1. Management of Respiratory Problems in Children
DR SADASIVAM SURESH

2. Learning objectives:
Increase understanding of common respiratory disorders in children
To be able to recognise common respiratory symptoms and presentations  in a child under 2 years of age
To understand the ongoing management and surveillance in paediatric asthma
Investigations in children with respiratory problem - a systematic approach
Multidisciplinary management in chronic conditions.
Antibiotics and physiotherapy - synergy in management of chronic respiratory conditions

3. Chronic Cough in Children

4. Road Map Definition Clinical presentation Differential diagnosis
Investigations
Management

5. Mechanism of Cough

6. Definition Chronic cough – daily cough for more than 4 weeks
Dry Cough - Discussed separately
Moist cough
This presentation

7. Figure 1 Differentiated cough patterns.
Marais, B J et al. Arch Dis Child 2005;90:
Copyright ©2005 BMJ Publishing Group Ltd.

8. Clinical Presentation
Cough as a symptom
Associated symptoms
Wheeze
Pyrexia
Diurnal variation
Exercise & activity
Sleep
Other systemic symptoms
Reflux
Cardiac
Congenital abnormality

11. Suppurative Cough

12. Decision Tree

16. Investigations

17. Management points Value of CXR Chronic Bronchitis of unknown aetiology
Follow-up CXR & timing
Chronic Bronchitis of unknown aetiology
Physiotherapy
Prolonged course of antibiotics
Role of Bronchoscopy
Sequential investigation

18. Family/Patient preference

19. Cough Benefits

20. What is it and what to do about it.
Bronchiolitis Croup
What is it and what to do about it.

21. bronchiolitis Affects infants, males = females
At risk - bottle fed, crowding
- CHD, CNLD
Causes
RSV
Human metapneumovirus
Influenza
parainfluenza (3)
adenovirus
Illness predominately seen in infants
Hospitalized - 80% in 1st year 50% 1-3 months
Severe bronciolitis more severe in males

22. Figure 1 Comparison of the frequency of detection of human metapneumovirus (hMPV) with other respiratory viral pathogens. RSV, respiratory syncytial virus.
Garcia-Garcia, M L et al. Arch Dis Child 2006;91:
Copyright ©2006 BMJ Publishing Group Ltd.

23. Figure 4 Age distribution of hMPV and RSV single infections.
Garcia-Garcia, M L et al. Arch Dis Child 2006;91:
Copyright ©2006 BMJ Publishing Group Ltd.

24. Figure 3 Monthly distribution of hMPV and RSV single infections.
Garcia-Garcia, M L et al. Arch Dis Child 2006;91:
Copyright ©2006 BMJ Publishing Group Ltd.

25. RSV Predominant pathogen 2 strains - A and B
All children exposed by 3 years
Spreads from nasopharynx to lungs
Kills respiratory epithelial cells
In vitro - large syncytia
A may be associated with more severe disease

26. Pathogenesis Ciliated epithelial necrosis
Mononuclear cell infiltrate, oedema, mucous plugs
CXR - hyperinflation and patchy infiltrates, collapse
Repair - cilia by day 15
Thought to be little smooth muscle contraction - little response to bronchdiloators

27. Clinical Incubation - 5 days Coryza
tachypnoea, wheeze, crackles, hypoxia - 1 to 3 weeks
Bacterial superinfection rare (1-2%)
Residual symptoms
Wheeze average 9 days, ceases with coincident rise in secretory IgA

28. diagnosis
Clinical
NPA - respiratory viruses

29. Management Oxygen - saturations < 94%
Fluids - oral feeds, NG feeds, IV fluids, ventilation
NOT - antibiotics, steroids, bronchodilators, physiotherapy
Ribavirin - expensive antiviral, no proven efficiency
Bronchodilators may be trialed - FHx asthma, atopy

30. RSV prevention
RSV immunoglobulin - monthly injection during winter, CNLD
Oxygen dependent, < 2 years
Decreases hospital admissions (NNT 17) and ICU admission (NNT 50)
IMPACT study

31. Croup - laryngotracheobronchitis
Changing epidemiology
Viral cause - most common:
Parainfluenza

32. symptoms
Barking cough
Stridor
Hoarse voice
+/- URTI symptoms

33. BEWARE <4 months: structural airway lesions High fevers
Day time onset
Cord, laryngeal cyst, paillomatosis, extrinsic compression eg vascular ring
Tracheitis, abscess, epiglottitis (rare since HIB immunization)

