Presentation on theme: "The Wheezing Child: assessment, treatment and referral"— Presentation transcript:
1 The Wheezing Child: assessment, treatment and referral Dr Christopher Hands, ST5 Paediatric RegistrarCroydon University Hospital, Thursday 11th September 2014
2 The Wheezing Child Why this talk: Common paediatric presenting problem End point of variety of pathological processesLarge burden of diseaseFrequent diagnostic uncertaintyWide variations in management amongst paediatricians and primary care physicians
5 Guidelines Guidelines on which this talk is based: SIGN (2006), Bronchiolitis in childrenSIGN/BTS (2012), British guideline on the management of asthmaBTS (2011) Guidelines for the management of community acquired pneumonia in children
6 BronchiolitisVirtually all infants are infected by RSV by the age of three years, around 40% to 50% develop involvement of the lower respiratory tract and 2% to 3% develop severe disease leading to hospitalisationPre-existing anatomical and immunological abnormalities related to maternal smoking in pregnancy in particular may mean that an RSV infection presents as severe bronchiolitis, rather than a mild respiratory illnessAirway oedema and mucus plugging are the predominant pathological features in infants with acute viral bronchiolitis
9 Bronchiolitis (2) Factors which predispose to acute bronchiolitis • Otherwise normal babies admitted to hospital for acute bronchiolitis have evidence of airflow obstruction before their bronchiolitic illness and this is still present at age 11 years• Evidence exists of abnormality of immune function in umbilical cord blood in babies of mothers who smoke during pregnancy and these babies subsequently develop RSV infection; the relation of these changes to RSV bronchiolitis has yet to be worked out in detail• In preterm babies who have airflow obstruction as a consequence of prematurity and of its treatment, a lesser degree of airway inflammation than usual can cause serious respiratory compromise
10 Bronchiolitis (3)Absolute indications for hospital referral for acute bronchiolitis• Cyanosis or really severe respiratory distress (respiratory rate >70 breaths/min, nasal flaring and/or grunting, severe chest wall recession)• Marked lethargy leading to poor feeding• Respiratory distress preventing feeding (<50% of usual intake in past 24 hours)• Apnoeic episodes• Diagnostic uncertainty (toxic infant, temperature ≥40 degrees centigrade)
11 Bronchiolitis (4)Relative indications for hospital referral for acute bronchiolitisPeak severity of illness day 3 – day 4• Congenital heart disease• Any survivor of extreme prematurity• Any pre-existing lung disease or immunodeficiency• Down's syndrome: these babies have a degree of pulmonary hypoplasia and may also have potential or actual upper airway obstruction• Social factors: isolated family (concerns about the ability of the family to notice any deterioration)
12 Bronchiolitis (5) Treatment: No evidence for efficacy of bronchodilators or steroids; both can have important adverse effectsIn hospital, nebulised hypertonic saline reduces length of staySIGN guideline is evidence-basedNICE guidance expected April 2015
13 Post-bronchiolitis symptoms Cough and wheeze may last several weeks after bronchiolitis (post-bronchiolitic syndrome)Intermittent symptoms may continue for several yearsNo study has shown that inhaled steroids are effectiveWheezing exacerbations may respond to standard bronchodilator therapy
14 Post-bronchiolitis symptoms (2) The relation between RSV infection and subsequent asthma is hotly debatedHowever, pre-existing atopy may be a marker for more severe bronchiolitis, and atopy itself predisposes to asthma
15 Asthma VIW/asthma most common paediatric ED presentation Major cause of morbidity and hospital admission, especially in winter monthsPreventative medication commonly under-used1.1 million children in the UK have asthma – 1 in 11 (Asthma UK)
20 Indications for specialist referral in children
21 Virus-induced wheezeBetween one quarter and one half of all pre-school children have symptoms of wheeze with a respiratory infectionMost do not go on to develop asthmaUnder-5s with episodic wheeze but without interval symptoms do not have asthma-type airway inflammation, and are not helped by steroidsEpisodes of wheeze and a history of atopy are strongly predictive of those who will develop asthma
22 Paediatric pneumoniaIn a study, the incidence of childhood community- acquired pneumonia was found to be 14.4/10,000 for year-olds, and 33.8/10,000 for children less than five years oldBetween 2006 and 2008, admission rates for childhood CAP declined by 19%, after the introduction of the conjugate pneumococcal vaccine (PCV7)S pneumoniae is still the most common cause of childhood CAPViruses cause 1/3-2/3 of cases of CAPMycoplasma is an important cause of CAP in school aged children
23 Paediatric pneumonia (2) Bacterial pneumonia should be considered in children when there is persistent or repetitive fever >38.5 degrees together with chest recession and a raised respiratory rateChildren with signs and symptoms of pneumonia who are not admitted to hospital should not have a chest x-rayAll children with a clear clinical diagnosis of pneumonia should receive antibiotics as bacterial and viral pneumonia cannot reliably be distinguished from each other.
