wheeze, stridor, cough, and other respiratory noises
TRANSCRIPT
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Wheeze, Stridor, Cough, and Other Respiratory Noises
Miles Weinberger, M.D.Professor of Pediatrics
www.uihealthcare.com/allerpulm
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Wheeze
Continuous musical sounds, typically expiratory in nature
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But What Do Parents Mean by “Wheeze”
Less than 50% agreement between parents and clinicians (Cane et al. Arch Dis Child 2000;82:327)
Wheeze most commonly used term for respiratory sounds until imitated or shown video (Elphick et al. Arch Dis Child 2001;84:35)
30% of parents used other words for wheeze and 30% labeled other sounds as “wheeze”(Cane et al. Arch Dis Child 2001;84)
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Causes of Wheezing
BronchiolitisAsthmaCystic fibrosisForeign body (monophonic)Bronchomalacia
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Causes of Wheezing
BronchiolitisAsthmaCystic fibrosisForeign body (monophonic)
Bronchomalacia
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5 m.o. with wheezing and retractionsOnset 6 weeks of ageNo response to albuterol
Patient GH
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Patient GH
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Patient GH
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BAL from RULn 52% neutrophilsn 400,000 cfu/ml Moraxella catarrhalisn 400,000 cfu/ml Haemophilus influenzae
Coughing and wheezing resolved with Augmentin ES600, 90 mg/kg/day divided BIDStridor and retractions when excited persisted from the mild laryngomalacia
Patient GH
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Bronchomalacia
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Bronchomalacia
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Noises and Clinical Consequences Associated with Bronchomalcia
Protracted bacterial bronchitis –most with bronchomalaciaBAL for persistent presence of cough, wheeze, or noisy breathingn Inflammation (neutrophilia)n High colony counts bacteria
– S. pneumo– H. influenza– M. catarrhalis
Improved with Augmentin, but recurrences common
Kompare M, Weinberger M. Protracted bacterial bronchitis in young children: association with airway malacia.J Pediatr 2012;160:88-92).
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Airway MalaciaAirway Malacia
BronchomalaciaTracheomalaciaBothNone seen41%41%
20%20%
13%13%
26%26%
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Stridor
Continuous inspiratory musical sound of variable pitch
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Laryngomalacia
Common to varying degrees – about 60% of stridor in infantsRepresents a delay in maturation of supporting laryngeal structures.Generally resolves by 2 years of ageRare cases result in pulmonary hypertensionLaser laryngoplasty for very occasional severe cases affecting feeding or growth
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What is “croup”?Transient inflammation of the laryngeal area causing upper airway obstruction characterized by inspiratory stridor - generally from viruses
Commonly associated with inflammation of the trachea and bronchi, hence the term “laryngotracheobronchitis”Typically accompanied by harsh barking cough from the tracheobronchitis – but a “croupy” cough alone is not croupResponds to epinephrine aerosol with transient relief and dexamethasone for sustatined benefit
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Etiologic Agents Recovered from Children with Croup
Paraflu 29%
Misc. vir.5%
Influenza A4%
Influenza B3%
RSV10%
Paraflu 318%
Paraflu 147%
M Pneumoniae4%
N = 360
Denny et al, Pediatr 71:871, 1983
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Epiglottitis
Bacterial infectionn H. influenza group Bn S. pyogenes (beta hemolytic streptococcus, group A)
Life threateningMedical emergencyTreatmentn Establish an airwayn Antibiotics
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Jennifer J -15 Y.O. Girl With 3 Weeks of recurrent stridor and dyspnea
First episode while detasseling - Rx with epinephrine in ER successful2nd episode next day while detasseling -same treatment with same resultThen daily episodes without detasseling and without response to epinephrineRespiratory sound called wheezingRx with inhaled bronchodilators, prednisone, and hospitalization without response
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Jennifer J - Spirometry Before and After Treadmill Exercise
Treadmill exercise induced “wheezing”(actually a high pitched stridor)Normal pre-exercise; decreased flow only on inspiration post-exerciseDiagnostic of extrathoracic airway obstruction
pre-exercise
post-exercise
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Sarah J - 15 Y.O. Girl With 1.5 Year History Recurrent Severe “Wheezing” and Dyspnea
Multiple paramedic calls for ER Rx because of severe respiratory distress
Rx with bronchodilators, inhaled and oral corticosteroids
Several hospitalizations
No consistent response to any treatment
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Sarah J - spirometry before and after preparing to perform bronchoprovocation
“Wheezing” (actually a high pitched inspiratory stridor and a monophonic expiratory wheeze)
and dyspnea began while preparing to perform bronchoprovocationInitially normal; then severe airflow obstruction apparent on both inspiration and expiration
before
after
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Vocal Cord Dysfunction Syndrome
Commonly mis-diagnosed as asthmaMay be present along with asthmaTwo clinical patterns (Doshi D. Weinberger M. Long-term outcome of vocal cord dysfunction. Ann Allergy Asthma Immunol 2006;96;794-799)
n Exercise induced (can be blocked with anti-cholinergic aerosol)
n Spontaneous
Treatment of spontaneous VCD – vocal cord training by a speech therapist familiar with the disorder
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History of D.D.
17 m.o. girl with 8 months of harsh nocturnal stridor and coughing
Rx with albuterol and corticosteroids
No response to treatment
Flexible bronchoscopy showed intermittent paradoxical vocal cord movement
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MRI of D.D.
