Approach to Wheezing Child - PowerPoint Presentation

Slide1

Approach to Wheezing Child

Dr. Mohamed Haseen Basha

Assistant professor ( Pediatrics)

Faculty of Medicine

Al Maarefa College of Science and Technology

Slide2

Wheeze

Wheeze is a continuous & musical sound

that originates

from oscillations in narrowed

airways, mostly

heard in expiration due to

critical airway obstruction.

Sign of lower (intra-thoracic) airway

obstruction.

If there is widespread narrowing of airways

leading

to various levels of obstruction to

airflow

(

eg

. asthma), polyphonic wheeze

is heard

i.e. sounds of various

pitches.

Monophonic wheeze (single pitch) is produced

in

larger airways during expiration

eg

. distal

tracheomalacia

,

bronchomalacia

.

Slide3

Infants & children are prone to wheeze due to different set of lung mechanics ( as compared to older children & adults)

Obstruction to airflow



airway caliber

Resistance to airway: In

children < 5 years, small caliber peripheral

airways

can contribute

upto

50

% of

airway resistance, m

arginal additional narrowing

can cause

further

flow limitation & subsequent

wheeze.



compliance of lung

Differences

in tracheal cartilage composition

& airway

muscle tone causes further increase in

airway compliance.

Slide4

All these mechanisms combine to make the Infant more susceptible to

airway

collapse



Increased resistance



Subsequent

wheeze

Many of these are outgrown in the 1

st

year

of

life itself

Slide5

The most likely diagnosis in children with recurrent wheezing is asthma. However, other diseases can present with wheezing in childhood, and patients with asthma may not wheeze.Some experts distinguish between wheezes and rhonchi based upon the dominant frequency, or pitch, of the sound. Wheezes have a dominant frequency greater than 400 Hz, whereas rhonchi are of lower frequency. However, the clinical significance of this distinction, if any, is not well defined.

Slide6

Slide7

Types of WheezersTransient wheezers - Risk

factor is

primarily diminished

lung size

Persistent wheezers

- Initial

risk factors

being exposure to passive smoking, Maternal asthma, Persistent

rhinitis,

Eczema

<1yr

age, H/O Allergy.

At

an increased risk of developing

clinical asthma

Late

onset

wheezers

Slide8

Causes of Wheezing

a) Infections

Viral : RSV (bronchiolitis)

Human meta

pneumovirus

Influenza, parainfluenza

Adenovirus

Rhinovirus

Others:

TB, Chlamydia trachomatis, Histoplasmosis

b) Asthma

c) Immunodeficiency states:

IgA deficiency,

B cell

deficiency, AIDS,

d) Mucociliary

clearance disorders

:

Cystic fibrosis, Primary

ciliary

dyskinesias

Bronchiectasis

Slide9

e) Anatomic abnormalities: Central airway abnormalities:

-

Malacia

of larynx, trachea, bronchi

- Tracheoesophageal fistula ( H type)

- Laryngeal cleft (leading to aspiration)

Extrinsic airway anomalies (leading to compression)

- Vascular ring/ sling

- Mediastinal

LN’pathy

(infection/ tumor)

- Esophageal foreign body

Intrinsic

airway anomalies:

-

Airway hemangioma

- Cystic

adenomatoid

malformation

-

Bronchial/ lung cyst

-

Congenital lobar emphysema

-

Aberrant tracheal bronchus

-

Sequestration

-

CHD with L

 R

shunt ( pulmonary edema)

- Foreign body

Slide10

f) Bronchopulmonary Dysplasia

g) Aspiration Syndromes

- GERD

- Pharyngeal/ swallow dysfunction

h) Interstitial lung disease

i

) Heart Failure

j) Anaphylaxis

k) Inhalation Injury – Burns

l) WALRTI, Wheeze

a/w

URTI

m) Drugs:

Ibuprofen, Aspirin, Rifampicin, Erythromycin

Slide11

Causes of wheezing in children

Acute

Asthma

Bronchiolitis

Bronchitis

Laryngotracheobronchitis

Bacterial tracheitis

Foreign body aspiration

Esophageal foreign body

Slide12

Causes of wheezing in children

Chronic or recurrent

Structural abnormalities

Functional abnormalities

Tracheo-bronchomalacia

Asthma

Vascular compression/rings

Gastroesophageal reflux

Tracheal stenosis/webs

Recurrent aspiration

Cystic lesions/masses

Cystic fibrosis

Tumors/lymphadenopathy

Immunodeficiency

Cardiomegaly

Primary ciliary dyskinesia

Bronchopulmonary dysplasia

Retained foreign body (trachea or esophagus)

