pediatric respiratory medicine...pediatric respiratory medicine 4 seasons lecture • bon appétit !...
TRANSCRIPT
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Pediatric Respiratory Medicine
4 Seasons Lecture
• Bon Appétit !
Objectives
1. Differences between children and adults in
respiratory medicine.
2. Wheezy child
3. Recurrent cough in children3. Recurrent cough in children
4. Respiratory emergencies in children &
protocol of management.
Pediatric Respiratory MedicineChildren are not small Adults!
Part 1
Dr. Malak Shaheen
(PhD Pediatrics, FCCP)
Overview of differencesAnatomical/ physiological
Psychosocial Differences
Wheezy Child
By
Malak Shaheen
Part 2
Malak Shaheen
(MD Pediatrics)
Symptoms, signs and clinical presentations of childhood asthma
Reported wheeze not always reliable
Good evidence that ‘doctor-diagnosed asthma’ based on reported symptoms includes children without asthmasymptoms includes children without asthma
Reported isolated cough reliable – is not asthma
Skin Prick Test if uncertain
Spectrum of disorders
Birth 1 year 5 years Adolescence
Spectrum of disorders
Birth 1 year 5 years Adolescence
Bronchiolitis Pre-school wheeze Asthma in school children
Spectrum of disorders
Birth 1 year 5 years Adolescence
Bronchiolitis Pre-school wheeze School children
RSV, adeno,
rhino50:50 atopic 90:10 atopic
Spectrum of disorders
Birth 1 year 5 years Adolescence
Bronchiolitis Pre-school wheeze School childrenBronchiolitis Pre-school wheeze School children
RSV, adeno 50:50 non-atopic:atopic 90:10 atopic
Mucosal inflammation
Little smooth muscleSmall
Airways;
Neutrophils;
Mucosal
inflam+
SM
Normal airways;
Eosinophils;
SM + muc inflam
SM very important
Clinical features
Birth 1 year 5 years Adolescence
Bronchiolitis Pre-school Schoolchildren
URTI URTI or allergens Allergens, URTI, exercise, cold air
Crackles and wheeze
Martinez description of phenotypesMartinez description of phenotypes
Martinez FD N Engl J Med. Martinez FD N Engl J Med. 1995 1995 Jan Jan 1919;;332332::133133--88. .
D.D. of wheezy infant
• 1. Infections (viral, other include chlamydia, TB, ….)
• 2. Asthma (3 phenotypes)
• 3. Anatomic abnormalities of airways (central, intrinsic or extrinsic)(central, intrinsic or extrinsic)
• 4. Inherited (CF or Immunodefeciency)
• 5. Aspiration Syndroms
• 6. Interstitial lung dis ( include; BO)
• 7. Foreign Body
Wheezing phenotypes(response to corticosteroids1)
• Post-bronchiolitis wheeze
Those with a family history of atopy respond to ICS 2
• Non-atopic viral wheezing
Different cell profile in airways 3
Little evidence for response to ICS 4Little evidence for response to ICS 4
• Atopic asthma
Good response to ICS
1. Ranganathan & McKenzie Minerva Pediatr. 2003 55:357-67
2. Chavasse RJ et al Arch Dis Child 2001; 85:143-8
3. Marguet C et al Am J Respir Crit Care Med 1999; 159:1533-40
4. Pao CS et al Am J Respir Crit Care Med 2001; 163:1278-82
Wheezing phenotypes –continued
• Chronic lung disease of prematurity
Response to ICS unproven
• Wheezing related to CF• Wheezing related to CF
Response to ICS unproven 1
• Obesity related wheeze
No more atopic than healthy community 2
1. Balfour-Lynn IM Thorax 2002; 57:742-8
2. Schachter LM et al Thorax 2001; 56:4-8
Evaluation of wheeze
Problems with reported symptoms
• Some parents confuse symptoms1,2
• Recollection of symptoms changes3
• Parents’ and children’s reports differ4• Parents’ and children’s reports differ4
• No translation of ‘wheeze’ in some languages5
1. Lee et al 1983 BMJ; 286: 1256-8
2. Fuller et al 1998 ERJ; 12 (2): 426-31
3. Peat et al 1992 Chest; 102: 153-7
4. Wong et al 1998 Arch Dis Child; 78: 379-80
5. Pararajasingam 1992 Thorax; 47: 529-32
Do parents know what wheeze is?
