Optimising the management of wheeze in preschool children

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1 Optimising the management of wheeze in preschool children McVea S, Bourke T. Optimising the management of wheeze in preschool children. Practitioner 2016;260(1794):11-14 Dr Steven McVea MB BCh BAO MRCPCH ST5 Paediatrics Dr Thomas Bourke MD MRCPCH Clinical Lecturer and Consultant Paediatrician Royal Belfast Hospital for Sick Children, Belfast, UK Practitioner Medical Publishing Ltd Practitioner Medical Publishing Ltd. Reprint orders to The Practitioner, 10 Fernthorpe Road, London SW16 6DR, United Kingdom. Telephone: +44 (0) www.

2 Optimising the management of wheeze in preschool children AUTHORS Dr Steven McVea MB BCh BAO MRCPCH ST5 Paediatrics Dr Thomas Bourke MD MRCPCH Clinical Lecturer and Consultant Paediatrician Royal Belfast Hospital for Sick Children, Belfast, UK Wheeze is a common problem in young children How should young children be assessed?» ONE THIRD OF ALL PRESCHOOL CHILDREN WILL HAVE AN EPISODE OF WHEEZE AND MANY of these present to primary care. Most will fall within a spectrum of diagnosis ranging from episodic viral wheeze to multiple trigger wheeze or early onset asthma. A small proportion will have other rare, but important, diagnoses such as foreign body aspiration, anaphylaxis, gastro-oesophageal reflux, congenital anatomical abnormalities or other chronic lung diseases. 1 We have described a structured What are the evidence-based treatment options? approach to diagnosis and management of bronchiolitis in a previous article in this journal last year so will not discuss this here. 2 In this article we suggest a practical approach to assessment of children aged two to five years with wheeze presenting to primary care. We describe typical and atypical features to allow differentiation between common and rare conditions and discuss some of the current controversy surrounding management. Finally, we suggest an evidence-based treatment approach with reference to current international guidelines. Which children should be referred? CLINICAL ASSESSMENT European Respiratory Society (ERS) Task Force guidelines suggest that clinical assessment should try to classify children into either episodic viral wheeze or multiple trigger wheeze phenotypes. 3 Episodic viral wheeze is characterised by discrete episodes of wheezing often associated with viral symptoms. There are no interval symptoms. In multiple trigger wheeze, wheeze is caused by several triggers including viral infection, exercise, smoke exposure and other allergens. In clinical practice children rarely fit neatly into either category and it is» 11

3 WHEEZE IN PRESCHOOL CHILDREN important to remember that the phenotype may change over time. The BTS/SIGN asthma guideline describes the clinical features which are suggestive of other diagnoses, see table 1, below. 4 Clinical examination may well be normal in a child presenting with chronic symptoms but it is essential to measure growth parameters and look for the features outlined in table 1, below. During an acute presentation it is important to note: Respiratory rate Use of accessory muscles Presence of grunting Level of consciousness Temperature Chest auscultation should confirm Table 1 wheeze and define whether this is widespread or focal. The presence of crepitations and whether these are focal or generalised should also be noted. Children with wheeze and intermediate-risk features who fail to respond to bronchodilators should be referred immediately REFERRAL CRITERIA Most children with wheeze can be managed safely in primary care. The child should be referred to hospital immediately if you suspect an inhaled foreign body or anaphylaxis (after administering IM adrenaline). NICE stratifies children with cough and chest signs into high- and intermediate-risk categories as outlined in table 2, below. 5 Children presenting with wheeze and high-risk features or those who have intermediate-risk features but fail to respond to bronchodilator therapy should be referred immediately. Urgent outpatient review should be considered for symptoms present from early infancy, chronic wet cough, failure Clinical features suggestive of diagnoses other than asthma in children presenting with wheeze, adapted from BTS/SIGN 4 Perinatal and family history Symptoms present from birth or perinatal lung problem Family history of unusual chest disease Severe upper respiratory tract disease Symptoms and signs Persistent moist cough Excessive vomiting Dysphagia Breathlessness with lightheadedness and peripheral tingling Inspiratory stridor Abnormal voice or cry Focal signs in chest Finger clubbing Failure to thrive Possible diagnosis Chronic lung disease of prematurity Developmental lung anomaly Neuromuscular disorder Defect of host defence Possible diagnosis Protracted bacterial bronchitis Recurrent aspiration Host defence disorder Gastro-oesophageal reflux ± aspiration Swallowing problems ± aspiration Hyperventilation/panic attacks Tracheal or laryngeal disorder Laryngeal problem Developmental anomaly Post-infective syndrome Tuberculosis Host defence disorder Gastro-oesophageal reflux 12

