Learning Outcome
Recall the causes of wheezing
Describe the risk factors for wheezing
Summarize the treatment of wheezing
Introduction
Wheezing is the symptomatic manifestation of any disease process that causes airway obstruction. Rene Laennec's development of the stethoscope in 1816 has enabled a better appreciation of wheeze at the bedside, in comparison to the previously established practice of ear-to-chest auscultation. Wheeze is a musical, high-pitched, adventitious sound generated anywhere from the larynx to the distal bronchioles during either expiration or inspiration. Modern-day computerized waveform analysis has allowed us to characterize wheeze with more precision and given us its definition as a sinusoidal waveform, typically between 100 Hz and 5000 Hz with a dominant frequency of at least 400 Hz, lasting at least 80 milliseconds. Wheeze may be audible without the aid of a stereoscope when the sound is loud, but in most cases, wheezes are auscultated with a stethoscope.
The presence of wheezing does not always mean that the patient has asthma, and a proper history and physical exam are required to make the diagnosis.
Causes
Wheezing is commonly experienced by people who have asthma; although, it can be heard in people with foreign bodies, congestive heart failure, a malignancy of the airway, or any lesion that causes narrowing of the airways. The presence of wheezing during expiration indicates that the individual’s peak expiratory flow rate is less than fifty percent compared to normal. The quality and duration of wheezing also depend on where in the airways the obstruction is located. In asthma, the wheezing is due to narrowing of the lower airways, whereas, with malignancies, the obstruction is usually in the upper, more proximal airways. In rare cases, wheezing may be heard both during inspiration and expiration. In severe asthma, no wheeze may be heard as the airflow will be so severely reduced, and chest auscultation will be silent. Since any process that reduces airway caliber generates wheeze, below are some of the many conditions that can cause wheezing.
Respiratory infections (croup, laryngitis)
Obstructive airway diseases (asthma,
Chronic obstructive pulmonary disease (COPD)
Pulmonary peribronchial edema (congestive heart failure)
Vocal cord dysfunction (paradoxical vocal fold motion [PVFM], vocal cord paralysis)
Airway compression: Intrinsic or extrinsic (squamous cell carcinomas, goiter)
Hyperdynamic airway collapse (tracheobronchomalacia)
Forced exhalation by normal individuals
Risk Factors
The reported prevalence of wheezing amongst young children between 2 to 3 years of age is 26% in the United States. The global prevalence is lower in the adolescent age range, approximately 12%. Global surveys reveal a similar prevalence in adults, with European and Australian surveys reporting the highest prevalence rates, up to 17%.
Assessment
History should be targeted toward the various etiologies of wheezing listed above. For example, patients who have had head and neck cancer surgery and/or radiation may develop vocal cord paralysis. Additionally, a prior history of endotracheal intubation can alert one to the possibility of tracheal subglottic stenosis.
Physical examination of the trachea and thorax will identify wheeze. Wheeze associated with asthma is most commonly heard during expiration; however, wheeze is neither sensitive nor specific for asthma, so the wheezes can certainly extend into inspiration also. Upper airway obstruction from tonsilar hypertrophy can be evaluated with an oral examination, and palpation of the neck could identify a goiter.
Evaluation
When wheezing is heard, some workup is required because it is an abnormal sound. The first imaging test of choice in a patient with wheezing is a chest x-ray to look for a foreign body or a lesion in the central airway. In the non-acute setting, if asthma is suspected, the next step is to obtain baseline pulmonary function tests with bronchodilator administration. Following this, it may be necessary to perform an airway challenge test with a bronchoconstrictive agent such as methacholine. If the wheezing resolves with a bronchodilation agent, a tumor or mass as the cause is a much less likely consideration. If there is no resolution after a breathing treatment, and a tumor or mass is suspected, then a CT scan of the chest and bronchoscopy may be required if possible malignancy is suspected on CT.
Medical Management
Treatment predominantly revolves around the suspected etiology of wheezing. The ubiquitous approach to ensuring Airway, Breathing, and Circulation (ABCs) are stable is the priority. Those with signs of impending respiratory failure may require either noninvasive positive pressure ventilation or invasive mechanical ventilation following endotracheal intubation. In cases of anaphylaxis, epinephrine would be required. Nebulized, short-acting, b2 agonists such as albuterol and nebulized short-acting muscarinic antagonists are often administered while further workup is being performed.
Nursing Management
Listen to the chest for wheezing
Assess for respiratory distress
Administer bronchodilators
Provide oxygen if saturation is low
Urge patients to quit smoking
Take medications as prescribed
Keep away from second-hand smoke
Do not keep pets if you have persistent wheezing
When To Seek Help
No air entry in the chest
Coordination of Care
Wheezing is a common sign encountered in clinical practice by the nurse practitioner, primary care provider, internist, cardiologist, and pulmonologist. When wheezing is heard, some workup is required because it is an abnormal sound. The first imaging test of choice in a patient with wheezing is a chest x-ray to look for a foreign body or a lesion in the central airway. In the non-acute setting, if asthma is suspected, the next step is to obtain baseline pulmonary function tests with bronchodilator administration. Following this, it may be necessary to perform an airway challenge test with a bronchoconstrictive agent such as methacholine. If the wheezing resolves with a bronchodilation agent, a tumor or mass as the cause is a much less likely consideration. If there is no resolution after a breathing treatment, and a tumor or mass is suspected, then a CT scan of the chest and bronchoscopy may be required if possible malignancy is suspected on CT.
