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TRANSCRIPT
Respiratory Top Tips
CHINEDU NWOKORO13th June 2019
Practical Paediatrics Update
Outline
◼ Chronic Cough
◼ Wheezy infants and preschoolers (when is it asthma?)
◼ Investigation and Pitfalls
◼ Clinical Cases
What is a normal cough frequency?
◼ Mean 11 cough epochs / 24 hours with no preceding RTI (range 1-34)
◼ Munyard P, Bush A Arch Dis Child 1996; 7:531-4
What is a normal cough frequency?
◼ Mean 11 cough epochs / 24 hours with no preceding RTI (range 1-34)
◼ Nocturnal cough is suspicious…
◼ Munyard P, Bush A Arch Dis Child 1996; 7:531-4
◼ Most cough related to acute RTI resolves within 1-3 weeks (90% <3 weeks) (non-asthmatics)
◼ Hay AD Fam Pract. 2003 Dec;20(6):696-705 (preschool)◼ Butler CC BMJ 2003; 327: 1088-1089 (6m-12y)
Chronic cough - Respiratory infections
What is normal ?
◼ 6-10 RTIs / year (age 0-4 yrs)
◼ 2.5-5 RTI / year (age 10-14 yrs)
◼ Most resolve without treatment◼ Monto AS Epidemiol Rev 1994; 16(2): 351-73 (review article)
What is a chronic cough?
◼ Adults > 8 weeks (BTS 2006)
◼ Children no universal definition - range >3-12 weeks
◼ Primary care children 80% with chronic cough have 5 or more consultations
◼ Marchant JM et al Chest 2008;134:303-9◼ Morrice AH Eur Resp J 2004; 24:481-492◼ Chang AB J Asthma 2001; 38: 299-309
Chronic Cough – History - 1
◼ How and when did cough start? (NNU/ v.acute/ RTI)
◼ What is nature of the cough? (wet/honk/paroxysmal)
◼ Is cough an isolated symptom? (wheeze/SOB/fever/thriving)
◼ What triggers cough? ( cold air/exercise/feeding/lying down)
◼ Coughing during sleep? (not much with habit cough)
◼ What treatment given and what effect?
◼ Antibiotics (which? How long? Taken properly?)
◼ Inhalers (which? Doses? Technique?)
Chronic Cough – History - 2
◼ Normal viral RTI and GI illness?
◼ Dysphagia/vomiting
◼ Are there symptom free episodes?
◼ Exposure to other children? (nursery/siblings)
◼ Atopy? pets? HDM? Hay Fever?
◼ Cigarette smoke exposure
◼ Damp - fungal spores
◼ (Ab)Normal birth history / neonatal RDS
◼ Relevant family history
Chronic cough – Red Flags
What’s not normal?
◼ Persistent wet cough – at least 4 weeks
◼ No symptom free intervals
◼ Poor weight gain and growth
◼ Persistent or focal signs in the chest / clubbing
◼ Other infections at other sites (ear discharge)
◼ Unusual organisms
◼ Abnormal CXR
Chronic Cough - Differentials
Dry coughAtopyHarrison SulcusWheezeFHExercise/Noct sx
RhinitisThroat clearingHayfever
Wet coughPoor growthSteatorrhoeaClubbingOther infxns
RefluxExercise/noct sxDysphagiaFood aversion
Brassy/BarkingHx of TOFistulaLymphadenopathy
No clinical signsDistractibilityQuiet nights“Abnormal” cough
Dry coughClubbingBreathlessnessRestrictive spiroHypoxaemia
ProgressiveWeight lossfever/night sweatsHaemoptysisLymphadenopathy
WHEEZE +ASTHMA
UACS
BRONCHIECTASIS
ASPIRATION LUNG DISEASE
MALACIACOMPRESSIONNARROWING
FOREIGN BODY
PSYCHOGENIC/ HABIT COUGH
INTERSTITIAL LUNG DISEASE/
FIBROSIS
TUBERCULOSISLYMPHOPROLIF
DISEASE
Post-Pertussis Chronic Cough
◼ Classic (severe) pertussis:
◼ Incubation 7-10d (coryzal stage)
◼ ≥ 21 d paroxysmal cough + whoops/vomiting
◼ Lymphocytosis.
