2 History Taking of Common Pediatric Cases
2.5 Wheezing
• Wheezing is a continuous musical sound heard mainly during expiration, result-ing from partial obstruction of intrathoracic airways [6].
• Although wheezing is usually heard during expiration, it can be heard in both inspiration and expiration when there is fixed airway obstruction in both intra- and extra-thoracic airways [7].
• The word “wheezing” is frequently used imprecisely by parents to describe other noises. Therefore, the use of video clips may be helpful.
• Viral bronchiolitis and asthma are the most common causes of wheezing in children, so differentiation between these two conditions is mandatory (see Table 2.1) [8].
• Cough associated with fever, chills, night sweats, and weight loss is sugges-tive of tuberculosis or malignancy.
• Cough followed by vomiting is typical of pertussis.
• Cough with dysphonia may suggest laryngeal or glottic pathology.
• A cough that disappears during sleep or that is most remarkable when atten-tion is drawn to it is suggestive of a psychogenic cough, which most com-monly occurs in adolescents [6].
• A cough that occurs during or after eating may suggest aspiration or GER.
Table 2.1 Short case scenarios of common causes of wheezing in children [6, 10–12, 90]
Short case scenarios Diagnosis and special points in
favor A boy, aged 7 years, with a history of atopic dermatitis is
referred to the hospital’s outpatient department because of a long history of recurrent wheezing, breathing difficulty, and cough. He wakes coughing and wheezing in the early morning, 2 or 3 times a week. The symptoms often occur with exercise and sometimes interfere with sleep.
Bronchodilators alleviate the symptoms. According to his mother, he had tended to be wheezy since about 7 months of age. His 4-year-old brother has had eczema since the age of 8 months
Asthma
– A history of recurrent wheeze, breathing difficulty, and cough – Symptoms often occur
with exercise and are improved by bronchodilators.
– There is usually a family history of asthma – There is a strong
association between asthma and other atopic diseases (e.g., eczema, rhinoconjunctivitis, and food allergy)
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Short case scenarios Diagnosis and special points in
favor A 3-month-old infant presents with wheezing associated
with dyspnea, rhinorrhea, sniffles, cough, fast breathing, irritability, poor feeding, and occasional vomiting. The condition deteriorates at night and has been getting worse over the course of 3 days since the onset of symptoms
Bronchiolitis – Common age is
1–9 months; it is uncommon after 1 year – The condition deteriorates
at night and is getting worse over the course of 3–6 days
– Small and premature infants can develop recurrent apnea, which is a serious complication A 6-year-old unwell child presents with a 6-day history of
wheezing, breathing difficulty, fast breathing, cough, chest pain, and fever. In the last day before admission, the condition gets worse. The fever increased and became associated with a rigor as well as brief periods of delirium
Pneumonia
– The child is usually unwell with cough, fast breathing, fever, and chills
– Pleuritic chest pain may be present
– The condition usually develops and deteriorates over days
A 2-year-old previously healthy child presents with a 3-day history of wheezing and severe cough, which does not respond to medication. The symptoms developed after sudden choking
Foreign-body inhalation – Foreign-body inhalation is
common in toddlers – A history of sudden
choking or small-object inhalation may present in a previously healthy child – Symptoms do not respond
to medication Table 2.1 (continued)
• Identity: Age
• Chief complaint(s): Wheezing, noisy breathing, or abnormal breathing sound
• History of present illness:
1. Onset: Sudden (suggests foreign-body aspiration) or gradual (suggests an infection)
2. Duration: What is the duration of wheezing? Is the wheezing a new presenta-tion or recurrent? Is it episodic or persistent?
History Station 2.4: Wheezing
Continued on the next page 2.5 Wheezing
3. Timing: Nocturnal or early morning wheezing or coughing may suggest GER or sensitivity to common bedroom allergens.
4. Progression and severity of the attack: Compare it to the previous episodes.
Does it interfere with the child’s activities? Does it awaken the child from sleep?
5. Was the episode of wheezing preceded by choking or gagging?
6. Aggravating and relieving factors: Exercise (asthma), emotions, specific sea-son, cold air, humidity, respiratory infections, feeding (GER and tracheo-esophageal fistula (TEF)), agitation or crying (tracheomalacia, bronchomalacia, or a fixed intraluminal or extraluminal obstruction), a cer-tain position. Does the wheezing respond to bronchodilators?
7. Triggering factors: Tobacco smoke, strong odors, fumes, chemicals, dust, ani-mal dander, infection, meals, exercise, change in seasons, or change in tem-perature or humidity
8. Associated symptoms: Cough (duration in days), sputum, hemoptysis, fever, chest pain, cyanosis, runny nose, sore throat, inability to communicate
• Past history:
A—Birth history: Prematurity (bronchopulmonary dysplasia), premature rup-ture of membranes during birth, mechanical ventilation, or prolonged supple-mental oxygen after birth
B—Past medical and surgical history: Previous episodes, history of choking, recurrent chest infections, asthma, congenital heart disease, congestive heart failure, cystic fibrosis, immunodeficiency, allergic rhinitis, food allergies, atopy, results of pulmonary function tests, recent surgical procedures, or intubation
– If there are recurrent attacks of wheezing, ask about age of onset of first attack, triggers, frequency and severity of previous episodes, previous hospi-talization, or ICU admissions.
• Medication history: Bronchodilators, home nebulizer use, recent use of medications (e.g., beta-blockers, aspirin, and other nonsteroidal anti-inflam-matory drugs (NSAIDs)), allergies
• Developmental history: Developmental delay, growth retardation
• Immunization history: BCG, DPT, and Hib
• Feeding/dietary history: Poor feeding, feeding difficulty
• Family history: Asthma, wheezing, allergies, hay fever, atopy, and heart disease
• Social history: Smoking, traveling, house pets, or overcrowded house
• Review of systems: Night sweats; allergy; vomiting; difficulty swallowing;
failure to thrive; large, voluminous, foul-smelling, and fatty stools that tend to stick to the toilet (steatorrhea); recurrent/chronic diarrhea; recurrent chest infections
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• The presence of wheeze at birth or early infancy suggests congenital struc-tural abnormalities.
• Recurrent episodes of wheezing, cough, dyspnea, and chest tightness are sug-gestive of asthma.
• In a previously well infant, a new onset of wheezing in combination with symptoms of upper-respiratory tract infection typically points to the diagno-sis of bronchiolitis.
• Recurrent wheezing may imply GER, particularly if exacerbated by feeding.
However, if triggered by upper-respiratory infections, it may point to reactive airways disease.
• Persistent wheezing should lead to a consideration of mechanical obstruc-tion, which may have a number of causes (e.g., airway foreign body, external airway compression, or congenital airway narrowing).
• Recurrent wheezing, especially along with recurrent/chronic diarrhea since early infancy that is difficult to control, should raise the concern for cystic fibrosis. Additional probabilities are primary ciliary dyskinesia, recurrent aspiration, anatomic abnormalities, or immune deficiency.
• Wheezing associated with failure to thrive (in spite of good appetite and suf-ficient dietary consumption), steatorrheic stools, and recurrent infections strongly suggest cystic fibrosis [9].