MRCP PACES Approaches Approach to Wheeze

Differential diagnosis

  • Lower airway
    • Foreign body
    • Asthma
      • NSAID
      • Aspirin
      • Allergic bronchopulmonary aspergillosis
      • Occupational
    • COPD
      • Alpha 1 antitrypsin deficiency
    • Mediastinal mass
    • Lung cancer
    • Lymphadenopathy
      • Sarcoidosis
    • Bronchitis
    • Churg-Strauss syndrome
    • Anaphylaxis
  • Fluid overload
    • Congestive cardiac failure
    • Liver disease
    • Nephrotic syndrome
  • Carcinoid syndrome
  • Gastro-oesophageal reflux disease
  • Upper airway
    • Thyroid mass
    • Head and neck cancer
    • Laryngeal cancer
    • Epiglottitis
    • Smoke inhalation
    • Tracheobronchomalacia

Relevant points in the history

  • Wheeze
    • What do you mean by wheeze?
    • What were you doing when you noticed it?
    • How old were you when it first happened?
    • What do you think caused it?
    • Were there any other symptoms?
  • Lower airway
    • Asthma and allergic bronchopulmonary aspergillosis
      • Do you have a cough that just won’t go away?
      • Do you bring up any phlegm when you cough?
      • Are your symptoms worse at night?
      • Have you noticed that this breathlessness is brought on by specific triggers?
      • Is the wheeze worse in the cold, after exercise or in dusty environments?
      • Do you notice that your chest feels tight?
      • Have you ever tried an inhaler?
        • What inhalers have you tried?
        • Has the dose or number of puffs changed recently?
        • How do you use the inhaler?
        • Do you take your inhaler every day as prescribed?
      • Do you have eczema?
      • Have you noticed intermittent episodes of a runny nose?
      • Does anyone in the family have eczema, asthma or a runny nose?
      • Do you keep any pets at home?
      • What is your job?
      • Have you taken any medication such as over the counter painkillers or aspirin recently?
    • Chronic obstructive pulmonary disease
      • Do you, or have you ever smoked?
      • Do you find that you are bringing up more phlegm than usual?
      • Do you feel breathless on walking?
    • Churg-Strauss syndrome
      • Have you noticed a rash anywhere on your body?
      • Have you noticed any weakness anywhere?
      • Any tingling in your hands or feet?
      • Have you noticed anything unusual in your urine?
      • Has there ever been any blood in your urine?
    • Neoplastic
      • Do you, or have you ever smoked?
      • Have you lost any weight?
      • Do you feel like you have no appetite?
      • Have you ever coughed up blood?
      • Do you feel breathless?
      • Have you noticed any change in your voice?
      • Have you had any fever?
      • Have you noticed any sweating at night?
    • Anaphylaxis
      • Have your eyes ever gone puffy?
      • Have you noticed any tongue or lip swelling?
      • Have you ever noticed any other sounds when you breathe in?
      • Have you noticed any rashes?
  • Fluid overload
    • Have you noticed any leg swelling?
    • How many pillows do you sleep on at night?
    • Do you ever wake up in the middle of the night feeling breathless?
    • Have you ever noticed any bubbles in your urine?
  • Carcinoid syndrome
    • Have you ever noticed your face going red?
    • Do you have any diarrhoea?
    • Do you have any tummy pain?
  • Gastro-oesophageal reflux disease
    • Have you ever noticed a sour, acid taste in your mouth?
    • Do you get a burning sensation in your chest?
    • Does it get worse on an empty stomach?
    • Is it worse when you lie down?
  • Upper airway
    • Have you had any problems swallowing?
    • Do you notice that your throat appears a bit swollen?
    • Have you had a sore throat or fever recently?

Examination

  • General
    • Comfortable at rest / respiratory distress
    • Cyanosis
    • Sputum pot
    • Tar staining of fingers
    • Barrel chest
    • Rash – vasculitic / urticaria / purpura
  • Lungs
    • Hyper-expanded
    • Listen for wheeze
    • Listen for crepitations (bronchiectasis / fluid overload)
    • Cervical lymphadenopathy
  • Cardiac
    • Right ventricular heave
    • Displaced apex beat
    • Jugular venous pulsation
    • PSM of tricuspid regurgitation (carcinoid syndrome)
    • Peripheral oedema

