CONDITIONS PRESENTING WITH WHEEZE

A wheeze is a high pitched sound during expiration due to narrowing of the small airways. Infections or allergic reactions can cause narrowing of the airways.

Clinical Features

  • Wheezing sound from the chest
  • Prolonged expiratory phase of respiration
  • Increased effort at expiration
  • Diminished air entry on auscultation
  • Lower chest indrawing
  • Recurrent cough especially at night
  • Hyper-inflated chest
  • Cyanosis in severe cases.
  • When wheezy coughs occur repeatedly, the child is considered to have asthma.

Wheezing may or may not be complicated by pneumonia of bacterial or viral aetiology.

Conditions That Present with Wheeze

  • Bronchiolitis: Child less than 2 years of age. Seasonal outbreaks. Caused by respiratory syncytial virus in most cases. It is not relieved by rapid acting bronchodilators. Secondary bacterial infections are common.
  • Wheeze associated with coughs and colds: Responds to bronchodilators.
  • Foreign body: May have history of choking but may have occurred unnoticed. No response to bronchodilators.
  • Pneumonia: Fever and crepitations in the chest.
  • Asthma: Recurrent wheeze with or without upper or lower respiratory infections. Good response to bronchodilators.

MANAGEMENT

For children with first episode of wheeze:

  • Give a rapid-acting bronchodilator – salbutamol via metered dose inhaler 2 puffs (200μg) with or without a spacer according to age. Spacer can be made using a 1 litre plastic container. If inhaler is not available use nebulizer 2.5ml salbutamol. If neither is available give adrenaline 0.05ml/kg of 1:1,000 solution subcutaneously.
  • Assess response after 15
    minutes. Signs of response are:

    • Less respiratory distress
    • Less lower chest retraction
    • Improved breath sounds
    • Manage according to the cause and severity
  • Bronchiolitis: Classify and treat as for pneumonia under 5 years of age.
  • Wheeze associated with cough or cold: Treat at home.
  • Foreign body: Foreign body with partial airway obstruction will need removal via bronchoscopy.
  • Pneumonia: See sections above on pneumonia.

For a child with asthma (children with recurrent wheezing):

  • First episode and no respiratory distress:
    • Treat at home with inhaler or oral salbutamol
  • Respiratory distress or recurrent wheeze
    • Response to a rapidly-acting bronchodilator is an important part of the assessment of a child with recurrent wheezing to determine whether the child can be managed at home or should be admitted for more intensive treatment.
    • Rapid acting bronchodilator should be given as above and the child’s condition should be assessed 30 minutes later. If respiratory distress has resolved – the child should be treated with inhaler at home. The mother
      should be taught how to use the inhaler. If inhaler is not possible, then oral salbutamol should be used.
    • The Table below presents drugs and dosages for treating a child with wheeze.

Admit the child if still distressed with or without cyanosis and:

  • Give oxygen until cyanosis disappears or oxygen saturation >90%.
  • Give first dose of prednisone 2mg/kg/day continue for 3-5 days. IV hydrocortisone 4mg/kg only if oral prednisone is not possible.
  • Repeat rapid acting bronchodilator (preferably salbutamol inhaler) at hourly intervals for 3 doses.
  • If not improved IV aminophylline 5mg/kg can be given slowly over 20 minutes.
  • Monitor vital signs every 3hrs. Signs of improvement are:
    • Less respiratory distress (easier breathing)
    • Less chest retraction
    • Improved breath sound especially in a previously quiet chest.
    • When the patient stabilizes, discharge child on inhaler or oral salbutamol.

Treatment of child with wheeze

Rapid acting bronchodilator Oral salbutamol 3 times daily for 5 days
Age or weight 2mg tablet 4mg tablet
Subcutaneous epinephrine (adrenaline) (1:1,000 = 0.1%) 0.01ml/kg bodyweight 2–12 mon (10kg) 2 ¼*
Salbutamol inhaler in a spacer 750–1,000ml 2 puffs per dose. 1 dose in 10 min. 12 mon to 5 yrs (10–19kg) 1
Nebulized salbutamol 5mg/ml
  • Under 1 yr 0.5ml salbutamol in 2.0ml sterile water
  • >1 yr 1.0ml salbutamol in 2.0ml sterile water

Note:

  • (a) In all cases use of inhaler is better and cheaper than nebulizer or oral salbutamol.
  • (b) Steroids should be used early. Oral steroids are as effective as parenteral ones.
  • (c) When this is done aminophylline is rarely needed.
  • (d) Fluids should be limited to two thirds of the daily requirement.
  • (e) Antibiotics should be given only if there are clear signs of infection.
  • (f) Adrenaline is only used if use of inhaler is not possible.