Respiratory Paediatrics For GP’s - PowerPoint Presentation

Respiratory Paediatrics For GP’s
Respiratory Paediatrics For GP’s

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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

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wheeze asthma viral cough asthma wheeze cough viral atopic acute history chronic children symptoms examination pbb child wet diagnosis

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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.

Shom More....