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Wheeze

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: John Fani Srour, M.D.

Overview

Overview

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: John Fani Srour, M.D.

Overview

A wheeze is a continuous, coarse, whistling sound produced in the respiratory airways during breathing. For wheezes to occur, some part of the respiratory tree must be narrowed or obstructed, or airflow velocity within the respiratory tree must be heightened. Wheezing is commonly experienced by persons with a lung disease; the most common cause of recurrent wheezing is asthma, a form of reactive airway disease.

References

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Pathophysiology

Pathophysiology

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: John Fani Srour, M.D.

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Pathophysiology

Inflamed airways and bronchoconstriction in asthma. Airways narrowed as a result of the inflammatory response cause wheezing.

References

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Causes

Causes

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: John Fani Srour, M.D.

Causes

Common Causes

The most common causes in clinical practice are:

Causes by Organ System

Cardiovascular Cardiac asthma (pulmonary edema), Cardiomegaly, Descending aortic aneurysm, Pulmonary edema, Pulmonary embolism, Right sided aortic arch, Vascular compression/ rings, Heart failure
Chemical / poisoning Dialyzer hypersensitivity syndrome, Food allergies, Peanut Allergy, Chemical poisoning
Dermatologic No underlying causes
Drug Side Effect Aztreonam, ACE inhibitors, Acetylcysteine, Adenosine, Aspirin, Aztreonam, Beta blockers, Cefpodoxime, Dexchlorpheniramine, Dipyridamole, Dextran, Ivacaftor, Loratadine, Marijuana , Medication-induced bronchoconstriction, NSAIDs, Oprelvekin, Pentamidine Isethionate, Pramipexole, Protamine, Ramucirumab, Sacrosidase, Sotalol, Tobramycin, trichophyton mentagrophytes and trichophyton rubrum
Ear Nose Throat Aspiration (foreign particles or foods), Bilateral vocal cord paralysis, Hypertrophied tonsils, Intrathoracic goiter, Laryngeal edema, Laryngocele, Laryngostenosis, Laryngotracheobronchitis, Mobile supraglottic soft tissue, Paroxysmal vocal cord motion, Postextubation granuloma, Postlobectomy bronchial torsion, Postnasal drip syndrome, Post-radiation stenosis, Retropharyngeal abscess, Supraglottitis, Vocal cord dysfunction, Vocal cord hematoma, Sinusitis
Endocrine Intrathoracic goiter, Obesity
Environmental asthma, Byssinosis, Hay fever
Gastroenterologic Gastroesophageal Reflux Disease
Genetic Cystic fibrosis, Milk allergy, Obesity, Primary ciliary dyskinesia, Vascular compression/rings, Alpha 1-Antitrypsin Deficiency, Ciliary dyskinesia-bronchiectasis
Hematologic Lymphadenopathy
Iatrogenic Aspiration (foreign particles or foods), Esophageal foreign body, Mendelson’s syndrome (aspiration pneumonitis)
Infectious Disease Allergic bronchopulmonary aspergillosis, Cold induced wheezing, Bronchitis, Bronchiolitis, pneumonia, Lymphadenopathy, Retropharyngeal abscess, Tuberculosis, Ascariasis, Hookworm, Paragonimiases – lung infection, Strongyloidiasis, Toxocariasis, Aspergillosis
Musculoskeletal / Ortho Cricoarytenoid arthritis
Neurologic No underlying causes
Nutritional / Metabolic Obesity
Obstetric/Gynecologic No underlying causes
Oncologic Carcinoid syndrome, Lymphadenopathy, Lymphangitic carcinomatosis, Malignancy (bronchogenic tumors), Bronchial adenomata syndrome, Mastocytosis
Opthalmologic No underlying causes
Overdose / Toxicity chemical poisoning
Psychiatric Psychogenic wheezing
Pulmonary Bronchiectasis, Bronchiolitis, Bronchiolitis obliterans, Bronchitis, Bronchopulmonary dysplasia, Carcinoid syndrome, Chronic obstructive pulmonary disease: Chronic bronchitis and Emphysema, Cold induced wheezing, Cystic fibrosis, Pulmonary hemorrhage, pneumonia, Interstitial lung disease, Postlobectomy bronchial torsion, Postradiation stenosis, Primary ciliary dyskinesia, Pulmonary edema, Pulmonary embolism, Tracheal stenosis, Tracheobronchitis, Tracheobronchomegaly, Tracheomalacia, Wegener’s granulomatosis, Pulmonary eosinophilia, Tuberculosis, Alpha 1-Antitrypsin Deficiency, Extrinsic allergic alveolitis, Bronchial adenomata syndrome, Ciliary dyskinesia-bronchiectasis, Tracheobronchopathia osteoplastica, Aspergillosis
Renal / Electrolyte No underlying causes
Rheum / Immune / Allergy Allergic bronchopulmonary aspergillosis, Anaphylaxis, Angioedema, Asthma, Cricoarytenoid arthritis, Immunodeficiency, Interstitial lung disease, Lymphadenopathy, Milk allergy, Relapsing polychondritis, Wegener’s granulomatosis, Pulmonary eosinophilia, Extrinsic allergic alveolitis, Graft-versus-host disease, Hay fever, Mastocytosis
Sexual No underlying causes
Trauma No underlying causes
Urologic No underlying causes
Miscellaneous Amyloid deposition, Tracheobronchopathia osteochondroplastica