4 to thrive or systemic involvement. Routine outpatient review should be considered if diagnosis remains in doubt or there is failure to respond to the therapies discussed below. Children fit enough to be managed at home should not be prescribed a course of oral steroids MANAGEMENT OF WHEEZE Acute wheeze Those with high-risk features on assessment should be treated immediately with inhaled bronchodilator therapy. Those with intermediate risk should be treated immediately with bronchodilator therapy and reassessed minutes later. Intermediate-risk children who respond, and low-risk children, can be managed at home with bronchodilator therapy via a spacer. Parents should be advised that reassessment will be needed if they struggle to cope or if deterioration is evident. 5 The ERS Task Force recommends that children fit enough to be managed at home should not be prescribed a course of oral corticosteroid therapy. 3,6 Oral corticosteroids may continue to be used in children admitted to hospital with severe wheeze but even in this group the evidence base is controversial. 6 Recurrent wheeze There is no evidence to support the use of regular inhaled corticosteroids or leukotriene receptor antagonists in children with mild episodic viral wheeze. 6,7 These children can safely be managed with intermittent bronchodilator therapy alone. In children whose episodic viral wheeze is frequent or requires admission to hospital then a trial of inhaled corticosteroids should be considered as described below. 11 Although some guidelines suggest leukotriene receptor antagonists can be considered, 3 a recent Cochrane review suggests no benefit in children with episodic viral wheeze. 7 In children with multiple trigger wheeze whose symptoms are frequent (breathlessness on most days) consideration should be given to preventer therapy with either inhaled corticosteroids or leukotriene receptor antagonists. Bush and colleagues describe a pragmatic approach which involves introducing preventer therapy (either inhaled corticosteroids or leukotriene receptor antagonists at standard dose for 4-8 weeks). 6 Following the trial period the treatment should be tapered and stopped and only reintroduced if symptoms recur. This allows the clinician to distinguish between those responding to treatment and those simply recovering. If symptom control remains poor on initial preventer therapy review compliance and inhaler technique If symptom control remains poor on initial preventer therapy it is important to review compliance and inhaler technique and assess again for atypical features. If no cause for poor response can be found then it would be reasonable to trial combined inhaled corticosteroid and leukotriene receptor antagonist» Table 2 NICE risk classification in children presenting with chest signs 5 Respiratory rate (RR) Other respiratory features Colour Activity Hydration/feeding Temperature High risk RR > 60 breaths/min for any age Intermittent apnoea Grunting Moderate or severe chest indrawing Cyanosis Pale, mottled, ashen, blue No response to social cues Unable to be roused, or if rousable does not stay awake Appears ill to healthcare professional Reduced skin turgor Age < 3 months and temperature 38 C Age 3-6 months and temperature 39 C Intermediate risk Tachypnoea: RR breaths/min, age 6-12 months RR breaths/min, age > 12 months Nasal flaring Crackles Oxygen saturation 95% in air (if available) Pallor reported by parent/carer No response to normal social cues Awakes only with prolonged stimulation Decreased activity No smile Poor feeding in infants (< 50% of normal fluid intake in preceding 24 hours) Dry mucous membranes Reduced urine output Capillary refill time 3 sec Fever for 5 days Activity and appearance are highly subjective and considered poor markers of severity by some experts 13

