Wheeze

1. Overview

Wheeze is a high-pitched musical respiratory sound caused by airflow through narrowed or compressed airways. It is usually expiratory, but severe airway obstruction may produce inspiratory and expiratory wheeze. In OSCEs, the first priority is to decide whether the patient is acutely unwell.

The commonest causes are asthma and COPD, but wheeze can also occur with infection, anaphylaxis, pulmonary oedema, bronchiectasis, bronchiolitis, foreign body aspiration and malignancy. A silent chest in a severely breathless patient is a life-threatening sign because it may indicate minimal air movement.

Key OSCE priorities

• Assess severity immediately.
• Check whether the patient can speak in full sentences.
• Ask about onset, triggers, pattern and previous episodes.
• Differentiate asthma, COPD, infection, anaphylaxis and cardiac wheeze.
• Ask about inhaler use, inhaler technique and recent reliever use.
• Ask about smoking and occupational exposure.
• Check oxygen saturation and peak flow where appropriate.
• Look for red flags such as cyanosis, exhaustion, confusion or silent chest.
• Perform respiratory and cardiovascular examination.
• Escalate urgently if severe or life-threatening features are present.

Important causes

• Asthma.
• COPD.
• Acute bronchitis.
• Pneumonia.
• Anaphylaxis.
• Pulmonary oedema or heart failure.
• Bronchiectasis.
• Foreign body aspiration.
• Vocal cord dysfunction.
• Lung cancer causing airway obstruction.
• Pulmonary embolism.
• Gastro-oesophageal reflux triggering bronchospasm.

Red flag features

• Unable to speak in full sentences.
• Severe breathlessness at rest.
• Cyanosis.
• Low oxygen saturation.
• Silent chest.
• Exhaustion.
• Confusion or reduced consciousness.
• Hypotension.
• Chest pain.
• Haemoptysis.
• Stridor rather than wheeze.
• Facial or tongue swelling suggesting anaphylaxis.
• Poor response to initial bronchodilator treatment.

2. History Taking

Opening

• Wash hands.
• Introduce yourself.
• Confirm patient identity.
• Explain that you would like to ask about their wheeze and breathing.
• Gain consent.
• Check whether the patient is too breathless to speak.
• If acutely unwell, state that you would assess using ABCDE and call for senior help.

Presenting complaint

• Ask when the wheeze started.
• Ask whether onset was sudden or gradual.
• Ask whether it is constant or episodic.
• Ask whether it is getting better, worse or staying the same.
• Ask whether this has happened before.
• Ask whether it is associated with shortness of breath.
• Ask whether there is cough or sputum.
• Ask whether there is chest tightness or chest pain.

Severity assessment

• Ask whether the patient can speak in full sentences.
• Ask whether they are breathless at rest.
• Ask whether they feel exhausted.
• Ask whether they feel drowsy or confused.
• Ask whether their reliever inhaler is helping.
• Ask how often they are using their reliever inhaler.
• Ask whether they have needed emergency treatment before.
• Ask whether they have ever been admitted to ICU or ventilated for asthma or COPD.

Pattern and triggers

• Exercise.
• Cold air.
• Dust.
• Pollen.
• Animals.
• Viral infection.
• Smoke or fumes.
• Occupational exposure.
• Emotion or anxiety.
• Food, medication or insect sting suggesting allergy.
• Lying flat suggesting cardiac wheeze.
• Meals or reflux symptoms.

Asthma-focused history

• Episodic wheeze.
• Chest tightness.
• Cough, especially at night or early morning.
• Symptoms vary over time.
• Symptoms triggered by exercise, allergens, cold air or viral infections.
• Personal history of eczema, allergic rhinitis or atopy.
• Family history of asthma or atopy.
• Relief with bronchodilator inhaler.
• Current preventer inhaler use.
• Recent increase in reliever use.
• Previous asthma attacks, hospital admission or ICU admission.

COPD-focused history

• Smoking history.
• Age over 35 with chronic respiratory symptoms.
• Chronic cough.
• Chronic sputum production.
• Progressive exertional breathlessness.
• Frequent winter bronchitis.
• Previous COPD diagnosis.
• Previous exacerbations.
• Home oxygen or nebuliser use.
• Baseline exercise tolerance.

Infection screen

• Fever.
• Rigors.
• Productive cough.
• Change in sputum colour or volume.
• Pleuritic chest pain.
• Recent viral illness.
• Sick contacts.
• Recent hospital admission.
• Immunosuppression.
• Confusion in older patients.