24 Paediatric pneumonia (3) Children aged <2 years presenting with mild symptoms of lower respiratory tract infection do not usually have pneumonia and need not be treated with antibiotics but should be reviewed if symptoms persistAmoxicillin is recommended as first choice for oral antibiotic therapy in all children because it is effective against the majority of pathogens which cause CAP in this group, is well tolerated and cheap.
27 Case 15 year-old boy5th child of 7 in Somali family living in 2 bedroom house in NorburyMother reports that he has been coughing ‘off and on’ for the last six monthsOn direct questioning she says she thinks it’s worse at nightVitamin D deficiency, takes Abidec; no allergiesImms up to date up to one year; has not had pre-school boosterBorn in Somalia at term; came to UK one year ago
28 Case 1: Examination Active, bright and alert, thin Allergic nasal creaseHarrison’s sulciNo respiratory distressSlightly prolonged expiratory phase; faint end-expiratory wheeze throughoutPEFR 80% of predictedExamination otherwise unremarkable
29 Case 1: Questions Does this child need further investigations? What treatment would you initiate?
30 Case 2 8 month-old Hungarian girl Has been coughing for the last two days with a runny noseMother brought her to the surgery today because she ‘seems to be having difficulty catching her breath’Doesn’t want to drink as much milk as normal, but is eating her normal finger foods and riceBorn in the UK at 36 weeks by caesarian section; stayed in hospital for five days because of jaundiceNo medical problems, Health Start vitamins, immunisations up-to-dateNo family history of atopy
31 Case 2: Examination Active, alert, coughing Smiling and playful Normal posture and movementsHeart rate 130, normal heart sounds, no murmursCapillary refill time 1.5 secondsTemperature 37.8 degreesRespiratory rate 55; moderate subcostal recession and some intercostal recessionShowers of fine crackles throughout the lung fields; polyphonic wheeze throughout(Oxygen saturations 97%)
32 Case 2: Questions Does this child need further investigations? What treatment would you initiate?
33 Case 33 year-old girlHas been unwell with a temperature and a cough since yesterday; doesn’t seem to be improvingMother has noticed that her daughter is having difficulty breathingHas been eating and drinking ok, still passing urine regularlyBorn at term; hospital admission for bronchiolitis at four months, otherwise has been well.No medications; immunisations up-to-date
34 Case 3: Examination Alert, watchful and miserable Clinging to her motherTemperature 38.5, heart rate 140, capillary refill time one secondRespiratory rate 40; moderate subcostal recessionOxygen saturations 95%Reduced air entry and fine expiratory crackles at the right base
35 Case 3: Questions Does this child need further investigations? What treatment would you initiate?
36 Case 4 2 year-old Ghanaian boy Developed runny nose and cough last night (both elder brothers unwell with colds)This lunchtime started to have difficulty breathing and his mother can hear wheezingBorn at term in the UK, normally wellHas eczema, normally managed with emollients; has had two courses of topical steroids in the last six monthsHas never had wheeze beforeImmunisations up-to-dateBoth brothers have hayfever; mother has hayfever and eczema
37 Case 4: Examination Alert, happy, breathless Temperature 37.9 degrees Respiratory rate 60; oxygen saturations 93%Good air entry throughout; widespread harsh wheezeHeart rate 120; capillary refill time 2 secondsGiven salbutamol 100 micrograms ten puffs via spacer in the surgeryFollowing therapy:Respiratory rate 35; oxygen saturations 98%; minimal wheezeHeart rate 150
38 Case 4: QuestionsDoes this child need further assessment in the emergency department?What treatment would you initiate?Is there a role for oral steroids in this child’s treatment?