• How do you know your child is wheezy?
>20% parents of wheezers do not mention sound 1
• Videos of stridor, wheeze and nasal congestion
Disagreement between what audio-videos show and what
parents call the noise in 20% 2
1. Cane RS et al Arch Dis Child 2001; 84:31-4
2. Young B et al Arch Dis Child 2002; 87; 131-4
What is ‘doctor-diagnosed’ asthma?
• A term used in epidemiology
• Never validated
• Do children with ‘doctor-diagnosed’ asthma • Do children with ‘doctor-diagnosed’ asthma (DDA) have the same attributes as those with ‘doctor-observed’ wheeze (DOW)? 1
1. Chan EY et al ERS abstract 2003
2. Lowe L BMJ 2004 328: 1026-7
Attributes of DDA and DOW
• Skin-prick test positivity 1 Total IgE SD score
(schoolchildren)Controls 19% -0.04
DDA 51% 0.4
DOW 82% 1.25
• Specific airway resistance 2• Specific airway resistance 2
Controls = DDA < DOW
1.Chan et al In press
2.Lowe et al Arch Dis Child 2004 89:504
Letter• Dear ER doctorThis child’s parents give a history of difficulty in breathing.
I have asked them to bring her up when they next notice it. when they next notice it.
Please could you examine her for upper airway noise and/or wheeze and document this. If she is wheezy please record the response to a bronchodilator and let me know the results.
Any tests?
1. Knowledge of atopic status helps
2. Bronchodilator responsiveness testing has a good diagnostic profile
(80% sensitivity and specificity for previous (80% sensitivity and specificity for previous wheeze)
3. Chest radiography, sweat testing, pH study
and bronchoscopy only for true persistent wheezing
4. Immune deficiencies present with pneumonia not wheezing
60%
80%
100%
Perc
ent
po
sitiv
e
Non-wheezers
Wheezers
40%
60%
80%
100%
Perc
ent
po
sitiv
e
Non-wheezers
Wheezers
SPT positivity to one or more common aeroallergens
0%
20%
40%
0 2 4 6 8 10
Age (years)
Perc
ent
po
sitiv
e
Wheezers
0%
20%
0 2 4 6 8 10
Age (years)
Perc
ent
po
sitiv
e
TotalTotal IgEIgE in 2 in 2 --10 year old children in 10 year old children in
East London East London 11
20%
25%
pro
po
rtio
n in
po
pu
lati
on
Healthy n=253Healthy n=253
Coughers n=87Coughers n=87
WheezersWheezers n=183n=183
0%
5%
10%
15%
-2.5 -2 -1 .5 -1 -0.5 0 0.5 1 1.5 2 2.5 3 3.5 4
z scores for log IgE
pro
po
rtio
n in
po
pu
lati
on
sam
ple
1.Chan E et al,1.Chan E et al, ClinClin Exp Allergy, 2003.Exp Allergy, 2003.
pH Study
• GORD in preschool children with wheeze is evident in 64% of them.
• pH study vs. Fat-laden macrophages ?
Bronchoscopy
• Performed safely
• Yield potentially relevant
informationsinformations
• Structural airway
abnormalitys
• Eosinophilic airway
inflammation
• Bacterial infections
Management of Acute wheezingManagement of Acute wheezing
Medical treatment of moderate to severe bronchiolitis
• Stop feeding– Babies obligate nasal breathers
– Increase work of breathing
– May increase chance of vomiting
– NG tubes increase total airway resistance
– Why block a small hole?
Acute wheeze
– Why block a small hole?
• Do not disturb
• Drugs only have brief value and reserved for MILD disease where feeding is possible Bronchodilators produce modest short-term improvement in clinical features of mild or moderately severe
bronchiolitis. Arch Pediatr Adolesc Med. 1996 Nov;150(11):1166-72.