34. treatment Humidification - placebo effect
Steroids - parenteral, oral, nebulized
Rapid onset of therapeutic effect - improvement within 1-2 hours and sustained
Nebulized adrenaline
intubation
Little work done on oral steroids - most on parental dexamethasone
Asthma doses benefit - duration of hospital stay, need for adrenaline, clinical parameters, dose can be repeated 24 hours later - prolonged courses unnecessary
Nebulized budesonide 2mg
Nebulized adrenaline: rapid improvement, duration of effect 2-3 hours
Traditionally admitted to hospital?home if no stridor at 2-3 hours, one dose only
Intubation - virtually never: if previous airway abnormality

35. Admit if Stridor at rest Needed nebulized adrenaline < 12 months
Past Hx severe croup
High risk child eg Down syndrome

36. Under 2 years Stridor -Laryngomalacia -Congenital lesion - biphasic
Congenital lung lesions
-CCAM

37. Thanks to Dr Scott Burgess PhD FRACP
Asthma in children
Thanks to
Dr Scott Burgess PhD FRACP

38. Outline What is asthma Pre-school wheeze Montelukast (Singulair)
Inhaled corticosteroids
LABAs
Difficult asthma / when to refer
Managing acute asthma in general practice

39. What is asthma? Asthma is characterised by four key features: Symptoms
Bronchoconstriction
Bronchodilation
Inflammation

40. What is asthma? Asthma is characterised by four key features: Symptoms
Bronchoconstriction
Bronchodilation
Inflammation
Wheeze:
Due to vibration of airways as gas flows through them
Most commonly expiratory
Parents often become confused by rattle from large airway secretions.

41. What is asthma? Asthma is characterised by four key features: Symptoms
Bronchoconstriction
Bronchodilation
Inflammation
Cough:
Cough is a common feature of asthma
However, a chronic isolated cough is not asthma and will not respond to salbutamol and ICS.

42. What is asthma? Asthma is characterised by four key features: Symptoms
Bronchoconstriction
Bronchodilation
Inflammation
Bronchoconstriction:
Narrowing of airways in response to a trigger
Basis of challenge testing and can be helpful in difficult diagnosis.

43. What is asthma? Asthma is characterised by four key features: Symptoms
Bronchoconstriction
Bronchodilation
Inflammation
Bronchodilation – reversible airways narrowing
Improvement in work of breathing and lung function following salbutamol
Again very helpful – lung function testing when child is unwell.

44. What is asthma? Asthma is characterised by four key features: Symptoms
Bronchoconstriction
Bronchodilation
Inflammation
Inflammation – most commonly eosinophilic
Basis of steroid treatment
Difficult to test – exhaled nitric oxide and induced sputum
Little known about inflammation in preschool wheeze.

45. Pre-school wheeze Small children have small air-pipes
Poiseuille’s law: flow is proportional to 4th power of the radius of the pipe
Small changes in the size of the pipes results in big changes in flow
Viral induced oedema can cause wheeze independent of smooth muscle constriction
Half of all children wheeze at some point
Infants whose mother’s smoke have narrower small airways
Some infants have narrower airways and wheeze with viral infections but grow out of the tendency to wheeze with time – transient wheezers.

46. Pre-school wheeze Pragmatically we divide children into:
Viral induced wheeze [viral exacerbations only]
Multi-trigger wheeze [viral exacerbations as well as symptoms with exercise, at night, exposure to smoke and allergens] (Brand 2008)
Mixed evidence regarding oral steroids in pre-school wheeze
Probably little and more likely no benefit (Csonka 2003 and Panickar 2009)
No benefit from parent initiated oral steroid in preschool wheeze (Vuillermin 2011)
No benefit from ICS in viral induced wheeze (Wilson 1995)
Modest benefit from ICS in children with multi-trigger wheeze [treat 7 children to prevent 1 exacerbation] (Castro-Rodriguez 2009)
ICS do not modify disease progress at any age.

47. Montelukast (Singulair)
Leukotreine receptor antagonist block receptors on smooth muscle and other cells, preventing the action of these mediators
The effects are modest:
Preschool wheeze – 9 children to prevent exacerbation and 19 to prevent medical review, no effect on hospitalisation rates
School aged wheeze – more effective but not as effective as ICS
Modest effect as add on to low dose ICS (not supported by PBS for this role)
Side-effects are very uncommon
Consider as first line for school aged children whose parents don’t want ICS (although low does ICS don’t have measurable side effects)
Role in exercise induced asthma.