Anaphylaxis and allergy screen

• Sudden onset wheeze after food, medication, insect sting or latex exposure.
• Facial, lip or tongue swelling.
• Throat tightness.
• Hoarse voice.
• Urticaria or widespread rash.
• Itching.
• Abdominal pain or vomiting.
• Dizziness, collapse or hypotension.
• Previous anaphylaxis.
• Adrenaline auto-injector use.

Cardiac wheeze screen

• Orthopnoea.
• Paroxysmal nocturnal dyspnoea.
• Ankle swelling.
• Pink frothy sputum.
• Nocturnal cough.
• Known heart failure.
• Ischaemic heart disease.
• Hypertension.
• Valvular heart disease.
• Chest pain or palpitations.

Foreign body and airway obstruction screen

• Sudden onset during eating or drinking.
• Choking episode.
• Coughing fit followed by wheeze.
• Unilateral wheeze.
• Stridor or noisy breathing from the neck.
• Voice change.
• Recurrent pneumonia in the same area.
• Risk factors for aspiration such as neurological disease or reduced consciousness.

Pulmonary embolism screen

• Sudden breathlessness.
• Pleuritic chest pain.
• Haemoptysis.
• Syncope or collapse.
• Unilateral leg swelling or calf pain.
• Recent surgery.
• Recent immobility or long-haul travel.
• Active cancer.
• Pregnancy or postpartum period.
• Oestrogen therapy.
• Previous DVT or PE.

Past medical history

• Asthma.
• COPD.
• Bronchiectasis.
• Previous pneumonia.
• Tuberculosis.
• Pulmonary embolism.
• Pneumothorax.
• Heart failure.
• Ischaemic heart disease.
• Atopy, eczema or allergic rhinitis.
• Gastro-oesophageal reflux disease.
• Vocal cord dysfunction.
• Previous anaphylaxis.
• Lung cancer or airway disease.

Drug history and allergies

• Current inhalers.
• Reliever inhaler use and frequency.
• Preventer inhaler use and adherence.
• Inhaler technique.
• Oral steroid use.
• Recent antibiotics.
• Beta-blockers, which may worsen bronchospasm.
• NSAID sensitivity in asthma.
• ACE inhibitors if cough is present.
• Antihistamines or adrenaline auto-injector if allergic disease is present.
• Drug allergies and reaction.

Family history

• Asthma.
• Atopy.
• Eczema.
• Allergic rhinitis.
• COPD.
• Alpha-1 antitrypsin deficiency if young COPD is suspected.
• Thromboembolic disease if PE is suspected.

Social history

• Smoking status and pack-year history.
• Vaping.
• Cannabis or recreational drug use.
• Occupation and exposure to dust, fumes, flour, animals, latex or chemicals.
• Pets, birds or mould exposure.
• Housing conditions.
• Exercise tolerance.
• Impact on sleep, work and daily activities.
• Recent travel.
• Ability to afford and use inhalers.

Ideas, concerns and expectations

• Ask what the patient thinks is causing the wheeze.
• Ask what they are most worried about.
• Ask whether they are worried about asthma, COPD, allergy, infection or heart disease.
• Ask what they were hoping would happen today.
• Acknowledge that wheeze and breathlessness can be frightening.

Red flags

• Severe breathlessness.
• Unable to speak in full sentences.
• Silent chest.
• Cyanosis.
• Confusion or drowsiness.
• Exhaustion.
• Hypotension.
• Facial, lip or tongue swelling.
• Stridor.
• Chest pain.
• Haemoptysis.
• Poor response to reliever inhaler.
• Previous ICU admission for asthma.

Closing the history

• Summarise the key points back to the patient.
• Ask if they would like to add anything else.
• Thank the patient.
• State that you would check observations, oxygen saturation, peak flow if appropriate, and examine the respiratory and cardiovascular systems.

3. Physical Examination

The examination should assess severity first. In acute wheeze, look for respiratory distress, hypoxia, silent chest, exhaustion, anaphylaxis, infection, pneumothorax and heart failure.

Before starting the examination

• Wash hands or use alcohol gel.
• Introduce yourself with name and role.
• Confirm the patient's identity.
• Explain the examination clearly.
• Gain consent.
• Ask whether the patient is comfortable to proceed.
• Position the patient sitting upright.
• Expose the chest appropriately while maintaining dignity.
• Ask for a chaperone if appropriate.

Initial assessment

• Look from the end of the bed.
• Assess whether the patient is breathless, cyanosed, pale, sweaty or exhausted.
• Check whether the patient can speak in full sentences.
• Look for tripod position.
• Look for use of accessory muscles.
• Look for intercostal or subcostal recession.
• Look for oxygen therapy, nebuliser, inhalers or spacer.
• Look for urticaria, facial swelling or angioedema suggesting anaphylaxis.
• If acutely unwell, perform ABCDE assessment and call for senior help.

