asthma and wheeze in children · salbutamol every day – laughing, cold air, exercise. case 4...
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Asthma and wheeze in children
Dr David McNamara2018
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What is wheeze?
A high pitched musical noiseIndicates lower airway obstruction– Listen for a prolonged expiratory phase
Low agreement between physicians and parentsParents often report rattles, stertor, stridor as “wheeze”“What do you mean when you use the word wheeze?”
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Red Flags
Daily or constant symptoms– Infant with wheeze every day since birth– Daily wet or moist cough
Failure to thriveDigital clubbing
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No single definitionNo definitive diagnostic testVarying syndromes by age
Bronch-iolitis
What Is Asthma in Children?
Preschool Wheeze/ Asthma
School Age Asthma
Not salbutamol responsive
Congenital problems
Salbutamol responsive
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Congenital issues
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Presentation
May present in infancy or olderConstant noisy breathing and signs of increased work of breathingOften present as recurrent acute illness
“What is your child’s breathing like during a usual week?”
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Causes
Structural narrowing – malacia, stenosis
Compression – blood vessels or heart
Functional – chronic aspiration/dysphagia
Chronic illness – CF/immune deficiency
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Case 1
10 month oldAdmit for “Recurrent bronchiolitis”Wheeze since 3 – 4 months of ageTachypnoea with wheeze all the timeWorse when feeding or playingNot responsive to salbutamol or atroventGrowing wellTachypnoea with wheeze all the time
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Case 1(2)
Recommended bronchoscopyàAirway narrowing in lower trachea
(tracheomalacia)
Lessons from Case 1– Beware daily wheeze
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Bronchiolitis
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Bronchiolitis
Acute wheezy illness in infantTriggered by viral illness– RSV, rhinovirus, adenovirus, HMV
Shortness of breath, wheeze, hyperexpansion, crackles in chestTreatment is supportive and avoiding cross infectionConsider outpatient referral if recurrent
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Salbutamol and steroids
Bronchodilators not effective (as of yet)
Steroids are not indicated in bronchiolitis
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Pre-school Wheeze
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Pre-School WheezeTwo distinct groups– Those who only wheeze with viruses (infrequent)– Those with frequent wheeze– Pattern does not predict later asthma or not
Only regular wheezers (incl those with frequent viral exacerbations) benefit from preventers à treat as asthmaCan swap groups – review and trial off meds each 3 months
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Inhaled corticosteroids in preschoolers
DO benefit “interval” symptoms
MAY NOT prevent exacerbations
DO NOT prevent loss of lung function
DO result in loss of linear growth
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Systemic steroids/PrednisoloneOnly recommended in severe pre school wheeze (in hospital)Not well studied in preschool asthma– No positive studies except severe - Why? – They all get better anyway
SO WHAT?– Normal to have 8 – 10 viral illnesses per year– That’s 30 – 50 days of prednisolone
This recommendation remains contentious
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Case 2Four year old girl2 x previous admit with wheeze requiring IV treatment (parainfluenza 3)Presented acutely with wheeze, requiring ICU admit and IV treatment (rhinovirus)On flixotide– No interval symptoms except salbutamol with
exercise– No eczema or hayfever– Sister with asthma
What preventive treatment next?
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Case 2 (2/2)
Added montelukastDischarged from clinic but readmitted the next dayNow on regular flixotide and regular montelukast (adult dose)– No interval symptoms or regular salbutamol– Fingers crossed
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Lessons from Case 2
Regular montelukast better than PRNOften cannot prevent exacerbations in this age groupCan reduce interval symptoms/improve QOL
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Case 3
14 month old presented to PICU with severe wheeze and coryzaEx 34/40 infant
What question next?
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Case 3 (2/2)Salbutamol about 2 x per week for wheezeCommenced on flixotideà resolution of interval symptoms but exacerbations continueFor montelukast if another severe episode
Lesson from Case 3Pre-schoolers with frequent wheeze will benefit from flixotide
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School age asthma
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Goal: All children who have asthma are correctly diagnosed promptly In children – based on having characteristic symptoms in
absence of another cause AND assessing response to treatment
In adults – based on having characteristic symptoms in
absence of another cause AND measures of airflow obstruction
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Considerations in poor control
•Not taking medication•Poor inhaler technique•Asthma plus other problem•Not asthma
Primary
Care
Secondary
Care
Step 4 or 5
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Case 412 year old girl2 episodes respiratory arrest, both after viruses - Runny nose then onset of wheezeHad been non-compliant with seretide each timeCurrently adherentNight waking 2x per weekSalbutamol every day – laughing, cold air, exercise
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Case 4
Spirometry– FEV1 44%, FVC 84%, FEV1/FVC 46%
Salbutamol response– +88%
Treatment?Change brand of inhaler (to vannair)MontelukastOne month course prednisone
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Case 4 - end
Subsequent reviews– “improved but current poor control”
Recurrent courses of steroidsTrialled SMART therapy?Theophylline?Omalizumab – IgE > 2000– Next mAb funded soon*
Dysfunctional breathing clinicDiscuss psychosocial
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Questions?