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Respiratory Paediatrics For GP’s

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1 Respiratory Paediatrics For GP’s
Dr. Jennifer Townshend Consultant Paediatrician

2 Overview Context Some common presentations Common complains
Wheezy infant Wheezy child Chronic cough Respiratory paediatrics is a huge part of general paediatrics and something I imagine you see quite commonly in your day to day practice. The purpose of this evening is to go through some presentations of common conditions in the form of cases that I have been faced with and I’m sure will feel similar to all of you, and refresh your memories on best practice and to give you a structure for how to approach and manage these conditions within the context of your surgeries.

3 Blue background slides
Audience participation

4 Is it important? Respiratory distress is the most common complaint for which children seek medical care. Up to 10% of children have a persistent cough at any one time 1/3 of 1-5 year olds suffer recurrent wheeze

5 A familiar case? 9 year old boy Diagnosed with asthma 4 years ago
Never free from symptoms Ends up in hospital about once per year Nothing seems to be working

6 What are your thoughts? What do you want to know?
What else could be going on?

7 Subsequent questions Typical history of poorly controlled asthma
Very poor compliance Poor inhaler technique Smoking (never in the house) Chaotic family situation Parents separated last month Dad no idea what inhalers he takes

8 On examination Not clubbed, normal chest shape
Audible wheeze through out Lung function 65% predicted 18% reversibility post salbutamol Wheeze resolves post inhaler CXR normal Eosinophils 0.4, IgE 112

9 What is the likely diagnosis?
Poorly controlled atopic asthma

10 Are you concerned? RF for life threatening disease Poor compliance
Poor technique Chaotic social situation Parental smoking, risk of child smoking

11 Another familiar case? 18 month old girl
‘There’s something wrong with my child – she picks up everything. I think its her immune system’ ‘She’s always chesty, and pants with her breathing’ ‘This has been going on for as long as I can remember…..’

12 What do you think? What else do you want to know?
What could be going on? Some potential red flags – has this been going on since birth? Are these genuine recurrent chest infections?

13 Further questioning Well until 9 months of age
Developed viral URTI – very chesty at this time Clarify chesty means wheeze and dry cough’ Period where completely symptom free Subsequent pattern: URTI wheeze and SOB Resolves completely before the next episode Thriving No FH atopy, no premature birth Normal examination

14 What is the likely diagnosis?
Episodic viral wheeze

15 Wheeze

16 Wheeze What is it?

17 Wheeze What is it? ‘a continuous high pitched musical sound emitting from the chest in expiration as a result of narrowing of the small airways’

18 Wheeze Where does it come from? Closed cavity
Relationship between pressure and volume

19 Wheeze What causes it? All that wheezes is not asthma……..

20 Alerting symptom/Sign
Possible diagnosis Clinical Clue

21 Alerting symptom/Sign
Possible diagnosis Clinical Clue Wheeze present from birth Structural Laryngeal Congestive heart failure GORD +/- aspiration Present from birth Persistent wheeze, no variation Wheeze present shortly after birth BPD Compromised host defence CF Immunodeficiency PCD FTT, malabsorption FTT, rct infections FTT, rct ear infections Sudden onset in previously well child Foreign body aspiration History Unilateral reduced breath sounds Persistent wet cough Bronchiectasis Rct infections, FTT Purulent sputum Post viral wheeze Post bronchiolitic cough Obliterative bronchiolitis History of recent bronchiolitis Fine creps, hyperinfation

22 Asthma phenotypes Asthma more complex, especially in children
Different patterns of illness having different underlying pathogenesis Different phenotypes have different management strategies and different prognosis

23 Atopic Asthma Most commonly recognised phenotype
Classical characteristics

24 Atopic asthma - characteristics
School aged child Episodic ‘exacerbations’: (wet) cough/wheeze/SOB Interval symptoms: (dry) cough, nocturnal,exercise Identifiable triggers Personal/FH atopy Raised eosinophils/IgE

25 What about cough varient asthma?
Very rare to cough without wheeze in asthma (McKenzie, 1994) More likely to be a marker for another condition But, does exist – consider trial of asthma therapy if all other conditions excluded