Bronchiolitis obliterans

Pulmonary edema

Vocal cord dysfunction

Interstitial lung disease

Slide13

Two important aspects of the medical history include the

P

atient's

age at the onset of wheezing

The

course of

onset (

acute versus gradual)

Slide14

Clinical Manifestations

HISTORY

Onset, Duration & associated factors

of wheezing

Birth history:

weeks of gestation, NICU admission, h/o intubation / O2 requirement, maternal complications

eg

. Infection- HSV, HIV; prenatal smoke exposure

Past medical history:

co-morbid conditions

eg

. syndromes or association.

Social history:

Environmental history of smokers at home, number of siblings, occupation of inhabitants at home, pets, TB exposure.

Family

history:

Cystic Fibrosis, immunodeficiency

, asthma in 1

st

degree relatives

OR

any

other recurrent respiratory conditions

should be obtained.

Slide15

RISKS OF FAMILY HISTORY OF ATOPY

No family history

:

16%

Single parent atopy : 22

%

Maternal

Atopy

: 32

%

Both parents atopic

:

50%

Slide16

Medical history in wheezing infant:

Did the onset of symptoms begin at birth or thereafter?

Is the infant a noisy breather & when is it most prominent?

Is there a history of cough apart from wheezing?

Was there an earlier LRTI?

Have there been any emergency department visits, hospitalizations, or ICU admission for Respiratory Distress ?

Is there a history of eczema?

How is the infant growing & developing? Is there associated failure to thrive?

Are there s/o intestinal malabsorption including frequent , greasy, or oily stools?

Is there a maternal history of genital HSV infection?

Slide17

What was the gestational age at delivery?

Was the patient

intubated

as neonate?

Does the infant bottle feed in the bed or crib, especially in propped position?

Are there any feeding difficulties including choking, gagging, arching, or vomiting with feeds?

Any new food exposure?

Is there a toddler in the home or lapse in supervision in which foreign body aspiration could have happened?

Change in caregivers or chance or non accidental trauma?

Slide18

Features in the history that favor the diagnosis of asthma include:

Intermittent episodes of wheezing that usually are the result of a common trigger (

ie

, upper respiratory infections, weather changes, exercise, or allergens)

Seasonal variation

Family history of asthma and/or atopy

Good response to asthma medications

Positive asthma predictive index

Slide19

Features suggestive of a diagnosis other than asthma in children

History

Onset of symptoms in early infancy

Neonatal respiratory distress +/-

ventilator

support

Neonatal neurologic dysfunction

Intractable wheezing unresponsive to bronchodilators

Wheezing associated with feeding or vomiting

Difficulty swallowing +/- recurrent vomiting

Diarrhea

Poor weight gain

Stridor

Oxygen requirement >1 week after acute attack

Slide20

PHYSICAL EXAMINATION

:

Measurement

of

Weight

and H

eight

Vitals especially RR, SPO2

Growth charts for signs of FTT

Upper airway signs of atopy: boggy

turbinates

, posterior oropharynx cobble stoning

Evaluate skin for eczema, hemangioma

Midline lesions may be associated with intrathoracic lesions

Clubbing

Stridor

+/-

Slide21

Signs of Respiratory Distress- Tachypnea, nasal flaring, tracheal tugging, SCR/ICR, excessive use of accessory muscles

Prolonged expiratory time, expiratory whistling sounds.

Auscultation: aeration to be noted, expiratory wheeze, lack of audible wheeze due to complete airway obstruction.

Trial of bronchodilators to evaluate change of wheezing

Slide22

Chest examination should focus on the following features:Inspection:

For

the presence of respiratory distress, tachypnea, retractions, or structural abnormalities

.

Pertinent

findings include an increased anteroposterior (AP)

diameter associated

with chronic hyperinflation, pectus excavatum caused

by chronic

airway obstruction and exaggerated swings in

intrathoracic pressure

, or scoliosis complicated by airway

compression.

Palpation:

To

detect supratracheal lymphadenopathy or tracheal deviation.

