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CHICAGO – , explained Erik Hysinger, MD, MS, of the division of pulmonary medicine at Cincinnati Children’s Hospital.
Localized wheezing is not consistent with asthmatic or viral wheezing, which is typically diffuse and polyphonic, Dr. Hysinger emphasized at the annual meeting of the American Academy of Pediatrics.
“Localized wheezing is less common than diffuse wheezing and typically has a homophonous sound,” Dr. Hysinger said. It also usually arises from a central airway pathology. “High flow rates create loud amplitude sounds.”
Dr. Hysinger also covered management strategies for focal wheezing, starting with an initial trial of bronchodilators. Any wheezing resulting from a central airway problem, however, isn’t likely to respond to bronchodilators. Standard work-up for any of these causes is usually a chest x-ray, often paired with a bronchoscopy. Persistent wheezing likely needs a chest CT, and many of these conditions will require referral to a subspecialist.
Airway occlusion diagnoses
Four potential causes of an airway blockage are a foreign body, a bronchial cast, mucous plugs, or airway tumors.
A foreign body typically occurs with a cough, wheezing, stridor, and respiratory distress. It is most common in children under age 4 years, usually in those without a history of aspiration, yet providers initially misdiagnose more than 20% of patients with a foreign body. The foreign object – often coins, food, or batteries – frequently ends up in the right main bronchus and may go undetected up to a month, potentially leading to pneumonia, abscess, atelectasis, bronchiectasis, or airway erosion.
An endobronchial cast is rarer than a foreign body, but can be large enough to completely fill a lung with branching mucin, fibrin, and inflammatory cells. The wheezing sounds homophonous, with a barky or brassy cough accompanied by atelectasis. Dr. Hysinger recommended ordering chest x-ray, echocardiogram, and bronchoscopy. Although often idiopathic, these casts also can result from asthma or another disease: neutrophilic inflammation typically indicates a heart condition whereas asthma or influenza leads to eosinophilic inflammation.
Treatment should involve clearing the airway, followed by hypertonic saline, an inhaled tissue plasminogen activator, and a bronchoscopy for extraction.
Although distinct from endobronchial casts, a mucus plug also presents with wheezing, a cough, and atelectasis, and potentially respiratory distress or failure, and hypoxemia. Mucus plugs are diagnosed with a chest x-ray and flexible bronchoscopy, and then treated by removing the plug and clearing the airway, hypertonic saline, and mucolytics.
The rarest cause of an airway blockage is an airway tumor, often mistaken for asthma. Benign causes include papillomatosis, hemangioma, and hamartomas, while potentially malignant causes include a carcinoid, mucoepidermoid carcinoma, inflammatory myofibromas, and granular cell tumors.
In addition to a chest x-ray and bronchoscopy, a chest CT scan plus a biopsy and resection are necessary to diagnose airway tumors. Treatment will depend on the specific type of tumor identified.
“Overall survival is excellent,” Dr. Hysinger said of children with airway tumors.
Airway narrowing diagnoses
Two possible diagnoses for an intrinsic airway narrowing include bronchomalacia, occurring in only 1 of 2,100 children, and bronchial stenosis.
In bronchomalacia – diagnosed primarily with bronchoscopy – the airway collapses from weakening of the cartilage and posterior membrane. Bronchomalacia sounds like homophonous wheezing with a barky or brassy cough, and it’s frequently accompanied by recurrent bronchitis and/or pneumonia. Intervention is rarely necessary when occurring on its own, but severe cases may require endobronchial stents. Dr. Hysinger also recommended considering ipratroprium instead of albuterol.
Bronchial stenosis involves a fixed narrowing of the bronchi and can be congenital – typically occurring with heart disease – or acquired after an intubation and suction trauma or bronchiolitis obliterans (“popcorn lung”). A chest x-ray and bronchoscopy again are standard, but MRI may be necessary as well. Aside from helping the patient clear the airway, bronchial stenosis typically needs limited management unless the patient is symptomatic. In that case, options include balloon dilation, endobronchial stents, or a slide bronchoplasty.
Airway compression diagnoses
An extrinsic airway compression could have a vascular cause or could result from pressure by an extrinsic mass or the axial skeleton.
Vascular compression usually occurs due to abnormal vasculature development, particularly with vascular stents, Dr. Hysinger said. The wheezing presents with stridor, feeding intolerance, recurrent infections, and cyanotic episodes. The work-up should include a chest x-ray, bronchoscopy, and a chest CT and/or MRI. A variety of interventions may be necessary to treat it, including an aortopexy, pulmonary artery trunk–pexy, arterioplasty, vessel implantation, or endobronchial stent. Residual malacia may remain after treatment, however.
