Pediatric emergency medicine trisk 1657 1657
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be the predominant presenting clinical feature and wheezing may be absent
despite careful lung auscultation.
FIGURE 84.2 Approach to wheezing in children 1 year or older. URI, upper respiratory
infection.
Physical Examination
Wheezing must be distinguished from other causes of “noisy breathing” in
children, including the stridor of upper airway obstruction (see Chapter 75 Stridor
), the stertor of nasal congestion, and audible rhonchi. Because of the dynamic
flexibility of airway structures, these clinical features of airway obstruction vary
in accordance with the respiratory phase. Accordingly, upper airway collapse and
stridor are typically worse on inspiration, whereas lower airway narrowing and
wheezing are accentuated on expiration. Moreover, sounds originating in the
upper airway passages (e.g., stridor, stertor) are transmitted with uniform quality
and intensity across both lung fields. In contrast, wheezes tend to be polyphonic
in pitch and distributed somewhat unevenly in intensity and location due to
inevitable variation in airway narrowing that occurs. Importantly, wheezes
