Dr Jennifer Townshend Consultant Paediatrician Context Some common presentations Common complains Wheezy infant Wheezy child Chronic cough Overview Audience participation Blue background slides ID: 237856
Download Presentation The PPT/PDF document "Respiratory Paediatrics For GP’s" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Respiratory Paediatrics For GP’s
Dr.
Jennifer Townshend
Consultant PaediatricianSlide2
ContextSome common presentations
Common complains
Wheezy infantWheezy childChronic cough
OverviewSlide3
Audience participation
Blue background slidesSlide4
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?Slide5
9 year old boy
Diagnosed with asthma 4 years ago
Never free from symptomsEnds up in hospital about once per yearNothing seems to be working
A familiar case?Slide6
What do you want to know?
What else could be going on?
What are your thoughts?Slide7
Typical history of poorly controlled asthma
Very poor compliance
Poor inhaler techniqueSmoking (never in the house)Chaotic family situation
Parents separated last month
Dad no idea what inhalers he takes
Subsequent questionsSlide8
Not clubbed, normal chest shape
Audible wheeze through out
Lung function 65% predicted18% reversibility post salbutamol
Wheeze resolves post inhaler
CXR normal
Eosinophils 0.4, IgE 112
On examinationSlide9
Poorly controlled atopic asthma
What is the likely diagnosis?Slide10
RF for life threatening disease
Poor compliance
Poor techniqueChaotic social situation
Parental smoking, risk of child smoking
Are you concerned?Slide11
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? Slide12
What else do you want to know?
What could be going on?
What do you think?Slide13
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 questioningSlide14
Episodic viral wheeze
What is the likely diagnosis?Slide15
WheezeSlide16
What is it?
WheezeSlide17
What is it?
‘
a continuous high pitched
musical sound emitting from the chest in expiration as a result of narrowing of the small airways’
WheezeSlide18
Where does it come from?
Closed cavity
Relationship between pressure and volume
Wheeze Slide19
What causes it?
All that wheezes is not asthma……..
WheezeSlide20
Alerting symptom/Sign
Possible diagnosis
Clinical ClueSlide21
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
BPD
Compromised host
defence
CF
Immunodeficiency
PCD
FTT,
malabsorption
FTT,
rct
infections
FTT,
rct
ear
infections
Sudden
onset in previously well child
Foreign body aspiration
History
Unilateral
reduced breath sounds
Persistent wet cough
Compromised
host defence
Bronchiectasis
Rct
infections, FTT
Purulent sputum
Post viral wheeze
Post bronchiolitic coughObliterative bronchiolitisHistory of recent bronchiolitisFine creps, hyperinfationSlide22
Asthma more complex, especially in children
Different patterns of illness having different underlying pathogenesis
Different phenotypes have different management strategies and different prognosis
Asthma phenotypesSlide23
Most commonly recognised phenotype
Classical characteristics
Atopic AsthmaSlide24
School aged child
Episodic
‘exacerbations’: (wet) cough/wheeze/SOBInterval symptoms: (dry)
cough,
nocturnal,exercise
Identifiable triggers
Personal/FH
atopy
Raised
eosinophils
/IgE
Atopic asthma - characteristicsSlide25
Very rare to cough without wheeze in asthma
(McKenzie, 1994)
More likely to be a marker for another conditionBut, does exist – consider trial of asthma therapy if all other conditions excluded
What about cough
varient
asthma?Slide26
Step wise approach to medication
Support self management
EducationShared decision makingAsthma management plan
Delivery techniques
Avoidance of triggers
Associated allergies?
Regular review
monitoring for side effects
compliance
Management of atopic asthmaSlide27
Inhaled corticosteroids
Friend? Foe? Practically?
Long acting beta agonistsBetter then doubling dose of ICSBut safe??
A few things to mentionSlide28
Many variables
Secondary or tertiary?
