Download - 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