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Expiratory Wheezing

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Expiratory Wheezing, Expiratory Wheeze, Wheeze, Wheezing

  • See Also
  1. Stridor
  2. Noisy Breathing
  • Epidemiology
  1. Recurrent wheezing Incidence in age <5 years: 50%
    1. Only 30% of recurrent Wheezing are subsequently diagnosed with Asthma at age >5 years
  • Pathophysiology
  1. Airway wall fluttering results from flow limitation
  2. Expiration typically occurs passively with elastic recoil of the chest wall
    1. Obstruction to outflow requires active expulsion of air
    2. Resulting positive intrapleural pressure worsens the obstruction
  3. Wheezing is more common in children than adults
    1. Inflammation of a child's smaller Bronchi has a greater impact on airway resistance
    2. Obstruction is more likely in a child's airway due to less chest elastic recoil
    3. A child's compliant airway walls collapse more easily under negative pressure
  • Causes
  • Infants
  1. Acute
    1. RSV or other Bronchiolitis (most common cause in infants)
    2. Asthma Exacerbation
    3. Other respiratory infection (Acute Bronchitis, Pneumonia)
    4. Foreign Body Aspiration (uncommon under age 1 year)
  2. Chronic or Recurrent: Common
    1. Asthma
    2. Gastroesophageal Reflux
  3. Chronic or Recurrent: Uncommon or Rare
    1. Aspiration Pneumonitis
    2. Anomalous innominate artery
    3. Anomalous left common Carotid Artery
    4. Bronchopulmonary Dysplasia
    5. Bronchomalacia
    6. Choanal Atresia
    7. Congenital Lobar Emphysema
    8. Congestive Heart Failure
    9. Cystic Fibrosis or ciliary Dyskinesia
    10. Double aortic arch
    11. Diaphragmatic Hernia
    12. Extrinsic compression by tumor (Neuroblastoma)
    13. Hemosiderosis
    14. Tracheal Stenosis
    15. Tracheomalacia
    16. Tracheoesophageal Fistula
    17. Vascular Ring
    18. Visceral larval migrans
  4. Associated with recurrent, frequent and severe Bacterial or fungal respiratory infections
    1. Immunodeficiency (esp. prolonged infections >14 days)
    2. Ciliary Dyskinesia (chronic Rhinitis since birth, wet cough, Wheezing)
    3. Cystic Fibrosis (or other chronic lung condition)
  • Causes
  • Children and Adolescents
  1. Acute
    1. Asthma Exacerbation (most common cause in children)
    2. RSV or other Bronchiolitis
    3. Acute Bronchitis
    4. Pneumonia
    5. Foreign Body Aspiration (uncommon after preschool age, if no Developmental Delay)
  2. Chronic or Recurrent: Common
    1. Asthma
    2. Allergic Rhinitis
    3. Gastroesophageal Reflux disease
    4. Obstructive Sleep Apnea (adenoid hypertrophy, also with craniofacial abnormalities)
  3. Chronic or Recurrent: Uncommon or rare
    1. a1-antitrypsin Deficiency
    2. Aspergillosis
    3. Cystic Fibrosis
    4. Ciliary Dysmotility Syndrome
    5. Sarcoidosis
    6. Tumors or Lymph Node compression
    7. Vocal Cord Dysfunction
  • Causes
  • Adults
  1. Acute
    1. Asthma Exacerbation
    2. COPD exacerbation
    3. Acute Bronchitis
    4. Anaphylaxis
    5. Acute Decompensated Congestive Heart Failure (Left Ventricular Failure, "cardiac Wheezing")
    6. Aspiration
    7. Acute Pulmonary Embolism
    8. Acute airway obstruction (Foreign Body Aspiration, Neck Mass)
    9. Laryngospasm
  2. Chronic or Recurrent: Common
    1. Asthma
    2. COPD (Chronic Bronchitis, Emphysema)
    3. Sarcoidosis
  3. Chronic or Recurrent: Uncommon to Rare
    1. Extrinsic allergic alveolitis (Hypersensitivity pneumonitis)
    2. Carcinoid Syndrome
    3. Systemic Mastocytosis
    4. Vocal Cord Dysfunction
    5. Cystic Fibrosis
    6. Eosinophilic syndromes (e.g. Nonasthmatic Eosinophilic Bronchitis, Allergic Bronchopulmonary Aspergillosis)
    7. Factitious Asthma
  • History
  1. Onset
