One-liner#

Evaluate wheezing to differentiate asthma and COPD (most common) from cardiac causes, upper airway obstruction, and focal lesions, recognizing that “all that wheezes is not asthma.”

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• Severe respiratory distress: SpO₂ <92%, accessory muscle use, inability to speak in full sentences
• Stridor (inspiratory wheeze) suggesting upper airway obstruction
• Unilateral wheeze with acute onset (foreign body, tumor, mucus plug)
• Anaphylaxis: wheeze + urticaria + angioedema + hypotension
• Silent chest in known asthmatic (severe bronchospasm, impending respiratory failure)
• New wheeze with hemoptysis (PE, malignancy)
• Wheeze not responding to bronchodilators with worsening distress

Key history#

Wheeze characteristics:

• Timing: inspiratory (upper airway), expiratory (lower airway), biphasic (fixed obstruction)
• Onset: acute (asthma exacerbation, anaphylaxis, foreign body) vs chronic (COPD, asthma)
• Location: diffuse (asthma, COPD) vs focal/unilateral (tumor, foreign body, mucus plug)
• Triggers: allergens, exercise, cold air (asthma); infections (COPD, asthma); position (cardiac)

Associated symptoms:

• Dyspnea: severity, timing, positional component
• Cough: productive (COPD, bronchiectasis) vs dry (asthma)
• Chest tightness: asthma, cardiac
• Orthopnea/PND: heart failure (“cardiac asthma”)
• Fever: infection
• Urticaria, angioedema: anaphylaxis
• Heartburn: GERD-triggered asthma
• Weight loss, hemoptysis: malignancy

Past medical history:

• Known asthma or COPD: baseline control, recent exacerbations, current medications
• Cardiac disease: HF, valvular disease
• Allergies: environmental, food, drug
• Prior intubation for asthma (high-risk)

Smoking history:

• Pack-years (COPD risk)
• Current vs former

Medication review:

• Beta-blockers: can trigger bronchospasm (even eye drops)
  • If beta-blocker needed for cardiac indication in asthmatic: use cardioselective (metoprolol, bisoprolol) at lowest effective dose; monitor closely
  • Avoid non-selective (propranolol, carvedilol) in asthmatics
• NSAIDs/aspirin: aspirin-exacerbated respiratory disease (AERD)
• ACE inhibitors: cough (not wheeze, but often confused)
• Current asthma/COPD medications and adherence

Inhaler technique (assess at every visit):

• Poor technique is a common cause of “uncontrolled” asthma
• MDI requires coordination; spacer improves delivery
• DPI requires adequate inspiratory flow
• Demonstrate and observe technique; correct errors

Occupational/environmental:

• Occupational asthma: symptoms worse at work, improve on weekends/vacation
• Allergen exposure: pets, dust, mold
• Irritant exposure: smoke, fumes, chemicals

Focused exam#

• Vitals: SpO₂ (most important), RR, HR, BP
• General: respiratory distress, ability to speak in full sentences, use of accessory muscles
• HEENT: nasal polyps (AERD, allergic rhinitis), angioedema, stridor
• Neck: JVD (HF), tracheal position, goiter
• Lungs:
  • Wheeze location: diffuse vs focal vs unilateral
  • Wheeze timing: inspiratory (upper airway) vs expiratory (lower airway) vs biphasic
  • Breath sounds: decreased (severe obstruction, effusion), absent unilaterally (pneumothorax)
  • Crackles: HF, pneumonia
  • Prolonged expiratory phase: obstructive disease
• Cardiac: S3 (HF), murmurs, irregular rhythm
• Skin: urticaria, eczema (atopy)
• Extremities: edema (HF), clubbing

Severity assessment (asthma/COPD):

• Mild: speaks in sentences, SpO₂ >94%, no accessory muscles
• Moderate: speaks in phrases, SpO₂ 90–94%, some accessory muscle use
• Severe: speaks in words, SpO₂ <90%, accessory muscles, agitation
• Life-threatening: silent chest, cyanosis, altered mental status, bradycardia

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

Immediate assessment:

• SpO₂ on room air
• Respiratory rate and work of breathing
• Ability to speak in full sentences

