Wheeze. Dr Jo Harrison

Transcription

1 Wheeze Dr Jo Harrison

2 Wheeze - Physiology a continuous musical sound that lasts longer than 250 msec. can be high-pitched or low-pitched, consist of single or multiple notes, and occur during inspiration or expiration. can originate from airways of any size throughout the conducting airways.

3 Wheeze - Physiology Wheeze indicates expiratory flow limitation Represents fluttering of airway walls at site of limitation Energy conservation mechanism when driving pressure exceeds pressure required to produce maximal flow Infants more likely to wheeze Smaller, more compliant airways Less airway narrowing required to achieve flow limitation

4 Causes of Wheeze Asthma Inhaled foreign body Bronchiectasis CF PCD Aspiration Structural abnormality of airway Tracheobronchomalacia Vocal Cord Dysfunction Mediastinal masses Cardiac

5 Foreign Body Inhalation Acute onset May be unilateral 1 to 3 years of age Unwitnessed in 50% Investigation CXR Treatment Rigid bronchoscopy

6 Causes of wheeze Asthma Inhaled foreign body Bronchiectasis CF PCD Aspiration Structural abnormality of airway Tracheobronchomalacia VCD Mediastinal masses Cardiac

7 Structural Abnormality Vascular rings and slings unusual congenital anomalies that occur early in the development of the aortic arch and great vessels Right sided aortic arch Double aortic arch Pulmonary artery sling Tracheal stenosis

8 Structural Abnormality Investigations CXR Barium swallow Bronchoscopy CTA/MRA Treatment Surgical correction

9 Causes of Wheeze Asthma Inhaled foreign body Bronchiectasis CF PCD Aspiration Structural abnormality of airway Tracheobronchomalacia VCD Mediastinal masses Cardiac

10 Tracheobronchomalacia Inherent weakness in the structural integrity of the cartilaginous rings Dynamic wall collapse and airway obstruction Characterized by expiratory airway collapse Harsh, low pitched monophonic expiratory wheeze Exacerbated by increased respiratory effort e.g. crying and coughing Improves during sleep Rarely may cause apnoea dying spells

11 Tracheobronchomalacia - diagnosis Flexible bronchoscopy AP collapse of trachea D shaped cartilaginous rings Multi-detector CT Virtual bronchoscopy Bronchography

12 Tracheobronchomalacia - treatment Most improve spontaneously between 12 and 24 months of age Surgical tracheopexy or aortopexy Tracheostomy +/- CPAP

13 Causes of wheeze Asthma Inhaled foreign body Bronchiectasis CF PCD Aspiration Structural abnormality of airway Tracheobronchomalacia VCD Mediastinal masses Cardiac

14 Vocal Cord Dysfunction (VCD) Abnormal adduction of the vocal cords Airflow obstruction at the level of the larynx Mimics asthma Increased incidence of psychiatric disease F:M ratio 3:1

15 VCD - diagnosis History Inspiratory difficulty Tightness in throat No response to BDR Examination PFT Often normal Limitation of inspiratory flow

16 VCD - diagnosis Laryngoscopy during episode paradoxical adduction of vocal cords during inspiration

17 VCD -Treatment Speech therapy vocal cord relaxation techniques breathing exercises Psychotherapy Underlying psychiatric conditions Anticholinergic Exercise related VCD

18 Causes of wheeze Asthma Inhaled foreign body Bronchiectasis CF PCD Aspiration Structural abnormality of airway Tracheobronchomalacia VCD Mediastinal masses Cardiac

19 Mediastinal Mass tumours thymic lesions bronchogenic cysts angiomatous lesions enlarged lymph nodes

20 Causes of wheeze Asthma Inhaled foreign body Bronchiectasis CF PCD Aspiration Structural abnormality of airway Tracheobronchomalacia VCD Mediastinal masses Cardiac

21 Cardiac Causes of Wheeze External compression of airways Left atrial enlargement PA enlargement Left ventricular failure or pulmonary venous outflow obstruction distension of the pulmonary vascular bed, bronchiolar wall oedema, increased airway resistance, and wheezing

22 Thank you!