dr julian vyas - gp cme north/sat_room7_0830... · pathway gpcme . parental use of terminology is...

Dr Julian VyasRespiratory Paediatrician

Auckland

8:30 - 9:25 WS #97: Kids with Wheezing or Reflux?

9:35 - 10:30 WS #109: Kids with Wheezing or Reflux? (Repeated)

GPCME

Wheeze or Reflux

- in children

Julian Vyas

Respiratory Paediatrician

STARSHIP HOSPITAL

No Conflicts of Interest to Declare

GPCME

Who is this?

What did he do?

Paediatric Update GPCME

what is wheeze?

Definition:A wheeze is a high-pitched, musical, adventitious lung sound produced by

airflow through narrowed airways.

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wheeze indicates turbulent i.e. abnormal airflow

through an airway.

Can be:

• acute or chronic

• focal or diffuse

• monophonic or polyphonic

what does “wheeze” mean?

Indicates

different

underlying

pathologies

W final

common

pathway

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Parental use of terminology is unreliable

• whistling, squeaking, gasping, abnormal rate or style of breathing, or same as cough (1-5)

• Tokelau (Crane, ISAAC Study) - video questionnaire - “wheeze” also used for SOB, and (6)

cough

1: Elphick, ADC 20012: Michel, ERJ 20063: Elphick ERJ 20004: Cane ADC 20005: Cane, ADC 20016: Crane, ERJ 2003 Elphick, ADC 2001

what is wheeze?

terminology used by parents

to describe noisy breathing

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what is wheeze?“Physician diagnosed wheeze”

Murray (2004): wheeze vs iPFT (sRAW) - <4y

• 458 children. 41% Parents reported wheeze in 1st year of life

• sRaw: signif incr in those w Dr confirmed wheeze vs never, or unconfirmed

(p<0.001)

A proportion of parents may have limited

understanding of what medical

professionals mean by the term ‘‘wheeze’’Murray, ADC, 2004, 89, 540

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what is wheeze?

Elphick (2004): 2 “experienced” Drs -

compared wheeze heard by steth vs

computerised acoustic analysis• Both could discriminate between wheeze, crackles and

rattle

• W: Convergent Validity k=0.07 (-0.13 to 0.26) - “poor”

• R: CV k= 0.11 (-0.05 to 0.27) - “poor”

• C: CV k= 0.36 (0.18-0.54) - “fair”

• Wheeze: agreement between observers was poor

“stethoscope is unreliable for assessing

respiratory sounds in infants.”

“Physician diagnosed wheeze”

Elphick, ADC, 2004, 89,1059

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how common is wheeze?

ALSPAC Study1: 26% of 6265 by 18/12

Tucson Study2: c33% by 3y

50% cumulative by 5y3

1:4 Kiwi kids have “asthma” —> 1:6 Kiwi adults

1. Henderson. Thorax 2008; 2. Martinez. NEJM, 1995; 3. Bisgaard, Ped Pulmonol 2007;

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Who is this?

What did he do?

GPCME

Causes of recurrent wheeze

Wheeze or Reflux

• Pre-school wheeze: VIW vs MTV vs asthma

• Asthma

• GOR ± aspiration

• CSLD/protracted bronchitis/ Bronchiectasis/ CF

• Structural airway disease: malacia, stenosis

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Wheeze Phenotypes

MTW

Transient

Persistent

?EVW

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Wheeze phenotypes

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✴ Viral Induced wheeze: Wheeze during discrete time periods - often assoc with

viral RTI’s; Sx free between RTI’s; ? less ICS responsive.

✴ Multi trigger Wheeze: Wheeze with discrete exacerbations - as per episodic

wheeze; Sx between episodes; other triggers (exercise, smoke, allergens); ICS

responsive.

✴ Asthma: ongoing Sx beyond pre school, ICS responsive, known triggers, FH.

✴ PBB/CSLD/CF/Bx: moist cough, abN CXR when well, failure to

thrive/malabsorption, other sites of infection.

Wheeze Clinical Causes

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✴ Reflux: ease of vomiting, hoarse voice, ? snoring, middle ear disease, post-

prandial Sx, Sx when recumbent, empirical response to GOR Rx

✴ Aspiration: cough w swallowing (diff foodstuffs), Sx with eating, assoc w:

✴ dyspnoea

✴ devel delay: CP, Down Sy,

✴ laryngeal abnormalities incl supraglottoplasty for laryngomalacia

✴ neuromuscular disease: Duchenne, SMA etc

✴ (T-O fistula - rare)

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Wheeze Clinical Causes

Wheeze from reflux

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http://www.theasthmacenter.org/images/uploads/image/GERD.gif

Reflux from wheeze!

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http://www.hon.ch/OESO/books/Vol_5_Eso_Junction/Articles/art088.html

✴ Asthma

✴ Recurrent/ persistent cough or wheeze

✴ chronic bronchitis/COPD

✴ Bronchiectasis

✴ IPF/ ILD

✴OSA

✴ BOS - post lung transplant

GOR assoc lung diseases

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✴ vomits easily

✴ “at risk group” - CP, 213, etc

✴ symptoms when lying down

✴ back arching - Sandifer’s sy.