Causes in Alphabetical Order

References

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Differentiating Wheeze from other Conditions

Differentiating Wheeze from other Conditions

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Karina Zavaleta, MD [2], Iqra Qamar M.D.[3], Anmol Pitliya, M.B.B.S. M.D.[4]

Differential diagnosis of Wheezing

For the differential diagnosis of wheeze and cough, click here.
For the differential diagnosis of wheeze and fever, click here.
For the differential diagnosis of wheeze and slurred speech, click here.

Etiology on the basis of anatomy Diseases Clinical manifestations Diagnosis Other features
Symptoms Physical exam Labs Pulmonary function testing Imaging
Onset Cough Dyspnea Fever Slurred speech Cyanosis Auscultation Chest imaging Other Gold standard
Extrathoracic upper airway diseases Laryngeal edema

(Anaphylaxis)[1][2][3][4][5]

Acute + + – + +
  • Not specific
  • Not required
  • Not required

Acute onset with one of them:

Two or more after the exposure to a likely allergen

BP reduced after exposure of a known allergen

Cricoarytenoid arthritis[6][7] Acute + + – + –
  • Clear chest
Vocal fold edema/hematoma/paralysis[9] Acute + + – + –
  • Not specific
  • Variable
  • Clear chest
  • Not required
Paradoxical vocal fold motion[10][11] Acute + + – + –
  • Clear chest
  • CT and color flow doppler to rule out other diseases[13]
Laryngeal stenosis[15] Acute, Chronic + + – + +
  • Not specific
  • FV loop variable
  • Clear chest
Laryngocele[17][18][19][20][21] Chronic + + – – –
  • Not specific
  • Normal function
  • Clear chest
Etiology on the basis of anatomy Diseases Clinical manifestations Diagnosis Other features
Symptoms Physical exam Labs Pulmonary function testing Imaging
Onset Cough Dyspnea Fever Slurred speech Cyanosis Auscultation Chest imaging Other Gold standard
Extrathoracic upper airway diseases Epiglottitis (supraglottitis)[22][23][24][25][26] Acute – + + + –
  • Normal function
  • Clear chest
  • Tripod posture
  • Drooling
  • Tenderness of the anterior part of the neck
Goiter[27][28][29][30][31][32][33][34] Chronic + + – – –
  • Airflow limitation of the volume loop depending on the size and localization[35]
Postnasal drip syndrome[38][39][40] Acute + + – – –
  • Increase of IgE
  • Positive intradermic test[41]
  • Clear chest
  • Sinus CT may be helpful
  • Clinical diagnosis
Relapsing polychondritis [42][43][44][45][46][47][48] Acute + + + – –
  • Variable flow volume loop
  • Tracheal narrowing
  • Cartilaginous calcification, bronchial wall thickness, and tracheal narrowing is observed on CT 
  • MRI can distinguish fibrosis from inflammation 

Mc Adam criteria:[47]

