Respiratory Paediatrics For GP’s

Dr. Jennifer TownshendConsultant Paediatrician

Context Some common presentations Common complains

◦ Wheezy infant◦ Wheezy child◦ Chronic cough

Overview

Audience participation

Blue background slides

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?

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?

What do you want to know?

What else could be going on?

What are your thoughts?

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

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

Poorly controlled atopic asthma

What is the likely diagnosis?

RF for life threatening disease◦ Poor compliance◦ Poor technique◦ Chaotic social situation◦ Parental smoking, risk of child smoking

Are you concerned?

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?

What else do you want to know?

What could be going on?

What do you think?

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

Episodic viral wheeze

What is the likely diagnosis?

Wheeze

What is it?

Wheeze

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

Where does it come from?

◦ Closed cavity◦ Relationship between pressure and volume

Wheeze

What causes it?

• All that wheezes is not asthma……..

Wheeze

Alerting symptom/Sign

Possible diagnosis Clinical Clue

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

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

Most commonly recognised phenotype

Classical characteristics

Atopic Asthma

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

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?

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

Inhaled corticosteroids◦ Friend? Foe? Practically?

Long acting beta agonists◦ Better then doubling dose of ICS◦ But safe??

A few things to mention

Many variables

Secondary or tertiary?

Atopic asthma – when to refer

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

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

Atopic Asthma

Episodic viral wheeze‘the wheezing infant’

Asthma phenotypes (2)

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

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

Acute management◦ Salbutamol in under 2’s◦ Corticosteroids

Long term management

Prognosis

Different phenotypes – so what?

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

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

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…..

What else do you want to know?

What are your thoughts?

No FH of atopy No personal history of atopy No smoking in family

Always hungry, but still slim

Further questioning

Sats 91% in air Increased work of breathing Hyperinflated No wheeze, no creps Clubbed

On examination

CXR: chronic changes

Sweat test – confirmed Cystic fibrosis

18 month old child Well until 13 months

‘Never been right since’

Coughs every day, no break in between

Case 2

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

Well child Nasal crusting Wet cough Normal chest shape Chest clear to auscultation

Recurrent viral URTI’s Reassure Reassess in summer months

On examination

Important physiological reflex

Common (up to 10% children)

OTC medicine – cochrane review

Cough

Acute cough

Recurrent acute cough

Persistent none remitting cough

Different cough types

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 )

Uncertainty about diagnosis of pneumonia IFB Possible chronic problem Prolonged clinical course True haemoptysis

When to consider CXR/Referral

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

Chronic cough > 8 weeks 3-8 weeks ‘grey area’

◦ Subacute (post viral)◦ Pertussis

Chronic cough

Structural Immunodeficiency Suppurative (PBB, bronchiectasis) Recurrent aspiration Pertussis Retained IFB TB Bronchcospasm Intersitial lung disease/cardiac

Differential

Structural Immunodeficiency Suppurative (PBB, bronchiectasis) Recurrent aspiration Pertussis Retained IFB TB Bronchcospasm Intersitial lung disease/cardiac

Differential

Persistent Bacterial Bronchitis

Conducting airways

RespiratorySpaces

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

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

Consider different types of cough

Assessment

Barking ◦ large airway

Honking◦ psychogenic

Paroxysmal ◦ pertussis

Chronic fruity◦ suppurative

Dry/tight ◦ bronchospasm

Types of cough

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

When would you refer

(when have you referred?)

Red flags

Neonatal onset Chronic wet cough Cough after choking episode Neuro-developmental problems Chest wall deformity Recurrent pneumonia Growth faltering Clubbing

Red flags – specialist referral

Watchful waiting – 6-8 weeks Removal of aeroallergens Trial anti-asthma treatment Trial antibiotics for PBB

Approach to management

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

Thank you.