Respiratory Paediatrics For GP’s
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Transcript Respiratory Paediatrics For GP’s
Dr. Jennifer Townshend
Consultant Paediatrician
Context
Some common presentations
Common complains
◦ Wheezy infant
◦ Wheezy child
◦ Chronic cough
Audience participation
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
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
What do you want to know?
What else could be going on?
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
Not clubbed, normal chest shape
Audible wheeze through out
Lung function 65% predicted
◦ 18% reversibility post salbutamol
◦ Wheeze resolves post inhaler
CXR normal
Eosinophils 0.4, IgE 112
Poorly controlled atopic asthma
RF for life threatening disease
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Poor compliance
Poor technique
Chaotic social situation
Parental smoking, risk of child smoking
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…..’
What else do you want to know?
What could be going on?
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
Episodic viral wheeze
What is it?
What is it?
‘a continuous high pitched musical sound emitting
from the chest in expiration as a result of narrowing of
the small airways’
Where does it come from?
◦ Closed cavity
◦ Relationship between pressure and volume
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
Asthma more complex, especially in children
Different patterns of illness having different
underlying pathogenesis
Different phenotypes have different
management strategies and different
prognosis
Most commonly recognised phenotype
Classical characteristics
School aged child
Episodic
◦ ‘exacerbations’: (wet) cough/wheeze/SOB
◦ Interval symptoms: (dry) cough, nocturnal,exercise
Identifiable triggers
Personal/FH atopy
Raised eosinophils/IgE
Very rare to cough without wheeze in asthma
(McKenzie, 1994)
More likely to be a marker for another
condition
But, does exist – consider trial of asthma
therapy if all other conditions excluded
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
Inhaled corticosteroids
◦ Friend? Foe? Practically?
Long acting beta agonists
◦ Better then doubling dose of ICS
◦ But safe??
Many variables
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
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
Atopic Asthma
Episodic viral wheeze
‘the wheezing infant’
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
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
Acute management
◦ Salbutamol in under 2’s
◦ Corticosteroids
Long term management
Prognosis
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
Consider other causes
Acute
symptoms
Try and identify the
phenotype
Draw a time line of
wheeze
Manage according to
severity and phenotypeSymptoms
Interval
symptoms
Time
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
Some mild SOB, no real wheeze
What else do you want to know?
No FH of atopy
No personal history of atopy
No smoking in family
Always hungry, but still slim
Sats 91% in air
Increased work of breathing
Hyperinflated
No wheeze, no creps
Clubbed
CXR: chronic changes
Sweat test – confirmed Cystic fibrosis
18 month old child
Well until 13 months
‘Never been right since’
Coughs every day, no break in between
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
Well child
Nasal crusting
Wet cough
Normal chest shape
Chest clear to auscultation
Recurrent viral URTI’s
Reassure
Reassess in summer months
Important physiological reflex
Common (up to 10% children)
OTC medicine – cochrane review
Acute cough
Recurrent acute cough
Persistent none remitting cough
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
Uncertainty about diagnosis of pneumonia
IFB
Possible chronic problem
Prolonged clinical course
True haemoptysis
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
Chronic cough > 8 weeks
3-8 weeks ‘grey area’
◦ Subacute (post viral)
◦ Pertussis
Structural
Immunodeficiency
Suppurative (PBB, bronchiectasis)
Recurrent aspiration
Pertussis
Retained IFB
TB
Bronchcospasm
Intersitial lung disease/cardiac
Structural
Immunodeficiency
Suppurative (PBB, bronchiectasis)
Recurrent aspiration
Pertussis
Retained IFB
TB
Bronchcospasm
Intersitial lung disease/cardiac
Conducting
airways
Respiratory
Spaces
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
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)
Consider different types of cough
Barking
◦ large airway
Honking
◦ psychogenic
Paroxysmal
◦ pertussis
Chronic fruity
◦ suppurative
Dry/tight
◦ bronchospasm
Nature of the cough
◦ Time, diurnal and sleep, sputum, wheeze
Age of onset
Feeding relation
IFB?
Relieving (beta agonist, ab’s)
Cigarette smoke
FH
When would you refer
(when have you referred?)
Neonatal onset
Chronic wet cough
Cough after choking episode
Neuro-developmental problems
Chest wall deformity
Recurrent pneumonia
Growth faltering
Clubbing
Watchful waiting – 6-8 weeks
Removal of aeroallergens
Trial anti-asthma treatment
Trial antibiotics for PBB
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