Symptom: Wheezing

Initial Grading Reminder

CTCAE grading of wheezing:

Grade 1: Detectable airway noise with minimal symptoms
Grade 2: Moderate symptoms; medical intervention indicated; limiting instrumental ADLs
Grade 3: Severe respiratory symptoms limiting self-care ADLs; oxygen therapy or hospitalization indicated
Grade 4: Life-threatening consequences; urgent intervention indicated

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Do you have emphysema or asthma? Have you had issues with wheezing in the past? Is this a new or worsening symptom? When did it start or get worse? Has it developed gradually or suddenly?

Note: More sudden onset would be suggestive of pneumonitis.

Grade the symptom

Ask the patient:

Can you hear a wheezing noise when you breathe? Do you hear that noise all the time or just when you’re doing an activity? Are you short of breath all the time or just when you lie flat, when you walk, use stairs, or do an activity? If you take it easy, does it get better? Is it affecting your ability to take care of yourself?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Do you have any chest pain? Any swelling in your legs? Do you have any weakness or numbness or tingling?

Patient Factors to Consider That Affect the Approach to Intervention

Consider the following in individualizing the intervention: Is the patient a good or poor historian? Any language barriers or cognitive deficits? Is the patient reliable (able to carry out treatment recommendations)? Does this patient have alcohol/substance abuse issues? Does the patient have transportation? Is there sufficient caregiver support?

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    Suggested Intervention

    Patients with new-onset moderate or worse (or worsening) wheezing should be seen.

    Patients with any of the red-flag symptoms should be seen immediately.

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    Nursing Assessment of Potential Causes

    Pneumonitis - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear uncomfortable?
    • Did the patient have difficulty walking to the exam room? Or going up stairs?
    • Does the patient appear short of breath?
    • Is the patient tachypneic?
    • Does the patient appear to be in respiratory distress?
    • Has the patient noted any change in breathing?
    • Does the patient feel short of breath?
    • Does the patient note new dyspnea on exertion?
    • Does the patient notice a new cough? Or a change in an existing cough?
    • Have symptoms worsened?
    • Are symptoms limiting ADLs?
    • Associated symptoms?
      • Fatigue
      • Wheezing
    • Is the pulse oximetry low? Is it lower than baseline or compared with last visit? Is it low on exertion?
    • Is there a pre-existing pulmonary autoimmune condition (i.e., sarcoidosis)?
    • Is there a history of prior respiratory compromise (e.g., asthma, COPD, congestive heart failure)?
    • Has the patient experienced other immune-related adverse effects?

    Neuropathy - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear weak?
    • Does the patient appear uncomfortable?
    • Altered ambulation or general movement?
    • If muscular weakness is present, any respiratory difficulties apparent?
    • Does the patient report weakness (unilateral or bilateral)?
    • Does the patient report new or worsened pain, numbness, or tingling?
    • Does the patient report difficulty walking or holding items?
    • Motor deficits
    • Sensory deficits
    • Mental status changes
    • Paresthesias
    • Laboratory values
    • Does the patient have diabetes mellitus?
    • Are there neurologic signs and symptoms?
    • Results of prior imaging
      • Metastases to spinal cord
      • Other metastases that may cause symptoms

    Differential Diagnosis

    What do you suspect is the cause of the wheezing?