Presentation on theme: "Dr. Jennifer Townshend Consultant Paediatrician. Context Some common presentations Common complains ◦ Wheezy infant ◦ Wheezy child ◦ Chronic cough."— Presentation transcript:
Dr. Jennifer Townshend Consultant Paediatrician
Context Some common presentations Common complains ◦ Wheezy infant ◦ Wheezy child ◦ Chronic cough
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
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
What do you want to know? What else could be going on?
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
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
Poorly controlled atopic asthma
RF for life threatening disease ◦ Poor compliance ◦ Poor technique ◦ Chaotic social situation ◦ Parental smoking, risk of child smoking
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…..’
What else do you want to know? What could be going on?
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
Episodic viral 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’
Where does it come from? ◦ Closed cavity ◦ Relationship between pressure and volume
What causes it? All that wheezes is not asthma……..
Alerting symptom/Sign Possible diagnosisClinical 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 aspirationHistory Unilateral reduced breath sounds Persistent wet coughCompromised host defence Bronchiectasis Rct infections, FTT Purulent sputum Post viral wheezePost bronchiolitic cough Obliterative bronchiolitis History of recent bronchiolitis Fine creps, hyperinfation
Asthma more complex, especially in children Different patterns of illness having different underlying pathogenesis Different phenotypes have different management strategies and different prognosis
Most commonly recognised phenotype Classical characteristics
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
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
Inhaled corticosteroids ◦ Friend? Foe? Practically? Long acting beta agonists ◦ Better then doubling dose of ICS ◦ But safe??
Many variables Secondary or tertiary?
FeatureComment 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 hospitalSuggests dangerous pattern of illness Particularly severe acute asthma such as needing IV therapies or intensive care These high risk patients should always be referred
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
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
Risk factors for development into atopic phenotype ◦ FH/personal history of atopy ◦ Premature birth/low birth weight ◦ Smoking ◦ Bronchiolitis as an infant
Acute management ◦ Salbutamol in under 2’s ◦ Corticosteroids Long term management 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
Consider other causes Try and identify the phenotype Draw a time line of wheeze Manage according to severity and phenotype Time Symptoms Acute symptoms Interval symptoms
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
What else do you want to know?
No FH of atopy No personal history of atopy No smoking in family Always hungry, but still slim
Sats 91% in air Increased work of breathing Hyperinflated No wheeze, no creps Clubbed
18 month old child Well until 13 months ‘Never been right since’ Coughs every day, no break in between
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
Well child Nasal crusting Wet cough Normal chest shape Chest clear to auscultation Recurrent viral URTI’s Reassure Reassess in summer months
Important physiological reflex Common (up to 10% children) OTC medicine – cochrane review
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
Uncertainty about diagnosis of pneumonia IFB Possible chronic problem Prolonged clinical course True haemoptysis
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
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
Watchful waiting – 6-8 weeks Removal of aeroallergens Trial anti-asthma treatment Trial antibiotics for PBB
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