  • Involvement of cartilage of ears, ribs, nose, and eyes
Retropharyngeal abscess[50][51][52] Subacute – + + + –
  • Normal function
  • Neck CT or presence of pus during the surgical procedure[54]
Tonsillar hypertrophy[55] Acute, chronic – + – + hyponasal speech –
  • Not specific
  • Flow loop shows inspiratory slowing
  • Clear chest
  • Not required
  • More in children and adolescents
Tumor of pharynx/larynx/upper trachea[57][58] Chronic + + – – –
  • Not specific
  • Flow loop shows inspiratory slowing
  • Not required
  • CT provide information about the grade of invasion
  • MRI can make a difference between tumors in the mucosa or bone marrow[59]
Etiology on the basis of anatomy Diseases Clinical manifestations Diagnosis Other features
Symptoms Physical exam Labs Pulmonary function testing Imaging
Onset Cough Dyspnea Fever Slurred speech Cyanosis Auscultation Chest imaging Other Gold standard
Central airway diseases

(Intrathoracic upper airway obstruction)

Mediastinal mass/lymphadenopathy[60][61] Chronic + + + – –
  • Size, location, and density of the mass can be observed
  • In chest CT, location, size, tissue characteristic, and relationship with other structures of the mass is observed
  • Information of posterior mediastinal mass can be provided in chest or spine MRI [63]
Respiratory papillomatosis[64][65] Chronic + + – + –
  • Not specific
  • Not specific
Tracheobronchomalacia[67] Chronic + + – – –
  • Not specifc
  • Airway compression from other structures
Tracheal stenosis[70][71][72][73] Acute – + – – +
  • Not specific
  • FV loop variable
  • Extension of the narrowing observed in CT or MRI
  • Long segment stenosis incompatible with survival[75]
Tracheal and bronchial tumors[76][77][78] Chronic + + – – –
  • Not specific
  • FV loop variable
Vascular ring or aneurysm[80][81][82][83][84][85] Chronic + + – – –
  • Not required
  • Usually asymptomatic
  • Chest or abdominal pain appears when other structures are compressed
Etiology on the basis of anatomy Diseases Clinical manifestations Diagnosis Other features
Symptoms Physical exam Labs Pulmonary function testing Imaging
Onset Cough Dyspnea Fever Slurred speech Cyanosis Auscultation Chest imaging Other Gold standard
Lower airway obstruction Bronchiectasis[87][88] Chronic + + – – –
  • Tram lines or end–on ring shadows in chest CT [90]
Bronchiolitis[91][92][93][94][95] Acute + + + – + For bacterial infection in neonates:
  • Hyperinflation
  • Mosaic attenuation
  • Increased bronchial wall[96]
  • Clinical diagnosis
Carcinoid syndrome[97][98][99] Chronic – + – – –
  • Not specific
  • Liver metastases are visualized in MRI
Heart failure[102][103] Chronic + + – – –
  • Not required
  • Clinical diagnosis (test are supportive)
Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) [107] Chronic + + – – –
  • Not specific
  • Mosaic pattern and nodules observed in chest CT
  • Single neuroendocrine cell and/ or linear proliferation of the cells that involves bronchial epithelium
Etiology on the basis of anatomy Diseases Clinical manifestations Diagnosis Other features
Symptoms Physical exam Labs Pulmonary function testing Imaging
Onset Cough Dyspnea Fever Slurred speech Cyanosis Auscultation Chest imaging Other Gold standard
Lower airway obstruction Noncardiogenic pulmonary edema[108][109][110] Acute + + – – +
  • Bilateral alveolar infiltration
  • Bilateral opacities in CT

According to Berlin definition:[111]

  • One week of new or worse respiratory symptoms or clinical insult
  • Symptoms can not be explain by cardiac disease
  • Bilateral opacities in chest X–Ray or CT
  • Compromised oxygenation
  • High altitute pulmonary edema (HAPE)
  • Neurogenic pulmonary edema
Parasitic infection with VLM (eg, Ascaris, Strongyloides, filaria)[112][113][114][115] Acute + + + – –
  • Not specific
  • Bilateral peribronchial infiltration
  • Parenchymal infiltration
  • Subpleural nodules, ground–glass opacities observed on chest CT [117]
  • Larve on biopsy
Pulmonary thromboembolism [118][119] Acute, subacute, Chronic + + – – –
  • Not required
Reactive airways dysfunction syndrome[123][124][125][126] Acute + + – – –
  • Normal or hyperinflation
  • CT to rule out other diseases
 Clinical diagnosis:
  • History of exposure
  • Acute onset with sympotoms in 24h
  • Airway obstruction > 3 months[124]
  • Burning sensation in the throat
  • Chest pain
  • High dose of inhalation of the irritant

