WHEEZING Differential Diagnosis of Wheezing asthma: recurrent wheezing episodes pneumonia: fever, cough, malaise ...
WHEEZING
Differential Diagnosis of Wheezing
- asthma: recurrent wheezing episodes
- pneumonia: fever, cough, malaise
- bronchiolitis: first episode of wheezing (see Bronchiolitis Section)
- CF: prolonged wheezing unresponsive to therapy
- foreign body aspiration: sudden onset wheezing and coughing
- gastroesophageal reflux with aspiration: feeding difficulties
- congestive heart failure: associated FTT
BRONCHIOLITIS
- presents as first episode of wheezing associated with URI and signs of respiratory distress
- common, affects 15% of children in first 2 years of life
- peak incidence at 6 months, often in late fall and winter
- occurs in children prone to airway reactivity, i.e. increased incidence of asthma
Etiology
- RSV (75%)
- Parainfluenza, Influenza, Adenovirus
Clinical Features
- prodrome of URI with cough and fever
- feeding difficulties, irritability
- wheezing, respiratory distress, tachypnea, tachycardia
- children with chronic lung disease, severe CHD and
- immunodeficiency have a more severe course of the illness
Diagnosis
- chest x-ray : air trapping, peribronchial thickening, atelectasis, increased linear markings
- nasopharyngeal swab : direct detection of viral antigen (immunofluorescence)
Management
Mild distress
- supportive: oral or IV hydration, antipyretics for fever
- humidified oxygen and/or inhaled bronchodilator (Ventolin)
Moderate to severe distress
- humidified oxygen
- inhaled bronchodilator (Ventolin) or racemic epinephrine
- continue only if effective
- Atrovent and steroids are not effective
- rarely intubation and ventilation
- consider ribavirin in high risk groups: BPD, CHD, congenital lungdisease, immunodeficient
- case fatality rate < 1%
Indications for hospitalization
- hypoxia: oxygen saturation < 92%
- ersistent resting tachypnea > 60/minute and retractions after several Ventolin masks
- past history of chronic lung disease, hemodynamically significant cardiac disease, neuromuscular problem, immunocompromise
- young infants < 3 months old (unless extremely mild)
- significant feeding problems
- social problem, i.e. inadequate care at home
