Presentation on theme: "Management of Respiratory Problems in Children"— Presentation transcript:
1Management of Respiratory Problems in Children DR SADASIVAM SURESH
2Learning objectives:Increase understanding of common respiratory disorders in childrenTo be able to recognise common respiratory symptoms and presentations in a child under 2 years of ageTo understand the ongoing management and surveillance in paediatric asthmaInvestigations in children with respiratory problem - a systematic approachMultidisciplinary management in chronic conditions.Antibiotics and physiotherapy - synergy in management of chronic respiratory conditions
17Management points Value of CXR Chronic Bronchitis of unknown aetiology Follow-up CXR & timingChronic Bronchitis of unknown aetiologyPhysiotherapyProlonged course of antibioticsRole of BronchoscopySequential investigation
20What is it and what to do about it. Bronchiolitis CroupWhat is it and what to do about it.
21bronchiolitis Affects infants, males = females At risk - bottle fed, crowding- CHD, CNLDCausesRSVHuman metapneumovirusInfluenzaparainfluenza (3)adenovirusIllness predominately seen in infantsHospitalized - 80% in 1st year 50% 1-3 monthsSevere bronciolitis more severe in males
25RSV Predominant pathogen 2 strains - A and B All children exposed by 3 yearsSpreads from nasopharynx to lungsKills respiratory epithelial cellsIn vitro - large syncytiaA may be associated with more severe disease
26Pathogenesis Ciliated epithelial necrosis Mononuclear cell infiltrate, oedema, mucous plugsCXR - hyperinflation and patchy infiltrates, collapseRepair - cilia by day 15Thought to be little smooth muscle contraction - little response to bronchdiloators
27Clinical Incubation - 5 days Coryza tachypnoea, wheeze, crackles, hypoxia - 1 to 3 weeksBacterial superinfection rare (1-2%)Residual symptomsWheeze average 9 days, ceases with coincident rise in secretory IgA
33BEWARE <4 months: structural airway lesions High fevers Day time onsetCord, laryngeal cyst, paillomatosis, extrinsic compression eg vascular ringTracheitis, abscess, epiglottitis (rare since HIB immunization)
34treatment Humidification - placebo effect Steroids - parenteral, oral, nebulizedRapid onset of therapeutic effect - improvement within 1-2 hours and sustainedNebulized adrenalineintubationLittle work done on oral steroids - most on parental dexamethasoneAsthma doses benefit - duration of hospital stay, need for adrenaline, clinical parameters, dose can be repeated 24 hours later - prolonged courses unnecessaryNebulized budesonide 2mgNebulized adrenaline: rapid improvement, duration of effect 2-3 hoursTraditionally admitted to hospital?home if no stridor at 2-3 hours, one dose onlyIntubation - virtually never: if previous airway abnormality
35Admit if Stridor at rest Needed nebulized adrenaline < 12 months Past Hx severe croupHigh risk child eg Down syndrome
37Thanks to Dr Scott Burgess PhD FRACP Asthma in childrenThanks toDr Scott Burgess PhD FRACP
38Outline What is asthma Pre-school wheeze Montelukast (Singulair) Inhaled corticosteroidsLABAsDifficult asthma / when to referManaging acute asthma in general practice
39What is asthma? Asthma is characterised by four key features: Symptoms BronchoconstrictionBronchodilationInflammation
40What is asthma? Asthma is characterised by four key features: Symptoms BronchoconstrictionBronchodilationInflammationWheeze:Due to vibration of airways as gas flows through themMost commonly expiratoryParents often become confused by rattle from large airway secretions.
41What is asthma? Asthma is characterised by four key features: Symptoms BronchoconstrictionBronchodilationInflammationCough:Cough is a common feature of asthmaHowever, a chronic isolated cough is not asthma and will not respond to salbutamol and ICS.
42What is asthma? Asthma is characterised by four key features: Symptoms BronchoconstrictionBronchodilationInflammationBronchoconstriction:Narrowing of airways in response to a triggerBasis of challenge testing and can be helpful in difficult diagnosis.
