wheezychest-140120062522-phpapp01 , approach in emergency department setting

1. ((Wheezy chest in pediatric age group)) Prepared by: Daniel Rawand Pols Sajad Abdulridha Ali Ghazwan Ardalab Slewa Supervised by: Dr. Siamand Yahya

3. High pitched, continuous, musical (whistling) sound, occurs when air flows through a narrowed airway. -Can originate from airway of any size -Heard mostly on expiration -Manifestation of lower respiratory tract What is wheezing?

4. Causes of Wheezing in Childhood

5. Approach to a wheezing child • Clinical History: • Patient age at onset of wheeze • Course: acute vs gradual • Pattern of wheezing? • Episodic: asthma • Persistent: congenital • Response to bronchodilators? • Is Wheezing associated with multiple systemic illnesses? • Cystic fibrosis and Immunodeficiency diseases

6. Wheeze associated with feeding? • Wheeze associated with cough? • Change in position? Worsening or improvement • Family hx of asthma?

7. Physical Examination • General • Vital signs including SpO2 % • Chest examination • Inspection: • Respiratory distress • Chest wall deformity (increased AP diameter) • allergic shiners/nasal polyps • Skin: eczema • Palpation: chest wall asymmetry with expansion, tracheal deviation • Percussion: difference in vocal resonance • Auscultation: • Location of wheeze • Character of wheeze • Other breath sounds associated with wheeze • Cardiac: presence of murmur

9. Investigations • CXR: AP and lateral views • Children with new onset wheezing of undetermined etiology • Chronic persistent wheezing not responding to treatment • Suspected FB aspiration • CXR findings: • Hyperinflation: • Generalized: suggests diffuse air trapping • Asthma/ Cystic fibrosis/ Primary ciliarydyskinesia • Localized hyperinflation: • Structural abnormalities/ FB aspiration • Other findings: atelectasis, bronchiectasis, mediastinal masses, enlarged LN’s, cardiomegaly, enlarged pulmonary vessels or pulmonary edema.

10. Chest CT scan: • Mediastinal masses or LN’s • Vascular anomalies • Bronchiectasis • Barium Swallow: • GERD • TEF • Vascular rings • Swallowing dysfunction • Pulmonary Function Tests (PFT’s) • Airway obstruction assessment • Response to bronchodilator

11. Other investigations: • Sweat Chloride Test: Cystic fibrosis screening in children with chronic lung problems, failure to thrive and diarrhea • Immunoglobulin levels: Screen for immunodeficiency. • Rapid antigen testing, viral cultures, sputum gram stain and culture.

12. Bronchiolitis

13. Bronchiolitis It is inflammatory obstruction of small airways. Age: first 2 years. 2- 12 months peak 6 months. more sever at 1-3 months. Seasonal disease, peak during winter & early spring.

14. Etiology & Epidemiology Predominantly viral: RSV Human metapeumovirus Influenza Adeno Para influenza Mumps, Entero, Rhino Mycoplasma pneumonia Chlamydia pneumonia, Chlamydia Trachomatis.

15. Etiology & Epidemiology Bronchiolitis common in • Male. • Not being breast fed. • Crowded condition.

16. Clinical manifestation - Mild URTI, diminished appetite, fever(38.5-39) - Respiratory distress with paroxysmal wheezy cough, dyspnea& irritability. - Infant is tachypnic which interfere with feeding - No other systemic complain. - Apnea(in 20% of hospitalized infants) Infant at risk for apnea: *premature infant *very young infant(1-4 months) * Chronic lung disease.

17. On examination Sign of respiratory distress (nasal flaring, retraction)+ wheezing. Auscultation : Fine crackle or overt ronchi+ prolongation of expiratory phase. Barely audible breath sound suggest a very sever disease with nearly complete bronchiolar obstruction. Hyperinflation of the lung may permit palpation of liver &spleen.

18. Investigation CXR: • Hyperinflated lung. • Bilateral interstitial abnormalities with peribronchial thickening. • Up to 20% having lobar, segmental, or sub segmental consolidation.

19. Investigation WBC & differential count are usually normal. Viral testing: • Rapid immunofluorescene. • Polymerase chain reaction • Viral culture Blood gas analysis: hypoxemia, hypercarbia

20. Treatment Supportive : mainstay of treatment. - Respiratory distress( hospitalization, positioning, cool&humidified oxygen). • Feeding :risk of aspiration( NG feeding) and parenteral fluids. Bronchodilater. Nebulized epinephrine. Corticosteroid : (oral, inhaler, parentral). Ribavirin . Antibiotic. RSV immunoglobulin. Intubation &mechanical ventilation.

21. Complication 1-increasingly labored breathing 2-cyanosis 3-dehydration 4-fatigue 5-severe respiratory failure

22. Childhood Asthma

23. Chronic inflammatory condition of the lung airways resulting in episodic airflow obstruction airway hyper responsiveness airway remodling.

