Approach to Wheeze 2018-01-30T16:36:58+08:00

Differential diagnosis

  • Lower airway
    • Foreign body
    • Asthma
      • NSAID
      • Aspirin
      • Allergic bronchopulmonary aspergillosis
      • Occupational
    • COPD
      • Alpha 1 antitrypsin deficiency
    • Mediastinal mass
    • Lung cancer
    • Lymphadenopathy
      • Sarcoidosis
    • Bronchitis
    • Churg-Strauss syndrome
    • Anaphylaxis
  • Fluid overload
    • Congestive cardiac failure
    • Liver disease
    • Nephrotic syndrome
  • Carcinoid syndrome
  • Gastro-oesophageal reflux disease
  • Upper airway
    • Thyroid mass
    • Head and neck cancer
    • Laryngeal cancer
    • Epiglottitis
    • Smoke inhalation
    • Tracheobronchomalacia

Relevant points in the history

  • Wheeze
    • What do you mean by wheeze?
    • What were you doing when you noticed it?
    • How old were you when it first happened?
    • What do you think caused it?
    • Were there any other symptoms?
  • Lower airway
    • Asthma and allergic bronchopulmonary aspergillosis
      • Do you have a cough that just won’t go away?
      • Do you bring up any phlegm when you cough?
      • Are your symptoms worse at night?
      • Have you noticed that this breathlessness is brought on by specific triggers?
      • Is the wheeze worse in the cold, after exercise or in dusty environments?
      • Do you notice that your chest feels tight?
      • Have you ever tried an inhaler?
        • What inhalers have you tried?
        • Has the dose or number of puffs changed recently?
        • How do you use the inhaler?
        • Do you take your inhaler every day as prescribed?
      • Do you have eczema?
      • Have you noticed intermittent episodes of a runny nose?
      • Does anyone in the family have eczema, asthma or a runny nose?
      • Do you keep any pets at home?
      • What is your job?
      • Have you taken any medication such as over the counter painkillers or aspirin recently?
    • Chronic obstructive pulmonary disease
      • Do you, or have you ever smoked?
      • Do you find that you are bringing up more phlegm than usual?
      • Do you feel breathless on walking?
    • Churg-Strauss syndrome
      • Have you noticed a rash anywhere on your body?
      • Have you noticed any weakness anywhere?
      • Any tingling in your hands or feet?
      • Have you noticed anything unusual in your urine?
      • Has there ever been any blood in your urine?
    • Neoplastic
      • Do you, or have you ever smoked?
      • Have you lost any weight?
      • Do you feel like you have no appetite?
      • Have you ever coughed up blood?
      • Do you feel breathless?
      • Have you noticed any change in your voice?
      • Have you had any fever?
      • Have you noticed any sweating at night?
    • Anaphylaxis
      • Have your eyes ever gone puffy?
      • Have you noticed any tongue or lip swelling?
      • Have you ever noticed any other sounds when you breathe in?
      • Have you noticed any rashes?
  • Fluid overload
    • Have you noticed any leg swelling?
    • How many pillows do you sleep on at night?
    • Do you ever wake up in the middle of the night feeling breathless?
    • Have you ever noticed any bubbles in your urine?
  • Carcinoid syndrome
    • Have you ever noticed your face going red?
    • Do you have any diarrhoea?
    • Do you have any tummy pain?
  • Gastro-oesophageal reflux disease
    • Have you ever noticed a sour, acid taste in your mouth?
    • Do you get a burning sensation in your chest?
    • Does it get worse on an empty stomach?
    • Is it worse when you lie down?
  • Upper airway
    • Have you had any problems swallowing?
    • Do you notice that your throat appears a bit swollen?
    • Have you had a sore throat or fever recently?

Examination

  • General
    • Comfortable at rest / respiratory distress
    • Cyanosis
    • Sputum pot
    • Tar staining of fingers
    • Barrel chest
    • Rash – vasculitic / urticaria / purpura
  • Lungs
    • Hyper-expanded
    • Listen for wheeze
    • Listen for crepitations (bronchiectasis / fluid overload)
    • Cervical lymphadenopathy
  • Cardiac
    • Right ventricular heave
    • Displaced apex beat
    • Jugular venous pulsation
    • PSM of tricuspid regurgitation (carcinoid syndrome)
    • Peripheral oedema

