Dr. H. Paramesh, MD, FAAP (USA), FIAP,FIAMS,FIAA,FICAAI*
Director, Pediatric Pulmonologist, Lakeside Institute of Child Health, Bangalore-42, India. *
|Wheeze is a dry, musical, non-palpable sound produced by air moving in high velocity past a fixed obstruction in the lower airways. The sound can be low or high-pitched. The fine wheeze produced at peripheral airways can be appreciated by auscultating by the bell of stethoscope at the open mouth.
The causes for acute wheeze are mainly for Bronchiolitis, Asthma, Foreign body aspiration, Vocal cord dysfunction, congenital silent defect activated at high altitude. But chronic wheeze from various causes from anatomical defects, mass lesions pressing on lower airways, genetic diseases like cystic fibrosis, Alpha-l-antitrypsin, immobile cilia syndrome, or Retained foreign body, etc.
Wheeze from congenital lesion starts early in life and intensifies with age and worsens with upper respiratory tract infections. The structural lesions of central airways sound is loudest during activities and disappears during quite breathing and alters with changes of position.
Our observation on 163 children who were admitted with wheeze to the hospital are finally diagnosed as Asthma is 52.76%; Bronchiolitis 25.16%; Mycoplasma Bronchitis 3.06%; Bronchopneumonia 14.72%; LTB 2.45%; EndoBronchial TB 0.61%; Pertussis Syndrome 0.61%, Severe Croup 0.61%.
Bronchiolitis: Epidemiologic features, clinical features, lab results are the same as asthma. The objective proof for diagnosis is low level of exhaled breath, Nitric oxide level and biopsy showing neutrophilic infiltrates unlike in asthma. It is worthy to note that Mycoplasma is an etiology in 5% of bronchiolitis and 10-20 % bronchitis. 40% of mycoplasma bronchiolitis wheeze in acute stage.
Foreign Body Aspiration: One has to have high index of suspicion in a child with sudden onset of wheeze started by choking and while playing mostly during daytime. The common age is 1-5 years in 77% of the cases and in 34% of the time there is no history of F.B aspiration and most of them are vegetable matters.
Vocal Cord Dysfunction (Laryngeal Dyskinesia): First recognized in 1842 by Dunglison, William Osler in 1902 defined as Spasm of Laryngeal muscle. The prevalance is not known, however 10% of refractory asthmatics have this problem. The causes are: myasthenia gravis, cortical injury from brain stem compression, exposure to environmental or occupational irritants like; chlorine, ammonia, cleaning chemicals, organic solvents, smoke and Gastroesophageal Reflux Disease (GERD). The clinical features are inspiratory and expiratory wheeze, stridor, hoarseness, shortness of breath. Laryngeal examination proves that there is adduction of vocal cords and narrowing of rima glottides during inspiration and in early expiration, and absence of gagging of coughing during laryngoscopy. Wheezing is greatest over larynx and is less evident over rest of lung fields.
The treatment in acute phase is panting (dog breathing), brings about the acute relief by physiologically increasing the glottic aperture. Bag and mask positive pressure breathing; IPPV: CPAP, anesthesia, Heliox therapy, while giving reassurance to the patient, later speech therapy and psychotherapy.
Wheezing in High Altitude: The gas in body increases in volume by 30% and if there is consumption of carbonated water, it further increases gas volume in the gut and intestine which can force its way in small silent defect in the diaphragm and produce wheeze and dyspnea. In addition, air leak syndromes are also high.
Asthma: It is true that all wheezes are not asthma and all asthmatics don't wheeze. Because in children, asthma is 90% present with cough and only 74% with wheeze.
The diagnosis of asthma in infants is not an easy task. The objective proofs are difficult to establish. The current criteria used for the diagnosis of asthma in infants are - Having three episodes of airway obstruction signs in ONE year. Other clinical features of atopy of skin or nose, family history of atopy and good response to bronchodilators. Atopy is the strongest predictor for wheezing in infant progressing to asthma.
Key Messages : Be alert to rule out other causes in a wheezing child. Early diagnosis and proper management is essential in asthmatic children to avoid airway remodeling. The diagnosis of asthma is only on clinical basis as of now. Recognition of atopy helps in future management and environment control measures.
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