Wheeze: Clinical Approach and Considerations

🌬️🎵 Wheeze is a high-pitched, whistling sound produced by turbulent airflow through narrowed or obstructed airways. It most commonly occurs during expiration due to dynamic airway collapse, but may be inspiratory or biphasic in severe or upper airway disease. Pathophysiologically, wheeze reflects bronchial smooth-muscle constriction, mucosal oedema, and mucus plugging.

🔍 Causes of Wheeze

• 🌿 Asthma - Chronic inflammatory airway disease with reversible bronchoconstriction and hyperresponsiveness.
• 🚬 COPD - Progressive airflow limitation due to emphysema and chronic bronchitis.
• 👶 Bronchiolitis - Viral small-airway inflammation in infants (classically RSV).
• 🚨 Anaphylaxis - IgE-mediated airway oedema and bronchospasm causing life-threatening obstruction.
• 🧩 Foreign Body Aspiration - Sudden onset unilateral wheeze and respiratory distress, especially in children.
• ❤️ Cardiac Asthma - Pulmonary oedema in left-sided heart failure mimicking asthma.
• 🦠 Respiratory Infections - Bronchitis, pneumonia → airway inflammation and mucus excess.
• 🔥 Gastro-oesophageal Reflux (GORD) - Acid micro-aspiration triggering bronchospasm, common in children.
• 🎤 Vocal Cord Dysfunction - Paradoxical vocal cord closure causing inspiratory “wheeze” (often stridor).
• 🫁 Bronchiectasis - Chronic airway dilation with recurrent infection and mucus retention.

🩺 Clinical Features

• 🎵 High-pitched whistling during breathing
• 😮‍💨 Breathlessness and air hunger
• 📦 Chest tightness
• 🌙 Nocturnal or early-morning cough
• ⏳ Prolonged expiratory phase
• 💪 Accessory muscle use in severe disease
• ⚠️ Fever, purulent sputum, cyanosis depending on cause

🧪 Diagnosis and Assessment

• 📝 History & Examination - Onset, triggers, smoking, atopy, occupational exposure.
• 📊 Spirometry - Obstruction with reversibility (asthma) or fixed obstruction (COPD).
• 📉 Peak Expiratory Flow (PEF) - Monitoring severity and variability in asthma.
• 🩻 Chest X-ray - Infection, collapse, foreign body, heart failure.
• 🩸 Blood Tests - Infection markers, eosinophilia, IgE if indicated.
• 🧬 Allergy Testing - When allergic asthma suspected.
• 🖥️ CT Chest - Chronic/refractory wheeze → assess for bronchiectasis or ILD.

🚑 Initial Management (Acute Wheeze)

• 🫁 Oxygen - Maintain SpO₂ 94–98% (88–92% in CO₂ retainers).
• 💨 Inhaled Bronchodilators - Salbutamol ± ipratropium via spacer/nebuliser.
• 💊 Systemic Corticosteroids - Reduce airway inflammation (asthma/COPD exacerbation).
• 🦠 Antibiotics - If bacterial infection suspected.
• 🧩 Foreign Body Removal - Urgent bronchoscopy if suspected.
• 💉 Adrenaline - Immediate IM injection in anaphylaxis.

📈 Chronic Management

• 🌿 Inhaled Corticosteroids (ICS) - Foundation therapy in asthma.
• ⏱️ LABA + ICS - Step-up therapy for persistent symptoms.
• 🔒 Anticholinergics - Key bronchodilators in COPD.
• 🚭 Trigger Control - Smoking cessation, allergen avoidance, GORD treatment.
• 💉 Vaccination - Influenza and pneumococcal vaccines.
• 📚 Self-Management Plans - Asthma action plans reduce admissions.

🚨 When to Refer

• ⚠️ Life-threatening or refractory wheeze
• 🧩 Suspected foreign body or airway abnormality
• ❓ Unexplained chronic wheeze
• 📉 Frequent exacerbations despite treatment

🧠 Teaching Pearl
Not all “wheeze” is asthma. Sudden unilateral wheeze suggests foreign body, nocturnal wheeze suggests asthma, and wheeze with orthopnoea suggests heart failure. Always localise, time, and contextualise wheeze before escalating therapy.