Presentation on theme: "Respiratory Paediatrics For GP’s"— Presentation transcript:
1 Respiratory Paediatrics For GP’s Dr. Jennifer TownshendConsultant Paediatrician
2 Overview Context Some common presentations Common complains Wheezy infantWheezy childChronic coughRespiratory 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.
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 time1/3 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 symptomsEnds up in hospital about once per yearNothing 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 compliancePoor inhaler techniqueSmoking (never in the house)Chaotic family situationParents separated last monthDad no idea what inhalers he takes
8 On examination Not clubbed, normal chest shape Audible wheeze through outLung function 65% predicted18% reversibility post salbutamolWheeze resolves post inhalerCXR normalEosinophils 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 techniqueChaotic social situationParental 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 timeClarify chesty means wheeze and dry cough’Period where completely symptom freeSubsequent pattern:URTI wheeze and SOBResolves completely before the next episodeThrivingNo FH atopy, no premature birthNormal examination
14 What is the likely diagnosis? Episodic viral wheeze
17 WheezeWhat 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 WheezeWhat causes it?All that wheezes is not asthma……..
20 Alerting symptom/Sign Possible diagnosisClinical Clue
21 Alerting symptom/Sign Possible diagnosisClinical ClueWheeze present from birthStructuralLaryngealCongestive heart failureGORD +/- aspirationPresent from birthPersistent wheeze, no variationWheeze present shortly after birthBPDCompromised host defenceCFImmunodeficiencyPCDFTT, malabsorptionFTT, rct infectionsFTT, rct ear infectionsSudden onset in previously well childForeign body aspirationHistoryUnilateral reduced breath soundsPersistent wet coughBronchiectasisRct infections, FTTPurulent sputumPost viral wheezePost bronchiolitic coughObliterative bronchiolitisHistory of recent bronchiolitisFine creps, hyperinfation
22 Asthma phenotypes Asthma more complex, especially in children Different patterns of illness having different underlying pathogenesisDifferent phenotypes have different management strategies and different prognosis
23 Atopic Asthma Most commonly recognised phenotype Classical characteristics
25 What about cough varient asthma? Very rare to cough without wheeze in asthma (McKenzie, 1994)More likely to be a marker for another conditionBut, does exist – consider trial of asthma therapy if all other conditions excluded
26 Management of atopic asthma Step wise approach to medicationSupport self managementEducationShared decision makingAsthma management planDelivery techniquesAvoidance of triggersAssociated allergies?Regular reviewmonitoring for side effectscompliance
27 A few things to mention Inhaled corticosteroids Friend? Foe? Practically?Long acting beta agonistsBetter then doubling dose of ICSBut 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 2001If 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 variablesSecondary or tertiary?Expertise of the team, support from nursing staff, access to tertiary servicesSecondary – 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 FeatureCommentPoor response to 800mcg per day of beclomethasone or equivalentPatient should be on other therpiesConcordance and drug delivery need careful assessmentPoor response to 400mcg per day of beclomethasone and needs add on therapies the primary care physician is unfamiliar withYoung child (< 5 yrs) where there is uncertainty over drug deliveryNeeds expertise of specialist asthma nurseYoung child < 1yr where there is often doubt over the diagnosisRecurrent admission to hospitalSuggests dangerous pattern of illnessParticularly severe acute asthma such as needing IV therapies or intensive careThese high risk patients should always be referred
30 Prognosis¼ of children who have a wheezing illness at age 7 will wheeze at age 33Majority have a period of remission in late adolescence followed by a relapseRecurrence of wheeze in later life is strongly associated with cigarette smoking and atopy
32 Episodic viral wheeze Characteristic features Common following RSV infectionOften no history of atopyClear pattern on concurrent viral URTIClear story of normality between episodesResponse to bronchodilators in over 2’s
