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I HAVE A PATIENT WITH WHEEZING OR STRIDOR

How do I determine the cause?

CHIEF COMPLAINT

PATIENT image

Mr. C is a 32-year-old man with occasional wheezing.

image What is the differential diagnosis of wheezing? How would you frame the differential?

CONSTRUCTING A DIFFERENTIAL DIAGNOSIS

Wheezing and stridor are symptoms of airflow obstruction caused by the vibration of the walls of pathologically narrow airways. Wheezing is a high-pitch musical sound produced primarily during expiration by airways of any size. Stridor is a single high-pitch, inspiratory sound that is produced by large airways with severe narrowing; it may be caused by severe obstruction of any proximal airway.

image Stridor is often a sign of impending airway obstruction and should be considered an emergency.

Distinguishing between wheezing and stridor is essential. Typically, patients with either wheezing or stridor describe their symptoms simply as wheezing. The physical exam will determine whether the patient actually has wheezing or stridor. Because the differential diagnosis for airway obstruction is extensive, an anatomic approach is helpful.

  1. Stridor

    1. Nasopharynx and oropharynx

      1. Tonsillar hypertrophy

      2. Pharyngitis

      3. Peritonsillar abscess

      4. Retropharyngeal abscess

    2. Laryngopharynx and larynx

      1. Epiglottitis

      2. Paradoxical vocal cord movement (PVCM)

      3. Anaphylaxis and laryngeal edema

      4. Postnasal drip

      5. Benign and malignant tumors of the larynx and upper airway

      6. Vocal cord paralysis

    3. Trachea

      1. Tracheal stenosis

      2. Tracheomalacia

      3. Goiter

    4. Proximal airways

      1. Foreign-body aspiration

      2. Ingestion or inhalation of caustic materials

      3. Burn injury

  2. Wheezing

    1. Proximal airways: Bronchitis

    2. Distal airways

      1. Asthma

      2. Chronic obstructive pulmonary disease (COPD)

      3. Pulmonary edema

      4. Pulmonary embolism

      5. Bronchiectasis

      6. Bronchiolitis

      7. Heart failure

      8. Sarcoidosis

image

Mr. C has been having symptoms for 1–2 years. His symptoms have always been so mild that he has never sought care. Over the last month, he has been more symptomatic with wheezing, chest tightness, and shortness of breath. His symptoms are worse with exercise and worse at night. He notes that he often goes days without symptoms.

image At this point, what is the leading hypothesis, what are the active alternatives, and is there a must not miss diagnosis? Given this differential diagnosis, what tests should be ordered?

RANKING THE DIFFERENTIAL DIAGNOSIS

Figure 33-1 shows an algorithmic approach to the patient with wheezing or stridor. The presence of wheezing, chest tightness, and shortness of breath are pivotal clues that place asthma at the top of the differential diagnosis. Although asthma is by far the most likely diagnosis, other diseases that could account for recurrent symptoms of airway obstruction should be considered (Table 33-1). Allergic rhinitis can cause cough and wheezing, but it would be very unusual for it to cause shortness of breath. Vocal cord dysfunction, such as PVCM, is frequently confused with asthma and can cause recurrent stridor. COPD can also cause chronic wheezing and pulmonary symptoms.

Figure 33-1.

Evaluation of the patient with wheezing or stridor.

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