Wheezing in Children: Case and Viva Q&A

1. Clinical Case of Wheezing in Children

Acute Wheezing in a 3-Year-Old

Patient Information

• Name: Emily
• Age: 3 years
• Sex: Female

Presenting Complaint

Emily is brought to the emergency department by her parents with complaints of difficulty breathing and a "whistling" sound when exhaling. The symptoms started about 6 hours ago and have been progressively worsening.

History of Present Illness

• Onset: Symptoms began suddenly this morning
• Progression: Gradually worsening over the day
• Associated symptoms: Cough, mild fever (38°C), decreased appetite
• Recent history: Had a mild cold for the past 2 days
• No history of similar episodes in the past

Past Medical History

• Full-term birth, normal development
• Up-to-date on vaccinations
• No known allergies
• No previous hospitalizations or surgeries

Family History

• Father has asthma
• Maternal grandmother has allergies

Physical Examination

• General: Alert but in mild respiratory distress
• Vital Signs:
  • Temperature: 38.2°C
  • Heart Rate: 130 bpm
  • Respiratory Rate: 40 breaths/min
  • Blood Pressure: 100/60 mmHg
  • SpO2: 92% on room air
• Respiratory:
  • Visible intercostal retractions
  • Audible wheezing on expiration
  • Prolonged expiratory phase
  • Decreased air entry bilaterally
• Cardiovascular: Regular rhythm, no murmurs
• ENT: Mildly erythematous pharynx, no tonsillar exudates
• Skin: No rashes or cyanosis

Initial Management

1. Oxygen therapy via nasal cannula to maintain SpO2 > 94%
2. Nebulized albuterol (2.5 mg) with ipratropium bromide (0.5 mg)
3. Oral prednisolone (1 mg/kg)
4. Reassessment after 20 minutes

Outcome

After two rounds of nebulized bronchodilators and systemic corticosteroids, Emily's respiratory status improved significantly. Her wheezing decreased, respiratory rate normalized, and SpO2 increased to 98% on room air. She was observed for 4 hours and then discharged home with a short course of oral prednisolone, an inhaled corticosteroid, and a rescue inhaler. Follow-up with a pediatrician was scheduled for 48 hours later.

Discussion

This case illustrates a typical presentation of acute wheezing in a young child, likely due to viral-induced bronchospasm or early asthma. The management demonstrates the standard approach of bronchodilators and corticosteroids, with close monitoring and follow-up. It highlights the importance of prompt recognition and treatment of respiratory distress in children, as well as the need for ongoing management and education for potential recurrences.

2. Clinical Presentations of Wheezing in Children

Various Clinical Presentations of Wheezing in Children

1. Acute Viral Bronchiolitis

   • Typically affects infants < 2 years old
   • Preceded by upper respiratory tract infection symptoms
   • Rapid onset of wheezing, cough, and increased work of breathing
   • Often associated with RSV or other respiratory viruses
   • May lead to feeding difficulties and dehydration
   • Characteristic crackles on auscultation

2. Asthma Exacerbation

   • Recurrent episodes of wheezing, coughing, and shortness of breath
   • Often triggered by viral infections, allergens, or exercise
   • May have nocturnal symptoms or early morning worsening
   • Family history of asthma or atopy is common
   • Response to bronchodilators is typically good
   • May have associated atopic conditions (eczema, allergic rhinitis)

3. Foreign Body Aspiration

   • Sudden onset of cough and wheezing in a previously healthy child
   • May have a history of choking episode
   • Unilateral wheezing or decreased breath sounds
   • Can present with recurrent pneumonia in the same location
   • May have intermittent symptoms if foreign body is mobile
   • Chest X-ray may show hyperinflation or atelectasis

4. Allergic Reaction / Anaphylaxis

   • Rapid onset of wheezing along with other systemic symptoms
   • May have associated urticaria, angioedema, or gastrointestinal symptoms
   • Often has a history of exposure to a known allergen
   • Can progress rapidly to respiratory failure and shock
   • May have concurrent cardiovascular symptoms (tachycardia, hypotension)