ABCDE assessment if acutely unwell

• Airway: check if the patient can speak and assess for stridor, swelling or obstruction.
• Breathing: assess respiratory rate, oxygen saturation, work of breathing, chest expansion and auscultate the chest.
• Circulation: assess pulse, blood pressure, capillary refill, skin temperature and obtain IV access if needed.
• Disability: assess consciousness level and capillary blood glucose.
• Exposure: check temperature, rash, allergen exposure, leg swelling and signs of infection while maintaining dignity.

Vital signs

• Respiratory rate.
• Oxygen saturation.
• Heart rate.
• Blood pressure.
• Temperature.
• Level of consciousness.
• Peak expiratory flow if asthma is suspected and safe to perform.
• Pain score if chest pain is present.

Hands

• Look for peripheral cyanosis.
• Check capillary refill time.
• Look for tremor from beta-agonist use.
• Look for nicotine staining.
• Look for finger clubbing.
• Look for asterixis suggesting carbon dioxide retention.
• Assess peripheral temperature.
• Look for urticaria or rash if allergy is suspected.

Pulse and blood pressure

• Assess pulse rate.
• Assess pulse rhythm.
• Tachycardia may occur with hypoxia, beta-agonist use, infection, PE or anaphylaxis.
• An irregularly irregular pulse suggests atrial fibrillation.
• Measure blood pressure.
• Hypotension suggests severe asthma, anaphylaxis, sepsis, PE or shock.

Face, mouth and neck

• Look for central cyanosis.
• Look for facial, lip or tongue swelling.
• Listen for stridor.
• Look for hoarse voice.
• Look for conjunctival pallor.
• Look for pursed-lip breathing.
• Assess cervical and supraclavicular lymph nodes.
• Check tracheal position.
• Assess jugular venous pressure.

Chest inspection

• Inspect chest shape.
• Look for hyperinflation or barrel chest.
• Look for symmetrical chest movement.
• Look for scars.
• Look for deformity.
• Look for respiratory distress.
• Observe respiratory pattern.
• Look for chest drain or surgical emphysema if relevant.

Palpation

• Confirm tracheal position.
• Assess chest expansion.
• Compare expansion on both sides.
• Palpate for chest wall tenderness.
• Palpate for subcutaneous emphysema if pneumothorax is suspected.
• Assess tactile vocal fremitus if consolidation or effusion is suspected.

Percussion

• Percuss symmetrical areas of the chest.
• Hyperresonance may suggest hyperinflation or pneumothorax.
• Dullness may suggest consolidation, collapse or pleural effusion.
• Compare side to side.
• Marked unilateral hyperresonance with reduced breath sounds is concerning for pneumothorax.

Auscultation

• Auscultate symmetrical areas of the chest.
• Assess air entry.
• Listen for expiratory wheeze.
• Listen for polyphonic wheeze suggesting widespread airway narrowing.
• Listen for monophonic wheeze suggesting focal airway obstruction.
• Listen for crackles suggesting infection or pulmonary oedema.
• Listen for bronchial breathing suggesting consolidation.
• A silent chest in a severely breathless patient is a life-threatening sign.

Cardiovascular examination

• Assess JVP.
• Auscultate heart sounds.
• Listen for murmurs.
• Look for peripheral oedema.
• Look for signs of heart failure.
• Cardiac wheeze may occur in pulmonary oedema.

Peripheral and abdominal examination

• Check calves for unilateral swelling or tenderness if PE is suspected.
• Look for peripheral oedema.
• Assess for hepatomegaly if right heart failure is suspected.
• Look for urticaria or widespread rash if anaphylaxis is suspected.
• Check temperature and signs of infection.

Specific findings to mention in wheeze OSCE

• Diffuse expiratory wheeze suggests asthma or COPD.
• Silent chest with distress suggests life-threatening asthma.
• Wheeze with facial swelling, rash and hypotension suggests anaphylaxis.
• Wheeze with crackles, raised JVP and oedema suggests cardiac wheeze.
• Unilateral wheeze suggests focal airway obstruction or foreign body.
• Wheeze with fever and focal crackles suggests infection.
• Normal auscultation does not exclude asthma between attacks.

To complete the examination

To complete my examination, I would review observations, check oxygen saturation, measure peak flow if appropriate, perform ECG and chest X-ray if indicated, request blood tests and blood gas if severe, and arrange spirometry or objective airway testing when stable.