The most common reasons for airway compression by some kind of mass is a reactive lymphadenopathy, a tumor, or an infection, including tuberculosis or histoplasmosis. Severe narrowing of the airway can lead to respiratory failure, but because the compression can develop slowly, the wheezing can be mistaken for asthma. In addition to a chest CT and bronchoscopy, a patient will need other work-ups depending on the cause. Possibilities include a biopsy, a gastric aspirate (for tuberculosis), a bronchoalveolar lavage, or antibody titers.
Similarly, because therapeutic intervention requires treating the underlying infection, specific treatments will vary. Tumors typically will need resection, chemotherapy, and/or radiation – and, until the airway is fully cleared, the patient may need chronic mechanical ventilation.
Children with severe scoliosis or kyphosis are those most likely to experience airway compression resulting from pressure by the axial skeleton, in which the spine’s curvature directly presses on the airway. In addition to the wheeze, these patients may have respiratory distress or recurrent focal pneumonia, Dr. Hysinger said. The standard work-up involves a chest x-ray, chest CT, spinal MRI, and bronchoscopy.
Consider using spinal rods, but they can both help the condition or potentially exacerbate the compression, Dr. Hysinger said. Either way, children also will need help with airway clearance and coughing.
Dr. Hysinger concluded by reviewing what you may consider changing in your current practice, including the initial trial of bronchodilators, a chest x-ray, and a subspecialist referral.
No funding was used for this presentation, and Dr. Hysinger reported having no relevant financial disclosures.
CHICAGO – , explained Erik Hysinger, MD, MS, of the division of pulmonary medicine at Cincinnati Children’s Hospital.
Localized wheezing is not consistent with asthmatic or viral wheezing, which is typically diffuse and polyphonic, Dr. Hysinger emphasized at the annual meeting of the American Academy of Pediatrics.
“Localized wheezing is less common than diffuse wheezing and typically has a homophonous sound,” Dr. Hysinger said. It also usually arises from a central airway pathology. “High flow rates create loud amplitude sounds.”
Dr. Hysinger also covered management strategies for focal wheezing, starting with an initial trial of bronchodilators. Any wheezing resulting from a central airway problem, however, isn’t likely to respond to bronchodilators. Standard work-up for any of these causes is usually a chest x-ray, often paired with a bronchoscopy. Persistent wheezing likely needs a chest CT, and many of these conditions will require referral to a subspecialist.
Airway occlusion diagnoses
Four potential causes of an airway blockage are a foreign body, a bronchial cast, mucous plugs, or airway tumors.
A foreign body typically occurs with a cough, wheezing, stridor, and respiratory distress. It is most common in children under age 4 years, usually in those without a history of aspiration, yet providers initially misdiagnose more than 20% of patients with a foreign body. The foreign object – often coins, food, or batteries – frequently ends up in the right main bronchus and may go undetected up to a month, potentially leading to pneumonia, abscess, atelectasis, bronchiectasis, or airway erosion.
An endobronchial cast is rarer than a foreign body, but can be large enough to completely fill a lung with branching mucin, fibrin, and inflammatory cells. The wheezing sounds homophonous, with a barky or brassy cough accompanied by atelectasis. Dr. Hysinger recommended ordering chest x-ray, echocardiogram, and bronchoscopy. Although often idiopathic, these casts also can result from asthma or another disease: neutrophilic inflammation typically indicates a heart condition whereas asthma or influenza leads to eosinophilic inflammation.
Treatment should involve clearing the airway, followed by hypertonic saline, an inhaled tissue plasminogen activator, and a bronchoscopy for extraction.
Although distinct from endobronchial casts, a mucus plug also presents with wheezing, a cough, and atelectasis, and potentially respiratory distress or failure, and hypoxemia. Mucus plugs are diagnosed with a chest x-ray and flexible bronchoscopy, and then treated by removing the plug and clearing the airway, hypertonic saline, and mucolytics.
The rarest cause of an airway blockage is an airway tumor, often mistaken for asthma. Benign causes include papillomatosis, hemangioma, and hamartomas, while potentially malignant causes include a carcinoid, mucoepidermoid carcinoma, inflammatory myofibromas, and granular cell tumors.
In addition to a chest x-ray and bronchoscopy, a chest CT scan plus a biopsy and resection are necessary to diagnose airway tumors. Treatment will depend on the specific type of tumor identified.
“Overall survival is excellent,” Dr. Hysinger said of children with airway tumors.
Airway narrowing diagnoses
Two possible diagnoses for an intrinsic airway narrowing include bronchomalacia, occurring in only 1 of 2,100 children, and bronchial stenosis.