References

  1. ↑ Sampson HA, Muñoz-Furlong A, Campbell RL, Adkinson NF, Bock SA, Branum A, Brown SG, Camargo CA, Cydulka R, Galli SJ, Gidudu J, Gruchalla RS, Harlor AD, Hepner DL, Lewis LM, Lieberman PL, Metcalfe DD, O’Connor R, Muraro A, Rudman A, Schmitt C, Scherrer D, Simons FE, Thomas S, Wood JP, Decker WW (February 2006). “Second symposium on the definition and management of anaphylaxis: summary report–Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium”. J. Allergy Clin. Immunol. 117 (2): 391–7. doi:10.1016/j.jaci.2005.12.1303. PMID 16461139.
  2. ↑ Sampson HA, Muñoz-Furlong A, Bock SA, Schmitt C, Bass R, Chowdhury BA, Decker WW, Furlong TJ, Galli SJ, Golden DB, Gruchalla RS, Harlor AD, Hepner DL, Howarth M, Kaplan AP, Levy JH, Lewis LM, Lieberman PL, Metcalfe DD, Murphy R, Pollart SM, Pumphrey RS, Rosenwasser LJ, Simons FE, Wood JP, Camargo CA (March 2005). “Symposium on the definition and management of anaphylaxis: summary report”. J. Allergy Clin. Immunol. 115 (3): 584–91. doi:10.1016/j.jaci.2005.01.009. PMID 15753908.
  3. ↑ Kemp SF, Lockey RF (September 2002). “Anaphylaxis: a review of causes and mechanisms”. J. Allergy Clin. Immunol. 110 (3): 341–8. PMID 12209078.
  4. ↑ Ewan PW, Dugué P, Mirakian R, Dixon TA, Harper JN, Nasser SM (January 2010). “BSACI guidelines for the investigation of suspected anaphylaxis during general anaesthesia”. Clin. Exp. Allergy. 40 (1): 15–31. doi:10.1111/j.1365-2222.2009.03404.x. PMID 20205694.
  5. ↑ Simons FE (February 2010). “Anaphylaxis”. J. Allergy Clin. Immunol. 125 (2 Suppl 2): S161–81. doi:10.1016/j.jaci.2009.12.981. PMID 20176258.
  6. ↑ Kelly CA (February 1993). “Rheumatoid arthritis: other rheumatoid lung problems”. Baillieres Clin Rheumatol. 7 (1): 17–29. PMID 8519073.
  7. ↑ Geterud A, Ejnell H, Månsson I, Sandberg N, Bake B, Bjelle A (October 1986). “Severe airway obstruction caused by laryngeal rheumatoid arthritis”. J. Rheumatol. 13 (5): 948–51. PMID 3820205.
  8. ↑ 8.0 8.1 Greco A, Fusconi M, Macri GF, Marinelli C, Polettini E, Benincasa AT, de Vincentiis M (2012). “Cricoarytenoid joint involvement in rheumatoid arthritis: radiologic evaluation”. Am J Otolaryngol. 33 (6): 753–5. doi:10.1016/j.amjoto.2012.06.004. PMID 22884484.
  9. ↑ Ishman SL, Halum SL, Patel NJ, Kerschner JE, Merati AL (October 2006). “Management of vocal paralysis: a comparison of adult and pediatric practices”. Otolaryngol Head Neck Surg. 135 (4): 590–4. doi:10.1016/j.otohns.2006.04.014. PMID 17011423.
  10. ↑ Morris MJ, Christopher KL (November 2010). “Diagnostic criteria for the classification of vocal cord dysfunction”. Chest. 138 (5): 1213–23. doi:10.1378/chest.09-2944. PMID 21051397.
  11. ↑ Tilles SA, Ayars AG, Picciano JF, Altman K (November 2013). “Exercise-induced vocal cord dysfunction and exercise-induced laryngomalacia in children and adolescents: the same clinical syndrome?”. Ann. Allergy Asthma Immunol. 111 (5): 342–346.e1. doi:10.1016/j.anai.2013.07.025. PMID 24125138.