26 Management of atopic asthma
Step wise approach to medication Support self management Education Shared decision making Asthma management plan Delivery techniques Avoidance of triggers Associated allergies? Regular review monitoring for side effects compliance

27 A few things to mention Inhaled corticosteroids
Friend? Foe? Practically? Long acting beta agonists Better then doubling dose of ICS But safe?? Mention significant benefit for all major outcome measures seen at moderate doses (400mcg bec) but relatively flat does response curve thereafter. Side effects more likely after 400mcg. Height velocity but adults attain near normal height. More worryingly adrenal suppression reports with number of reports of acute adrenal crisis and one death in 2001 If needing higher doses is diagnosis correct, is it genuinely severe? Avoidable triggers? Concordance and delivery? Other therapies to add on

28 Atopic asthma – when to refer
Many variables Secondary or tertiary? Expertise of the team, support from nursing staff, access to tertiary services Secondary – many have a good knowledge but may not have access to specialist nurse and or investigations that might help with the diagnosis.

29 Atopic asthma – when to refer
Feature Comment Poor response to 800mcg per day of beclomethasone or equivalent Patient should be on other therpies Concordance and drug delivery need careful assessment Poor response to 400mcg per day of beclomethasone and needs add on therapies the primary care physician is unfamiliar with Young child (< 5 yrs) where there is uncertainty over drug delivery Needs expertise of specialist asthma nurse Young child < 1yr where there is often doubt over the diagnosis Recurrent admission to hospital Suggests dangerous pattern of illness Particularly severe acute asthma such as needing IV therapies or intensive care These high risk patients should always be referred

30 Prognosis ¼ of children who have a wheezing illness at age 7 will wheeze at age 33 Majority have a period of remission in late adolescence followed by a relapse Recurrence of wheeze in later life is strongly associated with cigarette smoking and atopy

31 Asthma phenotypes (2) Atopic Asthma Episodic viral wheeze
‘the wheezing infant’

32 Episodic viral wheeze Characteristic features
Common following RSV infection Often no history of atopy Clear pattern on concurrent viral URTI Clear story of normality between episodes Response to bronchodilators in over 2’s

33 Episodic viral wheeze Risk factors for development into atopic phenotype FH/personal history of atopy Premature birth/low birth weight Smoking Bronchiolitis as an infant

34 Different phenotypes – so what?
Acute management Salbutamol in under 2’s Corticosteroids Long term management Prognosis

35 Episodic Viral Wheeze – prognosis
30-50% of children have one episode 66% out grow their symptoms before school age Atopic asthma can start with EVW but often have atopic phenotype and/or FH

36 Practically Consider other causes Try and identify the phenotype
Draw a time line of wheeze Manage according to severity and phenotype Acute symptoms Interval symptoms Symptoms Time

37 Some more cases….. 11 year old boy Presented ‘exacerbation of asthma’
Difficult to control asthma for years Primary symptom is cough Wet Every day No real relief from inhalers Some mild SOB, no real wheeze

38 What are your thoughts? What else do you want to know?

39 Further questioning No FH of atopy No personal history of atopy
No smoking in family Always hungry, but still slim

40 On examination Sats 91% in air Increased work of breathing
Hyperinflated No wheeze, no creps Clubbed

41 CXR: chronic changes Sweat test – confirmed Cystic fibrosis

42 Case 2 18 month old child Well until 13 months
‘Never been right since’ Coughs every day, no break in between

43 Further questioning Started nursery at 13 months
Recurrent episodes of runny nose Wet cough associated with runny nose Cough beginning to recede after a few weeks Then further runny nose and cough starts again Thriving

44 On examination Well child Nasal crusting Wet cough Normal chest shape
Chest clear to auscultation Recurrent viral URTI’s Reassure Reassess in summer months

45 Cough Important physiological reflex Common (up to 10% children)
OTC medicine – cochrane review Clears airways of secretions or aspirated material As a symptom it is none specific and many of the potential causes in children are different to those in adults OTC remedies for cough are among the most common given to children despite the lack of evidence for their use May provoke parental anxiety and disrupt sleep

