Diagnostic Evaluation of Infants with Recurrent or Persistent Wheezing

Publication Date: August 3, 2016
Last Updated: December 16, 2022

Diagnosis

For infants with persistent wheezing despite treatment with bronchodilators, inhaled corticosteroids, or systemic corticosteroids, the ATS suggests an airway survey via flexible fiberoptic bronchoscopy. (C, VL)
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For infants with persistent wheezing despite treatment with bronchodilators, inhaled corticosteroids, or systemic corticosteroids, the ATS suggests bronchoalveolar lavage (BAL). (C, VL)
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The ATS recommends research studies in infants with persistent wheezing despite treatment with bronchodilators, inhaled corticosteroids, or systemic corticosteroids, which compare clinical outcomes among those who are managed according to results from infant pulmonary function testing using the raised-volume rapid thoracoabdominal compression (RVRTC) method versus those who are managed according to clinical assessment alone.
For infants who do not have eczema but have persistent wheezing despite treatment with bronchodilators, inhaled corticosteroids, or systemic corticosteroids, the ATS suggests that clinicians and caregivers do NOT use empiric food avoidance or dietary changes. (C, VL)
The ATS recommends research studies that determine if food avoidance or dietary changes guided by food allergy testing improves clinical outcomes in infants who do not have eczema but have persistent wheezing despite treatment with bronchodilators, inhaled corticosteroids, or systemic corticosteroids.
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For infants with persistent wheezing despite treatment with bronchodilators, inhaled corticosteroids, or systemic corticosteroids, the ATS suggests 24-hour esophageal pH monitoring. (C, VL)
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For infants with persistent wheezing despite treatment with bronchodilators, inhaled corticosteroids, or systemic corticosteroids, the ATS suggests 24-hour esophageal pH monitoring rather than upper gastrointestinal radiography. (C, VL)
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For infants with persistent wheezing despite treatment with bronchodilators, inhaled corticosteroids, or systemic corticosteroids, the ATS suggests 24-hour esophageal pH monitoring rather than gastrointestinal scintigraphy. (C, VL)
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For infants with persistent wheezing despite treatment with bronchodilators, inhaled corticosteroids, or systemic corticosteroids, the ATS suggests performing videofluoroscopic swallowing studies. (C, VL)
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Recommendation Grading

Overview

Title

Diagnostic Evaluation of Infants with Recurrent or Persistent Wheezing

Authoring Organization

American Thoracic Society

Publication Month/Year

August 3, 2016

Last Updated Month/Year

November 25, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

These guidelines are not intended to be a comprehensive review of the evaluation of infantile wheezing, but rather to provide evidence-based recommendations for a set of specialized diagnostic tests frequently considered in the evaluation of this patient population. Clinicians will be able to use these recommendations when considering specific diagnostic tests for the evaluation of persistent wheezing.

Target Patient Population

Infants with persistent wheezing

PICO Questions

  1. Should Infants with Persistent Wheezing despite Treatment with Bronchodilators, Inhaled Corticosteroids, or Systemic Corticosteroids Undergo Airway Survey via Flexible Fiberoptic Bronchoscopy?

  2. Should Infants with Persistent Wheezing despite Treatment with Bronchodilators, Inhaled Corticosteroids, or Systemic Corticosteroids Undergo Bronchoalveolar Lavage?

  3. Should Infants with Persistent Wheezing despite Treatment with Bronchodilators, Inhaled Corticosteroids, or Systemic Corticosteroids Be Managed according to the Results of Infant Pulmonary Function Testing Using the Raised-Volume Rapid Thoracoabdominal Compression Technique or Clinical Assessment Alone?

  4. Should Infants without Eczema Who Have Persistent Wheezing despite Treatment with Bronchodilators, Inhaled Corticosteroids, or Systemic Corticosteroids Undergo Empiric Food Avoidance?

  5. Should Infants with Persistent Wheezing despite Treatment with Bronchodilators, Inhaled Corticosteroids, or Systemic Corticosteroids Undergo 24-Hour Esophageal pH Monitoring?

  6. Should Infants with Persistent Wheezing despite Treatment with Bronchodilators, Inhaled Corticosteroids, or Systemic Corticosteroids Undergo an Upper Gastrointestinal Series Rather Than 24-Hour Esophageal pH Monitoring?

  7. Should Infants with Persistent Wheezing That Is Not Relieved by Bronchodilators, Inhaled Corticosteroids, or Systemic Corticosteroids Undergo Gastroesophageal Scintigraphy Rather Than 24-Hour Esophageal pH Monitoring?

  8. Should Infants without Neurologic Pathology with Persistent Wheezing That Is Not Relieved by Bronchodilators, Inhaled Corticosteroids, or Systemic Corticosteroids Undergo a Swallowing Function Study?

Inclusion Criteria

Male, Female, Infant

Health Care Settings

Ambulatory, Emergency care

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis

Keywords

wheezing, infant wheezing

Source Citation

Ren CL, Esther CR Jr, Debley JS, Sockrider M, Yilmaz O, Amin N, Bazzy-Asaad A, Davis SD, Durand M, Ewig JM, Yuksel H, Lombardi E, Noah TL, Radford P, Ranganathan S, Teper A, Weinberger M, Brozek J, Wilson KC; ATS Ad Hoc Committee on Infants with Recurrent or Persistent Wheezing. Am J Respir Crit Care Med. 2016 Aug 1;194(3):356-73.

Supplemental Methodology Resources

Data Supplement