48. Inhaled corticosteroids steroids (ICS)
When to start?
Frequent exacerbations (every 4-6 weeks regularly)
Persistent disease:
Symptoms between exacerbations (waking at night, minimal exertion, frequent wheeze)
Using reliever 2-3 times per week (except for exercise)
Abnormal lung function with bronchodilator response
Medication and dose
All inhaled steroids are much the same
Start low or moderate (eg Fluticasone ug/day) and wean as able
Steep dose response curve (most children controlled with 100 micrograms per day)
Side-effects more likely as increase, especially at 500 ug/day or higher.

49. Inhaled corticosteroids steroids (ICS) 2
How to give?
Puffer and spacer unless child refuses to use
Dry powder device only in those >= 7 years of age
Face mask only in those < 3 years of age
Must know how to use and demonstrate to child / parent
Check inhalation technique as regularly as you can
Placebos and information on lung delivery can be helpful
Wash spacer in soapy water and air dry to reduced static and increase delivery.

50. Long acting beta agonists (LABA) Seretide / Symbicort
Pre-school children: There are no trials of LABAs in pre-school children and no indications for prescription in this group (Do not prescribe to pre-school children)
LABA as add on to ICS: BTS guidelines
LABA plus low dose ICS vs moderate dose ICS
Safety and a note of caution: No evidence of significant adverse effects when used in combination with ICS. Adverse event profile in younger children not well recorded.

51. Difficult asthma / when to refer
Asthma that is not well controlled despite moderate dose ICS plus add on medication eg Seretide 500 ug / day
Previously - Difficult asthma clinic at Mater Children’s Hospital
6 years and older
Poorly controlled asthma
Physician, nurse, scientists, psychologist and research assistant
Top 3 reasons: Not asthma, poor inhalation technique, poor adherence
Comprehensive Asthma Assessment and Management Program
When to refer?
Worried about diagnosis: Chronic moist cough, poor weight gain, focal signs
Not well controlled on Flixotide 250 ug per day and good inhalation technique.

52. Managing acute asthma in your practice
Stay calm and keep them calm
Call for help (000) if severe or dose not respond to first dose of salbutamol
Airway and oxygen (keep sats >94%)
Given salbutamol [a lot] – Asthma foundation 4 puffs (but can give up to 12puffs)
Given oral prednisone 2mg/kg orally (no need for IV)
If responds:
Give written plan
Ensure knows how to give medication
Follow-up to review management
Patient should go to hospital if needing reliever more than every 3 hours.

53. Lung function testing in General Practice
Who performs LFT in children?
What are the barriers to performing lung function testing?

54. Top Tips Confirm the diagnosis ICS
History of musical not rattly wheeze, wheeze not cough
Review when unwell
Lung function testing
ICS
Low or moderate dose (Flixotide 50ug twice daily or 125 ug twice daily)
Do not use LABA 1st line or in pre-school children
Demonstrate use of spacer and check technique
Check for concerns as well as provide general educational information
Provide asthma plan
Ask about smoking / encourage stop smoking even if away from child.

55. Lung Volumes VT: Tidal Volume VC: Vital capacity
IRV: Inspiratory reserve volume IC: Inspiratory capacity
ERV: Expiratory reserve volume FRC: Functional reserve capacity RV: Residual volume TLC: Total lung capacity

56. In summary: Rapid flight through respiratory paediatrics
Common presentations to general practice
High percentage managed by general paediatricians
Definite role for tertiary specialists to treat, empower, educate and advocacy

57. Helping Kids Breathe and Sleep Better
OUR VISION:  To provide high quality holistic care in paediatric respiratory and sleep medicine to children and their families.
OUR MISSION: Q-Class will provide readily accessible comprehensive care to children with respiratory and sleep problems in a multidisciplinary setting and promote ongoing health and well-being in partnership with their family.
Helping Kids Breathe and Sleep Better

58. CASE STUDY - 1

59. Case Study - 1
Interpret flow volume loop
Possible diagnosis

60. CASE STUDY - 2

61. CASE STUDY - 2 Comment on flow volume loop
Comment on Bronchodilator response
Comment on FVC

62. CASE STUDY - 3

63. CASE STUDY - 4

64. CASE STUDY 3 & 4
Comment on the lung function values
What is the likely diagnosis
Comment on the mid expiratory flow values

65. CASE STUDY - 5 Comment on lung function values/loop
The residual volume is 230% predicted –likely diagnosis?

66. CASE STUDY -6

67. CASE STUDY - 6
Patient attended respiratory clinic for follow-up after ICU admission
The green highlighted value was at the time of ICU admission
Comment on possible diagnosis and long term outlook

68. CASE STUDY 7 These are lung function value of a 32 year old adult
What more information would you like to know?

69. CASE STUDY - 8
Well controlled asthmatic what other history would you ask?