This document provides an overview of evaluating and managing childhood wheezing. It begins by describing different respiratory sounds like wheezing, stridor, and rattles. Wheezing can be caused by bronchospasm, secretions, masses, or airway narrowing. A history should ascertain the cause, severity, recurrence, and impact on the child. Common causes include infections, asthma, foreign bodies, and gastroesophageal reflux. Investigations may include chest x-rays, swallow studies, and pulmonary function tests. Recurrent wheezing is evaluated for viral-induced, hyperactive airway, or asthma phenotypes. Management depends on the identified cause and severity, ranging from bronchodilators for acute episodes to
This document provides an overview of evaluating and managing childhood wheezing. It begins by describing different respiratory sounds like wheezing, stridor, and rattles. Wheezing can be caused by bronchospasm, secretions, masses, or airway narrowing. A history should ascertain the cause, severity, recurrence, and impact on the child. Common causes include infections, asthma, foreign bodies, and gastroesophageal reflux. Investigations may include chest x-rays, swallow studies, and pulmonary function tests. Recurrent wheezing is evaluated for viral-induced, hyperactive airway, or asthma phenotypes. Management depends on the identified cause and severity, ranging from bronchodilators for acute episodes to
This document provides an overview of evaluating and managing childhood wheezing. It begins by describing different respiratory sounds like wheezing, stridor, and rattles. Wheezing can be caused by bronchospasm, secretions, masses, or airway narrowing. A history should ascertain the cause, severity, recurrence, and impact on the child. Common causes include infections, asthma, foreign bodies, and gastroesophageal reflux. Investigations may include chest x-rays, swallow studies, and pulmonary function tests. Recurrent wheezing is evaluated for viral-induced, hyperactive airway, or asthma phenotypes. Management depends on the identified cause and severity, ranging from bronchodilators for acute episodes to
This document provides an overview of evaluating and managing childhood wheezing. It begins by describing different respiratory sounds like wheezing, stridor, and rattles. Wheezing can be caused by bronchospasm, secretions, masses, or airway narrowing. A history should ascertain the cause, severity, recurrence, and impact on the child. Common causes include infections, asthma, foreign bodies, and gastroesophageal reflux. Investigations may include chest x-rays, swallow studies, and pulmonary function tests. Recurrent wheezing is evaluated for viral-induced, hyperactive airway, or asthma phenotypes. Management depends on the identified cause and severity, ranging from bronchodilators for acute episodes to
Neonate trachea = size peripherals airway of adult produce high pitch sound Infant bronchus = wheeze Important : airway size Biphasic wheeze severe obstruction. The coarser the wheeze the larger airway obstruction.
Causes - age Infant 3 years old Infection bronchiolitis, viral pneumonia. Wheezing disorders asthma, post-viral wheeze. Development abnormalities - tracheo-oesophageal fistula - bronchomalacia, airway compression syndromes, congenital heart disease Host defence defect (CF, ciliary dyskinesia, defects of immunity) Post-viral syndromes ( Bronchiolitis obliterans, airway stricture) Recurrent aspiration syndrome and GERD. Perinatal BPD, congenital infection, meconium pneumonitis
Preschool
Infection viral or atypical pneumonia
Development anomaly Foreign body Aspiration syndromes Typical wheezing/Wheezing disorder asthma Chronic obstructive lung disorder bronchiectasis, bronchiolitis obliterans, BPD.
School Typical wheezing/wheezing disorder asthma Development anomaly Chronic obstructive lung disease.
Wheezing in children longitudinal
data. At least 20 % children wheeze at age 1 year At least 50 % children had wheezing episodes by 6 year old.
History
Cause Severity Recurrent/persistent Acute/Chronic Effect to the children overall growth, development, ability to function. Effect to parents and family.
History - Antenatal congenital infection, maternal smoking - Natal prematurity, meconium, ventilated - Postnatal persistent tachypnea, cough, ventilated When wheeze, URTI/cold, admission. LRTI. Associated feature tachypnea and cough Severity each episode. Feeding problems. Dysmophism and CNS (hypotonia/hypertonia) Foreign body Recurrent chest infection or recurrent fever Failure to thrive Cardiac problem
Family history of atopy (allergic rhinitis,
asthma, eczema) Environmental history smoking, nursery, irritant pollution, pets.
Physical examination
General examination clubbing
Growth - FTT Dysmophism Chest deformity Listen to the breath sound wheeze Respiratory examination- localized sign Severity of respiratory distress CVS CNS
Clinical clue Symptoms present from birth, perinatal lung problem
Developmental anomaly, perinatal
infection, CF, CLD, ciliary dyskinesia
Family history unusual lung
disease
CF
Recurrent febrile illness
Infective cause, host defense
defect
FTT
CF, host defense defect
Feeding problem
Aspiration syndrome, GERD.
Abnormal voice or cry
Neurodevelopment abnormality
Focal physical sign
Focal developmental abnormality
End of History & Examination
Acute Recurrent Persistent
- Mild - Moderate - Severe - Growth and development
Recurrent wheeze Infection? Hyperactive airway? Asthma? 80 % of childhood asthmatic symptoms started before 3 years old. Many children wheeze resolved without treatment. When to treat? When the next attack? Can we prevent it?
Phenotype
Martinez et al
Clinical (ERS Guideline)
Episodic viral wheeze trigger by viral infection (URTI) Multi-trigger wheeze not only viral others such as allergen, exercise, weather, environment pollution like cigarette smoke. Not stable, change over time
API indexs
Clinical: Asthma Increase probability
Lower probability
Symptoms with cold only, with no
interval symptoms. Isolated cough in the absence of wheeze or difficulty in breathing. History of moist cough. Prominent dizziness, lightheadedness, peripheral tingling. Repeated normal physical examination of chest when symptomatic. No response to trial of asthma therapy. Clinical features pointing to alternative diagnosis.
More than one of the following
symptoms wheeze, cough, difficulty in breathing, chest tightness particularly if these are recurrent, worse at night and early in the morning, occurred in response to, or are worse after, exercise or other triggers such as pets, cold or damp air, or with emotion or laughter or occurred apart from cold. Personnel history of atopic disorder, Family history of atopic disorder and/or asthma. Widespread wheeze heard on auscultation. History of improvement in symptoms or lung function in response to adequate therapy.
BGMA 2009 children diagnosis.
Management
Cause Severity
Acute wheezing Bronchiolitis severity, treat the symptoms. Hypertonic saline and salbutamol nebuliser. Viral pneumonia - conservative
Persistent wheezing. Structure/congenital Post- viral wheeze support ?oral prednisolone
Recurrent wheeze to treat or not
Asthma treat accordingly to achieve good control. Hyperactive airway GERD, aspiration, post infection lung syndrome (BO, bronchiectasis). Control the hyperactive airway and treat the cause. BPD treat accordingly. Aim good QOL and optimized lung development. Structure/congenital treat accordingly
Recurrent wheezer preschool,
?asthma, viral induced wheeze
Episodic or multi-trigger API index Atopy Environment Severity background and admissions
Recurrent wheezer Acute B2 agonist. Chronic Preventer Episodic both intermittent or persistent montelukast work. Very high intermittent ICS. Multitriigger both work. Atopy better ICS.
