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1. Wheezing is a high-pitched whistling sound made

while breathing, usually during expiration
2. Prolonged expiratory phase by the rapid passage
of air through airways that are narrowed
3. Polyphonic in widespread narrowing of airways
4. Monophonic in larger airway obstruction like
broncho or tracheo malacia
5. Factors: Bronchospasm, mucosal edema and
secretions
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• Smaller airway caliber
• More compliant chest wall (less rigid as compared
to adults)
• Airways collapse during expiration
• Less stiffness of tracheal cartilage
• Increased smooth muscle tone
• More lymphocytes in respiratory mucosa and more
inflammatory mediators
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1. Medium or high pitched inspiratory sound
associated with laryngeal or extrathoracic
tracheal obstruction

2. Commonest causes are:

1. Croup,

2. Foreign body

3. Laryngomalacia
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1. Wheeze from birth:
1. Congenital Tracheo bronchomalacia
2. Congenital Bronchial stenosis
3. Vascular rings
4. CHD with Lt to Rt shunt
2. Isolated episode: Bronchiolitis
3. Persistent wheeze from 1 year: Cystic fibrosis
4. Recurrent wheeze: Asthma
5. Sudden onset of severe wheeze in a healthy
child: Foreign body
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1. Transient early wheezers: 20%; wheeze during LRI
before 3 years; no recurrence
2. Persistent wheezers: 13.7%; wheeze starts before
3 years; recurrent episodes even after 6 years
3. Late onset wheezers: 15%; first episode after 6
years
4. Rest never wheezed by 6 years

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1. Rare
2. Focal bronchomalacia
3. Persistant wheeze from early chilhood
4. persistent dyspnoea and cyanosis after birth
5. Stenting or surgery

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• Male : female = 2 : 1
• Insufficient cartilage
• Dynamic collapse; >50
reduction of tracheal diameter
during expiration
• Low pitched monophonic
wheeze
• Good prognosis
• Associated anomalies: TEF
• Improves over 3 yrs of age
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1. Types:
1. Double aortic arc
2. Right aortic arch with ligamentum arteriosum
3. Aberrant innominate artery
4. Anomalous left pulmonary artery
2. Clinical:
1. Compression of trachea and esophagus
2. Wheeze from childhood;
3. Aggravated by crying, feeding and neck flexion
4. Diagnosis by barium swallow
5. Surgical correction
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Double aortic arch Rt aortic arch Aberrant lt pul artery

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 Cardiomegaly

 Left atrial enlargement,

 Dilated pulmonary artery

 Pulmonary edema

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• Sudden onset
• h/o chocking
• Chronic cough
• Persistent wheezing – localized to one side
• Recurrent pneumonia
• CXR: pendulum sign in fluroscopy
• Treatment: Bronchoscopy

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• A viral disease of infancy
• Respiratory syncytial virus 50%
• Adenovirus, parainfluenza virus etc less
common
• No bacterial etiology;
• Secondary bacterial infection uncommon
• More in male
• Less in breastfed
• Transmitted by less symptomatic adults

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• Minor bronchiolar inflammation
• Air trapping; hyperinflation
• Hypoxemia
• Hypercapnea

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 Starts as mild ARI
 Gradually respiratory distress sets in
 Chest in drawing
 Ascultatory signs: Wheeze; crackles;
prolonged expiration;
 Respiratory sound inaudible in severe
obstruction
 Reduced O saturation in pulse oxymetry
 Concurrent bacterial complications
uncommon

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 Hyperinflated lung

 Atrophic thymus

 Bowing of cardiac
shadow

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 Salbutmol nebulization: .25 ml in 2.5 NaCl ½ to full
dose depending on weight ; repeat 2-3 times at ½
hourly interwals
 Nebulized epinephrine
 Cool humidified oxygen
 In severe distress tube or iv feeding
 Clear nasal secretions
 Steroids and antibiotics not useful

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 1% fatality

 Recovery over 7-15 days

 60 % stop wheezing

 Rest may go in for recurrent wheeze

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• Viral origin;
• Bacterial infection may supervene
• More in winter
• Fever malaise
• Purulent sputum
• Minimal wheeze
• Severe wheeze is termed asthmatic bronchitis
• Severe cough
• Recovery over 1-2 weeks
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• Inherited multisystem disorder

• Pulmonary and gastrointestinal manifestations

• Dysfunction of epithelial surface

• Chloride is not secreted and hence water not transported;

mucous secretions are thick and tenacious ; obstruct air
ways

• Chloride is not reabsorbed from sweat

• Similar pathology in liver, pancreas etc

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• Autosomal recessive
• More common in white population
• Meconium ileus at birth
• Persistent wheeze from 1 year
• Seat chloride greater than 60 mmol/L
• Aerosol antibiotics and bronchodilators

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• Chronic inflammatory airway disease

