Approach to wheezing in infants and children
- Khoulood Fakhoury, MD
Khoulood Fakhoury, MD
- Assistant Professor of Pediatrics
- Baylor College of Medicine
Wheezing is a common presenting symptom of respiratory disease in infants and children. A nationwide survey performed in the United States between 1988 and 1994 showed that the prevalence for wheezing amongst two to three year olds was 26 percent and amongst 9 to 11 year olds was 13 percent . One in three children experience at least one acute wheezing illness before the age of three years [2,3]. Wheezing may be either a benign, self-limited process or the presenting symptom of a significant respiratory disease . The role of the treating clinician is to try to reach the most likely diagnosis as quickly and efficiently as possible so that therapy, if necessary, can be instituted and the parental concerns can be addressed.
The most likely diagnosis in children with recurrent wheezing is asthma, regardless of the age of onset, evidence of atopic disease, precipitating causes, or frequency of wheezing . However, other diseases can present with wheezing in infancy and childhood, and patients with asthma may not wheeze. The differential diagnosis of wheezing includes a variety of congenital and acquired conditions (table 1).
Clinical history and physical examination often allow accurate diagnosis. However, radiographic examination, pulmonary function testing, bronchoscopy, sweat chloride concentration, and selective laboratory studies are helpful tools in establishing the underlying etiology of wheezing when used appropriately [5,6]. The initial evaluation of a wheezing child is directed toward the exclusion of alternative diagnoses, followed by a therapeutic trial of bronchodilators if asthma is suspected.
A diagnostic approach to wheezing in childhood is presented in this topic review. An overview of recurrent wheezing phenotypes, a review of the causes of nonasthmatic wheezing in children, and the diagnosis and management of asthma are presented separately. Virus-induced wheezing and the emergent evaluation of children with acute respiratory distress are also discussed separately. (See "Wheezing phenotypes and prediction of asthma in young children" and "Wheezing illnesses other than asthma in children" and "Asthma in children younger than 12 years: Initial evaluation and diagnosis" and "Asthma in children younger than 12 years: Treatment of persistent asthma with controller medications" and "Virus-induced wheezing and asthma: An overview" and "Treatment of recurrent virus-induced wheezing in young children" and "Acute respiratory distress in children: Emergency evaluation and initial stabilization".)
DEFINITION AND PHYSIOLOGY OF WHEEZING
A wheeze is a continuous musical sound heard during chest auscultation that lasts longer than 250 msec . It is produced by the oscillation of opposing walls of an airway narrowed almost to the point of closure . It can be high pitched or low pitched, consist of single or multiple notes, and occur during inspiration or expiration. Wheezes can originate from airways of any size throughout the proximal conducting airways. Wheezing requires sufficient airflow to generate airway oscillation and produce sound in addition to narrowing or compression of the airway. Thus, the absence of wheezing in a patient who presents with acute asthma may be an ominous finding, suggesting impending respiratory failure.
- Eldeirawi K, Persky VW. History of ear infections and prevalence of asthma in a national sample of children aged 2 to 11 years: the Third National Health and Nutrition Examination Survey, 1988 to 1994. Chest 2004; 125:1685.
- Taussig LM, Wright AL, Holberg CJ, et al. Tucson Children's Respiratory Study: 1980 to present. J Allergy Clin Immunol 2003; 111:661.
- Bloomberg GR. Recurrent wheezing illness in preschool-aged children: assessment and management in primary care practice. Postgrad Med 2009; 121:48.
- Dorkin HL. Noisy breathing. In: Respiratory disease in children: Diagnosis and management, Loughlin GM, Eigen H (Eds), Williams and Wilkins, 1994. p.167.
- Martinati LC, Boner AL. Clinical diagnosis of wheezing in early childhood. Allergy 1995; 50:701.
- Chipps BE. Evaluation of infants and children with refractory lower respiratory tract symptoms. Ann Allergy Asthma Immunol 2010; 104:279.
- Loudon R, Murphy RL Jr. Lung sounds. Am Rev Respir Dis 1984; 130:663.
- Forgacs P. The functional basis of pulmonary sounds. Chest 1978; 73:399.
- Panitch HB. Wheezing and lower airway obstruction. In: A practical guide to pediatric respiratory disease, Schidlow D, Smith D (Eds), Mosby, St. Louis 1994. p.39.
- Meslier N, Charbonneau G, Racineux JL. Wheezes. Eur Respir J 1995; 8:1942.
- Mikami R, Murao M, Cugell DW, et al. International Symposium on Lung Sounds. Synopsis of proceedings. Chest 1987; 92:342.
- Finder JD. Understanding airway disease in infants. Curr Probl Pediatr 1999; 29:65.
- Mellis C. Respiratory noises: how useful are they clinically? Pediatr Clin North Am 2009; 56:1.
- Cane RS, Ranganathan SC, McKenzie SA. What do parents of wheezy children understand by "wheeze"? Arch Dis Child 2000; 82:327.
- Goldsobel AB, Chipps BE. Cough in the pediatric population. J Pediatr 2010; 156:352.
- Wright AL, Holberg CJ, Martinez FD, et al. Breast feeding and lower respiratory tract illness in the first year of life. Group Health Medical Associates. BMJ 1989; 299:946.
- Martinez FD, Wright AL, Taussig LM, et al. Asthma and wheezing in the first six years of life. The Group Health Medical Associates. N Engl J Med 1995; 332:133.
- Fireman P. The wheezing infant. Pediatr Rev 1986; 7:247.
- Tinker E, Charles MD. Not all that wheezes is asthma. In: Emergency medicine news, 2001. Vol 23, Issue 8, p.36,57.
- McLaren CA, Elliott MJ, Roebuck DJ. Vascular compression of the airway in children. Paediatr Respir Rev 2008; 9:85.
- Official American Thoracic Society Clinical Practice Guidelines: Diagnostic Evaluation of Infants with Recurrent or Persistent Wheezing. http://www.thoracic.org/about/newsroom/press-releases/journal/wheezing-in-infants.pdf.
- Morgan WJ, Geller DE, Tepper RS, Taussig LM. Partial expiratory flow-volume curves in infants and young children. Pediatr Pulmonol 1988; 5:232.
- Hilman BC. Evaluation of the wheezing infant. Allergy Proc 1994; 15:1.
- Jartti T, van den Hoogen B, Garofalo RP, et al. Metapneumovirus and acute wheezing in children. Lancet 2002; 360:1393.
- Williams JV, Harris PA, Tollefson SJ, et al. Human metapneumovirus and lower respiratory tract disease in otherwise healthy infants and children. N Engl J Med 2004; 350:443.
- Biscardi S, Lorrot M, Marc E, et al. Mycoplasma pneumoniae and asthma in children. Clin Infect Dis 2004; 38:1341.
- Principi N, Esposito S. Emerging role of Mycoplasma pneumoniae and Chlamydia pneumoniae in paediatric respiratory-tract infections. Lancet Infect Dis 2001; 1:334.
- O'Sullivan BP, Finger L, Zwerdling RG. Use of nasopharyngoscopy in the evaluation of children with noisy breathing. Chest 2004; 125:1265.
- Salvatore S, Arrigo S, Luini C, Vandenplas Y. Esophageal impedance in children: symptom-based results. J Pediatr 2010; 157:949.