Wheezing in Older Children

Asthma is the most common cause of wheezing in school age children and adolescents. An inflammatory condition characterized by variable, reversible airway obstruction and hyperreactivity, asthma is a complex, heterogeneous disorder with numerous phenotypes. The pathophysiology, genetics, natural history, and response to treatment vary widely among these phenotypes. Characteristic symptoms—wheezing, cough, and chest tightness—may be precipitated by a variety of triggers including allergens, exercise, infection, weather change, and emotion. Diagnosis is based on history, symptom report, and detection of reversible airflow obstruction using objective measures of lung function. Disease management is focused on control rather than severity. Asthma controller medications include antiinflammatory agents (e.g., inhaled corticosteroids, leukotriene modifiers), long-acting beta-agonists, and long-acting muscarinic antagonists. Short-acting beta-adrenergic agonists (e.g., albuterol) are required for symptom relief. Trigger avoidance, environmental controls, frequent monitoring of symptoms and treatment response, periodic assessment of pulmonary function, and effective patient-physician partnership are also critical to successful asthma management. Asthma exacerbations in children may be mild and respond quickly to home administration of short-acting bronchodilators but can also rapidly progress into a medical emergency. Any asthma exacerbation that fails to respond to home management should be assessed and treated in an acute care facility or physician's office. Short-acting beta agonists and systemic corticosteroids are the mainstay of therapy for acute episodes. Severe exacerbations should be treated in a hospital setting with inhaled anticholinergic medications, intravenous magnesium sulfate, supplemental oxygen, subcutaneous epinephrine, and, in extreme cases, mechanical ventilation.