◼ ’Whoop’ may be absent, partic. young infants
◼ “100 day cough” – can last weeks – months
◼ Laryngeal sensory neuropathy → persistence
◼ Usu nil rx – can use Pregabalin/gabapentin/amytrypt
Post-Pertussis Chronic Cough
◼ Vaccination → milder disease
◼ Whoop is absent (6% only)
◼ Non-specific, wet/dry “100-day cough”
◼ Under-diagnosed in adults and adolescents, who may be reservoirs for infection of unvaccinated infants.
◼ Up to 80% of infections in unvaccinated children were acquired from siblings and parents (n.b. vacc in utero)
Post-Pertussis Chronic Cough
Pertussis seropositivity
- Cough duration- Sleep disturbance- Parental concern
Post-Pertussis Chronic Cough
Cough duration is significantly longer in pertussis than mycoplasma
- 118 days vs 39 days
Chronic cough – Persistent bacterial bronchitis
◼ Persistent wet cough
◼ Investigate if red flags/pointers
◼ Can’t investigate everyone…
◼ 100 children, cough > 3 weeks
◼ Hx, Ex, Serial investigation
Chronic Cough - Persistent bacterial bronchitis
◼ ‘Specific cough’ 69
◼ Persistent bacterial bronchitis 45
◼ Bronchiectasis 6
◼ Asthma 4
◼ Eosinophilic bronchitis 4
◼ Aspiration 5
◼ Mycoplasma 2
◼ B.Pertussis 1
◼ TB 1
◼ Bronchiolitis obliterans 1
◼ ‘Non-specific cough’ 31
◼ Natural resolution 24
◼ Upper airway CS 3
◼ Gastro-Oe reflux 3
◼ Habit cough 1
◼ 20/29 (70%) dry cough resolved spontaneously
◼ 14/71 (20%) wet cough resolved spontaneously
◼ Most important pointers:
◼ wet cough
◼ abnormal chest findings
◼ CXR abnormalities
Persistent bacterial bronchitis: Outcome/16s
◼ Commonest organisms – haemophilus/strep
◼ Median age 3.7 years
◼ Risk of progression to bronchiectasis – swab + treat
◼ Suggest 1/12 co-amoxiclav
◼ If not responsive, look harder for reasons (see prev)
◼ Newer diagnostic methods – 16s PCR
Chronic cough and asthma
◼ Cough-variant asthma – dubious diagnosis
◼ Does it respond to asthma meds?
◼ Asthmatic physiology?
◼ Differentials? (GORD, UACS, OSA)
◼ Night cough in a non-atopic child – rarely asthma
◼ Rhinitis
◼ Aeroallergen sensitivity → nasal steroid, antihist
◼ GORD →
◼ Foreign body
◼ Poor asthma control
◼ Hearing deficit and laryngitis
◼ Polyps
◼ Assoc asthma, aspirin sensitivity, montelukast resp
◼ Aeroallergen sensitivity
◼ Exclude CF/PCD/Foreign body/Immunodeficiency
Chronic Cough – The Nose
Chronic cough and GORD
◼ 40% adults with chronic cough have GORD
◼ In children: Cause and effect difficult to prove
◼ Imaging, ?aspiration?
◼ Cough reflux? Reflux vs Reflex theory?