46 Different cough types Acute cough Recurrent acute cough
Persistent none remitting cough Less than 3 weeks duration – usually URTI and self limiting 12 URTI’s per year, mainly in winter, cough up to 3 weeks each time – easy to look like a chronic cough Atrypical history, longer duration – more difficult to assess and often incorrectly diagnosed – eg asthma and inappropriately treated

47 Acute cough (< 3 weeks )
Vast majority viral URTI History and examination important to rule out chronic illness Consider Pertussis Allergy Inhaled foreign body Rarely – presenting feature of serious underlying disorder

48 When to consider CXR/Referral
Uncertainty about diagnosis of pneumonia IFB Possible chronic problem Prolonged clinical course True haemoptysis

49 How to manage acute cough
Antipyretics and fluids as required Antibiotics not beneficial in absence of signs of pneumonia Bronchodilators not helpful in children who don’t have asthma OTC remedies not effective Macrolide for pertussis EXPLANATION – reduce future consultations

50 Chronic cough Chronic cough > 8 weeks 3-8 weeks ‘grey area’
Subacute (post viral) Pertussis Prospective cohort study of school aged children presenting to primary care with a cough lasting longer than 14 days found around a third had serological evidence of recent pertussis infection and nearly 90% of these children had been fully immunised

51 Differential Structural Immunodeficiency
Suppurative (PBB, bronchiectasis) Recurrent aspiration Pertussis Retained IFB TB Bronchcospasm Intersitial lung disease/cardiac

52 Differential Structural Immunodeficiency
Suppurative (PBB, bronchiectasis) Recurrent aspiration Pertussis Retained IFB TB Bronchcospasm Intersitial lung disease/cardiac

53 Persistent Bacterial Bronchitis
Conducting airways Respiratory Spaces

54 Persistent Bacterial Bronchitis
Increasingly common cause chronic wet cough Age 5 mo – 14 years (3 years) Initial viral trigger ‘vicious circle theory’ Asthma can also be a trigger H. Influenzae (NT) & S. Pneumoniae Prolonged course antibiotics required (diagnosis) Is entirely curable Untreated may progress to bronchiectasis In one tertiary centre, of all children referred with persistent cough, following investigations which included a bronchoscopy, the most common diagnosis was PBB in 40%. More than 50% had been referred with a diagnosis of asthma. In primary care the distribution of diagnoses is likely to be different – more asthmatics are cared for in primary care, and there will be a higher prevelence of pertussis

55 Differentiating PBB from Asthma
Symptom PBB Asthma Age Typically < 6 yrs Typically > 5 yrs Cough type Wet (‘smokers’) Dry Cough duration Persistent Intermittent Change with posture Yes No SOB With coughing With exercise Wheeze ‘Rattle’ Genuine wheeze Response to antibiotics Dramatic (> 2 weeks) None (natural history)

56 Assessment Consider different types of cough

57 Types of cough Barking Honking Paroxysmal Chronic fruity Dry/tight
large airway Honking psychogenic Paroxysmal pertussis Chronic fruity suppurative Dry/tight bronchospasm Psychogenic – typically better in sleep or when child is distracted, more prominent if I the presence of teachers or care givers. Habit may be re-infored by secondary gain, eg time off school

58 History Nature of the cough Age of onset Feeding relation IFB?
Time, diurnal and sleep, sputum, wheeze Age of onset Feeding relation IFB? Relieving (beta agonist, ab’s) Cigarette smoke FH

59 Red flags When would you refer (when have you referred?)

60 Red flags – specialist referral
Neonatal onset Chronic wet cough Cough after choking episode Neuro-developmental problems Chest wall deformity Recurrent pneumonia Growth faltering Clubbing

61 Approach to management
Watchful waiting – 6-8 weeks Removal of aeroallergens Trial anti-asthma treatment Trial antibiotics for PBB Trial antiasthma treatment if genuine evidence of bronchial hyper=responsiveness, ensure effective delivery and drug doses, clearly define treatment outcomes eg symptoms diary /PEFR to be re-assed at 8-12 weeks then stop treatment and review the effect. If child > 6 and old enough for spirometry advise reversibility testing

62 Summary Respiratory paediatrics is fascinating!
…..and relevant to everyday practice Think of other causes of wheeze Identify asthma phenotypes Classify different cough types Consider PBB Refer if unsure

63 Thank you.

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