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 "Emergency evaluation and immediate management of acute respiratory distress in children".)
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.
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