history of worsening wheeze, cough, green sputum and dyspnoea on exertion. Inspiratory stridor and expiratory wheeze were noted on clinical examination. Thomas Kurian
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- 95. CT of the thorax showed a large retrosternal goitre Bronchoscopy revealed extrinsic tracheal compression Thyroidectomy led to resolution of symptoms Thomas Kurian
- 96. Take home message • ●For patients with rapid onset of respiratory distress associated with wheezing or stridor, the key initial steps are to ensure adequate oxygenation and ventilation based on pulse oximetry and arterial blood gas measurement, followed by a rapid assessment made to determine the most likely cause. If asthma and COPD nebulized bronchodilator treatment • If there is evidence of anaphylaxis, subcutaneous epinephrine should be given immediately. Thomas Kurian
- 97. • ●For patients with impending respiratory failure and suspicion of central airway obstruction, endotracheal intubation by an experienced clinician should precede a diagnostic evaluation if the initial measures have failed to improve the situation Thomas Kurian
- 98. 1. Spirometry 2. Flow volume loop 3. Imaging of the neck and chest 4. Direct visualization of the airway is often necessary Thomas Kurian
- 99. Thomas Kurian
Editor's Notes
- — Wheezes are defined as high-pitched, continuous sounds lasting for at least 250 msec. They generally are louder than normal breath sounds.
- However, stridor (monophonic inspiratory wheeze heard loudest over the neck) is a worrisome sign of upper airway obstruction.
- Upper airway obstruction due to tumor or stenosis with an airway diameter <8 mm usually causes dyspnea on exertion; when the diameter is <5 mm, stridor is usually evident
- Inflammation of the cartilage of the nose or ears may alert the clinician to possible airway narrowing or collapsibility due to relapsing polychondritis Stigmata of rheumatoid arthritis might suggest bronchiolitis or cricoarytenoid joint arthritis with airway obstruction.
- performing flow volume loops (instead of expiratory spirometry alone) during bronchoprovocation challenge testing may provide a clue to possible paradoxical vocal cord motion (PVCM). While patients with PVCM may develop flattening of the inspiratory portion of the flow volume loop in response to pharmacologic bronchoprovocation challenge, direct laryngoscopy is required to confirm the diagnosis.
- In fact, a normal P(A-a)O2 gradient is good evidence in favor of an upper airway cause of wheezing in a patient with wheezing and respiratory distress. On the other hand, an increased P(A-a)O2 gradient or a reduced DLCO suggest small airway disease or lung parenchymal involvement (eg, bronchiolitis, bronchiectasis, COPD, lymphangioleiomyomatosis, proximal airway obstruction with atelectasis).
- Conventional chest radiographs, with particular attention to the trachea and central airways, should be performed in all patients with the combination of wheezing, acute respiratory distress, and lack of response to inhaled bronchodilator therapy The conventional chest radiograph is generally insensitive for central airway lesions, although it can sometimes identify central airway narrowing involving long segments of the trachea (eg, relapsing polychondritis, tracheobronchopathia osteochondroplastica, amyloidosis, granulomatosis with polyangiitis [Wegener's], tumors).
- (eg, tumor, amyloid, respiratory papillomatosis).
- During bronchoscopy, biopsy samples can be obtained and foreign bodies can be removed. The decision about whether to use flexible or rigid bronchoscopy usually depends on the anticipated location and severity of tracheal lesions, and also whether a therapeutic intervention (eg, stent, laser resection) is planned.
- Viral : RSV (Bronchiolitis) Influenza, Parainfluenza Adenovirus Rhinovirus Others: TB Chlamydia trachomatis Histoplasmosis
- 3) Anatomic abnormalities: a) Central airway abnormalities: - Malacia of larynx, trachea, bronchi - Tracheoesophageal fistula ( H type) b) Extrinsic airway anomalies - Vascular ring/ sling - Mediastinal LN’pathy (infection/ tumor) - Esophageal foreign body c) Intrinsic airway anomalies: - Airway hemangioma - Cystic adenomatoid malformation - Bronchial/ lung cyst - Congenital lobar emphysema - Aberrant tracheal bronchus - Sequestration - CHD with L R shunt ( pulmonary edema) - Foreign body
- Δ FVC : 650 ml (29 %)
- ( pre term, LBW, mortality) ( pre eclampsia)
- She should receive peri op hydrocortisone There is risk of adrenal crisis in the context of surgery
- A: Patient 1 — chest x-ray showed diffuse fine nodules. B: Patient 1 — computed tomography showed a widespread, bilateral fine micronodular pattern.