Risk Management
Wheezing is a common sign encountered in clinical practice by the nurse practitioner, primary care provider, internist, cardiologist, and pulmonologist. When wheezing is heard, some workup is required because it is an abnormal sound. The first imaging test of choice in a patient with wheezing is a chest x-ray to look for a foreign body or a lesion in the central airway. In the non-acute setting, if asthma is suspected, the next step is to obtain baseline pulmonary function tests with bronchodilator administration. Following this, it may be necessary to perform an airway challenge test with a bronchoconstrictive agent such as methacholine. If the wheezing resolves with a bronchodilation agent, a tumor or mass as the cause is a much less likely consideration. If there is no resolution after a breathing treatment, and a tumor or mass is suspected, then a CT scan of the chest and bronchoscopy may be required if possible malignancy is suspected on CT.
References
1.Gracia-Tabuenca J, Seppä VP, Jauhiainen M, Kotaniemi-Syrjänen A, Malmström K, Pelkonen A, Mäkelä M, Viik J, Malmberg LP. Tidal breathing flow volume profiles during sleep in wheezing infants measured by impedance pneumography. J Appl Physiol (1985). 2019 May 01;126(5):1409-1418. [PubMed: 30763165]
2.Peçanha MB, Freitas RB, Moreira TR, Silva LS, Oliveira LL, Cardoso SA. Prevalence of vitamin D deficiency and its relationship with factors associated with recurrent wheezing. J Bras Pneumol. 2019 Feb 11;45(1):e20170431. [PMC free article: PMC6534403] [PubMed: 30758429]
3.Arrais M, Lulua O, Quifica F, Rosado-Pinto J, Gama JMR, Taborda-Barata L. Prevalence of asthma, allergic rhinitis and eczema in 6-7-year-old schoolchildren from Luanda, Angola. Allergol Immunopathol (Madr). 2019 Nov-Dec;47(6):523-534. [PubMed: 30745247]
4.Sabil A, Glos M, Günther A, Schöbel C, Veauthier C, Fietze I, Penzel T. Comparison of Apnea Detection Using Oronasal Thermal Airflow Sensor, Nasal Pressure Transducer, Respiratory Inductance Plethysmography and Tracheal Sound Sensor. J Clin Sleep Med. 2019 Feb 15;15(2):285-292. [PMC free article: PMC6374099] [PubMed: 30736876]
5.Zamani A, Khanjani N, Bagheri Hosseinabadi M, Ranjbar Homghavandi M, Miri R. The effect of chronic exposure to flour dust on pulmonary functions. Int J Occup Saf Ergon. 2021 Jun;27(2):497-503. [PubMed: 30760129]
6.Khoo SK, Read J, Franks K, Zhang G, Bizzintino J, Coleman L, McCrae C, Öberg L, Troy NM, Prastanti F, Everard J, Oo S, Borland ML, Maciewicz RA, Le Souëf PN, Laing IA, Bosco A. Upper Airway Cell Transcriptomics Identify a Major New Immunological Phenotype with Strong Clinical Correlates in Young Children with Acute Wheezing. J Immunol. 2019 Mar 15;202(6):1845-1858. [PubMed: 30745463]
7.Khawaja A, Kotloff R. A 31-Year-Old Man With Airflow Obstruction, Intrathoracic Adenopathy, and Pulmonary Nodules. Chest. 2019 Feb;155(2):e55-e59. [PubMed: 30732704]
8.Mikeš O, Vrbová M, Klánová J, Čupr P, Švancara J, Pikhart H. Early-life exposure to household chemicals and wheezing in children. Sci Total Environ. 2019 May 01;663:418-425. [PubMed: 30716632]
9.Kwong CG, Bacharier LB. Phenotypes of wheezing and asthma in preschool children. Curr Opin Allergy Clin Immunol. 2019 Apr;19(2):148-153. [PMC free article: PMC6395501] [PubMed: 30640211]
10.Laidlaw TM. Pathogenesis of NSAID-induced reactions in aspirin-exacerbated respiratory disease. World J Otorhinolaryngol Head Neck Surg. 2018 Sep;4(3):162-168. [PMC free article: PMC6251957] [PubMed: 30506046]
11.Lee YJ, Fujisawa T, Kim CK. Biomarkers for Recurrent Wheezing and Asthma in Preschool Children. Allergy Asthma Immunol Res. 2019 Jan;11(1):16-28. [PMC free article: PMC6267183] [PubMed: 30479074]
12.Ullmann N, Mirra V, Di Marco A, Pavone M, Porcaro F, Negro V, Onofri A, Cutrera R. Asthma: Differential Diagnosis and Comorbidities. Front Pediatr. 2018;6:276. [PMC free article: PMC6178921] [PubMed: 30338252]
13.Rocha BM, Filos D, Mendes L, Serbes G, Ulukaya S, Kahya YP, Jakovljevic N, Turukalo TL, Vogiatzis IM, Perantoni E, Kaimakamis E, Natsiavas P, Oliveira A, Jácome C, Marques A, Maglaveras N, Pedro Paiva R, Chouvarda I, de Carvalho P. An open access database for the evaluation of respiratory sound classification algorithms. Physiol Meas. 2019 Mar 22;40(3):035001. [PubMed: 30708353]
14.Sánchez T, Gozal D, Smith DL, Foncea C, Betancur C, Brockmann PE. Association between air pollution and sleep disordered breathing in children. Pediatr Pulmonol. 2019 May;54(5):544-550. [PubMed: 30719878]