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)

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Wheeze or Reflux

- in children

Julian Vyas

Respiratory Paediatrician

STARSHIP HOSPITAL

No Conflicts of Interest to Declare

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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?

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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

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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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