5. Cystic Fibrosis Exacerbation

   • Chronic or recurrent wheezing in a child with known CF
   • Associated with increased cough and sputum production
   • May have weight loss or failure to thrive
   • Often accompanied by recurrent respiratory infections
   • Characteristic upper lobe bronchiectasis on imaging

6. Gastroesophageal Reflux Disease (GERD)

   • Wheezing associated with feeding or when lying down
   • May have concurrent symptoms of reflux (regurgitation, heartburn)
   • Can present with chronic cough, especially at night
   • May not respond well to typical asthma treatments
   • Often improves with anti-reflux measures and medications

7. Tracheomalacia or Bronchomalacia

   • Inspiratory or expiratory stridor that may be mistaken for wheezing
   • Symptoms worsen with agitation or crying
   • Often improves when the child is calm or sleeping
   • May be associated with other congenital anomalies
   • Diagnosis often requires bronchoscopy

8. Vocal Cord Dysfunction

   • Wheezing-like sound, often more prominent on inspiration
   • May be triggered by exercise or stress
   • Often mistaken for treatment-resistant asthma
   • Symptoms may resolve quickly without intervention
   • Diagnosis confirmed by laryngoscopy during an episode

3. Viva Questions and Answers on Wheezing in Children

Viva Questions and Answers: Wheezing in Children

Q1: What is the pathophysiological mechanism of wheezing?

A: Wheezing occurs due to narrowing of the airways, which can be caused by:

• Bronchoconstriction (smooth muscle contraction)
• Inflammation and edema of the airway wall
• Excessive mucus production
• Structural abnormalities of the airways

These factors lead to turbulent airflow, particularly during expiration, producing the characteristic whistling sound. The pitch and intensity of the wheeze depend on the degree of airway narrowing and the velocity of airflow.

Q2: How do you differentiate between upper and lower airway wheezing?

A: Differentiation between upper and lower airway wheezing involves:

• Upper airway wheezing (stridor):
  • Usually louder during inspiration
  • Often heard without a stethoscope
  • Typically localized to the neck/upper chest
  • Associated with conditions like croup or foreign body aspiration in the upper airway
• Lower airway wheezing:
  • Usually more prominent during expiration
  • Often requires a stethoscope to hear
  • Heard throughout the chest, may be localized or diffuse
  • Associated with conditions like asthma, bronchiolitis, or lower airway obstruction

Q3: What are the key differences in managing acute wheezing in infants versus older children?

A: Key differences include:

• Infants (< 2 years):
  • More likely to have viral bronchiolitis
  • May not respond well to bronchodilators
  • Emphasis on supportive care (hydration, oxygenation)
  • Careful use of nebulized hypertonic saline in some cases
  • Corticosteroids generally not recommended for first-time wheezers
• Older children:
  • More likely to have asthma
  • Usually respond well to bronchodilators
  • Systemic corticosteroids often indicated
  • May benefit from inhaled corticosteroids for ongoing management
  • Education on trigger avoidance and proper inhaler technique is crucial

Q4: What are the indications for chest imaging in a wheezing child?

A: Indications for chest imaging include:

• Suspicion of foreign body aspiration
• Focal or asymmetrical findings on auscultation
• Failure to respond to standard therapy
• Severe or life-threatening presentation
• Suspected pneumonia or other complications
• Recurrent wheezing episodes without clear etiology
• Evaluation of congenital anomalies or chronic lung disease

Note that routine chest X-rays are not recommended for typical presentations of asthma or viral bronchiolitis.

Q5: Describe the approach to a child with recurrent wheezing who is not responding to standard asthma therapy.

