Transcript Wheeze in preschool children

Wheeze in preschool children
Dr Paula McQueen
Consultant Paediatrician
Royal Surrey County Hospital
• Preschool wheeze is common
• 26% of infants in the ALSPAC study had had at
least one episode of wheeze by the age of 18
months
Causes of wheeze
• Common causes
• Uncommon Causes
• Allergies
• Asthma or reactive airway
disease
• Gastroesophageal reflux disease
• Infections
• Bronchiolitis
• Bronchitis
• Pneumonia
• Upper respiratory infection
• Obstructive sleep apnea
•
•
•
•
•
•
•
•
•
•
•
•
Bronchopulmonary dysplasia
Foreign body aspiration
Bronchiolitis obliterans
Congenital vascular
abnormalities
Congestive heart failure
Cystic fibrosis
Immunodeficiency diseases
Mediastinal masses
Primary ciliary dyskinesia
Tracheobronchial anomalies
Tumor or malignancy
Vocal cord dysfunction
Case study 1
• 3 year old boy with
wheeze
What do we want to know?
• Is it wheeze?
• Is it intermittent or persistent?
• Does it occur just with viral infections or are
there other triggers?
• Is the child otherwise well and thriving?
• Any history of atopy?
• Any family history of atopy?
Case study 1
• 3 year old boy with
wheeze
• Wheezy just with URTIs,
well inbetween
• No eczema, no food
allergies
• No family history of
asthma
• Growing along the 75th
centile
Episodic viral wheeze
• The child wheezes only with only with viral
upper respiratory infections and is otherwise
totally symptom free.
• Not associated with Eosinophillic
inflammation and remodelling
Case study 2
•
•
•
•
3 year old boy
Eczema
Egg allergy
Wheezes with URTI also
on exercise and with
Grandmas cat
Multiple trigger wheeze
• Child wheezes with viral URTIs but also with
other triggers such as exercise and other
allergens
• Is associated with more airflow obstruction
than EVW
• Airway pathology (eosinophillic inflammation
and remodelling) is similar to childhood and
adult asthma
Management of Preschool wheeze
•
•
•
•
Home enviroment
Bronchodilators
Corticosteroids
Leucotriene receptor antagonists
Home Enviroment
• Optimise home enviroment
• Stop smoking
• Remove triggers
Bronchodilators
• Short acting β agonists
• Cochrane review in 2002 showed no clear
evidence to support their use in children <2
years
• Anticholinergics
• Cochrane review in 2005 no significant
differences in length of hospital stay, RR, SaO2
and hospitalisation between Ipratropium and
placebo
Corticosteroids
Cochrane 2009: Inhaled
steroids for episodic viral
wheeze of childhood
• 3 X episodic high dose ICS
– Reduced oral steroid requirement
– Preferred by parents
• 2 X maintenance ICS
– No change in oral steroid or hospital admissions
• Conclusions:
– Episodic ICS may be partially effective at treating
viral induced wheeze
Corticosteroids
• No evidence to support the use of
intermittent inhaled steroids at licensed doses
in children with episodic viral wheeze.
• No evidence to support the use of regular
inhaled steroids in preschool children who do
not wheeze between colds
• Any preschool child with viral induced wheeze
who is well enough to stay at home should
not be prescribed prednisolone.
Montelukast
• Objective: To determine whether short courses of
Montelukast would modify the severity of asthma
episode
• 2-14yr asthmatics RCT over 12m
• Montelukast administered at first sign of
asthma or virus. Continued for 7days +
• 681 episodes in 202 children
– Less unscheduled healthcare utilization
– Symptoms reduced
– Less time off school/work
• Non-significant reductions in episode
duration, B-agonist use,steroid use
PREVIA study
• Prevention of Viral Induced Asthma
• 2-5yrs patient with history of intermittent asthma
associated with viral infections
• 12m, multi-center (UCL), double-blinded
• Daily montelukast or placebo for 12m
• Symptoms, B-agonist, healthcare use
– Reduced rate of exacerbations by 31% (1.6/yr versus 2.3/yr)
– Delayed time to first exacerbation by 2m
– Reduced ICS prescriptions
• Study of children with ASTHMA!
Management of Episodic Viral Wheeze
• >2 years Intermittent bronchodilators as
needed
• Trial of intermittent montelukast at start of
URTI continue until symptoms have resolved
• For those children with severe EVW who have
repeated admissions to hospital trial of
prophylactic inhaled corticosteroid
Management of multiple trigger
wheeze