• Airway hyper responsiveness to provocative

exposures

• Gene cluster on chromosome 5

• Incidence: Boys 14%; Girls 10%; poor 16%

• 80% get asthma before 6 years

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 Genetic

environ
mental
biologic

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Genetic:
• Multifacorial inheritance
• Proallergic and proinflammatory gene
clusters on chromosome 5
Biologic:
• Younger age
• Developing lung
• Altered airway responsiveness
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• Exposure to tobacco smoke: mother or
father
• Viral infections in early childhood
• Dust mites, animal dander, cockroaches
and some molds
• Food rarely provoke allergy
• Exercise induced asthma
• Aspirin induced asthma less common
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• Psychological exacerbation possible
• High levels of cat allergens found to prevent
asthma by inducing Ig.G
• Indoor and home allergens Cold air, ozone
and strong odor produce bronchospasm but
not inflammation

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• Acute asthma: triggered by viral infection only
• Chronic asthma: due to allergy; persists to
adulthood
• Obese girl with early onset puberty developing
asthma- produce inflammatory mediators from
adipose tissue plus reduced pulmonary
compliance

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• Shedding of epithelium
• Mucosal edema and hypertrophy
• Mucus plugs
• Cellular infiltration
• Hypertrophy of bronchial musculature
• Increased goblet cells

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• Expiratory wheeze
• Intermittent cough
• Shortness of breath
• Chest tightness
• Chest pain
• Nocturnal aggravation
• Inaudible breath sounds or wheeze in severe
cases

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• Sinusitis
• Gastroesophegeal reflex
• Tracheobronchomalacia
• Foreign body aspiration
• Tuberculosis
• Cystic fibrosis
• Ciliary dyskinesia
• Meditational mass
• Cardiomegaly
• CCF
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• Peek flow meter:
• FEV1 recorded by 3 attempts ;
highest taken
• 220 L/sec normal for child
• 80-50% yellow signal
• < 50% red signal
• Bronchodilator response:
>12% or 200L/sec is diagnostic
• Bronchial challenge test:
• methacholine , cold air, or
exercise
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• Hyperinflation of lung

• Tubular heart

• Flattening of diaphram

• Peribronchial thickening

• Bird’s wing sign

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• Step 4: severe:
• High dose inhaled corticosteroid, 1000μg/day
• B2 agonist inhalation
• + or - Oral prednisolone 2mg/kg
• Step 3: moderate
• Medium dose inhaled corticosteroid, 500μg/day
• B2 agonist inhalation
• Step 2: mild
• Low dose inhaled corticosteroid, 300 μg/day
• Bronchodilators - sos
• Step 1: mild intermittent:
• B2 agonist inhalation or oral preparations
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Stepwise Approach for Managing Asthma
in Children 12 Years of Age and Adults
1. In an acute asthma exacerbation, inhaled beta2
agonists are a mainstay of treatment
2. Administration via a metered-dose inhaler with a
spacer device is equally as effective as nebulized
therapy
3. There is no evidence to support the use of oral or
intravenous beta2 agonists in the treatment of acute
asthma
4. high-dose nebulized beta2 agonists six puffs for a
35-kg child administered every 20 minutes for six
doses may be more effective two puffs for a 35-kg
child in treating severe acute asthma
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5. Inhaled ipratropium bromide to beta2 agonist is
more effective than the beta2 agonist alone
6. Oral corticosteroids given early during an acute
asthma exacerbation (i.e., within 45 minutes of the
onset of symptoms) reduce hospital
7. Theophylline is not widely used in the treatment of
childhood asthma
8. Optimizing the dosage of inhaled corticosteroids
provides better control of asthma than oral
montelukast

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9. Salmeterol (Serevent) produces improved lung
function in children, but there is conflicting evidence
about whether it is uperior to short-acting beta2
agonists
10. Immunotherapy can be used as an adjunct to
standard drug therapy in allergic asthmatic children
11. there were 17 standard immunotherapy-related
deaths reported in the United States.
12. Metered-dose inhaler delivery is as effective as
nebulizer delivery

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1. Omalizumab is a recombinant DNA-derived
humanized IgG monoclonal antibody that binds
to IgE and inhibits mast cell release of allergic
mediators
2. Sublingual immunotherapy (SLIT): Dendritic cells
in the oral mucosa act as antigen presenting cells
to T-cells in the cervical lymph nodes. This
system modulates the allergic response by
creating immune tolerance to antigens
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Signs and symptoms Presumptive diagnosis
Associated with feeding, Gastroesophageal reflux
cough, and vomiting Disease
Associated with positional Tracheomalacia;
changes anomalies of the great
vessels
Episodic pattern, cough; Asthma
patient responds to
bronchodilators 43
Exacerbated by neck flexion; Vascular ring
relieved by neck
hyperextension
Heart murmurs or Cardiac disease
cardiomegaly,
History of multiple respiratory Cystic fibrosis or
illnesses; failure to thrive immunodeficiency

Seasonal pattern, nasal Bronchiolitis (RSV),

flaring, intercostal retractions croup, allergies

Sudden onset of wheezing Foreign body 44