In bronchomalacia – diagnosed primarily with bronchoscopy – the airway collapses from weakening of the cartilage and posterior membrane. Bronchomalacia sounds like homophonous wheezing with a barky or brassy cough, and it’s frequently accompanied by recurrent bronchitis and/or pneumonia. Intervention is rarely necessary when occurring on its own, but severe cases may require endobronchial stents. Dr. Hysinger also recommended considering ipratroprium instead of albuterol.
Bronchial stenosis involves a fixed narrowing of the bronchi and can be congenital – typically occurring with heart disease – or acquired after an intubation and suction trauma or bronchiolitis obliterans (“popcorn lung”). A chest x-ray and bronchoscopy again are standard, but MRI may be necessary as well. Aside from helping the patient clear the airway, bronchial stenosis typically needs limited management unless the patient is symptomatic. In that case, options include balloon dilation, endobronchial stents, or a slide bronchoplasty.
Airway compression diagnoses
An extrinsic airway compression could have a vascular cause or could result from pressure by an extrinsic mass or the axial skeleton.
Vascular compression usually occurs due to abnormal vasculature development, particularly with vascular stents, Dr. Hysinger said. The wheezing presents with stridor, feeding intolerance, recurrent infections, and cyanotic episodes. The work-up should include a chest x-ray, bronchoscopy, and a chest CT and/or MRI. A variety of interventions may be necessary to treat it, including an aortopexy, pulmonary artery trunk–pexy, arterioplasty, vessel implantation, or endobronchial stent. Residual malacia may remain after treatment, however.
The most common reasons for airway compression by some kind of mass is a reactive lymphadenopathy, a tumor, or an infection, including tuberculosis or histoplasmosis. Severe narrowing of the airway can lead to respiratory failure, but because the compression can develop slowly, the wheezing can be mistaken for asthma. In addition to a chest CT and bronchoscopy, a patient will need other work-ups depending on the cause. Possibilities include a biopsy, a gastric aspirate (for tuberculosis), a bronchoalveolar lavage, or antibody titers.
Similarly, because therapeutic intervention requires treating the underlying infection, specific treatments will vary. Tumors typically will need resection, chemotherapy, and/or radiation – and, until the airway is fully cleared, the patient may need chronic mechanical ventilation.
Children with severe scoliosis or kyphosis are those most likely to experience airway compression resulting from pressure by the axial skeleton, in which the spine’s curvature directly presses on the airway. In addition to the wheeze, these patients may have respiratory distress or recurrent focal pneumonia, Dr. Hysinger said. The standard work-up involves a chest x-ray, chest CT, spinal MRI, and bronchoscopy.
Consider using spinal rods, but they can both help the condition or potentially exacerbate the compression, Dr. Hysinger said. Either way, children also will need help with airway clearance and coughing.
Dr. Hysinger concluded by reviewing what you may consider changing in your current practice, including the initial trial of bronchodilators, a chest x-ray, and a subspecialist referral.
No funding was used for this presentation, and Dr. Hysinger reported having no relevant financial disclosures.
CHICAGO – , explained Erik Hysinger, MD, MS, of the division of pulmonary medicine at Cincinnati Children’s Hospital.
Localized wheezing is not consistent with asthmatic or viral wheezing, which is typically diffuse and polyphonic, Dr. Hysinger emphasized at the annual meeting of the American Academy of Pediatrics.
“Localized wheezing is less common than diffuse wheezing and typically has a homophonous sound,” Dr. Hysinger said. It also usually arises from a central airway pathology. “High flow rates create loud amplitude sounds.”
Dr. Hysinger also covered management strategies for focal wheezing, starting with an initial trial of bronchodilators. Any wheezing resulting from a central airway problem, however, isn’t likely to respond to bronchodilators. Standard work-up for any of these causes is usually a chest x-ray, often paired with a bronchoscopy. Persistent wheezing likely needs a chest CT, and many of these conditions will require referral to a subspecialist.
Airway occlusion diagnoses
Four potential causes of an airway blockage are a foreign body, a bronchial cast, mucous plugs, or airway tumors.
A foreign body typically occurs with a cough, wheezing, stridor, and respiratory distress. It is most common in children under age 4 years, usually in those without a history of aspiration, yet providers initially misdiagnose more than 20% of patients with a foreign body. The foreign object – often coins, food, or batteries – frequently ends up in the right main bronchus and may go undetected up to a month, potentially leading to pneumonia, abscess, atelectasis, bronchiectasis, or airway erosion.