4. Differential Diagnosis

Obstructive airway causes

• Asthma.
• COPD.
• Acute bronchitis.
• Bronchiectasis.
• Bronchiolitis in children.
• Cystic fibrosis if clinically relevant.

Emergency causes

• Life-threatening asthma.
• Severe COPD exacerbation.
• Anaphylaxis.
• Tension pneumothorax.
• Foreign body aspiration.
• Pulmonary embolism.
• Acute pulmonary oedema.

Cardiac causes

• Acute pulmonary oedema.
• Chronic heart failure.
• Mitral valve disease with pulmonary congestion.
• Arrhythmia precipitating heart failure.

Upper airway and focal airway causes

• Foreign body aspiration.
• Laryngeal oedema.
• Vocal cord dysfunction.
• Tracheal stenosis.
• Endobronchial tumour.
• External airway compression.

Important mimics

• Stridor, which is usually upper airway obstruction rather than wheeze.
• Panic attack with breathlessness but no objective wheeze.
• Metabolic acidosis causing tachypnoea rather than wheeze.
• Pleural disease causing breathlessness but not wheeze.

5. Investigations

Bedside tests

• Full observations.
• Oxygen saturation.
• Peak expiratory flow if asthma is suspected and safe.
• Capillary blood glucose if acutely unwell or diabetic.
• 12-lead ECG if cardiac cause, PE or severe illness is suspected.
• Urine dip if infection or systemic disease is suspected.
• Pregnancy test in women of reproductive age when relevant.

Blood tests

• Full blood count.
• Urea and electrolytes.
• CRP if infection is suspected.
• Blood cultures if sepsis or severe pneumonia is suspected.
• Troponin if ACS is suspected.
• BNP or NT-proBNP if heart failure is suspected.
• D-dimer only if PE is possible and clinical probability supports testing.
• Arterial or venous blood gas if severe wheeze, hypoxia, COPD exacerbation, exhaustion or respiratory failure is suspected.

Imaging

• Chest X-ray if pneumonia, pneumothorax, heart failure, malignancy or unclear diagnosis is suspected.
• Chest X-ray before discharge may be needed if severe or atypical features are present.
• CT pulmonary angiography if PE is suspected and imaging is indicated.
• CT chest if focal obstruction, malignancy or unexplained wheeze is suspected.
• Neck imaging or urgent airway assessment if upper airway obstruction is suspected.

Respiratory tests

• Spirometry when stable.
• Bronchodilator reversibility testing.
• Peak flow diary for variable airflow obstruction.
• FeNO where available if eosinophilic airway inflammation is suspected.
• Sputum culture if productive cough or infection is suspected.
• Allergy testing in selected patients with suspected allergic asthma.

Specialist investigations

• Bronchoscopy if foreign body, tumour or focal airway obstruction is suspected.
• Echocardiography if heart failure or valvular disease is suspected.
• ENT assessment if vocal cord dysfunction or upper airway pathology is suspected.
• Occupational respiratory assessment if work-related asthma is suspected.

Important investigation points

• Peak flow helps assess severity in suspected asthma.
• A normal peak flow does not exclude all causes of wheeze.
• Blood gas is important when respiratory failure or CO2 retention is suspected.
• Chest X-ray may be normal in asthma and COPD exacerbation.
• Spirometry should usually be performed when the patient is stable, not during severe acute distress.

6. Management

Management depends on severity and cause. In OSCEs, first identify whether the patient needs emergency treatment, oxygen, nebulisers, adrenaline for anaphylaxis, or urgent airway support.

Immediate approach if acutely unwell

1. Assess using ABCDE.
2. Call for senior help if severe breathlessness, hypoxia, silent chest, confusion, hypotension or anaphylaxis features are present.
3. Sit the patient upright.
4. Give oxygen if hypoxaemic according to local oxygen target protocol.
5. Attach monitoring if unstable.
6. Obtain IV access if clinically indicated.
7. Check peak flow if asthma is suspected and safe.
8. Treat the likely emergency cause according to local protocol.

Oxygen principles

• Oxygen is given for hypoxaemia, not for wheeze alone.
• Use local oxygen target saturation ranges.
• Most acutely unwell patients are usually targeted to 94 to 98 percent.
• Patients at risk of hypercapnic respiratory failure, such as some COPD patients, usually require a lower target range such as 88 to 92 percent.
• Check blood gas if severe COPD exacerbation, drowsiness or CO2 retention is suspected.

If asthma exacerbation is suspected

• Assess severity using symptoms, respiratory rate, oxygen saturation, pulse and peak flow.
• Give oxygen if hypoxaemic.
• Give inhaled or nebulised short-acting bronchodilator according to local protocol.
• Give systemic corticosteroids according to local protocol.
• Consider additional therapies and urgent escalation if poor response or life-threatening features are present.
• After stabilisation, review inhaler technique, adherence, triggers and action plan.

