From the Guidelines
The management of inspiratory wheezing primarily focuses on identifying and treating the underlying cause, as inspiratory wheezing typically indicates upper airway obstruction rather than the lower airway issues seen with expiratory wheezing. For acute management, securing the airway is the first priority, which may require supplemental oxygen, positioning the patient upright, and in severe cases, preparing for possible intubation. Specific treatments depend on the cause:
- for allergic reactions causing laryngeal edema, administer epinephrine (0.3-0.5 mg IM for adults, 0.15 mg for children) and consider antihistamines (diphenhydramine 25-50 mg IV/PO) and corticosteroids (methylprednisolone 125 mg IV or prednisone 40-60 mg PO) 1.
- for infectious causes like croup, use dexamethasone (0.6 mg/kg, maximum 10 mg) as a single oral dose and consider racemic epinephrine (0.05 mL/kg of 2.25% solution via nebulizer) for moderate to severe cases.
- Foreign body aspiration requires immediate bronchoscopy for removal.
- Vocal cord dysfunction may respond to breathing exercises and speech therapy. Heliox (helium-oxygen mixture) can be beneficial as a temporizing measure in severe upper airway obstruction by reducing airflow turbulence. The physiological basis for these interventions is that inspiratory wheezing occurs when air flows through a narrowed upper airway, creating turbulence and the characteristic high-pitched sound during inspiration. In terms of long-term management, the use of inhaled corticosteroids and long-acting beta2-agonists may be considered for patients with recurring severe exacerbations, as suggested by studies such as 1 and 1. However, the most recent and highest quality study 1 recommends high-dose inhaled corticosteroid, plus long-acting inhaled beta agonist and Consider omalizumab (Xolair) for patients who have allergies, which should be prioritized in management decisions.
From the FDA Drug Label
The use of albuterol sulfate inhalation solution can be continued as medically indicated to control recurring bouts of bronchospasm The management of inspiratory wheezing is not directly addressed in the provided drug labels, but bronchospasm can be a cause of wheezing.
- Albuterol sulfate inhalation solution is used to control recurring bouts of bronchospasm.
- The usual dosage for adults and for children weighing at least 15 kg is 2.5 mg of albuterol administered three to four times daily by nebulization 2. However, the FDA drug label does not provide specific guidance on the management of inspiratory wheezing.
From the Research
Management of Inspiratory Wheezing
The management of inspiratory wheezing can be complex and depends on the underlying cause. Some possible causes of inspiratory wheezing include:
- Functional upper airway obstruction, which can be secondary to chronic asthma, chronic sinusitis, or gastro-oesophageal reflux 3
- Anaphylaxis, a potentially life-threatening, multisystem allergic reaction that can cause airway, breathing, or circulatory compromise 4, 5, 6
- Upper airway obstruction, which can present with stridor or expiratory or inspiratory wheeze and is commonly misdiagnosed as asthma 7
Treatment Approaches
Treatment approaches for inspiratory wheezing may include:
- Treatment of underlying conditions, such as sinusitis and gastro-oesophageal reflux, which can lead to significant improvement of dyspnoea 3
- Administration of intramuscular epinephrine, which is the immediate treatment for anaphylaxis 4, 5, 6
- Supportive care for the patient's airway, breathing, and circulation, and a period of observation for potential biphasic reactions 4, 5, 6
- Consideration of adjunct medications, such as histamine H1 and H2 antagonists, corticosteroids, beta2 agonists, and glucagon, after epinephrine administration 6
Important Considerations
It is essential to exclude functional upper airway obstruction in cases of asthma refractory to treatment or asthmatic exacerbation without obvious cause to avoid unnecessary treatment with systemic steroids 3. Additionally, patients with anaphylaxis should be monitored for a biphasic reaction and provided with an emergency action plan, referral to an allergist, and patient education on avoidance of triggers and appropriate use of an epinephrine auto-injector 6