Percussion:

can

define the position of the diaphragm and detect differences in resonance among lung regions and is the most underperformed part of the examination.

Slide23

Auscultation:Allows

identification of the characteristics and location of wheezing, as well as variations in air entry among different lung regions.

A

prolonged expiratory phase suggests airway narrowing.

Wheezing

caused by a large or central airway obstruction (

eg

, vascular ring, subglottic stenosis,

tracheomalacia

) has a constant acoustic character throughout the lung but varies in loudness depending upon the distance from the site of obstruction.

D

egree

of narrowing varies from place to place within the lung in the setting of small airway obstruction (

eg

, asthma, cystic fibrosis, primary ciliary dyskinesia, aspiration).

F

ocal

wheezing is usually indicative of a localized and mostly structural airway abnormality,

Slide24

Crackles can be present with wheezing in asthma and in a variety of other conditions, such as those leading to bronchiectasis (eg

, cystic fibrosis, primary ciliary dyskinesia, immune deficiency).

Early inspiratory crackles

are often present in patients with asthma due to air flowing through secretions or slightly closed airways during inspiration.

Late inspiratory crackles

are usually associated with interstitial lung disease and early congestive heart failure. Thus, the presence of crackles does not exclude the diagnosis of asthma .

Decreased wheezing after bronchodilator therapy is suggestive of asthma but does not rule comorbid conditions if clinically suspected.

Slide25

Cardiac exam-

Murmurs

and signs of heart failure.

Examination

of the skin for eczema

(common in atopic patients) or other cutaneous lesions may assist in diagnosis.

Nasal

examination

may reveal signs of allergic rhinitis, sinusitis, or nasal polyps. The presence of nasal polyps in children necessitates an evaluation for cystic fibrosis.

Slide26

Features suggestive of a diagnosis other than asthma in children

Physical examination

Failure to thrive

Clubbing

Cardiac murmur

Stridor

Focal lung signs

Nasal polyps

Crackles on auscultation

Cyanosis

Laboratory features

Focal or persistent chest radiograph abnormalities

Anemia

Irreversible airflow obstruction

Hypoxemia

Slide27

Diagnostic evaluation

Initial evaluation depends on likely etiology

1. Chest X-ray:

hyperinflation, Space

Ooccupaying

Lesion, signs of chronic diseases like Bronchiectasis, Focal infiltrates

2. Trial of bronchodilators-

Diagnostic & therapeutic in

bronchiolitis

& asthma, won’t effect fixed obstruction

May worsen wheezing in tracheal/

bronchomalacia

.

3. Baseline immunity

in complicated cases

Slide28

Exclude other conditions

4) Structural

problems:

bronchoscopy

5

) Polysomnography

6) Esophageal

disease:

Barium swallow, pH probes

, Upper GI

scopy

7) Primary

ciliary dyskinesia:

N

asal

ciliary motility

, Exhaled

NO,

Electron Microscopy, saccharine test

8) TB

:

M

antoux

, induced sputum/ gastric lavage/

BAL for Culture,

microscopy

&

PCR

9) Bronchiectasis

: HRCT scan, BAL

10)

Cystic Fibrosis:

Sweat chloride test

,

11

) Systemic immune deficiency:

Ig

subtypes, lymphocytes

&

neutrophil function

, HIV

12

) Cardiovascular disease

:

ECHO, Angiography

13

) Viral testing (PCR, viral culture

) is helpful if

diagnosis is

uncertain.

Slide29

Treatment

1)

Comfort the child:

Try to keep your baby calm. Having a cough and a noisy wheeze frightens children and breathing is more difficult when they are upset.

2)

Offer frequent liquids

3)

Bronchodilators:

Administer

inhaled short acting beta-2 agonist

(

eg

salbutamol) & observe the

response. Response

is

unpredictable. Therapy

to be continued in all asthma

patients

with exacerbations with viral

illness.

4)

Ipratropium bromide

:

Anticholinergic agent

can

be used as adjunct therapy

Also

useful in patients with significant

Tracheal

or

Bronchomalacia

Slide30

5) Oral/ IV steroids: Used for atopic wheezing infants thought to have asthma i.e. refractory to other medications

6)

Inhaled steroids:

Appropriate for maintenance therapy in known reactive airways but not useful in acute illness

To be used if significant h/o atopy ( food allergy, eczema) present

Maintenance treatment with inhaled steroids is recommended for multiple-trigger wheeze.