Investigations

  • Full blood count to look for eosinophilia (ABPA, Churg-Strauss)
  • Serum precipitins to Aspergillus
  • Skin reactivity test to Aspergillus looking for immediate hypersensitivity
  • Chest radiograph to look for any consolidation / cavitary lesions / bronchiectasis / pulmonary oedema
  • Anti-neutrophil cytoplasmic antibody (anti-myeloperoxidase, Churg-Straus)
  • Spirometry
    • Asthma (GINA Guidelines)
      • FEV1/FVC < 0.7
      • FEV1 increases by more than 12% and 200ml post-bronchodilator, or
      • FEV1 increases by more than 12% and 200ml after anti-inflammatory treatment
      • Methacholine challenge if index of suspicion high and initial spirometry normal
    • COPD (GOLD Guidelines)
      • FEV1/FVC < 0.7
      • FEV1 ≥ 80% predicted: mild (GOLD 1)
      • FEV1 50 – 80% predicted: moderate (GOLD 2)
      • FEV1 30 – 50% predicted: severe (GOLD 3)
      • FEV1 <30% predicted: very severe (GOLD 4)
  • Consider high-resolution computed tomography scan to look for central bronchiectasis (ABPA)
  • Consider 24hr 5-hydroxyindolacetic acid (5-HIAA) if history suggestive of carcinoid syndrome
  • Consider ENT referral for larynoscopy, CT neck if all of the above negative

Management

  • Multidisciplinary team approach
  • Patient education: inhaler technique, compliance, standby prednisolone (asthma action plan)
    • Smoking cessation, weight loss programs
    • Trigger avoidance
  • Pulmonary rehabilitation
  • Asthma (increase treatment if symptoms occur > 2x/month)
    • Step 1: inhaled short-acting β2 agonist (salbutamol)
    • Step 2: low-dose inhaled corticosteroid (e.g. budesonide)
    • Step 3: low-dose ICS + long-acting β2 agonist (e.g. fluticasone / salmeterol, Seretide® 125/200 1 BD)
    • Step 4: medium/high-dose ICS + LAMA (e.g. Seretide 250 2 puffs BD, budesonide / formoterol, Symbicort® 400/12 2 puffs BD)
    • Other options for add-on therapy: leukotriene receptor antagonist, theophylline
    • Step 5: consider continuous oral steroids at lowest possible dose
    • Before step 5, consider referral for potential steroid-sparing treatment
      • Omalizumab, anti-IgE monoclonal antibody
  • COPD (GOLD Guidelines)
    • Staging now uses a combination of exacerbation history, airflow limitation and symptoms
      • Symptoms can be gauged using the modified Medical Research Council (mMRC) score
        • Grade 0: breathless with strenuous exercise
        • Grade 1: breathless when hurrying on level ground or walking up slight hill
        • Grade 2: walks slower than people of the same age because of breathlessness
        • Grade 3: breathless before walking 100m
        • Grade 4: unable to leave the house
      • Airflow limitation
        • GOLD 1: FEV1 > 80%
        • GOLD 2: FEV1 50 – 80%
        • GOLD 3: FEV1 30 – 50%
        • GOLD 4: FEV1 < 30%
      • The following table provides a framework for staging COPD
FEV1GOLD StageExacerbations
GOLD 3 and 4CD≥2, or ≥1 leading to hospital admission
GOLD 1 and 2AB1 not requiring admission
Symptoms (mMRC)Grade 0 – 1Grade ≥ 2
  • Inhaled therapy
    • Regular and as-needed use of bronchodilators improve FEV1 and symptoms
    • SABA: salbutamol
    • SAMA: ipratropium
    • SAMA+SABA (bronchodilator effect is additive): Berodual® (ipratropium + fenoterol)
    • ICS+LABA: Seretide® for patients who have exacerbations despite regular SAMA+SABA
    • LAMA: tiotropium for patients who have exacerbations despite regular ICS+LABA
    • Consider theophylline for refractory disease
  • Long-term oxygen therapy (ideally, proved by two separate ABGs three weeks apart)
    • For patients with PaO2 < 55mg Hg or SpO2 < 88% on room air, or
    • Patients with PaO2 < 60mg Hg or SpO2 < 90% on room air and polycythaemia / cor pulmonale
    • Must be used for at least 15 hours per day
    • Greater benefits are seen in patients using LTOT for more than 20 hours per day
  • Churg-Strauss
    • Screen for mononeuritis / polyneuropathy, renal impairment
    • Initiate therapy with glucocorticoids (usually start at 1mg/kg/day of prednisolone)
      • Can usually begin to taper steroids over 12 – 18 months once initial presentation controlled
    • Cyclophosphamide indicated for severe, multi-system disease
    • Other options: azathioprine (first-choice for maintenance), methotrexate, leflunomide
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