Differential of Wheezing in a Child

Differential of Wheezing in a Child

·        Common:

o   Asthma

o   „Happy wheezer‟:

§  Diagnosis of exclusion

§  Usually < 12 months

§  Chronic daytime wheeze and no cough

§  Child undistressed and not impact (ie feeding OK, not waking)

§  Less wheeze when asleep

§  Requires no therapy

§  ?Collapsible airways 

§  Can become an „unhappy‟ wheezer when they get a cold, in which case treat as for bronchiolitis

o   Bronchiolitis

·        Uncommon:

o   Inhalation: If convincing episode of inhaling a foreign body (stridor, went blue, etc) should be 

o   bronchoscoped – even if they you think they brought it all back up. Signs: unilateral wheeze or stridor. May present months or years later with haemoptysis. CXR – will have hyperinflation or collapse on side of inhaled object 

o   Cystic Fibrosis: 

§  If breast feed can still thrive for a month or two

§  Respiratory symptoms often present with wheeze not cough

o   Heart Failure:

§  Sweat when feeding + poor feeding/cyanosis

§  Wheezy – sounds like bronchiolitis 

§  Look for enlarged liver (but beware, bronchiolitis ® hyperinflation ® liver lower)

o   Aspiration:

§  If due to neurological problems, will cough and splutter when swallowing

§  Long vague history with unclear start 

§  Gives acute onset of wheeze – eg OK when you put them to bed, but sudden coughing and wheezing later 

§  If lying on back, most likely to aspirate into right upper lobe, but in practice they are wheezy everywhere

§  Hard to prove.  Diagnosis of exclusion.  Can do reflux probe to show they reflux often

o   Immune deficiency:

§  Rare.  Only consider if lots of serious illnesses

§  Cilia dyskinesia: usually starts with ears (middle ear has respiratory epithelium with cilia), then lungs and sinuses. Associated with dextrocardia

§  Hypogammaglobulinaema

o  Can confuse wheezing with soft stridor: eg laryngomalacia.  Inspiratory sound 

o  Rare congenital causes: cysts, tumours, lobar emphysema, tracheomalacia/bronchomalacia (not properly formed ® floppy)

·        Smoking contributes to all the above: 

o  Prenatally, maternally smoking ® ¯airway size

o  Post-natal ® inflammation/irritation