✴ post prandial symptoms

✴ wheezing without typical asthma provoking factors - exercise cold, viral

URTI etc

✴ associated hoarse voice, stridor/croup,

✴ wheeze doesn't respond salbutamol

✴ NB: response to salbutamol does not refute Dx GOR

Clues towards GOR related Resp Sx

Investigation

empirical treatment - see later

Ba study:

good sensitivity, poor specificity

neg predictive value low

impedance

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Investigation

pH probe: +

predictive 98%, -

predict 50%

? non acid reflux-

? resp Sx more

common with non

acid reflux

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Investigation

Impedance

manometry

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Treatment:

GOR & VIW/MTW

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Which of these was not a previously

recommended asthma treatment?

Stool of Camel or Crocodile

Thorn apple

Linctus of cat’s lung

Powdered millipede

Cigarettes

Squill - flower

Colonic irrigation

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Treatment - GORInfants:

feed thickeners🙂

elevate head of cot 🙂 - nocturnal cough

gaviscon 🙂

omeprazole😐

domperidone😐

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no magic bullet

? start with 3,

wean if gain control

Treatment - GOROlder children:

elevate head of bed 🙂 - nocturnal cough

gaviscon 🙂

omeprazole 🙂/😐

domperidone😐

macrolides 😐

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no magic bullet

? start with 3,

wean if gain control

EVW/MTW:

no cig smoke exposure

? air pollution

? drugs to prevent development of asthma -

not yet

Treatment - VIW

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EVW:

prn salbutamol - imps to assess if empirically beneficial

? intermittent leukotriene antagonists - ???

variable outcomes _ some benefits (decr time off day care/

parent work), but not reproducible.

Overall ? trial monteleukast in child with troublesome Sx.

? continue til child better.

Rx - VIW

1. AJRCCM 2007; 2. Ann Allergy Asthma Immunol 2011; 3. J Allergy Clin Immunol 2008; 4. Lancet Resp Med 2014

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PHARMAC: SA 1421 July 2015

Treatment

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no evidence to support use of ICS in pre

schoolers who do not wheeze

between viral RTI

Rx- ICS for EVW

1. AJRCCM 2007; 2. Ann Allergy Asthma Immunol 2011; 3. J Allergy Clin Immunol 2008

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Oral steroids:

Studies - mild episodes - suggest no

benefit for OCS in preschool wheeze who

don't need admission 1,2

1. NEJM 2011; 2. NEJM 2009

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Rx- EVW

EVW:

small study 7% HTS + salbut neb.

decr admission rate and LOS, not severity

? palivizumab - cost prohibitive, never tried in low risk

group

Treatment

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N child, Hx intermittent wheeze only, well on exam, thriving. No signif morbidity w viral infections - REASSURANCE

Otherwise well, but Hx vomiting, arching, ? GOR; or upper airway disease - INITIAL Rx as per Dx

REFER (Gen Paeds, ENT) IF NO RESPONSE

Pragmatic approach1

Bush et al, BMJ 2014, 348

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Well child with recurrent wheeze only with viral infection - TREAT

Well child with recurrent wheeze w infection and at other times- TREAT

Pragmatic approach1

Bush et al, BMJ 2014, 348

Significant history:

cough <1/12, wet, chronic, sudden onset, continuous

clubbed, chest deformity, stridor, fixed wheeze, other sites of infection, systemic

disease - INVESTIGATE ? REFER

Well child with wheeze only with viral infection

Well child with wheeze w infection and at other times

Pragmatic approach1

Bush et al, BMJ 2014, 348

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EVW: prn B2,

consider monteleukast - reassess after 4-8 w

No better- stop

consider alt DDx incl MTW, and other res disease

Acute: prednisone if needed admission/ of benefit previously

MTW: prn B2,

consider ICS - reassess after 4-8 w

No better- stop

consider alt DDx incl EVW, and other res disease

Acute: prednisone if needed admission/ of benefit before

?GOR - If no better - revisit Dx, Refer/ seek advice.

? EVW/MTW - if no better stop Rx, DONT ESCALATE - consider alt Dx - ? refer as per

severity / are of Sx.

But…if wheeze returns/increases/return on cessation, restart and consider escalation of

treatment after further 4w Rx.

If continuing Inhaled Rx - aim over time for lowest dose for Sx control.

Avoid nebulisers for either wheeze phenotype

Pragmatic approach

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EVW vs MTW• empirical b2’s

• no ICS for EVW

• consider monteleukast

• review and reassess

Dx/Rx

SUMMARY

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GOR• empirical Rx:

• thickeners

• raise cot/bed

• gaviscon

• omeprazole

• (? domperidone)

• Reassess Dx

Questions

Stool of Camel or

Crocodile

Thorn apple

Linctus of cat’s lung

Powdered milipedes

Cigarettes

Squill - flower

Colonic irrigation

GPCME

Answers

Rene Laennec.

invented the Stethoscope

Homer.

Iliad where first use of term

“Asthma”. Means “gagging painfully”

Stool of Camel or CrocodileThorn appleLinctus of cat’s lung Powdered milipedesCigarettesSquill - flowerColonic irrigation foxes lung

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