◼ No studies have demonstrated symptom improvement with medical or surgical treatment
◼ Asthma and acid blockade experience – poorly controlled
asthma not helped by empirical reflux meds even in those with proven reflux
◼ Trial of therapy (Gaviscon, PPI, H2 antagonist, Prokinetic macrolide, domperidone???), consider:
◼ Allergy, Impedance, J feeding, Fundoplication,
Chronic cough - Recurrent aspiration
◼ Bulbar problems, laryngeal abn, H-type TOF, GOR
◼ Predominantly right sided CXR signs
◼ Ba swallow/pH-Impedance study/SLT +/- ENT review
◼ Bronchoscopy/MLB - oedematous airways
Bronchial lavage - fat laden alveolar macrophages
◼ Isotope scan (milk scan)
◼ Bulbar EMG (even if anatomical anomaly), MRI if indicated
◼ Case AO: diagnosis of brainstem tumour from SLT Ix of chronic feed-related cough
Chronic cough - recurrent aspiration
H-ToF: coughing, choking with feeds, noisy breathing, abdominal distension (Post-repair TOF cough, residual GOR)
Chronic cough and CF
◼ Neonatal Screening: IRT + DNA (4 mutations)
– Immunoreactive Trypsin as screening test
◼ 5% false negative results from CF NBS programme
- Not all ‘mild’ / ’atypical’ (SPIDs) / CFTR variants
◼ Don’t forget the sweat test
◼ Sweat chloride
◼ >30 mmol/l (<6m)
◼ >40 mmol/L (>6m)
◼ >60 - diagnostic
◼ Realistically >30 → further testing
Chronic cough and CF – A Case
◼ TC – 13 years old, chronic “asthma”
◼ Born like:
◼ Presents like:
◼ Cough
◼ Wheeze
◼ Exercise limitation
◼ Reduced FEV1
◼ Admitted to local with “LRTI”
Chronic cough and CF – A Case
◼ Closer investigation
◼ Cachectic and stunted (wt 30kg @ 13y)
◼ Clubbed, Lifelong steatorrhoea, Wet cough, sputum
◼ Exercise capacity 30y (when well)
◼ FEV1 33%, nocturnal hypoxaemia
◼ Sweat [Cl-] = 95mmol/L, Stool elastase = <200mcg/g
◼ x2 CF genes → Dx confirmed
◼ A lifetime of mismanagement
◼ What happened???
Chronic cough and CF – A Case
◼ Engaged with treatment
◼ Started on CFTR modifier
◼ 6 months of treatment
30kg
FEV1 33%
Clubbed
Invalided
60kg
FEV1 99%
No clubbing
Sporty++
◼ Take a good history!!!
Chronic cough - and structural abnormality
◼ Tracheo – broncho – malacia (ToF-cough)
◼ Airway collapse during expiration /coughing
◼ Impaired airway clearance
◼ 30% of children (0-3) with persistent wet cough
have (some degree of) tracheomalacia (Zgherea)
◼ 74% of <5 with ++bact on BAL had malacia (Kompare)(retro review 70 kids – ++bugs on BAL for cough/wheeze/noisy resps)
◼ Airway compression / collapse (lymphadenopathy?)
◼ Other congenital abnormality (vascular ring)
Zgherea D Paediatrics 2012, Kompare J Paediatrics 2012
Chronic cough & tracheomalacia
Vascular ring causing chronic cough
Habit/Psychogenic cough
◼ Honking noise : theatrical
◼ Predominantly daytime but not exclusively
◼ Up to several times per minute
◼ May last for months ? Following infective trigger
◼ Exhausted / off school / headaches / abdominal pain
◼ Management
◼ Convince the parent – then convince the child
◼ Spirometry, FeNO, Distractibility
◼ Demonstrate, reassure, downplay
◼ Breathing control (SLT/Physio/Psychol)
Primary Ciliary Dyskinesia
Primary Ciliary Dyskinesia - features
◼ Neonatal breathing problems – 75%
◼ Situs inversus / dextrocardia 50%
◼ Mucousy (nasal) babies - difficult to feed
◼ Cough – leading to bronchiectasis in adulthood
◼ Polyps
◼ Can be misdiagnosed as asthma
◼ (rhinitis, polyps, cough and wheeze)
◼ Hearing problems
◼ Avoid grommets (Hearing aids/bone conduction)
◼ Nasal NO, Nasal brushings, Genetics
◼ Hydrocephalus, dev delay, infertility
Pulmonary TB in children
◼ Symptoms
◼ cough, fever, night sweats, fatigue, malaise, anorexia, weight loss
◼ Children often asymptomatic
◼ Investigations
◼ Rarely produce sputum → GW/IS, TST, IGRA
◼ Red flags:
◼ ‘Acute’ CXR/effusion in relatively well child
◼ Older children w. effusion (Whitechapel at least!)
◼ Exposure history (case: local child empyema ref)
So what do you do?
◼ No red flags, intermittent symptoms, dry cough, CXR (N):
- watch and wait
◼ Persistent symptoms, wet cough, CXR abnormal?
