Transcript Respiratory Paediatrics For GP’s

Dr. Jennifer Townshend
Consultant Paediatrician
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Context
Some common presentations
Common complains
◦ Wheezy infant
◦ Wheezy child
◦ Chronic cough
Audience participation
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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
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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
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What do you want to know?
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What else could be going on?
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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
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Not clubbed, normal chest shape
Audible wheeze through out
Lung function 65% predicted
◦ 18% reversibility post salbutamol
◦ Wheeze resolves post inhaler
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CXR normal
Eosinophils 0.4, IgE 112
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Poorly controlled atopic asthma
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RF for life threatening disease
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Poor compliance
Poor technique
Chaotic social situation
Parental smoking, risk of child smoking
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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…..’
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What else do you want to know?
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What could be going on?
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Well until 9 months of age
Developed viral URTI – very chesty at this time
◦ Clarify chesty means wheeze and dry cough’
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Period where completely symptom free
Subsequent pattern:
◦ URTI
wheeze and SOB
◦ Resolves completely before the next episode
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Thriving
No FH atopy, no premature birth
Normal examination
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Episodic viral wheeze
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What is it?
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What is it?
‘a continuous high pitched musical sound emitting
from the chest in expiration as a result of narrowing of
the small airways’
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Where does it come from?
◦ Closed cavity
◦ Relationship between pressure and volume
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What causes it?
• All that wheezes is not asthma……..
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
Wheeze present
shortly after birth
BPD
Compromised host
defence
• CF
• Immunodeficiency
• PCD
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 cough History of recent
bronchiolitis
Obliterative
Fine creps,
bronchiolitis
hyperinfation
Persistent wheeze, no
variation
• FTT, malabsorption
• FTT, rct infections
• FTT, rct ear
infections
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Asthma more complex, especially in children
Different patterns of illness having different
underlying pathogenesis
Different phenotypes have different
management strategies and different
prognosis
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Most commonly recognised phenotype
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Classical characteristics
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School aged child
Episodic
◦ ‘exacerbations’: (wet) cough/wheeze/SOB
◦ Interval symptoms: (dry) cough, nocturnal,exercise
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Identifiable triggers
Personal/FH atopy
Raised eosinophils/IgE
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Very rare to cough without wheeze in asthma
(McKenzie, 1994)
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More likely to be a marker for another
condition
But, does exist – consider trial of asthma
therapy if all other conditions excluded
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Step wise approach to medication
Support self management
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Education
Shared decision making
Asthma management plan
Delivery techniques
Avoidance of triggers
Associated allergies?
Regular review
◦ monitoring for side effects
◦ compliance
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Inhaled corticosteroids
◦ Friend? Foe? Practically?
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Long acting beta agonists
◦ Better then doubling dose of ICS
◦ But safe??
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Many variables
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Secondary or tertiary?
Feature
Poor response to 800mcg per day
of beclomethasone or equivalent
Comment
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
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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
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Atopic Asthma
Episodic viral wheeze
‘the wheezing infant’
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Characteristic features
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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
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Risk factors for development into atopic
phenotype
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FH/personal history of atopy
Premature birth/low birth weight
Smoking
Bronchiolitis as an infant
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Acute management
◦ Salbutamol in under 2’s
◦ Corticosteroids
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Long term management
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Prognosis
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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
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Consider other causes
Acute
symptoms
Try and identify the
phenotype
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Draw a time line of
wheeze
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Manage according to
severity and phenotypeSymptoms
Interval
symptoms
Time
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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
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Some mild SOB, no real wheeze
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What else do you want to know?
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No FH of atopy
No personal history of atopy
No smoking in family
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Always hungry, but still slim
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Sats 91% in air
Increased work of breathing
Hyperinflated
No wheeze, no creps
Clubbed
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CXR: chronic changes
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Sweat test – confirmed Cystic fibrosis
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18 month old child
Well until 13 months
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‘Never been right since’
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Coughs every day, no break in between
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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
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Well child
Nasal crusting
Wet cough
Normal chest shape
Chest clear to auscultation
Recurrent viral URTI’s
Reassure
Reassess in summer months
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Important physiological reflex
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Common (up to 10% children)
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OTC medicine – cochrane review
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Acute cough
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Recurrent acute cough
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Persistent none remitting cough
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Vast majority viral URTI
History and examination important to rule
out chronic illness
Consider
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Pertussis
Allergy
Inhaled foreign body
Rarely – presenting feature of serious underlying
disorder
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Uncertainty about diagnosis of pneumonia
IFB
Possible chronic problem
Prolonged clinical course
True haemoptysis
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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
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Chronic cough > 8 weeks
3-8 weeks ‘grey area’
◦ Subacute (post viral)
◦ Pertussis
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Structural
Immunodeficiency
Suppurative (PBB, bronchiectasis)
Recurrent aspiration
Pertussis
Retained IFB
TB
Bronchcospasm
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Intersitial lung disease/cardiac
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Structural
Immunodeficiency
Suppurative (PBB, bronchiectasis)
Recurrent aspiration
Pertussis
Retained IFB
TB
Bronchcospasm
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Intersitial lung disease/cardiac
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Conducting
airways
Respiratory
Spaces
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Increasingly common cause chronic wet cough
◦ Age 5 mo – 14 years (3 years)
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Initial viral trigger
‘vicious circle theory’
◦ Asthma can also be a trigger
◦ H. Influenzae (NT) & S. Pneumoniae
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Prolonged course antibiotics required (diagnosis)
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Is entirely curable
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Untreated may progress to bronchiectasis
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)
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Consider different types of cough
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Barking
◦ large airway
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Honking
◦ psychogenic
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Paroxysmal
◦ pertussis
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Chronic fruity
◦ suppurative
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Dry/tight
◦ bronchospasm
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Nature of the cough
◦ Time, diurnal and sleep, sputum, wheeze
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Age of onset
Feeding relation
IFB?
Relieving (beta agonist, ab’s)
Cigarette smoke
FH
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When would you refer
(when have you referred?)
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Neonatal onset
Chronic wet cough
Cough after choking episode
Neuro-developmental problems
Chest wall deformity
Recurrent pneumonia
Growth faltering
Clubbing
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Watchful waiting – 6-8 weeks
Removal of aeroallergens
Trial anti-asthma treatment
Trial antibiotics for PBB
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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