dr. jennifer townshend consultant paediatrician. context some common presentations common...
TRANSCRIPT
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Respiratory Paediatrics For GP’s
Dr. Jennifer TownshendConsultant Paediatrician
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Context Some common presentations Common complains
◦ Wheezy infant◦ Wheezy child◦ Chronic cough
Overview
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Audience participation
Blue background slides
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Respiratory distress is the most common complaint for which children seek medical care.
Up to 10% of children have a persistent cough at any one time
1/3 of 1-5 year olds suffer recurrent wheeze
Is it important?
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9 year old boy Diagnosed with asthma 4 years ago Never free from symptoms Ends up in hospital about once per year Nothing seems to be working
A familiar case?
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What do you want to know?
What else could be going on?
What are your thoughts?
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Typical history of poorly controlled asthma Very poor compliance Poor inhaler technique Smoking (never in the house) Chaotic family situation
◦ Parents separated last month◦ Dad no idea what inhalers he takes
Subsequent questions
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Not clubbed, normal chest shape Audible wheeze through out Lung function 65% predicted
◦ 18% reversibility post salbutamol◦ Wheeze resolves post inhaler
CXR normal Eosinophils 0.4, IgE 112
On examination
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Poorly controlled atopic asthma
What is the likely diagnosis?
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RF for life threatening disease◦ Poor compliance◦ Poor technique◦ Chaotic social situation◦ Parental smoking, risk of child smoking
Are you concerned?
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18 month old girl
‘There’s something wrong with my child – she picks up everything. I think its her immune system’
‘She’s always chesty, and pants with her breathing’
‘This has been going on for as long as I can remember…..’
Another familiar case?
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What else do you want to know?
What could be going on?
What do you think?
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Well until 9 months of age Developed viral URTI – very chesty at this
time◦ Clarify chesty means wheeze and dry cough’
Period where completely symptom free Subsequent pattern:
◦ URTI wheeze and SOB◦ Resolves completely before the next episode
Thriving No FH atopy, no premature birth Normal examination
Further questioning
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Episodic viral wheeze
What is the likely diagnosis?
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Wheeze
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What is it?
Wheeze
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What is it?
‘a continuous high pitched musical sound emitting from the chest in expiration as a result of narrowing of the small airways’
Wheeze
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Where does it come from?
◦ Closed cavity◦ Relationship between pressure and volume
Wheeze
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What causes it?
• All that wheezes is not asthma……..
Wheeze
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Alerting symptom/Sign
Possible diagnosis Clinical Clue
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Alerting symptom/Sign
Possible diagnosis Clinical Clue
Wheeze present from birth
Structural Laryngeal Congestive heart failure GORD +/- aspiration
Present from birth
Persistent wheeze, no variation
Wheeze present shortly after birth
BPDCompromised host defence• CF• Immunodeficiency• PCD
• FTT, malabsorption• FTT, rct infections• FTT, rct ear
infections
Sudden onset in previously well child
Foreign body aspiration HistoryUnilateral reduced breath sounds
Persistent wet cough Compromised host defenceBronchiectasis
Rct infections, FTTPurulent sputum
Post viral wheeze Post bronchiolitic cough
Obliterative bronchiolitis
History of recent bronchiolitisFine creps, hyperinfation
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Asthma more complex, especially in children
Different patterns of illness having different underlying pathogenesis
Different phenotypes have different management strategies and different prognosis
Asthma phenotypes
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Most commonly recognised phenotype
Classical characteristics
Atopic Asthma
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School aged child Episodic
◦ ‘exacerbations’: (wet) cough/wheeze/SOB◦ Interval symptoms: (dry) cough,
nocturnal,exercise Identifiable triggers Personal/FH atopy Raised eosinophils/IgE
Atopic asthma - characteristics
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Very rare to cough without wheeze in asthma (McKenzie, 1994)
More likely to be a marker for another condition
But, does exist – consider trial of asthma therapy if all other conditions excluded
What about cough varient asthma?
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Step wise approach to medication Support self management
◦ Education◦ Shared decision making◦ Asthma management plan◦ Delivery techniques◦ Avoidance of triggers
Associated allergies? Regular review
◦ monitoring for side effects◦ compliance
Management of atopic asthma
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Inhaled corticosteroids◦ Friend? Foe? Practically?
Long acting beta agonists◦ Better then doubling dose of ICS◦ But safe??
A few things to mention
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Many variables
Secondary or tertiary?
Atopic asthma – when to refer
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Feature Comment
Poor response to 800mcg per day of beclomethasone or equivalent
Patient should be on other therpiesConcordance and drug delivery need careful assessment
Poor response to 400mcg per day of beclomethasone and needs add on therapies the primary care physician is unfamiliar with
Young child (< 5 yrs) where there is uncertainty over drug delivery
Needs expertise of specialist asthma nurse
Young child < 1yr where there is often doubt over the diagnosis
Recurrent admission to hospital Suggests dangerous pattern of illness
Particularly severe acute asthma such as needing IV therapies or intensive care
These high risk patients should always be referred
Atopic asthma – when to refer
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¼ of children who have a wheezing illness at age 7 will wheeze at age 33
Majority have a period of remission in late adolescence followed by a relapse
Recurrence of wheeze in later life is strongly associated with cigarette smoking and atopy
Prognosis
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Atopic Asthma
Episodic viral wheeze‘the wheezing infant’
Asthma phenotypes (2)
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Characteristic features◦ Common following RSV infection◦ Often no history of atopy◦ Clear pattern on concurrent viral URTI◦ Clear story of normality between episodes◦ Response to bronchodilators in over 2’s
Episodic viral wheeze
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Risk factors for development into atopic phenotype◦ FH/personal history of atopy◦ Premature birth/low birth weight◦ Smoking ◦ Bronchiolitis as an infant
Episodic viral wheeze
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Acute management◦ Salbutamol in under 2’s◦ Corticosteroids
Long term management
Prognosis
Different phenotypes – so what?
