1 / 63

Respiratory Paediatrics For GP’s

Respiratory Paediatrics For GP’s. Dr. Jennifer Townshend Consultant Paediatrician. Overview. Context Some common presentations Common complains Wheezy infant Wheezy child Chronic cough. Blue background slides. Audience participation. Is it important?.

alan-brooks
Download Presentation

Respiratory Paediatrics For GP’s

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  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……..

  20. 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

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

  22. 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

  23. 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

  24. 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

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

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

  27. Atopic asthma – when to refer

  28. 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

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

  30. 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

  31. 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

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

  33. 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

  34. 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

  35. 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

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

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

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

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

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

  41. 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

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

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

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

  45. 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

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

  47. 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

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

More Related