Atopic asthma – when to referSlide29
Feature
Comment
Poor response to 800mcg per day of
beclomethasone
or equivalent
Patient should be on other
therpies
Concordance 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 referSlide30
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
PrognosisSlide31
Atopic Asthma
Episodic viral wheeze
‘the wheezing infant’
Asthma phenotypes (2)Slide32
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 wheezeSlide33
Risk
factors for development into atopic phenotype
FH/personal history of atopyPremature birth/low birth weightSmoking
Bronchiolitis as an infant
Episodic viral wheezeSlide34
Acute managementSalbutamol in under 2’s
Corticosteroids
Long term managementPrognosis
Different phenotypes – so what?Slide35
30-50% of children have one episode66% out grow their symptoms before school age
Atopic asthma can start with EVW but often have atopic phenotype and/or FH
Episodic Viral Wheeze – prognosisSlide36
Practically
Consider other causes
Try
and identify the phenotype
Draw a time line of wheeze
Manage according to severity and phenotype
Time
Symptoms
Acute
symptoms
Interval symptomsSlide37
11 year old boy
Presented ‘exacerbation of asthma’
Difficult to control asthma for yearsPrimary symptom is cough
Wet
Every day
No real relief from inhalers
Some mild SOB, no real wheeze
Some more cases…..Slide38
What else do you want to know?
What are your thoughts?Slide39
No FH of
atopy
No personal history of atopy
No smoking in family
Always hungry, but still slim
Further questioningSlide40
Sats
91% in air
Increased work of breathingHyperinflatedNo wheeze, no
creps
Clubbed
On examinationSlide41
CXR: chronic
changes
Sweat test – confirmed Cystic fibrosisSlide42
18 month old child
Well until 13 months
‘Never been right since’
Coughs every day, no break in between
Case 2Slide43
Started nursery at 13 months
Recurrent episodes of runny nose
Wet cough associated with runny noseCough beginning to recede after a few weeks
Then further runny nose and cough starts again
Thriving
Further questioningSlide44
Well child
Nasal crusting
Wet coughNormal chest shapeChest clear to auscultation
Recurrent viral URTI’s
Reassure
Reassess in summer months
On examinationSlide45
Important physiological reflex
Common (up to 10% children)
OTC medicine – cochrane review
CoughSlide46
Acute cough
Recurrent acute cough
Persistent none remitting cough
Different cough typesSlide47
Vast majority viral URTI
History and examination important to rule out chronic illness
ConsiderPertussisAllergyInhaled foreign body
Rarely – presenting feature of serious underlying disorder
Acute cough (< 3 weeks )Slide48
Uncertainty about diagnosis of pneumonia
IFB
Possible chronic problemProlonged clinical courseTrue haemoptysis
When to consider CXR/ReferralSlide49
Antipyretics and fluids as requiredAntibiotics not beneficial in absence of signs of pneumonia
Bronchodilators not helpful in children who don’t have asthma
OTC remedies not effectiveMacrolide for pertussis
EXPLANATION – reduce future consultations
How to manage acute coughSlide50
Chronic cough > 8 weeks3-8 weeks ‘grey area’
Subacute
(post viral)Pertussis
Chronic cough Slide51
StructuralImmunodeficiency
Suppurative
(PBB, bronchiectasis)Recurrent aspirationPertussis
Retained IFB
TB
Bronchcospasm
Intersitial
lung disease/cardiac
DifferentialSlide52
StructuralImmunodeficiency
Suppurative
(PBB, bronchiectasis)Recurrent
aspiration
Pertussis
Retained IFB
TB
Bronchcospasm
Intersitial
lung disease/cardiac
DifferentialSlide53
Persistent Bacterial Bronchitis
Conducting airways
Respiratory
SpacesSlide54
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 BronchitisSlide55
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 AsthmaSlide56
Consider different types of cough
AssessmentSlide57
Barking
large
airwayHonkingpsychogenicParoxysmal
pertussis
Chronic
fruity
suppurative
Dry/tight
bronchospasm
Types of coughSlide58
Nature of the cough
Time, diurnal and sleep, sputum, wheeze
Age of onsetFeeding relationIFB?Relieving (beta agonist,
ab’s
)
Cigarette smoke
FH
HistorySlide59
When would you refer
(when have you referred?)
Red flagsSlide60
Neonatal onset
Chronic wet cough
Cough after choking episodeNeuro-developmental problemsChest wall deformity
Recurrent pneumonia
Growth faltering
Clubbing
Red flags – specialist referralSlide61
Watchful waiting – 6-8 weeksRemoval of aeroallergens
Trial anti-asthma treatment
Trial antibiotics for PBB
Approach to managementSlide62
Respiratory paediatrics is fascinating!
…..and relevant to everyday practice
Think of other causes of wheezeIdentify asthma phenotypesClassify different cough types
Consider PBB
Refer if unsure
SummarySlide63
Thank you.