  12. ↑ Forrest LA, Husein T, Husein O (April 2012). “Paradoxical vocal cord motion: classification and treatment”. Laryngoscope. 122 (4): 844–53. doi:10.1002/lary.23176. PMID 22434681.
  13. ↑ Nastasi KJ, Howard DA, Raby RB, Lew DB, Blaiss MS (June 1997). “Airway fluoroscopic diagnosis of vocal cord dysfunction syndrome”. Ann. Allergy Asthma Immunol. 78 (6): 586–8. doi:10.1016/S1081-1206(10)63220-6. PMID 9207723.
  14. ↑ Chiang T, Marcinow AM, deSilva BW, Ence BN, Lindsey SE, Forrest LA (March 2013). “Exercise-induced paradoxical vocal fold motion disorder: diagnosis and management”. Laryngoscope. 123 (3): 727–31. doi:10.1002/lary.23654. PMID 23097011.
  15. ↑ Nair S, Nilakantan A, Sood A, Gupta A, Gupta A (September 2016). “Challenges in the Management of Laryngeal Stenosis”. Indian J Otolaryngol Head Neck Surg. 68 (3): 294–9. doi:10.1007/s12070-015-0936-2. PMC 4961642. PMID 27508129.
  16. ↑ Bogdasarian RS, Olson NR (1980). “Posterior glottic laryngeal stenosis”. Otolaryngol. Head Neck Surg. 88 (6): 765–72. PMID 7208045.
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  19. ↑ Sniezek JC, Johnson RE, Ramirez SG, Hayes DK (April 1996). “Laryngoceles and saccular cysts”. South. Med. J. 89 (4): 427–30. PMID 8614888.
  20. ↑ 20.0 20.1 Chu L, Gussack GS, Orr JB, Hood D (April 1994). “Neonatal laryngoceles. A cause for airway obstruction”. Arch. Otolaryngol. Head Neck Surg. 120 (4): 454–8. PMID 8166980.
  21. ↑ Civantos FJ, Holinger LD (March 1992). “Laryngoceles and saccular cysts in infants and children”. Arch. Otolaryngol. Head Neck Surg. 118 (3): 296–300. PMID 1554451.
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  50. ↑ Page NC, Bauer EM, Lieu JE (March 2008). “Clinical features and treatment of retropharyngeal abscess in children”. Otolaryngol Head Neck Surg. 138 (3): 300–6. doi:10.1016/j.otohns.2007.11.033. PMID 18312875.
  51. ↑ Craig FW, Schunk JE (June 2003). “Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management”. Pediatrics. 111 (6 Pt 1): 1394–8. PMID 12777558.
  52. ↑ Cmejrek RC, Coticchia JM, Arnold JE (December 2002). “Presentation, diagnosis, and management of deep-neck abscesses in infants”. Arch. Otolaryngol. Head Neck Surg. 128 (12): 1361–4. PMID 12479720.
  53. ↑ Knorr TL, Sinha V. PMID 28722903. Missing or empty |title= (help)
  54. ↑ Lazor JB, Cunningham MJ, Eavey RD, Weber AL (December 1994). “Comparison of computed tomography and surgical findings in deep neck infections”. Otolaryngol Head Neck Surg. 111 (6): 746–50. doi:10.1177/019459989411100608. PMID 7991254.
  55. ↑ Kaditis AG, Kalampouka E, Hatzinikolaou S, Lianou L, Papaefthimiou M, Gartagani-Panagiotopoulou P, Zintzaras E, Chrousos G (March 2010). “Associations of tonsillar hypertrophy and snoring with history of wheezing in childhood”. Pediatr. Pulmonol. 45 (3): 275–80. doi:10.1002/ppul.21174. PMID 20131382.
  56. ↑ Jazi SM, Barati B, Kheradmand A (December 2011). “Treatment of adenotonsillar hypertrophy: A prospective randomized trial comparing azithromycin vs. fluticasone”. J Res Med Sci. 16 (12): 1590–7. PMC 3434901. PMID 22973368.
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