33 Episodic viral wheezeRisk factors for development into atopic phenotypeFH/personal history of atopyPremature birth/low birth weightSmokingBronchiolitis as an infant
34 Different phenotypes – so what? Acute managementSalbutamol in under 2’sCorticosteroidsLong term managementPrognosis
35 Episodic Viral Wheeze – prognosis 30-50% of children have one episode66% out grow their symptoms before school ageAtopic 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 wheezeManage according to severity and phenotypeAcutesymptomsInterval symptomsSymptomsTime
37 Some more cases….. 11 year old boy Presented ‘exacerbation of asthma’ Difficult to control asthma for yearsPrimary symptom is coughWetEvery dayNo real relief from inhalersSome 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 familyAlways hungry, but still slim
40 On examination Sats 91% in air Increased work of breathing HyperinflatedNo wheeze, no crepsClubbed
41 CXR: chronic changesSweat 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 noseWet cough associated with runny noseCough beginning to recede after a few weeksThen further runny nose and cough starts againThriving
44 On examination Well child Nasal crusting Wet cough Normal chest shape Chest clear to auscultationRecurrent viral URTI’sReassureReassess in summer months
45 Cough Important physiological reflex Common (up to 10% children) OTC medicine – cochrane reviewClears airways of secretions or aspirated materialAs a symptom it is none specific and many of the potential causes in children are different to those in adultsOTC remedies for cough are among the most common given to children despite the lack of evidence for their useMay provoke parental anxiety and disrupt sleep
46 Different cough types Acute cough Recurrent acute cough Persistent none remitting coughLess than 3 weeks duration – usually URTI and self limiting12 URTI’s per year, mainly in winter, cough up to 3 weeks each time – easy to look like a chronic coughAtrypical history, longer duration – more difficult to assess and often incorrectly diagnosed – eg asthma and inappropriately treated
47 Acute cough (< 3 weeks ) Vast majority viral URTIHistory and examination important to rule out chronic illnessConsiderPertussisAllergyInhaled foreign bodyRarely – presenting feature of serious underlying disorder
48 When to consider CXR/Referral Uncertainty about diagnosis of pneumoniaIFBPossible chronic problemProlonged clinical courseTrue haemoptysis
49 How to manage acute cough Antipyretics and fluids as requiredAntibiotics not beneficial in absence of signs of pneumoniaBronchodilators not helpful in children who don’t have asthmaOTC remedies not effectiveMacrolide for pertussisEXPLANATION – reduce future consultations
50 Chronic cough Chronic cough > 8 weeks 3-8 weeks ‘grey area’ Subacute (post viral)PertussisProspective 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
54 Persistent Bacterial Bronchitis Increasingly common cause chronic wet coughAge 5 mo – 14 years (3 years)Initial viral trigger ‘vicious circle theory’Asthma can also be a triggerH. Influenzae (NT) & S. PneumoniaeProlonged course antibiotics required (diagnosis)Is entirely curableUntreated may progress to bronchiectasisIn 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 SymptomPBBAsthmaAgeTypically < 6 yrsTypically > 5 yrsCough typeWet (‘smokers’)DryCough durationPersistentIntermittentChange with postureYesNoSOBWith coughingWith exerciseWheeze‘Rattle’Genuine wheezeResponse to antibioticsDramatic (> 2 weeks)None (natural history)
57 Types of cough Barking Honking Paroxysmal Chronic fruity Dry/tight large airwayHonkingpsychogenicParoxysmalpertussisChronic fruitysuppurativeDry/tightbronchospasmPsychogenic – 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, wheezeAge of onsetFeeding relationIFB?Relieving (beta agonist, ab’s)Cigarette smokeFH
59 Red flagsWhen would you refer(when have you referred?)
60 Red flags – specialist referral Neonatal onsetChronic wet coughCough after choking episodeNeuro-developmental problemsChest wall deformityRecurrent pneumoniaGrowth falteringClubbing
61 Approach to management Watchful waiting – 6-8 weeksRemoval of aeroallergensTrial anti-asthma treatmentTrial antibiotics for PBBTrial 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 practiceThink of other causes of wheezeIdentify asthma phenotypesClassify different cough typesConsider PBBRefer if unsure
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