A: The approach should include:

1. Reassess the diagnosis:
   • Consider alternative diagnoses (e.g., cystic fibrosis, primary ciliary dyskinesia, anatomical abnormalities)
   • Evaluate for comorbidities (e.g., GERD, allergic rhinitis, obesity)
2. Review medication adherence and inhaler technique
3. Identify and address environmental triggers (allergens, irritants)
4. Consider further investigations:
   • Pulmonary function tests (in children old enough to perform them)
   • Allergy testing
   • Sweat chloride test (for cystic fibrosis)
   • Chest imaging
   • Bronchoscopy in select cases
5. Optimize treatment:
   • Step up asthma therapy as per guidelines
   • Consider add-on therapies (e.g., leukotriene receptor antagonists, long-acting beta-agonists)
   • In severe cases, consider biologics (e.g., omalizumab, mepolizumab)
6. Refer to a pediatric pulmonologist or allergist for specialized management

Q6: What are the key components of a comprehensive asthma action plan for a child?

A: A comprehensive asthma action plan should include:

• Personal details and emergency contacts
• Names and doses of daily controller medications
• Identification of asthma triggers and how to avoid them
• Description of symptoms or peak flow measurements for different zones:
  • Green zone (doing well)
  • Yellow zone (getting worse)
  • Red zone (medical alert)
• Specific instructions for each zone, including:
  • Which medications to take and when
  • When to seek medical attention
  • Emergency contact numbers
• Instructions for using a spacer device with inhalers
• A schedule for follow-up appointments
• Guidance on when to adjust treatment (e.g., during viral infections)

Q7: How does the approach to managing exercise-induced bronchoconstriction differ from other forms of asthma in children?

A: Management of exercise-induced bronchoconstriction (EIB) differs in several ways:

• Pre-exercise treatment:
  • Short-acting beta-agonists (e.g., albuterol) 15-20 minutes before exercise
  • Leukotriene receptor antagonists may be used daily in some cases
• Non-pharmacological approaches:
  • Proper warm-up exercises
  • Breathing through the nose to warm and humidify air
  • Using a face mask in cold weather
• Focus on allowing and encouraging regular physical activity, rather than restriction
• Education on the difference between normal breathlessness during exercise and asthma symptoms
• Consideration of alternative diagnoses if symptoms persist despite treatment (e.g., vocal cord dysfunction)

Q8: What are the potential long-term consequences of poorly controlled chronic wheezing in children?

A: Potential long-term consequences include:

• Airway remodeling, leading to fixed airflow obstruction
• Impaired lung growth and reduced lung function in adulthood
• Increased risk of COPD in adulthood
• Chronic respiratory symptoms persisting into adulthood
• Reduced quality of life and limitations in physical activities
• Increased healthcare utilization and costs
• Educational and occupational limitations due to frequent absences
• Psychological impacts (e.g., anxiety, depression)
• Sleep disturbances and associated cognitive impacts

Q9: How do you assess the severity of an acute asthma exacerbation in a child?

A: Severity assessment involves evaluating:

1. Clinical signs:
   • Work of breathing (retractions, nasal flaring)
   • Ability to speak in full sentences
   • Mental status (agitation, drowsiness)
   • Auscultation findings (degree of wheezing, air entry)
2. Vital signs:
   • Respiratory rate (compared to age-appropriate norms)
   • Heart rate
   • Oxygen saturation
3. Peak expiratory flow rate (in children old enough to perform)
4. Response to initial bronchodilator therapy

Severity is typically classified as mild, moderate, or severe based on these parameters. Life-threatening features include cyanosis, silent chest, poor respiratory effort, altered consciousness, and hypoxemia despite oxygen therapy.

Q10: What are the key differences between viral-induced wheezing and atopic asthma in preschool children?

A: Key differences include:

Feature	Viral-Induced Wheezing	Atopic Asthma
Trigger	Primarily viral infections	Multiple triggers (viruses, allergens, exercise)
Pattern	Episodic, often seasonal	Can be persistent or episodic
Family history	Less likely	Often positive for atopy or asthma
Associated conditions	Fewer atopic conditions	Often has eczema, allergic rhinitis
Response to treatment	Variable response to bronchodilators	Usually good response to bronchodilators
Long-term prognosis	Often outgrow by school age	More likely to persist
Maintenance therapy	Often not required	Often benefits from daily inhaled corticosteroids

Q11: What are the indications for initiating controller therapy in a child with recurrent wheezing?