    1. Onset as an infant: Congenital cause
    2. Sudden onset
      1. Foreign Body Aspiration (esp. age <3 years)
      2. Anaphylaxis
    3. Transient winter onset with upper respiratory symptoms and with cluster of cases
      1. Respiratory Syncytial Virus (fall to spring)
      2. Croup (fall and winter)
      3. Rhinovirus
      4. Human Metapneumovirus (winter to spring)
  2. Pattern
    1. Seasonal pattern (esp. peak pollen times)
      1. Asthma
      2. Allergic Rhinitis
    2. Persistent or recurrent respiratory illnesses with Wheezing
      1. Cystic Fibrosis
      2. Bronchopulmonary Dysplasia
      3. Laryngomalacia
      4. Immunodeficiency (e.g. Primary ciliary Dyskinesia, Agammaglobulinemia)
    3. Associated cough
      1. Cough After feeding: Gastroesophageal Reflux
      2. Dry, nighttime cough
        1. Gastroesophageal Reflux
        2. Allergic Rhinitis
        3. Asthma
        4. Obstructive Sleep Apnea
  3. Modifying Factors
    1. Wheezing after feeding
      1. Gastroesophageal Reflux (most common)
      2. Tracheoesophageal fistula
      3. Laryngeal cleft
      4. Esophageal atresia (newborns)
    2. Positional change
      1. Tracheomalacia
      2. Great Vessel anomalies or Vascular Rings (infants, esp. age <6 months)
  4. Family History
    1. Asthma
    2. Allergic Rhinitis
    3. Eczematous Dermatitis
  • Symptoms
  1. Expiratory whistling sound
  • Signs
  1. General: Signs of chronic systemic illness (e.g. Cystic Fibrosis, Immunodeficiency)
    1. Observe for ill, wan, tired appearance
    2. Review growth charts for fall in Growth Velocity
  2. Wheezing Intensity
    1. Wheezing in infant heard without stethoscope suggests Congenital Anomaly
  3. Wheezing Modifying maneuvers
    1. Worse with neck flexion and better with extension suggests Vascular Ring
  4. Severity: Asseess for outpatient versus inpatient management
    1. Observe for critical or ominous signs
      1. Altered Mental Status
      2. Diaphoresis
      3. Stridor or Drooling (e.g. severe croup, Epiglottitis, impending airway compromise)
    2. Observe for respiratory distress
      1. Neck or intercostal retractions
      2. Tachypnea
      3. Grunting (Auto-PEEP)
    3. Evaluate for acute conditions requiring intervention
      1. Pneumonia
      2. Croup
      3. Foreign Body Aspiration
  • Imaging
  1. Chest XRay
    1. Consider inspiratory/expiratory films or lateral decubitus XRays (may detect Airway Foreign Body)
    2. Evaluate for other associated findings
      1. Cardiomegaly or cephalization (Cardiomyopathy)
      2. Hyperinflation (Obstructive Lung Disease)
  2. Advanced Imaging (e.g. CT Chest, MRI Chest)
    1. Consider in high suspicion for pathology when Chest XRay is non-diagnostic
  • Evaluation
  1. Full Vital Signs including Oxygen Saturation, Respiratory Rate and Peak Flows (if possible)
    1. V-Q Mismatch in Asthma or Bronchiolitis is typically mild to moderate
    2. Severe V-Q Mismatch with significant Hypoxemia (O2 Sat <90%) suggests other underlying cause
      1. Example: Pneumonia
  2. Consider specific testing or empiric therapy in common conditions
    1. Asthma (e.g. Spirometry, empiric Bronchodilator trial)
    2. Allergic Rhinitis (e.g. Allergy Testing)
    3. Gastroesophageal Reflux (e.g. barium swallow, empiric Proton Pump Inhibitor)
  3. Consider testing for uncommon conditions
    1. Cystic Fibrosis (e.g. Sweat Chloride)
    2. Immunodeficiency (e.g. Serum Immunoglobulins, CBC)
  • References
  1. Claudius and Brown (2017) Crit Dec Emerg Med 31(12): 13-20
  2. Majoewsky (2012) EM:Rap-C3 2(5):2
  3. Bush (2007) Prim Care Respir J 16:7-15 [PubMed]
  4. Cagle (2026) Am Fam Physician 113(2): 132-6 [PubMed]
  5. Martinati (1995) Allergy 50:701-10 [PubMed]
  6. Weiss (2008) Am Fam Physician 77: 1109-14 [PubMed]