What’s new in pre-school

wheeze

Dr Mark Rosenthal

Royal Brompton Hospital

London UK.

Two types of doctor……..

LUMPERS

SPLITTERS

Pre 1990

Everything was asthma or ‘wheezy

bronchitis’

Silverman M Thorax 1993;48:1200. Out

of the mouths of babes and sucklings:

lessons from early childhood asthma

Divided wheezing illnesses

epidemiologically and physiologically into

asthma and virus associated wheezing

Key Symptom Patterns

Infant Wheezing Phenotypes

Transient wheeze

Non-atopic (viral

induced) wheeze

Atopic wheeze

Stein RT et al Thorax

1997;52:946-52

Martinez FD

Pediatrics 2002;109:362-7

Hendersen et al. Thorax 2008;63:974-980

Lumping or Splitting?

1980s 1990s 2000s 2010s

Asthma

Virus associated wheeze

STEROIDS

DO NOT

WORK!!!

children admitted with preschool wheeze

trial medication given by parents at next attack

prednisolone 20mg OD for 5 days

Lancet 2003

1 2 3 4 5 6 7

0

1

2

prednisolone

placebo

days

day s

ym

tom

sco

res

daytime scores

Lancet 2003

NO difference between high and low ECP groups

1 2 3 4 5 6 7

0

1

2

prednisolone

placebo

days

nig

ht

sym

tom

sco

res

night-time scores

Lancet 2003NO difference between high and low ECP groups

Study

1 – 5 yrs, n=700

on admissions unit with acute wheeze + clinical cold

recruited if symptomatic after MDI salbutamol – (8-12 puffs)

prednisolone 20 mg OD for 5 days

all assessed at 4 hrs – validated PRAM score

primary outcome– duration of admission

– time to fit for discharge

Placebo Prednisol

one

Male 62.8% 66.2%

Mean Age (SD)

(months)

26.3 25.8

Previous Episode

Wheeze

68.2% 63.6%

Doctor Diagnosed

Asthma

16.4% 18.6%

unpublished

0.0

00.2

50.5

00.7

51.0

0

336 179 125 65 47 0Placebo338 169 106 47 28 0Active

Number at risk

0 10 20 30 40 50analysis time

Active Placebo

Kaplan-Meier survival estimates

unpublished

Time to fit for discharge

Do steroids

prevent

symptoms?

Bisgaard et al

NEJM 2006;354:1998

400 ug budesonide bd at D3

of 2nd episode of wheeezing

and each subsequent one

SO…………….

Steroids do not help acutely

Steroids do not help chronically

Fluticasone significantly reduces

growth

RSV

NOTHING

HELPS!!

A salutary lesson on trial size

Montelukast and viral wheeze

Lumping or Splitting?

1980s 1990s 2000s 2010s

Asthma

Virus associated wheeze

WHY?

If you wheeze with Rhinovirus when aged 3 years,

risk of asthma aged 7 years GREATLY increased

HRV detected in 58% of children median

age 13 months admitted with wheezing

So……….Prevention?

Rhinovirus and RSV vaccines – easy to

say difficult to do

Easier to do is………..

Papers by E Von Mutius

THE END!!!!

ANY QUESTIONS?