A: Indications for initiating controller therapy include:

• Symptoms or need for reliever therapy more than twice per week
• Any night waking due to asthma symptoms
• Any exacerbation requiring oral corticosteroids in the past year
• More than 3-4 wheezing episodes per year
• Wheezing episodes that are severe or require emergency department visits
• Presence of risk factors for persistent asthma (e.g., atopic dermatitis, parental asthma)
• Impairment of normal activities due to asthma symptoms

The decision should be individualized based on the pattern and severity of symptoms, risk factors, and response to initial treatment.

Q12: How do you distinguish between asthma and vocal cord dysfunction in an adolescent with exercise-induced respiratory symptoms?

A: Distinguishing features include:

• Asthma:
  • Expiratory wheezing
  • Responds to bronchodilators
  • Symptoms often persist after exercise
  • Associated with other triggers (allergens, cold air)
  • Abnormal spirometry with bronchodilator reversibility
• Vocal Cord Dysfunction (VCD):
  • Inspiratory stridor
  • No response to bronchodilators
  • Symptoms often resolve quickly after exercise cessation
  • May be associated with psychological stressors
  • Normal spirometry or inspiratory flow limitation
  • Diagnosis confirmed by laryngoscopy during symptoms

Note that VCD and asthma can coexist, complicating the clinical picture.

Q13: What are the key considerations when prescribing inhaled corticosteroids for a child with asthma?

A: Key considerations include:

• Age-appropriate dosing and delivery device
• Balancing efficacy with potential side effects
• Choice of molecule (e.g., fluticasone, budesonide) based on potency and safety profile
• Frequency of dosing (once vs. twice daily)
• Use of spacer devices with metered-dose inhalers
• Proper technique and adherence education
• Monitoring for local side effects (oral thrush, dysphonia)
• Growth monitoring, especially in prepubertal children
• Consideration of combination therapy with long-acting beta-agonists in older children if needed
• Regular review and step-down when possible

Q14: How does the approach to managing acute wheezing differ in a child with a history of prematurity and bronchopulmonary dysplasia?

A: The approach differs in several ways:

• Higher risk of severe exacerbations and complications
• Lower threshold for hospital admission
• May require higher oxygen flow rates or earlier escalation to non-invasive ventilation
• More cautious use of beta-agonists due to potential for oxygen desaturation
• Consider early use of systemic corticosteroids
• Higher suspicion for concurrent bacterial infections
• May benefit from inhaled corticosteroids even for viral-induced wheezing
• Importance of optimizing nutrition and hydration
• Consider RSV prophylaxis in appropriate seasons
• Close follow-up and multi-disciplinary care involving neonatologists and pulmonologists

Q15: What are the potential adverse effects of long-term oral corticosteroid use in children with severe asthma, and how can they be mitigated?

A: Potential adverse effects and mitigation strategies:

Adverse Effect	Mitigation Strategy
Growth suppression	Use lowest effective dose, alternate-day dosing if possible
Adrenal suppression	Gradual tapering, stress dosing during illness
Osteoporosis	Calcium and vitamin D supplementation, weight-bearing exercise
Increased infection risk	Vaccination, prompt treatment of infections
Cushingoid features	Minimize duration of therapy, consider steroid-sparing agents
Hyperglycemia	Blood glucose monitoring, dietary modifications
Hypertension	Regular blood pressure monitoring, sodium restriction
Cataracts	Regular ophthalmological examinations
Mood changes	Psychological support, consider timing of doses

Additionally, explore steroid-sparing strategies such as biological therapies (e.g., omalizumab, mepolizumab) in severe cases.