A 66 year-old male with a history of hypertension and COPD presents with shortness of breath. He states that his symptoms are unimproved with home nebulizer treatments and denies fever, cough or new sputum production. On examination, he has stridor appreciated during inspiratory and expiratory phases.
1.9cm soft tissue thickening of the left tracheal wall at the level of the inferior thyroid gland. Luminal narrowing to 4 mm at this level.
Case courtesy of Dr Ian Bickle from Radiopaedia.org: 47677
An inspiratory, expiratory, or continuous monophonic sound that is loudest over the central airways.
A musical, high-pitched sound – more commonly expiratory. Requires sufficient airflow to induce airway oscillations.
Supraglottic: negative intratracheal pressure during inspiration causes airway collapse.
Glottic/Subglottic: fixed obstruction not impacted by changes in luminal/thoracic pressure.
Intrathoracic: increased pleural pressure compresses the narrowed airway.
An Algorithm for the Diagnosis of Wheezing and Stridor
Special thanks to Dr. Denna Zebda
, Assistant Professor, Department of Otorhinolaryngology – McGovern Medical School for her expertise and review of this algorithm.
- Sicari V, Zabbo CP. Stridor. [Updated 2021 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK525995/
- Patel PH, Mirabile VS, Sharma S. Wheezing. [Updated 2021 May 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482454/
- Bohadana A, Izbicki G, Kraman SS. Fundamentals of lung auscultation. N Engl J Med. 2014;370(21):2053.
- Orient JM, Sapira JD. Sapira’s Art & Science of Bedside Diagnosis. 4th ed. Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010.
A 6 year-old boy with a history of asthma presents to the emergency department via EMS for dyspnea. The patient is agitated on exam with nasal flaring and intercostal retractions. The parents report that his difficulty breathing started two days ago. The first day his MDI inhaler provided transient relief; however, over the next 24 hours he required nebulized albuterol 3 times with no significant relief. They deny any recent infections or steroid use and state that his immunizations are up-to-date.
On evaluation, vital signs are notable for BP 93/61, HR 140, RR 47, and SpO2 90%. He is afebrile; capillary glucose 113mg/dL. On examination, the patient is agitated with nasal flaring, intercostal retractions, shallow breathing with diminished breath sounds throughout.
Algorithm for the Management of Pediatric Asthma1-11
||Work of Breathing
||None or end-expiration
||Normal or minimal retractions
||Normal or minimally prolonged
||Severe wheezing or absent
||Suprasternal retractions, abdominal wall movement
This algorithm was developed by Dr. Joshua Niforatos. Joshua is an emergency medicine resident at The Johns Hopkins School of Medicine and an alumnus of the Cleveland Clinic Lerner College of Medicine.
Special thanks to Dr. Kelly Young
, Director of the Pediatric Emergency Medicine Fellowship at Harbor-UCLA Medical Center and Dr. Adeola Kosoko
, Assistant Professor, Assistant Residency Program Director, Director Of Diversity, Inclusion, And Mission at McGovern Medical School for their review of the algorithm.
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