An endobronchial cast is rarer than a foreign body, but can be large enough to completely fill a lung with branching mucin, fibrin, and inflammatory cells. The wheezing sounds homophonous, with a barky or brassy cough accompanied by atelectasis. Dr. Hysinger recommended ordering chest x-ray, echocardiogram, and bronchoscopy. Although often idiopathic, these casts also can result from asthma or another disease: neutrophilic inflammation typically indicates a heart condition whereas asthma or influenza leads to eosinophilic inflammation.
Treatment should involve clearing the airway, followed by hypertonic saline, an inhaled tissue plasminogen activator, and a bronchoscopy for extraction.
Although distinct from endobronchial casts, a mucus plug also presents with wheezing, a cough, and atelectasis, and potentially respiratory distress or failure, and hypoxemia. Mucus plugs are diagnosed with a chest x-ray and flexible bronchoscopy, and then treated by removing the plug and clearing the airway, hypertonic saline, and mucolytics.
The rarest cause of an airway blockage is an airway tumor, often mistaken for asthma. Benign causes include papillomatosis, hemangioma, and hamartomas, while potentially malignant causes include a carcinoid, mucoepidermoid carcinoma, inflammatory myofibromas, and granular cell tumors.
In addition to a chest x-ray and bronchoscopy, a chest CT scan plus a biopsy and resection are necessary to diagnose airway tumors. Treatment will depend on the specific type of tumor identified.
“Overall survival is excellent,” Dr. Hysinger said of children with airway tumors.
Airway narrowing diagnoses
Two possible diagnoses for an intrinsic airway narrowing include bronchomalacia, occurring in only 1 of 2,100 children, and bronchial stenosis.
In bronchomalacia – diagnosed primarily with bronchoscopy – the airway collapses from weakening of the cartilage and posterior membrane. Bronchomalacia sounds like homophonous wheezing with a barky or brassy cough, and it’s frequently accompanied by recurrent bronchitis and/or pneumonia. Intervention is rarely necessary when occurring on its own, but severe cases may require endobronchial stents. Dr. Hysinger also recommended considering ipratroprium instead of albuterol.
Bronchial stenosis involves a fixed narrowing of the bronchi and can be congenital – typically occurring with heart disease – or acquired after an intubation and suction trauma or bronchiolitis obliterans (“popcorn lung”). A chest x-ray and bronchoscopy again are standard, but MRI may be necessary as well. Aside from helping the patient clear the airway, bronchial stenosis typically needs limited management unless the patient is symptomatic. In that case, options include balloon dilation, endobronchial stents, or a slide bronchoplasty.
Airway compression diagnoses
An extrinsic airway compression could have a vascular cause or could result from pressure by an extrinsic mass or the axial skeleton.
Vascular compression usually occurs due to abnormal vasculature development, particularly with vascular stents, Dr. Hysinger said. The wheezing presents with stridor, feeding intolerance, recurrent infections, and cyanotic episodes. The work-up should include a chest x-ray, bronchoscopy, and a chest CT and/or MRI. A variety of interventions may be necessary to treat it, including an aortopexy, pulmonary artery trunk–pexy, arterioplasty, vessel implantation, or endobronchial stent. Residual malacia may remain after treatment, however.
The most common reasons for airway compression by some kind of mass is a reactive lymphadenopathy, a tumor, or an infection, including tuberculosis or histoplasmosis. Severe narrowing of the airway can lead to respiratory failure, but because the compression can develop slowly, the wheezing can be mistaken for asthma. In addition to a chest CT and bronchoscopy, a patient will need other work-ups depending on the cause. Possibilities include a biopsy, a gastric aspirate (for tuberculosis), a bronchoalveolar lavage, or antibody titers.
Similarly, because therapeutic intervention requires treating the underlying infection, specific treatments will vary. Tumors typically will need resection, chemotherapy, and/or radiation – and, until the airway is fully cleared, the patient may need chronic mechanical ventilation.
Children with severe scoliosis or kyphosis are those most likely to experience airway compression resulting from pressure by the axial skeleton, in which the spine’s curvature directly presses on the airway. In addition to the wheeze, these patients may have respiratory distress or recurrent focal pneumonia, Dr. Hysinger said. The standard work-up involves a chest x-ray, chest CT, spinal MRI, and bronchoscopy.
Consider using spinal rods, but they can both help the condition or potentially exacerbate the compression, Dr. Hysinger said. Either way, children also will need help with airway clearance and coughing.
Dr. Hysinger concluded by reviewing what you may consider changing in your current practice, including the initial trial of bronchodilators, a chest x-ray, and a subspecialist referral.
No funding was used for this presentation, and Dr. Hysinger reported having no relevant financial disclosures.
EXPERT ANALYSIS FROM AAP 2017