- 4 week course PO abx (aug/clari)
- If not-improved/improved but relapse
- Investigate further:
General Interventions
◼ Ensure fully immunised (incl flu), vitamin D replete
◼ Consider antibiotic prophylaxis (azithro MWF 10mg/kg)
◼ Lifestyle (exercise, ETS, damp, allergen, ?physio req)
◼ Nutrition (monitor growth, adequate hydration, calories)
◼ Monitoring (depends on cause/severity)
◼ Symptoms, spirometry, anthropometry, saturations
◼ Cough swab/sputum (every clinic)
◼ Consider annual CXR
◼ Normal immunity can change… (CVID)
Key references
◼ BTS Guideline
Recommendations for the assessment and management of cough in children
M Shields, A Bush et al for BTS 2007/8
◼ Chang AB et al
A cough algorithm for chronic cough in children
Pediatrics 2013: 131: e1576 – 83
◼ Shields MD et al
The difficult coughing child
Cough 2013:9;
Wheezy infants & pre-schoolers
◼ When is it asthma? When does it matter?
40% of children wheeze in the first year of life – only 30%
pre-school kids with recurrent wheeze have asthma at age
6yrs.
◼ What is meant by wheezing?
◼ What do parents mean by wheezing?
◼ Where does it come from?
◼ Turbulent, high velocity airflow in small airways
◼ Expiratory whistling sound
◼ Differentiate from:
◼ Inspiratory sounds (stridor, snoring/stertor)
◼ Ruttles, crepitations
◼ Mimic/Model it
◼ Smartphone recordings
Where does wheeze come from?
Causes of wheeze
◼ Broncho-constriction
◼ Asthma/multitrigger wheeze
◼ Episodic viral wheeze
◼ Dynamic large airway collapse (malacic segments)
◼ Bronchial oedema + secretions (infection, cardiac)
◼ (Intrathoracic) Large airway obstruction (LNs etc.)
◼ Reflux and aspiration, chronic suppurative lung dis
What is the chance of this being asthma?
A primary care approach to asthma mx?
Suspected AsthmaEpisodic cough & wheeze, viral/nocturnal/exercise symptoms, Salbutamol response
Diurnal/Symptomatic variation in lung function (PEFR/FEV-1), Other Atopy
Troublesome SymptomsSalbutamol used > 3 days/week
Disturbed sleep, School absence, Exercise limitationHospitalisation, Requires oral steroids, ACT Score <19, PEFR < 80% predicted
Initiate Preventer Treatment Age < 5 – Clenil Modulite 100mcg BD via MDI and spacer (mask or mouthpiece)
Age >5 – Clenil Modulite 200mcg BD via MDI and spacer (mouthpiece), PRN SalbutamolAssess ACT Score, PEFR after 3 months
Symptoms PersistAge < 5 – Add montelukast 4mg OD
Age > 5 – Start Seretide 50, TT BD via MDI + spacer
Reassess ACT Score, PEFR
Symptoms Persist?
Symptoms Resolved?Reduce/Stop Treatment
Reassess ACT Score, PEFRRestart/escalate or Reduce/discontinue
MonitorACT, PEFR
Salbutamol Px, Prednisolone PxSchool Absence, ++USMA
Cause for Concern?
Increase Steroid dose/Add montelukast 5mgReassess ACT Score, PEFR
Symptoms Persist?
Refer Secondary Care*
NO
YES
A primary care approach to asthma mx?
Suspected AsthmaEpisodic cough & wheeze, viral/nocturnal/exercise symptoms, Salbutamol response
Diurnal/Symptomatic variation in lung function (PEFR/FEV-1), Other Atopy
Troublesome SymptomsSalbutamol used > 3 days/week
Disturbed sleep, School absence, Exercise limitationHospitalisation, Requires oral steroids, ACT Score <19, PEFR < 80% predicted
Initiate Preventer Treatment Age < 5 – Clenil Modulite 100mcg BD via MDI and spacer (mask or mouthpiece)
Age >5 – Clenil Modulite 200mcg BD via MDI and spacer (mouthpiece), PRN SalbutamolAssess ACT Score, PEFR after 3 months
Symptoms PersistAge < 5 – Add montelukast 4mg OD
Age > 5 – Start Seretide 50, TT BD via MDI + spacer
Reassess ACT Score, PEFR
Symptoms Persist?
Symptoms Resolved?Reduce/Stop Treatment
Reassess ACT Score, PEFRRestart/escalate or Reduce/discontinue
MonitorACT, PEFR
Salbutamol Px, Prednisolone PxSchool Absence, ++USMA
Cause for Concern?
Increase Steroid dose/Add montelukast 5mgReassess ACT Score, PEFR
Symptoms Persist?