If COPD exacerbation is suspected

• Use controlled oxygen if at risk of hypercapnic respiratory failure.
• Give bronchodilators according to local protocol.
• Consider systemic corticosteroids according to local protocol.
• Consider antibiotics if increased sputum purulence or infective features are present.
• Check blood gas if severe, drowsy, hypoxic or retaining CO2.
• Consider non-invasive ventilation if respiratory acidosis persists according to local protocol.
• Review smoking cessation, inhaler technique and pulmonary rehabilitation.

If anaphylaxis is suspected

• Call for emergency help.
• Remove the trigger if possible.
• Give intramuscular adrenaline according to local anaphylaxis protocol.
• Lay the patient flat with legs elevated unless breathing is severely difficult.
• Give high-flow oxygen if hypoxaemic.
• Give IV fluids if hypotensive according to local protocol.
• Monitor closely and prepare for airway compromise.
• Arrange observation and provide adrenaline auto-injector education after recovery.

If cardiac wheeze is suspected

• Assess for heart failure and pulmonary oedema.
• Sit the patient upright.
• Give oxygen if hypoxaemic.
• Perform ECG and chest X-ray.
• Check BNP or NT-proBNP where appropriate.
• Give diuretics according to local protocol if fluid overloaded.
• Treat precipitating causes such as ACS, arrhythmia or infection.
• Consider non-invasive ventilation if severe pulmonary oedema and hypoxaemia persist.

If foreign body or upper airway obstruction is suspected

• Call for senior, anaesthetic or ENT help urgently if airway compromise is suspected.
• Assess airway and breathing immediately.
• Do not delay emergency management for investigations if severe obstruction is present.
• Bronchoscopy may be required for suspected lower airway foreign body.
• Differentiate wheeze from stridor, because stridor suggests upper airway obstruction.

Long-term management principles

• Confirm the diagnosis with objective testing when stable.
• Optimize inhaled therapy according to diagnosis and guideline.
• Review inhaler technique and adherence.
• Identify and reduce triggers.
• Offer smoking cessation support.
• Provide written asthma or COPD action plan where appropriate.
• Arrange follow-up after acute exacerbation.
• Refer to respiratory specialist if diagnosis is uncertain, symptoms are severe, or attacks are recurrent.

Safety-net advice

• Seek urgent help for worsening breathlessness.
• Seek urgent help if reliever inhaler is not working.
• Seek urgent help for blue lips, confusion, drowsiness or exhaustion.
• Seek urgent help for chest pain or collapse.
• Seek urgent help for facial swelling, throat tightness or widespread rash.
• Seek urgent help for coughing blood.
• Return for persistent fever, worsening sputum or recurrent attacks.

7. Examiner Questions

1. What is wheeze?
2. What are the common causes of wheeze?
3. What features suggest asthma?
4. What features suggest COPD?
5. What features suggest anaphylaxis?
6. What is cardiac wheeze?
7. What is the difference between wheeze and stridor?
8. What red flags suggest life-threatening asthma?
9. What bedside tests would you perform?
10. When would you request a blood gas?
11. What is the role of peak flow?
12. How would you manage acute severe wheeze?
13. Why should oxygen be controlled in some COPD patients?
14. What long-term advice would you give after an asthma attack?

Suggested short answers

8. OSCE Pearls

• Assess severity before taking a long history.
• Ask whether the patient can speak in full sentences.
• Silent chest is worse than loud wheeze in severe asthma.
• Always ask about previous ICU admission or ventilation.
• Ask about reliever inhaler use; increasing use suggests poor control.
• Ask about triggers and atopy for asthma.
• Ask about smoking and chronic sputum for COPD.
• Wheeze with rash, swelling or hypotension is anaphylaxis until proven otherwise.
• Wheeze with crackles and raised JVP may be cardiac wheeze.
• Stridor is not the same as wheeze.
• Unilateral wheeze suggests focal obstruction.
• Check oxygen saturation and peak flow where appropriate.
• Blood gas is important if severe or COPD with possible CO2 retention.
• Review inhaler technique before discharge or follow-up.

9. Example Presentation to Examiner

10. References

• BTS/NICE/SIGN guideline on asthma diagnosis, monitoring and chronic asthma management.
• NICE NG115: Chronic obstructive pulmonary disease in over 16s: diagnosis and management.
• British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings.
• Resuscitation Council UK guidance on anaphylaxis.
• Local respiratory, emergency medicine and oxygen therapy protocols.