Wheeze

• Asthma: Recurrent episodes of wheeze, cough, and breathlessness, often with diurnal variation and triggered by allergens, cold air, or exercise.
• Chronic Obstructive Pulmonary Disease (COPD): Persistent wheeze, chronic productive cough, history of smoking, and progressive breathlessness.
• Bronchiectasis: Chronic productive cough with purulent sputum, recurrent infections, possible wheeze.
• Pulmonary Oedema: Bilateral wheeze with fine crackles, particularly at lung bases, associated with heart failure symptoms (e.g., orthopnoea, paroxysmal nocturnal dyspnoea).
• Acute Bronchitis: Wheeze with cough, usually self-limiting, often following a viral upper respiratory infection.
• Allergic Bronchopulmonary Aspergillosis (ABPA): Wheeze with productive cough, eosinophilia, often in patients with asthma or cystic fibrosis.
• Foreign Body Aspiration: Sudden onset of wheeze, particularly in children, with a history of choking.
• Upper Airway Obstruction (e.g., vocal cord dysfunction, tracheal stenosis): Wheeze predominantly during inspiration, often with stridor.
• Pneumonia: Wheeze with cough, fever, purulent sputum, and pleuritic chest pain.
• Lung Cancer: Persistent wheeze, unexplained cough, haemoptysis, weight loss, particularly in smokers or those with occupational exposure.
• Pulmonary Embolism: Wheeze with sudden onset pleuritic chest pain, dyspnoea, possible haemoptysis, risk factors include immobility and thrombophilia.

• Congestive Heart Failure: Wheeze with orthopnoea, paroxysmal nocturnal dyspnoea, peripheral oedema, and raised jugular venous pressure (JVP).
• Cardiac Asthma: Wheezing due to left heart failure, often exacerbated by exertion or lying flat.
• Valvular Heart Disease (e.g., mitral stenosis): Wheeze with signs of heart failure, palpitations, or atrial fibrillation.
• Pericardial Effusion with Tamponade: Wheeze with chest pain, hypotension, muffled heart sounds, and pulsus paradoxus.

• Anaphylaxis: Acute onset wheeze, urticaria, angioedema, hypotension, often with a known allergen exposure.
• Gastroesophageal Reflux Disease (GORD): Wheeze, particularly at night, associated with heartburn, regurgitation, or sour taste in the mouth.
• Medication-Induced Wheeze (e.g., beta-blockers, NSAIDs): New onset wheeze after starting a medication known to cause bronchoconstriction.
• Vocal Cord Dysfunction: Wheeze and dyspnoea, often mistaken for asthma, with normal spirometry but abnormal flow-volume loops.
• Anxiety or Panic Attacks: Wheeze with hyperventilation, chest tightness, palpitations, and no underlying respiratory or cardiac disease.
• Obesity-Related Wheeze: Wheeze due to obesity-related respiratory compromise, often with exertional dyspnoea.
• Hyperventilation Syndrome: Wheeze with rapid, shallow breathing, often associated with anxiety, light-headedness, and tingling in the extremities.

Assess the specific symptoms presented by the patient:

• Onset and Duration: Sudden vs. gradual onset, intermittent vs. persistent wheeze.
• Triggers: Exposure to allergens, exercise, cold air, infections, or medications.
• Associated Symptoms: Cough, breathlessness, chest pain, sputum production, haemoptysis, systemic symptoms (e.g., fever, weight loss).
• Exacerbating and Relieving Factors: Response to bronchodilators, corticosteroids, or positional changes.
• Impact on Daily Life: Any limitations on activities, sleep disturbances, or impact on work and social life.
• Previous Episodes: Any history of similar symptoms, previous diagnoses, or hospital admissions.
• Smoking and Occupational History: Exposure to tobacco smoke, occupational hazards, or environmental pollutants.

Gather a detailed background including:

• Past Medical History: History of asthma, COPD, heart disease, previous respiratory infections, or atopy (e.g., eczema, hay fever).
• Drug History: Review of current medications, including recent changes or the introduction of new drugs.
• Family History: Family history of asthma, allergies, or other respiratory or cardiac conditions.
• Social History: Smoking, alcohol use, occupational exposures, living conditions, and any recent travel.
• Developmental History (in children): Birth history, growth, and development, particularly if wheeze is a recurrent problem.

• General Observations: Respiratory rate, oxygen saturation, use of accessory muscles, audible wheeze.
• Respiratory Examination: Auscultation for wheezes, crackles, or reduced breath sounds, assessment of chest expansion, percussion for hyperresonance.
• Cardiovascular Examination: Assessment for signs of heart failure (e.g., raised JVP, peripheral oedema), heart sounds (e.g., murmurs, gallops).
• Abdominal Examination: To assess for hepatomegaly, ascites, or signs of gastrointestinal reflux disease.
• Neurological Examination: If wheeze is associated with symptoms suggestive of neurological causes (e.g., hoarseness, dysphagia).
• ENT Examination: Assessment for nasal polyps, signs of allergic rhinitis, or upper airway obstruction.

• Spirometry: To assess for obstructive or restrictive lung disease, pre- and post-bronchodilator testing in asthma and COPD.
• Peak Flow Measurement: To monitor peak expiratory flow rate (PEFR), useful in diagnosing and managing asthma.
• Chest X-ray: To rule out pneumonia, lung cancer, pneumothorax, or other structural abnormalities.
• Full Blood Count (FBC): To assess for eosinophilia in asthma or ABPA, or to rule out infection.
• Arterial Blood Gas (ABG): To assess oxygenation, carbon dioxide levels, and acid-base status, particularly in severe wheeze or suspected respiratory failure.
• Allergy Testing: Skin prick tests or serum IgE levels if allergic asthma or ABPA is suspected.
• Electrocardiogram (ECG): To assess for cardiac causes of wheeze, particularly if there is associated chest pain or palpitations.
• Echocardiogram: If cardiac asthma or heart failure is suspected.
• CT Scan of the Chest: For detailed imaging if malignancy, pulmonary embolism, or other complex pathology is suspected.
• Bronchoscopy: If there is concern about foreign body aspiration, central airway obstruction, or need for biopsy in suspected malignancy.
• Methacholine Challenge Test: To diagnose asthma in patients with normal spirometry but ongoing symptoms.
• Barium Swallow: If gastroesophageal reflux is suspected as a contributing factor to wheeze.