approach to child with wheezing

8/19/2019 Approach to Child With Wheezing

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Approach to Child with Wheezing

Dato’ Dr. Ahmad Fadzil

Consultant of Paediatric Respiratory HTAA


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Wheeze

• Sound

• Airway turbulence

•

Airway obstruction• Monophasic

• Biphasic

• Monophonic• Polyphonic

STRIDOR

wheeze


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Recognized


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• Airway obstruction - where

Bronchospasm

Secretion

Mass

Airway narrowing


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Airway Development and wheeze

• Neonate trachea = size peripherals airway ofadult produce high pitch sound

• Infant bronchus = wheeze

• Important : airway size

• Biphasic wheeze – severe obstruction.

• The coarser the wheeze the larger airway

obstruction.


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• Louder – do not indicate severity,

• clinical sign & symptoms

mild

moderate

severe


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Aetiology

Anatomy Obstructions


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Common Causes

• Acute bronchiolitis

• Viral pneumonia

• Asthma

• Post viral infection

•

Hyperactive airway – previous lung damage- recurrent pneumonia

- recurrent aspiration or GERD

- congenital lung lesion

Bacteria pneumonia/pulmonary TB

Bronchiectasis, foreign body, anaphylaxis reaction

Cystic fibrosis, congenital lung lesion.


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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


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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.


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School

• Typical wheezing/wheezing disorder – asthma

• Development anomaly

• Chronic obstructive lung disease.


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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.


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History

• Cause

• Severity

• Recurrent/persistent• Acute/Chronic

• Effect to the children overall – growth,

development, ability to function.• Effect to parents and family.


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History

• - Antenatal – congenital infection, maternal smoking- Natal – prematurity, meconium, ventilated- Postnatal – persistent tachypnea, cough, ventilatedWhen – wheeze, URTI/cold, admission.

LRTI.Associated feature tachypnea and coughSeverity each episode.Feeding problems.Dysmophism and CNS (hypotonia/hypertonia)

Foreign bodyRecurrent chest infection or recurrent feverFailure to thriveCardiac problem


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• Family history of atopy (allergic rhinitis,

asthma, eczema)

• Environmental history – smoking, nursery,

irritant pollution, pets.


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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


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Clinical clue

Symptoms present from birth,perinatal lung problem

Developmental anomaly, perinatalinfection, CF, CLD, ciliary

dyskinesia

Family history unusual lungdisease

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


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End of History & Examination

Acute

Recurrent

Persistent

- Mild

- Moderate

- Severe- Growth and

development

Infection or post-infection

Congenital/structure

HyperactiveInflammation

Immune

Cardiac/CNS

Trachea

Bronchus

BronchiBronchioles

- Proximal

- Distal


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IX

•

Cause• Severity

• Chest x-ray


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CXR: What’s the

finding?


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CXR: What’s the

finding?

• Mediastinal shift

to the right

• Hyperinflated left

lung

• Thin wall cyst in

the left lung


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Investigations

Suspectedcause ofwheezing

Plainx-ray

Barium

swallow

pH –

study

CT-scan Bronchoscopy /BAL

Upper airway/

larynx

+ +++

Trachea/large-

Airway abn.

+ ++ +++

Lung

parenchyma

++ +++ ++

Foreign body ++ +++

Reflux and

aspiration

++ ++ ++ +

cardiac + ++ ++ ++


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Others

• Sweat test.

• Immune study.

•

Nasal biopsy.• RAST.

• Skin prick test.


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Recurrent wheeze

Bronchiolitis Bronchiolitis Bronchiolitis

Bronchiolitis Asthma Bronchiolitis

Bronchiolitis Viral pneumoniaBronchiolitis viral induces wheeze.

Asthma


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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?


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Phenotype


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Martinez et al


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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


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API indexs


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Management

• Cause• Severity


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Acute wheezing

•

Bronchiolitis – severity, treat the symptoms.Hypertonic saline and salbutamol nebuliser.

• Viral pneumonia - conservative


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Persistent wheezing.

• Structure/congenital

•Post- viral wheeze – support ?oralprednisolone


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Recurrent wheeze – to treat or not

• Asthma – treat accordingly to achieve goodcontrol.

• Hyperactive airway – GERD, aspiration, post

infection lung syndrome (BO, bronchiectasis).Control the hyperactive airway and treat thecause.

• BPD – treat accordingly. Aim good QOL andoptimized lung development.

• Structure/congenital – treat accordingly


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Recurrent wheezer – preschool,

?asthma, viral induced wheeze

• Episodic or multi-trigger

• API index

• Atopy

• Environment

• Severity – background and admissions


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Recurrent wheezer

• Acute – B2 agonist.

• Chronic

Preventer

• Episodic – both intermittent or persistent

montelukast work. Very high intermittent ICS.

• Multitriigger – both work. Atopy – better ICS.


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TQ

approach to child with wheezing

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