Respiratory Paediatrics For GP’s

1. Respiratory Paediatrics For GP’s Dr. Jennifer Townshend Consultant Paediatrician

2. Overview • Context • Some common presentations • Common complains • Wheezy infant • Wheezy child • Chronic cough

3. Blue background slides Audience participation

4. Is it important? • 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

5. A familiar case? • 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

6. What are your thoughts? • What do you want to know? • What else could be going on?

7. Subsequent questions • 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

8. On examination • 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

9. What is the likely diagnosis? • Poorly controlled atopic asthma

10. Are you concerned? • RF for life threatening disease • Poor compliance • Poor technique • Chaotic social situation • Parental smoking, risk of child smoking

11. Another familiar case? • 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…..’

12. What do you think? • What else do you want to know? • What could be going on?

13. Further questioning • 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

14. What is the likely diagnosis? • Episodic viral wheeze

15. Wheeze

16. Wheeze • What is it?

17. Wheeze • What is it? ‘a continuous high pitched musical sound emitting from the chest in expiration as a result of narrowing of the small airways’

18. Wheeze • Where does it come from? • Closed cavity • Relationship between pressure and volume

19. Wheeze • What causes it? • All that wheezes is not asthma……..

22. Asthma phenotypes • Asthma more complex, especially in children • Different patterns of illness having different underlying pathogenesis • Different phenotypes have different management strategies and different prognosis

23. Atopic Asthma • Most commonly recognised phenotype • Classical characteristics

24. Atopic asthma - characteristics • School aged child • Episodic • ‘exacerbations’: (wet) cough/wheeze/SOB • Interval symptoms: (dry) cough, nocturnal,exercise • Identifiable triggers • Personal/FH atopy • Raised eosinophils/IgE

25. What about cough varient asthma? • 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

26. Management of atopic asthma • Step wise approach to medication • Support self management • Education • Shared decision making • Asthma management plan • Delivery techniques • Avoidance of triggers • Associated allergies? • Regular review • monitoring for side effects • compliance

27. A few things to mention • Inhaled corticosteroids • Friend? Foe? Practically? • Long acting beta agonists • Better then doubling dose of ICS • But safe??

28. Atopic asthma – when to refer • Many variables • Secondary or tertiary?

29. Atopic asthma – when to refer

30. Prognosis • 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

31. Asthma phenotypes (2) • Atopic Asthma • Episodic viral wheeze ‘the wheezing infant’

32. Episodic viral wheeze • Characteristic features • 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

33. Episodic viral wheeze • Risk factors for development into atopic phenotype • FH/personal history of atopy • Premature birth/low birth weight • Smoking • Bronchiolitis as an infant

34. Different phenotypes – so what? • Acute management • Salbutamol in under 2’s • Corticosteroids • Long term management • Prognosis

35. Episodic Viral Wheeze – 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

36. Practically • Consider other causes • Try and identify the phenotype • Draw a time line of wheeze • Manage according to severity and phenotype Acute symptoms Interval symptoms Symptoms Time

37. Some more cases….. • 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

38. What are your thoughts? • What else do you want to know?

39. Further questioning • No FH of atopy • No personal history of atopy • No smoking in family • Always hungry, but still slim

40. On examination • Sats 91% in air • Increased work of breathing • Hyperinflated • No wheeze, no creps • Clubbed

41. CXR: chronic changes • Sweat test – confirmed Cystic fibrosis

42. Case 2 • 18 month old child • Well until 13 months • ‘Never been right since’ • Coughs every day, no break in between

43. Further questioning • 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

44. On examination • Well child • Nasal crusting • Wet cough • Normal chest shape • Chest clear to auscultation • Recurrent viral URTI’s • Reassure • Reassess in summer months

45. Cough • Important physiological reflex • Common (up to 10% children) • OTC medicine – cochrane review

46. Different cough types • Acute cough • Recurrent acute cough • Persistent none remitting cough

47. Acute cough (< 3 weeks ) • Vast majority viral URTI • History and examination important to rule out chronic illness • Consider • Pertussis • Allergy • Inhaled foreign body • Rarely – presenting feature of serious underlying disorder

48. When to consider CXR/Referral • Uncertainty about diagnosis of pneumonia • IFB • Possible chronic problem • Prolonged clinical course • True haemoptysis

49. How to manage acute cough • 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

50. Chronic cough • Chronic cough > 8 weeks • 3-8 weeks ‘grey area’ • Subacute (post viral) • Pertussis