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Dr. Jennifer Townshend Consultant Paediatrician.  Context  Some common presentations  Common complains ◦ Wheezy infant ◦ Wheezy child ◦ Chronic cough.

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Presentation on theme: "Dr. Jennifer Townshend Consultant Paediatrician.  Context  Some common presentations  Common complains ◦ Wheezy infant ◦ Wheezy child ◦ Chronic cough."— Presentation transcript:

1 Dr. Jennifer Townshend Consultant Paediatrician

2  Context  Some common presentations  Common complains ◦ Wheezy infant ◦ Wheezy child ◦ Chronic cough

3 Audience participation

4  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  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 do you want to know?  What else could be going on?

7  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  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  Poorly controlled atopic asthma

10  RF for life threatening disease ◦ Poor compliance ◦ Poor technique ◦ Chaotic social situation ◦ Parental smoking, risk of child smoking

11  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 else do you want to know?  What could be going on?

13  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  Episodic viral wheeze

15

16  What is it?

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

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

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

20 Alerting symptom/SignPossible diagnosisClinical Clue

21 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

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

23  Most commonly recognised phenotype  Classical characteristics

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

25  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  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  Inhaled corticosteroids ◦ Friend? Foe? Practically?  Long acting beta agonists ◦ Better then doubling dose of ICS ◦ But safe??

28  Many variables  Secondary or tertiary?

29 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

30  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  Atopic Asthma  Episodic viral wheeze ‘the wheezing infant’

32  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  Risk factors for development into atopic phenotype ◦ FH/personal history of atopy ◦ Premature birth/low birth weight ◦ Smoking ◦ Bronchiolitis as an infant

34  Acute management ◦ Salbutamol in under 2’s ◦ Corticosteroids  Long term management  Prognosis

35  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  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

37  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 else do you want to know?

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

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

41  CXR: chronic changes  Sweat test – confirmed Cystic fibrosis

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

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

45  Important physiological reflex  Common (up to 10% children)  OTC medicine – cochrane review

46  Acute cough  Recurrent acute cough  Persistent none remitting cough

47  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  Uncertainty about diagnosis of pneumonia  IFB  Possible chronic problem  Prolonged clinical course  True haemoptysis

49  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 > 8 weeks  3-8 weeks ‘grey area’ ◦ Subacute (post viral) ◦ Pertussis

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

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

53 Conducting airways Respiratory Spaces

54  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

55 SymptomPBBAsthma AgeTypically < 6 yrsTypically > 5 yrs Cough typeWet (‘smokers’)Dry Cough durationPersistentIntermittent Change with postureYesNo SOBWith coughingWith exercise Wheeze‘Rattle’Genuine wheeze Response to antibioticsDramatic (> 2 weeks)None (natural history)

56  Consider different types of cough

57  Barking ◦ large airway  Honking ◦ psychogenic  Paroxysmal ◦ pertussis  Chronic fruity ◦ suppurative  Dry/tight ◦ bronchospasm

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

59  When would you refer (when have you referred?)

60  Neonatal onset  Chronic wet cough  Cough after choking episode  Neuro-developmental problems  Chest wall deformity  Recurrent pneumonia  Growth faltering  Clubbing

61  Watchful waiting – 6-8 weeks  Removal of aeroallergens  Trial anti-asthma treatment  Trial antibiotics for PBB

62  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


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