Office workup:

When to order additional testing:

When NOT to order:

• Spirometry during acute exacerbation (wait until stable)
• CT chest for typical asthma/COPD with normal CXR
• Extensive workup for clear viral URI with reactive airways

Initial management#

Acute bronchospasm (asthma/COPD exacerbation):

1. Assess severity (see severity assessment above)
2. Bronchodilators:
   • Albuterol nebulizer 2.5 mg OR MDI 4–8 puffs via spacer
   • Can repeat every 20 minutes x 3 for moderate-severe
   • Add ipratropium 0.5 mg nebulizer for moderate-severe
3. Systemic steroids:
   • Prednisone 40–60 mg PO (or methylprednisolone if unable to take PO)
   • Start early; reduces treatment failure and relapse
4. Reassess after initial treatment:
   • Good response: discharge with bronchodilators + steroids + follow-up
   • Partial response: continue treatment; consider ED if not improving
   • Poor response: send to ED

Suspected cardiac wheeze:

• Diuretics (furosemide 40–80 mg IV/PO)
• Upright positioning
• Supplemental O₂ if hypoxic
• Bronchodilators may help symptomatically but treat underlying HF

Suspected anaphylaxis:

• Epinephrine 0.3–0.5 mg IM (1:1000) in anterolateral thigh
• Call 911
• Repeat epinephrine in 5–15 minutes if no improvement

Management by diagnosis#

Asthma#

Education:

• Chronic airway inflammation with reversible obstruction
• Controller medications (ICS) prevent symptoms; rescue medications (SABA) treat acute symptoms
• Identify and avoid triggers
• Asthma action plan for self-management

Treatment:

Acute exacerbation:

Maintenance therapy (see Asthma section in Dyspnea Chronic page for full stepwise approach):

Follow-up: Reassess in 1–2 days if moderate exacerbation. Review maintenance therapy; step up if needed.

COPD#

Education:

• Chronic, progressive airflow obstruction from smoking (usually)
• Smoking cessation is most important intervention
• Medications control symptoms and reduce exacerbations

Treatment:

Acute exacerbation:

Maintenance therapy (see COPD section in Dyspnea Chronic page for full GOLD-based approach)

Follow-up: Reassess in 48–72 hours. Review maintenance therapy after recovery.

Cardiac Asthma (Heart Failure)#

Education:

• Wheezing caused by pulmonary congestion from heart failure
• Fluid in lungs causes airway narrowing and bronchospasm
• Treating the heart failure resolves the wheeze

Recognition:

• Wheeze + orthopnea + edema + JVD
• Bilateral crackles in addition to wheezes
• Elevated BNP
• CXR shows cardiomegaly, pulmonary edema

Treatment:

• Diuretics are primary treatment (not bronchodilators)
• Furosemide 40–80 mg PO/IV
• Bronchodilators may provide symptomatic relief but don’t address cause
• Optimize HF medications (see HF section in Dyspnea Chronic page)

Follow-up: Cardiology referral if new diagnosis. Close follow-up for diuresis.

Vocal Cord Dysfunction (VCD)#

Education:

• Paradoxical vocal cord adduction during inspiration
• Causes inspiratory stridor often mistaken for asthma
• Does NOT respond to bronchodilators
• Often associated with anxiety, GERD, or post-nasal drip
• Diagnosis requires laryngoscopy during symptomatic episode

Recognition:

• Inspiratory stridor/wheeze (not expiratory)
• Throat tightness, difficulty getting air IN
• Normal SpO₂ during episodes
• Does not respond to albuterol
• Often young female; may have anxiety

Treatment:

• Acute: reassurance, relaxation techniques, panting breaths
• Long-term: speech therapy (laryngeal control techniques)
• Treat comorbidities: GERD, post-nasal drip, anxiety
• Avoid unnecessary asthma medications

Follow-up: ENT or pulmonology referral for laryngoscopy. Speech therapy referral.