Investigations

  • Full blood count to look for eosinophilia (ABPA, Churg-Strauss)
  • Serum precipitins to Aspergillus
  • Skin reactivity test to Aspergillus looking for immediate hypersensitivity
  • Chest radiograph to look for any consolidation / cavitary lesions / bronchiectasis / pulmonary oedema
  • Anti-neutrophil cytoplasmic antibody (anti-myeloperoxidase, Churg-Straus)
  • Spirometry
    • Asthma (GINA Guidelines)
      • FEV1/FVC < 0.7
      • FEV1 increases by more than 12% and 200ml post-bronchodilator, or
      • FEV1 increases by more than 12% and 200ml after anti-inflammatory treatment
      • Methacholine challenge if index of suspicion high and initial spirometry normal
    • COPD (GOLD Guidelines)
      • FEV1/FVC < 0.7
      • FEV1 ≥ 80% predicted: mild (GOLD 1)
      • FEV1 50 – 80% predicted: moderate (GOLD 2)
      • FEV1 30 – 50% predicted: severe (GOLD 3)
      • FEV1 <30% predicted: very severe (GOLD 4)
  • Consider high-resolution computed tomography scan to look for central bronchiectasis (ABPA)
  • Consider 24hr 5-hydroxyindolacetic acid (5-HIAA) if history suggestive of carcinoid syndrome
  • Consider ENT referral for larynoscopy, CT neck if all of the above negative

Management

  • Multidisciplinary team approach
  • Patient education: inhaler technique, compliance, standby prednisolone (asthma action plan)
    • Smoking cessation, weight loss programs
    • Trigger avoidance
  • Pulmonary rehabilitation
  • Asthma (increase treatment if symptoms occur > 2x/month)
    • Step 1: inhaled short-acting β2 agonist (salbutamol)
    • Step 2: low-dose inhaled corticosteroid (e.g. budesonide)
    • Step 3: low-dose ICS + long-acting β2 agonist (e.g. fluticasone / salmeterol, Seretide® 125/200 1 BD)
    • Step 4: medium/high-dose ICS + LAMA (e.g. Seretide 250 2 puffs BD, budesonide / formoterol, Symbicort® 400/12 2 puffs BD)
    • Other options for add-on therapy: leukotriene receptor antagonist, theophylline
    • Step 5: consider continuous oral steroids at lowest possible dose
    • Before step 5, consider referral for potential steroid-sparing treatment
      • Omalizumab, anti-IgE monoclonal antibody
  • COPD (GOLD Guidelines)
    • Staging now uses a combination of exacerbation history, airflow limitation and symptoms
      • Symptoms can be gauged using the modified Medical Research Council (mMRC) score
        • Grade 0: breathless with strenuous exercise
        • Grade 1: breathless when hurrying on level ground or walking up slight hill
        • Grade 2: walks slower than people of the same age because of breathlessness
        • Grade 3: breathless before walking 100m
        • Grade 4: unable to leave the house
      • Airflow limitation
        • GOLD 1: FEV1 > 80%
        • GOLD 2: FEV1 50 – 80%
        • GOLD 3: FEV1 30 – 50%
        • GOLD 4: FEV1 < 30%
      • The following table provides a framework for staging COPD
FEV1 GOLD Stage Exacerbations
GOLD 3 and 4 C D ≥2, or ≥1 leading to hospital admission
GOLD 1 and 2 A B 1 not requiring admission
Symptoms (mMRC) Grade 0 – 1 Grade ≥ 2
  • Inhaled therapy
    • Regular and as-needed use of bronchodilators improve FEV1 and symptoms
    • SABA: salbutamol
    • SAMA: ipratropium
    • SAMA+SABA (bronchodilator effect is additive): Berodual® (ipratropium + fenoterol)
    • ICS+LABA: Seretide® for patients who have exacerbations despite regular SAMA+SABA
    • LAMA: tiotropium for patients who have exacerbations despite regular ICS+LABA
    • Consider theophylline for refractory disease
  • Long-term oxygen therapy (ideally, proved by two separate ABGs three weeks apart)
    • For patients with PaO2 < 55mg Hg or SpO2 < 88% on room air, or
    • Patients with PaO2 < 60mg Hg or SpO2 < 90% on room air and polycythaemia / cor pulmonale
    • Must be used for at least 15 hours per day
    • Greater benefits are seen in patients using LTOT for more than 20 hours per day
  • Churg-Strauss
    • Screen for mononeuritis / polyneuropathy, renal impairment
    • Initiate therapy with glucocorticoids (usually start at 1mg/kg/day of prednisolone)
      • Can usually begin to taper steroids over 12 – 18 months once initial presentation controlled
    • Cyclophosphamide indicated for severe, multi-system disease
    • Other options: azathioprine (first-choice for maintenance), methotrexate, leflunomide

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This Sliding Bar can be switched on or off in theme options, and can take any widget you throw at it or even fill it with your custom HTML Code. Its perfect for grabbing the attention of your viewers. Choose between 1, 2, 3 or 4 columns, set the background color, widget divider color, activate transparency, a top border or fully disable it on desktop and mobile.