Slide31

7) In acute B

ronchiolitis:

M

ainstay of treatment is supportive

Hypoxemic child: cool humidified oxygen

- Avoid sedatives

Nebulized epinephrine more effective

8)

Montelukast

is recommended for the treatment

of episodic

(

viral) wheeze, to

be started when symptoms of a

viral

cold develop

9)

Ribavarine

:

antiviral administered by aerosol

- Used for children with

Congenital Heart Disease / Chronic Lung Disease

10)

No role of antibiotics

unless secondary

bacterial infection

Slide32

Prevention

1) Reduction in severity & incidence of ac. bronchiolitis due to RSV is possible through administration of

pooled

Hyperimmune

RSV Intravenous Immunoglobulin (RSV

IVIg

,

Respigam

)

2)

Palivizumab

,

a monoclonal antibody to the RSV F protein, before & during RSV season.

It is recommended for children < 2yrs age with chronic lung disease (BPD) or prematurity

3)

Inhaled corticosteroids and

montelukast

may be considered in preschool child with recurrent wheeze.

Slide33

4) Avoid smoking – Smoking in the home increases the risk of respiratory

problems in children

5)

Educating parents

regarding causative factors and treatment is useful.

6)

Allergen avoidance

may be considered when

sensitisation

has been established

7)

Meticulous handwashing

is the best measure to prevent nosocomial infection

Slide34

Approach to evaluation of wheezing in children based upon suspected diagnosis

Acute

Suspected diagnosis

Signs and symptoms

Diagnostic evaluation

Asthma

History of recurrent wheeze, cough, at least partial response to bronchodilator

History, PFT with bronchodilators, empiric

trial

of

bronchodilators, exercise or methacholine challenge testing, chest radiography only if atypical, skin (or in vitro) testing for aeroallergen sensitization if history suggests inhalant allergen triggers

Viral bronchiolitis

Prodrome

with rhinitis, occurs in infancy and early childhood, seasonal pattern

History, age, season, rapid antigen testing (RSV, influenza), viral cultures, chest radiography

Foreign body

Sudden onset of coughing and wheezing

History, physical examination, chest radiography, bronchoscopy

Slide35

Approach to evaluation of wheezing in children based upon suspected diagnosis

Chronic

Suspected diagnosis

Signs and symptoms

Diagnostic evaluation

Asthma

As above

As above

Tracheomalacia

Persistent wheeze, starts early in life, poor response to bronchodilators, varies with position and activity

History, fluoroscopy, flexible bronchoscopy

Cystic fibrosis

Chronic productive cough, crackles, with or without clubbing, failure to thrive, recurrent respiratory infections

Sweat chloride test, genetic testing

Swallowing dysfunction

Neurologic abnormality (nonuniversal), choking with eating, symptoms exaggerated by feeding

Radiographic swallowing study

Gastroesophageal reflux

Symptoms sometimes related to eating, vomiting, refusal to eat, failure to thrive

Barium swallow, pH probe, bronchoscopy and bronchoalveolar lavage

Vascular ring or sling

Persistent symptoms, starts early in infancy, may be exaggerated by position, homophonous wheeze

Barium swallow, MRI

Slide36

Chronic

Suspected diagnosis

Signs and symptoms

Diagnostic evaluation

Tracheal stenosis

Persistent symptoms, with or without stridor, homophonous wheeze

Chest radiograph, CT scan, bronchoscopy

Mediastinal nodes or mass

Persistent symptoms, localized wheezing, no response to bronchodilator, systemic symptoms of underlying disease

Chest radiograph, CT scan

Immunodeficiency

Recurrent sinopulmonary infections, crackles, FTT, clubbing

Immunoglobulins, vaccine responses

Primary ciliary dyskinesia

Persistent sinusitis and otitis media with draining ears, recurrent respiratory infection, wet cough with sputum production, crackles, clubbing, FTT

Ciliary biopsy, with or without genetic testing

Vocal cord dysfunction

Inspiratory stridor, poor response to bronchodilators, absent symptoms during sleep, teenage, exercise related

Exercise testing, pulmonary function tests, laryngoscopy while symptomatic

Bronchiolitis obliterans

History of predisposing disease,

ie

, viral infection or transplantation, dyspnea, persistent wheezing

Chest CT scan, lung biopsy

Slide37

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