Anaphylaxis#

Education:

• Severe allergic reaction; life-threatening emergency
• Requires immediate epinephrine
• All patients need epinephrine auto-injector prescription and allergist referral

Treatment:

Post-anaphylaxis:

• Observe 4–6 hours (biphasic reactions can occur)
• Prescribe epinephrine auto-injector (EpiPen, Auvi-Q)
• Allergist referral for trigger identification
• Anaphylaxis action plan

Aspirin-Exacerbated Respiratory Disease (AERD)#

Education:

• Triad: asthma + nasal polyps + aspirin/NSAID sensitivity
• Respiratory reaction (not anaphylaxis) to COX-1 inhibitors
• Chronic rhinosinusitis with nasal polyps
• Often severe, difficult-to-control asthma

Recognition:

• Asthma + nasal polyps + history of reaction to aspirin/NSAIDs
• Reaction is respiratory (wheeze, nasal congestion), not urticaria/anaphylaxis

Treatment:

• Avoid all NSAIDs and aspirin (acetaminophen usually safe)
• Aggressive asthma management (often requires high-dose ICS-LABA)
• Nasal steroids and saline irrigation for polyps
• Consider aspirin desensitization (specialist-directed)
• Biologics (dupilumab) for severe cases

Follow-up: Pulmonology and ENT co-management. Allergist for aspirin desensitization consideration.

Follow-up#

Default intervals:

• Asthma exacerbation: reassess in 1–2 days; follow-up in 2–4 weeks
• COPD exacerbation: reassess in 48–72 hours; follow-up in 2–4 weeks
• New asthma diagnosis: follow-up in 2–4 weeks to assess control
• Cardiac wheeze: close follow-up for diuresis; cardiology referral

Referral thresholds:

• Pulmonology: severe/uncontrolled asthma, COPD with FEV1 <50%, diagnostic uncertainty
• Cardiology: cardiac wheeze/HF
• Allergist: anaphylaxis, suspected allergic asthma, AERD
• ENT: VCD, nasal polyps, upper airway pathology

Return precautions:

• Worsening shortness of breath or wheeze
• Inhaler not helping
• Difficulty speaking in full sentences
• Blue lips or fingernails
• Chest pain
• Swelling of face, lips, or throat

Patient instructions#

• Wheezing is a whistling sound when you breathe, usually caused by narrowed airways. The most common causes are asthma and COPD.
• If you have asthma or COPD, take your controller medications every day, even when you feel well. Use your rescue inhaler (albuterol) when you have symptoms.
• Know your triggers and avoid them when possible. Common triggers include smoke, dust, pet dander, cold air, and respiratory infections.
• If you smoke, quitting is the most important thing you can do for your breathing.
• Seek emergency care if your breathing gets much worse, your inhaler isn’t helping, you can’t speak in full sentences, or your lips turn blue.
• If you had an allergic reaction with wheezing, always carry your epinephrine auto-injector and know how to use it.

Smartphrase snippets#

.WHEEZEASTHMA Wheezing consistent with asthma [exacerbation / new diagnosis]. SpO₂ [X]% on room air. Treated with albuterol [nebulizer / MDI] with [good / partial / poor] response. Started prednisone 40 mg daily x 5 days. Discharged with albuterol PRN and [ICS / ICS-LABA]. Asthma action plan reviewed. Return precautions discussed. Follow-up in [1–2 days / 2–4 weeks].

.WHEEZECOPD COPD exacerbation with wheezing. SpO₂ [X]% on room air. Started prednisone 40 mg x 5 days, increased bronchodilator frequency, [added azithromycin for purulent sputum / no antibiotics indicated]. Discussed return precautions. Reassess in 48–72 hours.

.WHEEZECARDIAC Wheezing with bilateral crackles, JVD, and peripheral edema consistent with cardiac asthma (heart failure exacerbation). BNP elevated at [X]. Started/increased furosemide to [dose]. Bronchodilators for symptomatic relief. Cardiology referral placed. Close follow-up for diuresis.

Related pages#

• Cough (Acute) — acute cough differential
• Cough (Chronic) — chronic cough including asthma
• Dyspnea (Acute) — acute shortness of breath
• Dyspnea (Chronic) — chronic shortness of breath
• Asthma (problem) — chronic asthma management
• COPD (problem) — chronic COPD management
• Heart Failure (problem) — HF management for cardiac asthma