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Wheezing is a relatively high-pitched whistling sound, which is generated by the movement of air through constricted or compressed small airways. It is both a symptom and auscultation, Longer expiratory phase wheezing.
The air flow through a constricted or compressed segment of small airway becomes turbulent, resulting in vibrations of the airway walls. This vibration generates the sound of wheezing. Wheezing occurs more frequently during expiration because of increased intrathoracic pressure during this phase narrows the airways.
Wheezing when breathing out alone indicates a weaker obstruction as wheezing in both the single and exhalation, showing a massive constriction. In contrast, a turbulent flow of the air generated by a narrowed segment of the sizeable extrathoracic airway inspiratory a whistling noise (stridor).
A narrowing of the small airways can be caused by a tumor, foreign body or thick secretions by bronchoconstriction, mucosal edema or external compression or partial obstruction. In general, the most common causes of asthma COPD But wheezing may also in other diseases of the small airways, including heart failure (cardiac asthma), anaphylaxis and toxic inhalation occur.
Sometimes wheezing manifests in healthy patients during an attack of acute bronchitis. In children and bronchiolitis and foreign body among the causes.
Causes of wheezing
There are some familiar suspects when trying to find the cause of wheezing. These symptoms can be similar to acute bronchitis, which is an infection of the upper respiratory tract or an unknown lung infection
Allergic reactions – sufferers, usually within 30 minutes after exposure to known or potential allergen often stuffy nose, hives, itchy eyes, sneezing Clinical evaluation: Asthma
Asthma is often positive anamnesis wheezing occurs spontaneously or after exposure to certain stimuli (e.g.. B. allergens, infections of the upper respiratory tract, cold, movement)
Clinical Evaluation: Pulmonary
Sometimes pulmonary function tests, peak flow measurement, methacholine or observation of response to empirical bronchodilators bronchiolitis in children <18 months (usually November to April in the northern hemisphere ) in general, symptoms of infections of the upper respiratory tract and tachypnea
Clinical evaluation COPD -Exacerbation in patients middle-aged or elderly patients often actual COPD history. Excessive smoking in the past, weak breath sounds dyspnea breathing with pursed lip use of respiratory muscles.
Sometimes chest x-ray and blood gas measurement drugs (eg. As ACE inhibitors, aspirin, beta blockers, NSAIDs) Current beginning of a new drug, usually in a patient with a previous reactive airway disease
Clinical evaluation: Endobronchial Tumors
Endobronchial Tumors can be linked to chronic wheezing, especially in patients with risk factors for or signs of cancer (eg. B. positive smoking history, night sweats, weight loss, hemoptysis) Can more focal than diffuse his chest x-ray or CT bronchoscopy (usually a spirometry preceded with flow volume curves indicating an obstruction) foreign body Sudden appearance in a small child, which has no symptoms of infections of the upper respiratory or constitutional symptoms chest x-ray or CT bronchoscopy GERD with chronic aspiration Chronic or recurrent wheezing, often with heartburn and nocturnal coughing.
No infections of the upper respiratory tract or allergic symptoms trial of acid-suppressive drugs.
Sometimes esophageal pH monitoring Inhaled irritants sudden onset of exposure in the workplace or improper use of cleaning agents Clinical assessment left-sided heart failure with pulmonary edema (cardiac asthma)
Humidity RG and signs of central or peripheral volume overload (reg. B. jammed neck veins, peripheral edema) dyspnea (while lying flat orthopnea) or 1-2 h after falling asleep (paroxysmal nocturnal dyspnea) chest x-ray ECG BNP measurement echocardiography * In most patients, a pulse oximetry should be performed.
A chest X-ray should be performed, unless the symptoms are very mild or clearly an exacerbation of known chronic diseases. BNP = brain (B type) natriuretic peptide; GERD = gastroesophageal reflux disease. Review If patients suffer from significant breathlessness, done evaluation and treatment at the same time.
The medical history will be a factor, whether the wheezing occurred for the first time or is a recurring symptom. Is it recurring, patients are asked about the earlier diagnosis and whether the current symptoms in type or severity are different.
In particular, if the diagnosis is certain, the rate of appearance (persistent vs z. B. intermittent, seasonal fluctuations) are (z. B. abruptly or gradually), temporal patterns and triggering or reinforcing factors (eg. As current infections the upper respiratory tract, exposure to allergens, cold air, exercise, feed listed in infants).
Among the critical associated symptoms include shortness of breath, fever, cough and sputum. In reviewing the body systems (respiratory infection), orthopnea, paroxysmal nocturnal dyspnea and peripheral edema (heart failure) should for symptoms and signs of causative diseases including fever, sore throat and runny nose; Night sweats, weight loss and fatigue (cancer); stuffy nose, itchy eyes, sneezing and skin rash (allergic reaction) and vomiting, heartburn and swallowing disorders (reflux with aspiration) are sought. The medical history should trigger, will be asked for factors that are known to wheeze, especially asthma, COPD and heart failure. Sometimes the patient’s medications list may be the only indication for such diagnoses (e. B. inhaled bronchodilators and corticosteroids in COPD, diuretics and ACE inhibitors in heart failure).