5 WHEEZE IN PRESCHOOL CHILDREN key points SELECTED BY Dr Matthew Lockyer GP, Suffolk One third of all preschool children will have an episode of wheeze and many of these present to primary care. Most will fall within a spectrum of diagnosis ranging from episodic viral wheeze to multiple trigger wheeze or early onset asthma. A small proportion will have other rare, but important, diagnoses such as foreign body aspiration, anaphylaxis, gastro-oesophageal reflux, congenital anatomical abnormalities or other chronic lung diseases. Clinical assessment should try to classify children into either episodic viral wheeze or multiple trigger wheeze phenotypes. Episodic viral wheeze is characterised by discrete episodes of wheezing often associated with viral symptoms. There are no interval symptoms. In multiple trigger wheeze, wheeze is caused by several triggers including viral infection, exercise, smoke exposure and other allergens. In clinical practice children rarely fit neatly into either category and the phenotype may change over time. Clinical examination may well be normal in a child presenting with chronic symptoms. The child should be referred to hospital immediately if you suspect an inhaled foreign body or anaphylaxis (after administering IM adrenaline). NICE recommends immediate referral for children with wheeze and high-risk features and also those with intermediate-risk features failing to respond to bronchodilator therapy. Urgent outpatient review should be considered for symptoms present from early infancy, chronic wet cough, failure to thrive or systemic involvement. Children with high-risk features on assessment should be treated immediately with inhaled bronchodilator therapy. Those with intermediate risk should be treated immediately with bronchodilator therapy and reassessed minutes later. Intermediate-risk children who respond and low-risk children can be managed at home with bronchodilator therapy via a spacer device. Parents should be advised that reassessment will be necessary if they struggle to cope or if deterioration is evident. The ERS Task Force recommends that children fit enough to be managed at home should not be prescribed oral corticosteroid therapy. Oral corticosteroids may continue to be used in children admitted to hospital with severe wheeze but even in this group the evidence base is controversial. There is no evidence to support the use of regular inhaled corticosteroids (ICS) or leukotriene receptor antagonists (LTRA) in children with mild episodic viral wheeze. These children can safely be managed with intermittent bronchodilator therapy alone. In children whose episodic viral wheeze is frequent or requiring admission to hospital then a trial of ICS should be considered. In children with multiple trigger wheeze whose symptoms are frequent (breathlessness on most days) consideration should be given to preventer therapy with either ICS or LTRA. therapy before considering onward referral to secondary care services. Long-acting beta-agonists are not licensed in preschool children. Parents should be strongly encouraged to discontinue smoking, given advice and referred to local support services. CONCLUSION Wheeze in preschool children is a common cause of presentation to primary care. Careful clinical assessment is required and most children will fall within a spectrum from episodic viral wheeze to multiple trigger wheeze. A small proportion will have other conditions. The majority are safely managed at home with an inhaled bronchodilator. A small proportion, particularly those with multiple trigger wheeze, may benefit from a trial of preventer therapy. REFERENCES 1 Ducharme FM, Tse SM, Chauhan B. Diagnosis, management, and prognosis of preschool wheeze. Lancet 2014;383(9928): McNaughten B, Bourke TW. Optimising the management of bronchiolitis in infants. Practitioner 2015;259(1784): Brand PLP, Caudri D, Eber E et al. Classification and pharmacological treatment of preschool wheezing: changes since Eur Respir J 2014;43; British Thoracic Society/Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. BTS/SIGN Available online: [Accessed 05/06/2016.] 5 National Institute for Health and Care Excellence. Clinical Knowledge Summary. Cough - acute with chest signs in children. Scenario: Viral-induced wheeze/possible asthma. Available online: [Accessed 05/06/2016.] 6 Bush A, Grigg J, Saglani S. Managing wheeze in preschool children. BMJ 2014; Feb 4;348:g15 7 Brodlie M, Gupta A, Rodriguez-Martinez CE et al. Leukotriene receptor antagonists as maintenance and intermittent therapy for episodic viral wheeze in children. Cochrane Database Syst Rev 2015 Oct 19;(10):CD pub2 We welcome your feedback If you wish to comment on this article or have a question for the authors, write to: editor@ 14