Wheeze. Respiratory Tract Symptoms. Prof RJ Green Department of Paediatrics. Cough. Wheeze/noisy breathing. Acute. Tight chest. Shortness of breath

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1 Wheeze Prof RJ Green Department of Paediatrics Respiratory Tract Symptoms Cough Tight chest Wheeze/noisy breathing Shortness of breath Acute Chronic

2 Respiratory rate Most important sign of respiratory distress > 50 bpm 2 12 months > 40 bpm 1-5 years. Respiratory tract Adventitious Sounds Upper airway Trachea Lower airway Alveoli

3 Respiratory tract Adventitious Sounds Upper airway - Snoring Trachea - Stridor Lower airway - Wheezing Alveoli - Crepitations Airway Diameter

4 Cause of Wheezing Not from obstruction of small airways Surface area too large From increased intrathoracic pressure + decreased large airway pressure = vibration of airway wall in large airways (Generations 1-5) Hyperinflation Barrel shaped chest Hoover sign Loss cardiac dullness Liver pushed down

5 Other signs Hper-resonance = think of pneumothorax No chest signs = think of PCP (RESPIRATORY DISTRESS MARKED) or LIP (NO REPIRATORY DISTRESS) Clubbing = think of cystic fibrosis Crepitations = think of pneumonia/consolidation APPROACH TO THE WHEEZY INFANT/ CHILD

6 Acute Wheeze Bronchiolitis Asthma Foreign Body Acute exacerbation of chronic condition What Is Bronchiolitis? 12 Bronchiolitis is acute inflammation of the airways, characterised by wheeze Bronchiolitis can result from a viral infection Respiratory Syncytial Virus (RSV) may be responsible for up to 90% of bronchiolitis cases in young Hall CB, McCarthy CA. In: Principles and Practice of Infectious Diseases 2000: ; Panitch HB et al. Clin Chest Med 1993;14: children

7 RSV Is a Common Virus Causing Bronchiolitis in Children In a clinical study in Argentina, RSV was the most common virus isolated from a sample of children aged <5 years with acute lower respiratory infection 7.8% 6.8% 6.5% 0.7% RSV Adenovirus 78.2% Parainfluenza Influenza A Influenza B New viruses (Human Metapneumovirus, Bocca, Corona) Carballal G et al. J Med Virol 2001;64: Bronchiolitis Prodromal URTI Low grade fever Wheeze Respiratory distress Hyperinflated chest Hall CB, McCarthy CA. In: Principles and Practice of Infectious Diseases 2000: ; Panitch HB et al. Clin Chest Med 1993;14:

8 Risk Factors for RSV-Induced Bronchiolitis Male Aged 3-6 months No breast feeding Crowded living conditions Lower cord serum RSV antibody titre Maternal smoking Day care attendance Born in summer 15 Panitch HB et al. Clin Chest Med 1993;14: Management Options Humidified oxygen: Beneficial?? Antibiotics -associated infection??efficacy of Bronchodilators Inhaled & oral B2 agonists Inhaled ipratropium bromide theophyllines??use of corticosteroids?use on leukotriene antagonists?efficacy of immunoglobulin

9 Chronic Wheezing Chronic Wheeze in Children Healthy wheezers Wheezing phenotypes Unhealthy wheezers Failing to thrive

10 WHEEZING PHENOTYPES 12 Longitudinal birth cohorts Original Tucson Group (Taussig L et al 1985) Persistent Atopic Non Atopic Transient Causes of Wheezing in Infancy Small airways disease Asthma Post bronchiolitis Other causes

11 TRANSIENT WHEEZERS Commonest form of wheeze Decrease lung function at birth No airway hyper-responsiveness Non Atopic No immune responses to viruses Resolves by 3 years Wheeze in first year better outcome Wheeze 2-3 year worse outcome due to maturity of immune system Affected by : Teenage pregnancy & smoking Male gender Day care- infections PERSISTENT NON ATOPIC WHEEZER Lung function abnormal at birth and reduced in later life Non Atopic Airway hyper-responsiveness Peak flow variability RSV induced wheeze due to alteration in airway tone BETTER OUTCOME THAN ATOPIC PERSISTENT WHEEZERS

12 Wheezing Often Persists Post Bronchiolitis Korppi M et al. Am J Dis Child 1993;146: Children with 60 wheezing 40 (%) % 1-2 (n=83) Age (years) 58% 2-3 (n=76) 83 children <2 years hospitalised with bronchiolitis, a large proportion 23 had subsequent wheezing PERSISTENT ATOPIC WHEEZER Lung function normal at birth but deteriorates with recurrent symptoms Increased symptoms with increasing age Airway liability Atopic (increase IgE at 6-9m; increase cytokines) Abnormal immune responses to viruses

13 Routine asthma follow-up questions How often have you had asthma symptoms in the last week? How often have you been woken at night because of asthma symptoms in the last week? How often have asthma symptoms limited your ability to be active in the last week? How many puffs of reliever medicine have you used in the last week? Have you missed any days of school/work because of asthma in the last month? Asthma Control CONTROLLED PARTLY CONTROLLED (Any measure present in any week) Daytime symptoms <2/week >2/week Limitation of None Any activities Nocturnal symptoms/awakening None Any Need for reliever/ rescue treatment <2/week >2/week Lung function (PEF/FEV1) Normal <80% predicted or personal best (if known) Uncontrolled 3 or more features of partly controlled asthma in any week

14 Reasons for poor asthma control Lack of adherence to controller medication Inability to use inhaler or powder device correctly Uncontrolled allergic rhinitis/sinusitis URTI Behavioural and mood disorders Ongoing allergen exposures Inadequate drug dosage Use of medications with adverse events (eg. B-blockers, aspirin, NSAID) Management of Asthma Anti-inflammatory Inhaled Bronchodilator Inhaled/PRN Patient education Check disease control Check inhaler technique

15 Other Causes of Wheezing in Infancy Cystic fibrosis Gastro-oesophageal reflux Chronic infections Immune deficiency Foreign body Cardiac pathology Congenital abnormalities Points on examination LOW, FTT systemic disease UAO: Tonsils, Adenoids, Polyps, Rhinitis Fixed Monophonic/asymmetric wheeze : foreign body Chest deformity- chronic lung disease Clubbing & Halitosis- chronic suppurative lung disease -bronchiectasis Stridor bronchomalacia, vascular ring mediastinal syndrome signs of cardiac or systemic disease

16 Exclude other conditions Structural problems: bronchoscopy URTD : Polysomnography, Esophageal disease: Barium swallow, ph probes, scopes and gram Primary ciliary dyskinesia: nasal ciliary motility, Exhaled NO, EM, saccharine test TB: mantoux, induced sputum/ gastric lavage/ BAL = Culture, microscopy & PCR Bronchiectasis: HRCT scan, BAL CF: sweat test, nasal potentials, genotypes Systemic immune deficiency: Ig subtypes, lymphocytes & neutrophil function, HIV Cardiovascular disease: echo, angiography