Chiari 1 malformation with herniation of cerebellar tonsil below foramen magnum
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Causes of Stridor
CroupEpiglottitisLaryngomalaciaChiari malformationVocal cord paralysisLaryngeal foreign bodyVocal cord dysfunction syndrome
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Cough
Forceful exhalation after quickly raising thoracoabdominal pressure, often to > 100 cm H20
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PertussisWhooping Cough
Most dangerous in unimmunized infantsOccurs in immunized adolescents and adultsn 26% of 130 college students with persistent cough
> 6 days (Mink et al, Clin infect Dis 1992;14:464-71)
n 21% of 75 adults with cough > 2 weeks (Wright et al, JAMA 1994;273:1044-6)
n 12% of 153 adults with cough > 2 weeks (Nennig et al, JAMA 1996;275:1672-4)
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Nasal Swab for Pertussis PCR
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Habit Cough SyndromeClinical Characteristics
Loud, repetitive, dry, barking coughDuration of weeks or monthsIrritating and disturbing to others -prevents school attendanceCommonly misdiagnosed as asthmaNo response to medicationAbsent once asleep
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Habit CoughRx With Suggestion Therapy - Outcome
Lockshin, Lindgren, Weinberger, Koviach. Ann Allergy 1991;67:405 (from U of IA Ped All/Pulm Clinic)
8/9 patients treated successfully with 15 minute session, 1/9 required 30 minutesMinor relapses controlled with autosuggestion technique1 required a 2nd session 9 days laterAll remained asymptomatic for median of 2.2 years
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Habit Cough SyndromeNatural History
Rojas, Sachs, Yunginger, O’Connell. Annals of Allergy 1991;66:106 (from the Mayo Clinic)
Follow-up of 62 pts (34 m & 26 f) for mean length of 7.9 yearsAges 4.6-15.6 (mean 10.5)Mean duration till Dx - 7.6 monthsMean duration till resolution 6.1 months16 pts still coughing for mean of 5.9 years from time of Dx
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Habit Cough SyndromeRx With Suggestion Therapy - Method
Physician must have confidence in successFocus patient’s attention on suppressing coughExplain coughReinforce even brief successesEmphasize that patient, not physician, is controlling coughSuccess usual in about 15 minutesEmphasize autosuggestion for minor relapses
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Donna E -9 Y.O. Girl With Cough for 2 Years
Treated as asthmaOral corticosteroidsn Growth retardedn Cushingoidn Hirsute
Several hospitalizations with IV antibiotics and corticosteroidsNo response to any of the therapy
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Patient MW14 m.o. coughing day and night4-5 spasms of coughing a day lasting 4-5 minutesInterferes with activityCoughing disturbs sleep, especially when lying on her back
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Patient MW
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Patient MW
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No inflammation on BALReferred to pediatric surgeryAortopexy performed
Patient MW
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Tracheomalacia - treatment
Behaviorally – successful for some mild cases (Wood RE. Localized tracheomalacia or bronchomalacia in children with intractable cough. J Pediatr 1990;116:404-406)
Aortopexy – stenting the trachea using a stitch between the sternum and the aorta to place tension on the connective tissue between the aorta and anterior wall of the trachea
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Aortopexy
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Cough now not troublesomeShe now sleeps well at night on her back
Patient MW
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History of A.K.4 y.o. with harsh barking cough
Present since infancy
Dx as asthma
Allergy skin testing negative
Rx with cromolyn, Singulair, prn albuterol, and multiple courses of steroids
Equivocal response to all treatment
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Upper Airway of A.K. Through Flexible Bronchoscope
Najada A, Weinberger M. Unusual cause of chronic cough in a four-year-old cured by uvulectomy. Pediatr Pulmonol 2002;34;144-146.
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3.y.o. girl with chronic cough
No response to bronchodilatorsNo response to prednisoloneNo response to antibioticNo airway inflammation on BALNo bacteria on BAL
epiglottis
Tonsillar tissue
Gurgel RK, Brookes JT, Weinberger MM, Smith RJ. Chronic cough and tonsillar hypertrophy.Ped Pulmonol 2008;43:1147–1149.
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Other Causes of CoughAcute viral bronchitis (or tracheobronchitis)Asthma (1215 tomorrow)
Protracted bacterial bronchitisM. Or C. PneumoniaeAspirationCystic fibrosisPrimary ciliary dyskinesiaHabit cough syndrome (Saturday at 1300)
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What about GERD and Cough???
Controlled clinical tirals have not shown PPIs to improve cough associated with GERD symptoms in infants, children, or adults.
Chang et al. Cough and reflux esophagitis in children: their co-existence and airway cellularity. BMC Pediatr 2006 Feb 27;6:4.
Chang et al. An objective study of acid reflux and cough inchildren using an ambulatory pHmetry–cough logger. Arch Dis Child. 2011 May;96(5):468-72.
Chang et al. Gastro-oesophageal reflux treatment for prolonged non-specific cough in children and adults. Cochrane Database Syst Rev. 2011 Jan 19;(1)
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What About Post-Nasal Drip?
A diagnostic label that is unhelpfulNo accepted definitionMucus dripping down the back of the throat not consistently associated with coughPresence of post-nasal drainage with cough likely indicates inflammation of lower airway in addition to the upper airway
Morice AH. Post-nasal drip syndrome – a symptom to be sniffed at? Pulmonary Pharmacology & Therapeutics 2004;17:343-5.Kemp A. Does post-nasal drip cause cough in childhood? Paediatr Resp Rev 2006;7:31-35.
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Other Respiratory Noises
Crackles – interrupted soundsn Fine crackles – inspiratory opening of
alveoli that closed on previous exhalation(s)n Coarse crackles (preferred terminology over
rhonchi) – movements of fluids in bronchi or bronchioles
Pleural rubsIncreased transmission of voice soundsn Bronchophony and egophonyn Whispering pectoriloquy
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Describing Respiratory Sounds
Inspiratory or expiratoryContinuous or interruptedPitchVolumeLocationDuration and frequency