Patients with a known disease should have indicators of the severity of the disease, as previous hospitalization, intubation or “ICU admission” be questioned. Also, conditions that predispose to heart failure identified, including atherosclerotic or congenital heart disease and hypertension.
A history of smoking and passive smoking are noted. Physical examination Vital signs are on fever, tachycardia, tachypnea and low oxygen saturation checked. Any signs of respiratory distress (eg. As use of the respiratory muscles, intercostal retractions, breathing with pursed lip, restlessness, cyanosis, decreased consciousness) should be noticed immediately.
The examination focuses on the lungs, particularly the scope of the import and efflux of air, symmetry of breath sounds and localization of wheezing (diffuse versus localized; inspiratory, expiratory or both). Any signs of compression (z. B. Ägophonie, dull sound head) or draining RG should be noted. The cardiac examination should focus on findings that indicate heart failure such as noise, a third heart sound (S3 gallop) and jugular venous expansion.
Upon examination of the nose and throat, the condition of the nasal mucosa (e.g. As a color, swelling), swelling of the face or tongue and signs of rhinitis, sinusitis or nasal polyps should be considered. The extremities are on clubbing and edema and examine the skin for signs of allergic reactions (eg. As urticaria, skin rash) or atopy (z. B. eczema). The general appearance of the patient is on constitutional changes, such as cachexia and barrel chest in severe COPD (Chronic obstructive pulmonary disease)
The following results are of particular importance: (use of the respiratory muscles, clinical signs of drowsiness or decreased consciousness festival inspiratory and expiratory wheezing swelling of the face and tongue angioedema) interpretation of the results in recurring wheezing in a patient with associated previous illnesses such as asthma, COPD or heart failure seems to represent an exacerbation usually. In patients who have both lung and heart disease, manifestations may be similar to (z. B. distended neck veins and peripheral edema in pulmonary heart disease due to COPD and heart failure), and an investigation is often required.
If the cause is asthma or COPD, former cough, postnasal drip, or exposure can be a trigger to allergens or toxic or irritating gases (eg. As cold air, dust, tobacco smoke, perfume). Clinical findings help to find the cause of wheezing in patients with no known history (see table: causes of wheezing).
Acute (Sudden) without wheezing symptoms of infections of the upper respiratory tract suggests an allergic reaction or threatening anaphylaxis out, especially if urticaria or angioedema are present. Fever and symptoms of an upper respiratory infection are suspicious of an infectious disease, acute bronchitis in older children and adults and bronchiolitis in children 2 years. Humidity RG, distended neck veins and peripheral edema point to a heart failure.
If wheezing occurs during feeding or vomiting of infants, it may be the result of reflux. Patients with asthma have paroxysmal generally or intermittent bouts of acute wheezing. Persistent, localized wheezing is indicative of focal bronchial obstruction by tumor or foreign body. Persistent wheezing, which manifests itself very early in life, suggests a congenital or structural abnormality. Persistent wheezing with sudden onset is related to foreign body aspiration, while the slowly progressive onset of wheezing a sign of extraluminal bronchial compression by a growing tumor or lymph nodes can be tested.
Tests attempt to assess the severity determine to establish a diagnosis and find out complications, Chest x-ray pulse oximetry (if diagnosis unclear) Sometimes BGA Sometimes pulmonary function tests The serious of the condition can be is assessed by pulse oximetry and in patients with respiratory distress or clinical signs of fatigue, blood gas tests. In patients with asthma usually, a peak flow measurement is performed at the bedside (or, if available, forced expiratory volume in 1 second [FEV1]). In patients with new-onset or undiagnosed persistent wheezing, a chest x-ray should be performed.
A radiograph can be moved in patients with asthma who have a typical exacerbation and patients with an apparent allergic reaction. Cardiomegaly, pleural effusion and fluid in the fossae speak for heart failure. Hyperinflation and radiation transparency indicate COPD. Segmental or subsegmental atelectasis or infiltrates are evidence of endobronchial obstructive disease. Radiological opacities in the airways or local hyperinflation indicate a foreign body. When the diagnosis of patients is unclear with recurrent wheezing, lung function tests can confirm the restriction of air flow and reversibility, and severity are determined. Methacholine challenge tests and load tests can confirm an airway hyperresponsiveness in patients in whom the diagnosis of asthma is questionable.
Treatment consists of treating the underlying causes. The wheezing itself can be reformed (n. D. Ed .: except for foreign body aspiration, tumors or vocal cord dysfunction) usually by inhalation of bronchodilators (z. B. Salbutamol 2.5 mg for inhalation via nebulizer or metered dose 180 mg). The long-term control of persistent asthmatic wheezing may require inhaled corticosteroids and leukotriene inhibitors. Intravenous H2 blockers (diphenhydramine), corticosteroids (methylprednisolone) and subcutaneous and inhaled epinephrine racemate are indicated in the case of anaphylaxis.
Asthma is the most common cause, but not all wheezing is asthma. Acute wheezing in a patient without lung disease may be caused by aspiration, allergic reaction or heart failure. Reactive airway disease can be confirmed by spirometry. Inhaled bronchodilators are the mainstay of acute treatment.