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30-50% of children have one episode 66% out grow their symptoms before school
age
Atopic asthma can start with EVW but often have atopic phenotype and/or FH
Episodic Viral Wheeze – prognosis
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Practically Consider other causes
Try and identify the phenotype
Draw a time line of wheeze
Manage according to severity and phenotype
Time
Symptoms
Acutesymptoms
Interval symptoms
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11 year old boy Presented ‘exacerbation of asthma’ Difficult to control asthma for years Primary symptom is cough
◦ Wet◦ Every day◦ No real relief from inhalers
Some mild SOB, no real wheeze
Some more cases…..
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What else do you want to know?
What are your thoughts?
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No FH of atopy No personal history of atopy No smoking in family
Always hungry, but still slim
Further questioning
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Sats 91% in air Increased work of breathing Hyperinflated No wheeze, no creps Clubbed
On examination
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CXR: chronic changes
Sweat test – confirmed Cystic fibrosis
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18 month old child Well until 13 months
‘Never been right since’
Coughs every day, no break in between
Case 2
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Started nursery at 13 months Recurrent episodes of runny nose Wet cough associated with runny nose Cough beginning to recede after a few
weeks Then further runny nose and cough starts
again Thriving
Further questioning
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Well child Nasal crusting Wet cough Normal chest shape Chest clear to auscultation
Recurrent viral URTI’s Reassure Reassess in summer months
On examination
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Important physiological reflex
Common (up to 10% children)
OTC medicine – cochrane review
Cough
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Acute cough
Recurrent acute cough
Persistent none remitting cough
Different cough types
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Vast majority viral URTI History and examination important to rule
out chronic illness Consider
◦ Pertussis◦ Allergy◦ Inhaled foreign body◦ Rarely – presenting feature of serious underlying
disorder
Acute cough (< 3 weeks )
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Uncertainty about diagnosis of pneumonia IFB Possible chronic problem Prolonged clinical course True haemoptysis
When to consider CXR/Referral
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Antipyretics and fluids as required Antibiotics not beneficial in absence of signs
of pneumonia Bronchodilators not helpful in children who
don’t have asthma OTC remedies not effective Macrolide for pertussis EXPLANATION – reduce future consultations
How to manage acute cough
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Chronic cough > 8 weeks 3-8 weeks ‘grey area’
◦ Subacute (post viral)◦ Pertussis
Chronic cough
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Structural Immunodeficiency Suppurative (PBB, bronchiectasis) Recurrent aspiration Pertussis Retained IFB TB Bronchcospasm Intersitial lung disease/cardiac
Differential
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Structural Immunodeficiency Suppurative (PBB, bronchiectasis) Recurrent aspiration Pertussis Retained IFB TB Bronchcospasm Intersitial lung disease/cardiac
Differential
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Persistent Bacterial Bronchitis
Conducting airways
RespiratorySpaces
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Increasingly common cause chronic wet cough◦ Age 5 mo – 14 years (3 years)
Initial viral trigger ‘vicious circle theory’◦ Asthma can also be a trigger◦ H. Influenzae (NT) & S. Pneumoniae
Prolonged course antibiotics required (diagnosis)
Is entirely curable
Untreated may progress to bronchiectasis
Persistent Bacterial Bronchitis
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Symptom PBB Asthma
Age Typically < 6 yrs Typically > 5 yrs
Cough type Wet (‘smokers’) Dry
Cough duration Persistent Intermittent
Change with posture
Yes No
SOB With coughing With exercise
Wheeze ‘Rattle’ Genuine wheeze
Response to antibiotics
Dramatic (> 2 weeks)
None (natural history)
Differentiating PBB from Asthma
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Consider different types of cough
Assessment
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Barking ◦ large airway
Honking◦ psychogenic
Paroxysmal ◦ pertussis
Chronic fruity◦ suppurative
Dry/tight ◦ bronchospasm
Types of cough
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Nature of the cough◦ Time, diurnal and sleep, sputum, wheeze
Age of onset Feeding relation IFB? Relieving (beta agonist, ab’s) Cigarette smoke FH
History
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When would you refer
(when have you referred?)
Red flags
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Neonatal onset Chronic wet cough Cough after choking episode Neuro-developmental problems Chest wall deformity Recurrent pneumonia Growth faltering Clubbing
Red flags – specialist referral
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Watchful waiting – 6-8 weeks Removal of aeroallergens Trial anti-asthma treatment Trial antibiotics for PBB
Approach to management
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Respiratory paediatrics is fascinating! …..and relevant to everyday practice Think of other causes of wheeze Identify asthma phenotypes Classify different cough types Consider PBB Refer if unsure
Summary
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Thank you.