pulmonary disorders
Wheezing
Evaluation of Wheezing
When patients are in significant respiratory distress, evaluation and treatment proceed at the same time. History of present illnessshould determine whether the wheezing is new or recurrent. If recurrent, patients are asked the previous diagnosis and whether current symptoms are different in nature or severity. Particularly when the diagnosis is unclear, the acuity of onset (eg, abrupt or gradual), temporal patterns (eg, persistent versus intermittent, seasonal variations), and provoking or exacerbating factors (eg, current upper respiratory infection, allergen exposure, cold air, exercise, feeding in infants) are noted. Important associated symptoms include shortness of breath, fever, cough, and sputum production. should seek symptoms and signs of causative disorders, including fever, sore throat, and rhinorrhea (respiratory infection); orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema ( Heart Failure (HF) ); night sweats, weight loss, and fatigue (cancer); nasal congestion, itching eyes, sneezing, and rash (allergic reaction); and vomiting, heartburn, and swallowing difficulties ( Past medical historyshould ask about conditions known to cause wheezing, particularly asthma, COPD, and heart failure. Sometimes the patient’s medication list may be the only indication of such diagnoses (eg, inhaled bronchodilators and corticosteroids in COPD; diuretics and angiotensin-converting enzyme inhibitors in heart failure). Patients with known disease should be asked about indicators of previous disease severity, such as previous hospitalization, intubation, or intensive care unit admission. Also, conditions that predispose to heart failure are identified, including atherosclerotic or congenital heart disease and hypertension. Smoking history and exposure to secondhand smoke should be noted. Vital signs are reviewed for presence of fever, tachycardia, tachypnea, and low oxygen saturation. Any signs of respiratory distress (eg, accessory muscle use, intercostal retractions, pursed lip breathing, agitation, cyanosis, decreased level of consciousness) should be immediately noted. Examination focuses on the lungs, particularly adequacy of air entry and exit, symmetry of breath sounds, and localization of wheezing (diffuse versus localized; inspiratory, expiratory, or both). Any signs of consolidation (eg, egophony, dullness to percussion) or crackles should be noted. The cardiac examination should focus on findings that might indicate heart failure, such as murmurs, a 3rd heart sound (S3 gallop), and jugular venous distention. The nose and throat examination should note appearance of the nasal mucosa (eg, color, congestion), swelling of the face or tongue, and signs of rhinitis, sinusitis, or nasal polyps. The extremities are examined for clubbing and edema, and the skin is examined for signs of allergic reactions (eg, urticaria, rash) or atopy (eg, eczema). The patient’s general appearance is noted for constitutional signs, such as the cachexia and barrel chest of severe COPD. The following findings are of particular concern: Accessory muscle use, clinical signs of tiring, or decreased level of consciousness Fixed inspiratory and expiratory wheezing Swelling of the face and tongue (angioedema) wheezing in a patient with a known history of disorders such as asthma, COPD, or heart failure is usually presumed to represent an exacerbation. In patients who have both lung and heart disease, manifestations may be similar (eg, neck vein distention and peripheral edema in Cor Pulmonale due to COPD and in Clinical findings help suggest a cause of wheezing in patients without a known history (see table). (sudden-onset) wheezing in the absence of symptoms of an upper respiratory infection (URI) suggests an allergic reaction or impending Anaphylaxis , especially if urticaria or angioedema is present. Fever and URI symptoms suggest infection, Patients with asthma usually have paroxysmal or intermittent bouts of acute wheezing. Persistent,localized wheezing suggests focal bronchial obstruction by a tumor or foreign body. Persistent wheezing manifesting very early in life suggests a congenital or structural abnormality. Persistent wheezing with sudden onset is consistent with foreign body aspiration, whereas the slowly progressive onset of wheezing may be a sign of extraluminal bronchial compression by a growing tumor or lymph node. Testing seeks to assess severity, determine diagnosis, and identify complications. Pulse oximetry Chest x-ray (if diagnosis unclear) Sometimes arterial blood gas (ABG) measurement Sometimes pulmonary function testing Severity is assessed by pulse oximetry and, in patients with respiratory distress or clinical signs of tiring, ABG testing. Patients known to have asthma usually have bedside peak flow measurements (or, when available, forced expiratory volume in 1 second [FEV1]). Patients with new-onset or undiagnosed persistent wheezing should have a chest x-ray. X-ray can be deferred in patients with asthma who are having a typical exacerbation and in patients having an obvious allergic reaction. Cardiomegaly, pleural effusion, and fluid in the major fissure suggest heart failure. Hyperinflation and hyperlucency suggest COPD. Segmental or subsegmental atelectasis or infiltrate suggests an obstructing endobronchial lesion. Radiopacity in the airways or focal areas of hyperinflation suggest a foreign body. In children, particularly preverbal children, who have sudden onset of focal wheezing, inspiratory and expiratory chest x-rays should be taken; asymmetric findings suggest foreign body aspiration. If the diagnosis is unclear in patients with recurrent wheezing, pulmonary function testing can confirm airflow limitation and quantify its reversibility and severity.Methacholinechallenge testing and exercise testing can confirm airway hyperreactivity in patients for whom the diagnosis of asthma is in question. 