• Result in tachycardia
• CXR only if need PICU
Ipratropium?• ‘There is not enough evidence to support the
uncritical use of anti-cholinergic therapy for
wheezing infants – under 2 years’
Acute wheeze
Cochrane Database Syst Rev. 2002;(1):CD001279.
….and of pre-school moderate to severe pre-school wheeze
• Smooth muscle now present
• The younger the child the less there is
• No evidence of value of corticosteroids in pre-school child
– But still recommended (prednisolone)
Acute wheeze
– But still recommended (prednisolone)
• Bronchodilators help - the older the child, the better they help
• Can add ipratropium to beta-agonists BUT not useful for non-severe attacks 1
1. AJCCRM 2003;2(2):109-15
Summary - wheeze
• Ask the parent to describe the symptoms
• Try not to use the word wheeze
• If unclear, skin prick test• 16% of preschool non-wheezers SPT positive • 16% of preschool non-wheezers SPT positive
• 43% wheezers positive 1
• 19% of schoolchildren non-wheezers SPT positive
• 80% wheezers are positive
• Diagnostic profile better than bronchodilator responsiveness
• Examine pre-school children when parents think they are wheezy or when they have a cold!
1. Chan et al 2005 Ped Pulmonol In press
Recurrent Isolated Cough
• Persistent isolated cough often confused and treated as asthma1
• Parents know when children are coughing, when it gets better or worse but not by how much 2
• Usually worse at night 2
• Do not lose sleep (parents might) 2• Do not lose sleep (parents might) 2
• Same atopic status as healthy children 3,4
1. Chang AB Arch Dis Child 1999; 80:211-3
2. Fuller P et al Eur Respir J 1998; 12:426-1
3. McKenzie SA et al Eur Respir J 2000; 15:833-8
4. McKenzie SA et al Eur Respir J 2001; 18:977-81
Causes of recurrent cough
• 1. BHR (? Asthma)
• 2. Post nasal drainage
• 3. Aspiration syndroms• 3. Aspiration syndroms
• 4. Recurrent chest infections
• 5. Idiopathic pulmonary hemosiderosis
TotalTotal IgEIgE in 2 in 2 --10 year old children in 10 year old children in
East London East London 11
20 %
25 %
pro
po
rtio
n in
po
pu
lati
on
Healthy n=253Healthy n=253
Coughers n=87Coughers n=87
WheezersWheezers n=183n=183
0 %
5 %
10 %
15 %
-2.5 -2 -1 .5 -1 -0.5 0 0. 5 1 1.5 2 2 .5 3 3.5 4
z scor e s for log I gE
pro
po
rtio
n in
po
pu
lati
on
sam
ple
1.Chan E et al,1.Chan E et al, ClinClin Exp Allergy, 2003.Exp Allergy, 2003.
Summary - cough• Isolated cough unlike asthma
• Most get better in 2 weeks
• Look out for bronchiectasis
• No good treatment • No good treatment
– modest response to high-dose (unlicensed)
fluticasone
– Do not respond to bronchodilator
Pediatric Respiratory
Emergencies
Part 4
Dr. Malak Shaheen
(PhD Pediatrics, MSc Critical Medicine)
Remember!
Not all respiratory distress
caused by respiratory causes.
How to differentiate?
Do you know non respiratory causes?
Remember!
The only way to confirm
RF is to perform Arterial
Blood gases (ABG)Blood gases (ABG)
Summary
Reported wheeze not always reliable
Good evidence that ‘DDA’ based on Good evidence that ‘DDA’ based on reported symptoms includes children without asthma
Investigate !
True or false?
1. Children with isolated cough are non-atopic
2. Inhaled corticosteroids are the recommended treatment for isolated cough
3. 50% pre-school wheezy children are atopic3. 50% pre-school wheezy children are atopic
4. Ipratropium is the drug of choice in the management of bronchiolitis
5. Infants with bronchiolitis should all have a chest radiograph
A 4yo child has night-time cough and no other symptoms
You would tell his parents
1. He is likely to have asthma
2. He is probably allergic2. He is probably allergic
3. He should have a sweat test
4. The cough is likely to improve in the next 3 weeks
5. Anti-reflux treatment is helpful
Further Readings ….
Further Readings ….
Second edition - 2015
Good luck!Good luck!