Refer Secondary Care*
NO
YES
Asthma Prediction – the API
◼ Frequent wheezing >3x/year under 3 yrs of age and Either
◼ One major risk factor (parental asthma or child with eczema)
◼ Or Two of three minor risk factors
(eosinophilia > 4%, wheezing without colds, and allergic rhinitis).
◼ Risk of having subsequent asthma increased by 4.3 to 9.8 times
◼ Increased risk of asthma persistence
◼ Castro-Rodriguez JA: Am J Resp Crit Care Med 2000: 162: 1403-1406
Tucson Children’s Respiratory study
Asthma phenotypes - temporal
Martinez F D Pediatrics 2002;109:362-367 Tucson Arizona
Asthma phenotypes
◼ Transient early wheeze resolves by age 3
◼ not assoc. FH or atopy. +ve assoc with smoking, prematurity, increased airway compliance, smaller airways, multiple siblings, PFTs track growth
◼ Non-atopic wheeze – viral related esp. RSV
◼ May have lower lung function/ smaller airways at birth
◼ No atopy or +ve SPT – PFTs abnormal till 13yrs
◼ Persistent Wheeze
◼ early onset - before age 3 yrs associated with more severe, persistent symptoms, poor early PFT, early allergy
◼ Late onset wheeze – later atopic development
Simpler asthma adviceClassify according to symptom pattern
◼ Episodic viral wheeze
◼ Multiple trigger wheeze/Asthma
- type may change over time
◼ Target symptom control – can’t modify progression
◼ ICS preferred maintenance rx
◼ LTRA = add-on/intermittent therapy (recent metaanalysis – no benefit in preschoolers)
◼ Assess periodically for sx remission, heterogenity?
◼ Caution with use of oral steroids (no evidence)Castro-Rodriquez et al. Treatment of asthma in young children: evidence-based recommendations Asthma Research and Practice 2016 2:5
Bush A. Managing asthma in preschool children BMJ 2014;348;g15
Other factors
◼ Passive smoking
◼ Mould exposure
◼ Obesity
◼ Pollution
Pollution and wheeze
◼ Pollution - especially particulates and ozone linked to asthma exacerbation
◼ moving from high → low PM10 regions → slows
rate of LF decline
◼ Acute changes in ambient PM10 assoc c incrasthma sx
◼ Prevalence of asthma/allergies in children increasing
◼ Air pollution increases resp infection (PAFr) WHO Europe FACT SHEET 2007:3.1
Esposito S. Impact of air pollution on respiratory diseases in children with recurrent wheezing or asthma. BMC Pulmonary Medicine 2014, 14:130
Obesity and Wheeze
◼ Obesity has been associated with
- Asthma and wheeze
- Severity of asthma
- Poor asthma control
Obesity is a pro-inflammatory condition
Association with poor physical fitness and exercise symptoms also
Meds Update
• New Inhalers• Relvar Ellipta (12+)• (92/22 OD = 250/50 BD)• Spiriva Respimat (6+)• (5mcg = 2 puff OD)• Generics
• Dexamethasone• Azithromycin
Biologics - update
◼ Omalizumab (6+)
◼ Mepolizumab (6+)
Important references
◼ Bush A. Managing asthma in preschool children BMJ 2014;348;g15
◼ R.J. Kurukulaaratchy Predicting persistent disease among children who wheeze during early life
Eur Resp J 2003;22: 767-771
◼ Castro-Rodriguez JA & Martinez FD
Tucson Children’s Respiratory study
◼ I.O.W. study, PIAMA study - Netherlands, ALSPAC –Avon,
◼ ISAAC 1991-2012
◼ Hussein, H.R., Gupta, A., Broughton, S. et al. Eur J Pediatr (2017). doi:10.1007/s00431-017-2936-6
Top tips to take-away
Cough
◼ Early onset wet cough: consider underlying cause
◼ Chronic wet cough: treat – investigate if not better
◼ Cough alone: unlikely to be asthma
Wheeze
◼ Consider airway abnormality in early onset wheeze
◼ If child has regular symptoms and the diagnosis of asthma is ‘probable’ (cough + wheeze +/- SOB(Ex) +/- atopy)
– give 3/12 trial of preventer treatment
◼ Be prepared to re-think if no atopy & no Rx response
Thank You – Questions?