As we move into the cooler seasons, patients may experience more profound wheezing. Controlling wheezing and understanding underlying causes are key, and in-depth discussions with patients can yield important information.

Telling Patients the Reason for Their Wheezing

Wheezing is a high pitched, whistle sound created by turbulent airflow within the airways that is a physical exam finding indicating a possible underlying pathology, said Brittany Duchene, MD, a pulmonary and critical care physician at University of Vermont Medical Center and an assistant professor at The Robert Larner, M.D. College of Medicine in Burlington, Vermont. This occurs when the airways are narrowed or partially blocked.

Explaining the medical definition of wheezing to patients can be somewhat challenging. “That is, stating that wheezing is a noise created by turbulent airflow may not be well understood by some patients, so using real life, common example is likely to be more effective in explaining what wheezing is to patients,” Duchene said.

For example, she recommends this messaging:

“Wheezing is a whistling noise that comes from your lungs when your windpipes are narrowed or there is something blocking them. If you try to breathe out through a wide-open mouth, the sounds the air makes is quiet. Now try breathing out when your lips are pursed like you are drinking out of a straw, the noise the air makes now is higher in pitch and louder.”

What Causes Wheezing?

A variety of lung, allergic, and cardiac conditions can cause wheezing. Asthma, chronic obstructive pulmonary disease (COPD), bronchitis, airway masses, bronchiectasis, cystic fibrosis, vocal cord dysfunction, smoking, sleep apnea, acid reflux, aspiration or infections such as pneumonia can all cause wheezing. Additionally, cardiac diseases including heart failure can also cause a wheeze due to airway edema from volume overload.

For your reference, below are common causes of wheezing that you can use to treat and guide your patients.

• Asthma: This is the most common cause of wheezing. In asthma the airways narrow due to a trigger of some sort (allergens, smoke, pollution, etc.). This airway narrowing results in increased airflow resistance, leading to wheezing, Duchene said.
• COPD: This is another common cause of wheezing that may reflect airway narrowing or increased mucus accumulation in the airways. “When mucus accumulates within an airway the obstruction present causes turbulent airflow generating a wheeze sound,” Duchene said.
• Infections: Diagnoses like respiratory syncytial virus influenza, COVID, or bacterial infections cause significant airway inflammation. “This inflammation causes an increased production of mucus as well as narrowing of the airways that contribute to the wheezing sound,” said Duchene.
• Gastroesophageal reflux disease: The condition is a common cause of wheezing. When stomach acid backs up into the esophagus, it can reach the level of the laryngopharynx and spill over into the airways, and this irritation results in airway inflammation and mucus production resulting in wheezing, she said. “Additionally, stomach acid can be a trigger to cause bronchoconstriction leading to airways narrowing, which also causes wheeze.”

What Short-Term Directives Can a Primary Care Physician Offer?

Khalilah Gates, MD, associate professor of medicine and medical education, Northwestern University Feinberg School of Medicine in Chicago, said she thinks of wheezing treatment in two groups.

Patients with known asthma/COPD. If acute flare of asthma is due to something like a viral infection, they may need steroids to decrease the inflammation and open the airways, said Gates.

“Albuterol is always our go-to ‘urgency/emergency’ inhaler. It binds to the receptors in the airways that make the airways open up, often improving symptoms including shortness of breath, chest tightness, and wheezing,” she said.

She also warned that albuterol should not be taken daily, multiple times day.

Advising your patients to be self-reliant is also key. “If the patient knows their triggers, they should avoid triggers,” she said.

For example, if they are allergic to cats and the allergy causes wheezing/shortness of breath, then they should avoid cats. “If patients use albuterol regularly, they should be on a maintenance medication which includes inhaled-steroid and a long-acting medication similar to albuterol but lasts longer,” added Gates.

For patients with new wheezing, but without a history of asthma or COPD, Gates said a more urgent evaluation should be performed.

“Sometimes in patients with no previous history of asthma, they will have wheezing after a severe viral infection…we saw a lot of this secondary to COVID,” she also said.

How to Determine What’s Causing Wheezing

The best way to determine severity of wheezing is clinical exam and how the patient looks. If the patient looks comfortable, the severity is likely mild-to-moderate, said Gates. A patient working hard to breathe is severe and should seek emergency care as soon as possible.

“For mild-to-moderate asthma-like symptoms, a peak flow meter, which measures how hard the patient can blow out, can be used to assess severity. The less they are able to blow out, the tighter and thus more severe is the airway tightness,” Gates said. Ask your patients to monitor their numbers as well. “These are helpful but are most helpful when patients know their numbers regularly,” she said.

During your appointment, be sure to advise your patient to get immediate medical attention if they experience any of these symptoms: “Severe shortness of breath, mental confusion, turning blue, tongue swelling which can be seen in allergic reaction, should go to the ER [emergency room] immediately,” she said. “If severe, paramedics should be called because they often can give medications to help instead of waiting to get to ER which could be a matter of life or death in severe situations.”

When to Refer Your Patient to a Specialist

If your treatment directives aren’t helping your patients with wheezing, consider a referral.

“My recommendations are always for primary care providers to reach out for assistance whenever they reach their limits of comfort,” said Gates. “In my practice, this typically happens once the patient is on maximum inhalers but is still have persistent breathing symptoms If a patient is being referred to a pulmonologist, having a chest x-ray and pulmonary function tests would be extremely helpful on that first visit.”

Duchene and Gates reported no disclosures.