25. Bronchial inflammation - Oedema - Excessive mucus production - Infiltration with cells (eosinophils, mast cells, neutrophils, lymphocytes) Genetic predisposition Atopy Bronchial hyperresponsiveness Environmental triggers - Upper respiratory tract infections - Allergens (e.g. house dust mite, grass pollens, pets) - environmental tobacco smoke - Cold air - Exercise -Emotional upset or anxiety -Chemical irritants (e.g. paint, aerosols) Airway narrowing Symptoms: Wheeze Cough Breathlessness Chest tightness

27. Onset of presentation • Transient wheezer • Onset ≤3 years of age then resolving • Initial risk factor is primarily diminished lung size • Normal lung function by 6 Years of age • Not associated with increased risk of developing clinical asthma • Persistent wheezer • Onset ≤3 years then persisting • Initial risk factors include passive smoke exposure, maternal asthma history and elevated IgE level in the first year of life • Irreversible reduction in lung function at 6 years of age • An increase risk of developing clinical asthma • Late onset wheezer • Onset of wheeze between 3 to 6 years

28. EARLY CHILDHOOD RISK FACTORS FOR PERSISTENT ASTHMA 1) Parental asthma 2) Allergy 3) Severe lower respiratory tract infection: 4) wheezing apart from cold 5) Male gender 6) Low birth weight 7) Environmental tobacco smoke exposure

29. Clinical features • -Intermittent dry coughing • -expiratory wheezing • Older children report associated • shortness of breath and • chest tightness • -Asthma should be suspected in any child  • with wheezing on more than one occasion.

30. -Other key features: • •worse at night and in the early morning • •triggers  • •Personal or family history of an atopic disease • •Positive response to asthma therapy. • Once  suspected,  the pattern or phenotype  should be  • further explored by asking: • •frequency • •triggers    • general activities • •sleep disturbance  • •How much school has been missed due to  • asthma?

31. Examination • -Examination of the chest is usually normal between  • attacks. • -In long­standing asthma  • hyperinflation  • Harrison sulci • generalized expiratory wheeze  • and prolonged expiratory phase.  • - Evidence of eczema  • - the nasal mucosa for allergic • rhinitis.  • Growth   

33. Investigations • CBC :Eosinophilia in a range of 15-20% • Eosinophilia in bronchial mucosa strongly suggest Asthma • Allergy testing • Pulse oximetry • Arterial blood gas analysis • Pulmonary function test : Applicable for children > 6 years • CXR

35. Classification of chronic Asthma

36. Asthma pharmacotherapy B2 agonist corticosteroids Anticholinergic agent Leukotreine modifier NSAID theophylline

37. A stepwise approach to the treatment of chronic asthma • Step 1 ( mild intermittent asthma) • No daily medication needed • Sever exacerbation may need systemic steroids • Step 2 (mild persistent) • Low dose inhaled corticosteroids daily

38. Step 3 (moderate persistent) -low to medium dose inhaled corticosteroids + long acting inhaled B2 agonist Step 4 ( sever persistent) - High dose inhaled corticosteroids + long acting inhaled B2 agonist + oral corticosteroids (if needed)

39. Classification of severity of acute asthma exacerbations

40. Management: • Acute asthma: • Semi sitting position • O2 to keep saturation > 92%. • Fluid if dehydrated. • Beta-2 agonist: Salbutamol each 20 min by mask until improved later on mask hourly if required. • Ipratropium bromide. • Steroids: Prednisolone. • If sever give steroids directly since • the onset of action is slow (4 hrs)

41. Criteria for admission to hospital Persisting breathlessness, tachypnoea Exhausted Still have a marked reduction in their predicted (or  usual) peak flow rate 4) Oxygen saturation (<92% in air). 5) Family in able to cope with the condition

42. (pMDI) Nebuliser Dry powder  inhaler

43. Gastro-oesophageal reflux

45. It is extremely common in infancy.  • - caused by  • 1) inappropriate relaxation of the lower oesophageal sphincter as a  result of functional  immaturity.  • A predominantly  fluid  diet,  • A mainly horizontal posture • A shortintra­abdominal length of oesophagus. • -resolves  spontaneously  by  12 months  of  age.

46. Severe reflux is more common in: 1)children with cerebral palsy or other  neurodevelopmental disorders. 2) preterm infants 3) following surgery for oesophagealatresia or  diaphragmatic hernia.

47. Complications of gastro­oesophageal reflux • Failure to thrive from severe vomiting • Oesophagitis– haematemesis, discomfort on  feeding or heartburn, iron deficiency anaemia • Recurrent pulmonary aspiration – recurrent pneumonia, cough or wheeze, apnoea in preterm infants •Dystonic neck posturing (Sandifer syndrome) • Apparent life­threatening events (ALTE)

48. Investigation • May be indicated if • the  history  is  atypical • complications are present  • failure to respond to treatment. • Investigations include: • •  24­hour oesophageal pH monitoring  • •  24­hour impedance monitoring.  • •  Endoscopy with oesophageal biopsies  • Contrast  studies  of  the  upper  • gastrointestinal  tract

49. Management • Uncomplicated  gastro­oesophageal  reflux can be managed by • Parental reassurance • adding  inert  thickening  agents  to  feeds  • (e.g.  Nestargel,  Carobel)    • 3) positioning  in  a  30° head­up prone position after feeds. • 4) acid suppression with either : H2 receptor antagonists • (e.g. ranitidine) • or: proton pump inhibitors • (e.g. omeprazole) • 5) If  the  child  fails  to  respond  to  these    • measures,other diagnoses such as cow’s milk protein  • allergy  should  be  considered • 6) Surgical  management: A Nissenfundoplication,

50. Cystic fibrosis