39 Case 58 week-old boy, seen with mother and two elder sisters, aged 3 years and 5 yearsStarted coughing this afternoon; now seems to have some difficulty in breathingMother thought he felt hot; measured his temperature as at homeBorn at 35 weeks by emergency caesarian section because of antepartum haemorrhageMother smoked throughout pregnancyBirthweight 1.8kg; current weight 2.9kgHas been well since birthMother is a single parent and has two further children at home, aged 7 and 10 years; all her other children are currently well
40 Case 5: Examination Active, alert, smiling Normal posture and movementsTemperature 38 degreesHR 140; capillary refill time 1 secondOxygen saturations 98%RR 50; mild-moderate subcostal recessionProlonged expiratory phaseGood air entry throughout; scattered crackles and faint wheeze throughout
41 Case 5: Questions What is the likely course of this child’s illness? Does this child need further assessment in the emergency department?What treatment would you initiate?
42 Case 65 year-old boyBecame unwell with cough and fever yesterday morningToday has had increasing difficulty in breathing and his chest hurtsBorn at term; no postnatal problemsUsed to have a salbutamol inhaler for intermittent episodes of wheezing, but it was lost a few months agoNo other medical problems; no medicationsNo family history of atopyNot immunised as his parents ‘don’t believe in it’
43 Case 6: examination Alert, miserable, coughing Temperature 38.5 degrees (paracetamol 2 hours ago)Respiratory rate 40; oxygen saturations 95%Does not cooperate with peak flow measurementProlonged expiratory phase; moderate subcostal recessionMinimal air entry left lower zone; widespread wheeze; resonant to percussion throughoutGiven ten puffs of salbutamol inhaler via spacer:Oxygen saturations 95%; minimal air entry left lower zone; respiratory rate 40; no wheeze
44 Case 6: Questions Does this child need further investigations? What treatment would you initiate?Does this child need any ongoing therapy?
45 Case 7 9 month-old Zambian girl (corrected gestational age) Cough and gradually worsening difficulty in breathing since yesterdayOnly child; both mother and father have coldsTwo previous hospital admissions with breathing difficulties, and has been assessed on several other occasions in the emergency departmentStage 3 retinopathy of prematurity; treated with laserTakes Abidec and SytronBorn in the UK at 27 weeks’ gestationStayed in NICU for 8 weeks; discharged home in air
46 Case 7: examination Alert, smiling Wriggling and trying to escape from mother’s lapTemperature 38 degreesHR 120; capillary refill time one secondOxygen saturations 97%Respiratory rate 45; moderate subcostal recessionGood air entry throughout; polyphonic wheeze heard throughoutTrial of inhaled salbutamol: no difference to wheeze or respiratory rate
47 Case 7: QuestionsDoes this child need further assessment in the emergency department?What treatment would you initiate?What is the diagnosis?
49 Summary PointsWheeze is caused by different pathophysiological processesAge of the child aids differentiation of disease processBronchiolitis: supportive care onlyMost infants with bronchiolitis don’t need hospital admissionMost children under 2 with mild-moderate symptoms don’t have pneumoniaMost pre-school children with wheeze don’t have asthmaMany asthma admissions are provoked by poor preventer use/lost salbutamol inhaler
50 References1. Bush A, Thomson A, ‘Acute Bronchiolitis’ British Medical Journal 2007;335:10372. British Thoracic Society Community Acquired Pneumonia in Children Group, 'Guidelines for the management of community acquired pneumonia in children: update 2011', Thorax 66: Supplement 23. Frank PI et al, ‘Long term prognosis in preschool children with wheeze: longitudinal postal questionnaire study ’, British Medical Journal 2008;336:1423-6
51 References (2)4. Maclennan C et al, ‘Airway inflammation in asymptomatic children with episodic wheeze’, Pediatric Pulmonology 2006; 41(6):577-835. Panickar J et al, 'Oral prednisolone for preschool children with acute virus-induced wheezing' New England Journal of Medicine 2009; 360:6. Scottish Intercollegiate Guidelines Network (2006), 'Bronchiolitis in children’7. Scottish Intercollegiate Guidelines Network and the British Thoracic Society (2012), ‘British guideline on the management of asthma’