43What is asthma? Asthma is characterised by four key features: Symptoms BronchoconstrictionBronchodilationInflammationBronchodilation – reversible airways narrowingImprovement in work of breathing and lung function following salbutamolAgain very helpful – lung function testing when child is unwell.
44What is asthma? Asthma is characterised by four key features: Symptoms BronchoconstrictionBronchodilationInflammationInflammation – most commonly eosinophilicBasis of steroid treatmentDifficult to test – exhaled nitric oxide and induced sputumLittle known about inflammation in preschool wheeze.
45Pre-school wheeze Small children have small air-pipes Poiseuille’s law: flow is proportional to 4th power of the radius of the pipeSmall changes in the size of the pipes results in big changes in flowViral induced oedema can cause wheeze independent of smooth muscle constrictionHalf of all children wheeze at some pointInfants whose mother’s smoke have narrower small airwaysSome infants have narrower airways and wheeze with viral infections but grow out of the tendency to wheeze with time – transient wheezers.
46Pre-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 wheezeProbably 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.
47Montelukast (Singulair) Leukotreine receptor antagonist block receptors on smooth muscle and other cells, preventing the action of these mediatorsThe effects are modest:Preschool wheeze – 9 children to prevent exacerbation and 19 to prevent medical review, no effect on hospitalisation ratesSchool aged wheeze – more effective but not as effective as ICSModest effect as add on to low dose ICS (not supported by PBS for this role)Side-effects are very uncommonConsider 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.
48Inhaled 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 responseMedication and doseAll inhaled steroids are much the sameStart low or moderate (eg Fluticasone ug/day) and wean as ableSteep dose response curve (most children controlled with 100 micrograms per day)Side-effects more likely as increase, especially at 500 ug/day or higher.
49Inhaled corticosteroids steroids (ICS) 2 How to give?Puffer and spacer unless child refuses to useDry powder device only in those >= 7 years of ageFace mask only in those < 3 years of ageMust know how to use and demonstrate to child / parentCheck inhalation technique as regularly as you canPlacebos and information on lung delivery can be helpfulWash spacer in soapy water and air dry to reduced static and increase delivery.
50Long 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 guidelinesLABA plus low dose ICS vs moderate dose ICSSafety 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.
51Difficult asthma / when to refer Asthma that is not well controlled despite moderate dose ICS plus add on medication eg Seretide 500 ug / dayPreviously - Difficult asthma clinic at Mater Children’s Hospital6 years and olderPoorly controlled asthmaPhysician, nurse, scientists, psychologist and research assistantTop 3 reasons: Not asthma, poor inhalation technique, poor adherenceComprehensive Asthma Assessment and Management ProgramWhen to refer?Worried about diagnosis: Chronic moist cough, poor weight gain, focal signsNot well controlled on Flixotide 250 ug per day and good inhalation technique.
52Managing acute asthma in your practice Stay calm and keep them calmCall for help (000) if severe or dose not respond to first dose of salbutamolAirway 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 planEnsure knows how to give medicationFollow-up to review managementPatient should go to hospital if needing reliever more than every 3 hours.
53Lung function testing in General Practice Who performs LFT in children?What are the barriers to performing lung function testing?
54Top Tips Confirm the diagnosis ICS History of musical not rattly wheeze, wheeze not coughReview when unwellLung function testingICSLow or moderate dose (Flixotide 50ug twice daily or 125 ug twice daily)Do not use LABA 1st line or in pre-school childrenDemonstrate use of spacer and check techniqueCheck for concerns as well as provide general educational informationProvide asthma planAsk about smoking / encourage stop smoking even if away from child.
56In summary: Rapid flight through respiratory paediatrics Common presentations to general practiceHigh percentage managed by general paediatriciansDefinite role for tertiary specialists to treat, empower, educate and advocacy
57Helping 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