a child with wheeze

8/10/2019 A Child With Wheeze

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What structural aspects must be consideredin the process of respiration?

• Trachea• Primary bronchi• Secondary bronchi• Tertiary bronchi• Bronchioles• Terminal bronchioles•

Respiratory bronchioles withstart of alveoli outpouches• Alveolar ducts with outpouchings

of alveoli

conductiveportion

exchangeportion



ExternalRespiration

InternalRespiration



Anatomy of Immune System



Physiology of Immune SystemTo discriminate self form non-self and to eliminate the

foreign substanceTo protect the host against foreign antigen



Definition of WheezePolyphonic(multiple pitch) noise coming from theairways believed to represent many airways of differentdimensions vibrating from abnormal narrowing.



eren a agnoses oConditions that can cause

WheezingTransient early wheezing Atopic asthma

Non-atopic asthmaRecurrent aspiration of feedsInhaled foreign bodyCystic fibrosisRecurrent anaphylaxis in a child with food allergiesCongenital abnormality of lung, airway or heartIdiopathic



Asthma



Definition of Asthma

• Chronic airway inflammation leading to increaseairway responsiveness that leads to recurrent episodesof wheezing, breathlessness, chest tightness andcoughing particularly at night or early morning.

• Often associated with widespread but variable airflowobstruction that is often reversible eitherspontaneously or with treatment.



• Reversible and variable airflow limitation asevidenced by >15% improvement in PEFR (PeakExpiratory Flow Rate), in response to administration ofa bronchodilator.



Recommendations to define pre-

school wheezing2 main categories:• Episodic (viral) wheeze.

only wheeze with viral infections and are well betweenepisodes.• Multiple trigger wheezers

have discrete exacerbations and symptoms in betweenthese episodes. Triggers are smoke, allergens, crying,laughing and exercise.



Pathophysiology of asthma



Clinical Features of AsthmaSymptoms worse at night and in the early morningSymptoms that triggers (eg: exercise, pets, dust, coldair, emotions, laughter)Intervals symptoms (between acute exacerbation)Personal or family history of an atopic diseasePositive response to asthma therapy.



Harrison’s sulciDepression at the base ofthe thorax with muscularinsertion of the diaphragmare called Harrison’s sulci,and are associated withchronic obstructive airwaysdisease such as asthmaduring childhood.



Management Aim of management-- To allow the child to lead a normal life by controllingthe symptoms and preventing exacerbations,optimising pulmonary function, while minimizingtreatment and side effects.



Outcome of AsthmaMajority has a good prognosis.Those more severe, persistent asthma cases , developlongitudinal changes in lung function. ( impaired lungfunction in childhood and decline in lung function inadulthood)Early intervention of anti-inflammatory therapy may

improve the short-term outcome of asthma.Disease progression to nonreversible airflowobstrcution may be observed in minority.



EpidemiologyEstimated prevalence of asthma in Malaysia is4.2%. (The Star, May 2011)

International Studies on Asthma and Allergy(ISAAC) has shown the prevalence of asthmaamong school children is 10%. (Protocol Ed3)

Among children up to 14 yrs old has aprevalence rate of 4.5% and age 15 years andabove is 4.1%. (The Star, May 2011)



Prevalence of childhood asthma is 24%, particullarly inMalays and those living in urban areas. ( Selangor ,2011)

A study of symptom control and severity of Asiansunder 16 years old shows that 2.5% controlled while53.4% uncontrolled asthma.(MIMS, Jul 2014)

As for severity, 24.5% had moderate to severepersistent symptoms.



Participants of uncontrolled asthma were the most

frequent users of anti-asthmatic medication andurgent healthcare services. (MIMS, Jul 2014)

Hospitalization was the most important factoraffecting life quality of Malaysian parents withasthmatic child.



Grading of severity in asthma1. IntermittentDaylight symptoms less than once a week

Noctural symptoms less than once a monthNo exercise induced symptomsBrief, infrequent exacerbation not affecting sleep andactivityNormal lung function



2. Persistent

Criteria Mild Moderate Severe

DaylightSymptoms

>once a week Daily Daily

NocturalSymptoms

>2x a month >once a week Daily

Exercise inducedsymptom

Present Present Daily

Exacerbation(affecting sleepand activity)

> 1x/month >2x/month Frequently,>2x/month

PERF/FEV1 >80% 60% - 80% <60%

PEFR: Peak Expiratoty Flow Metre FEV1: Forced Expiratory Vol in 1 sec



Acute exacerbation Assessment of severity:i. Diagnosis: cough,wheezing, breathless

ii.Triggering factor: food, exercise, drugs

iii.Severity: RR, RE, consious lvl.



Criteria for admissionFailure to respond to standard home treatment.Failure to respond to nebulised beta 2 agonist.

Relapse with 4 hours of nebulised beta 2 agonists.Severe acute asthma.



DrugsBronchodilatorsBeta 2 Agonist (SABA, LABA) Anticholinergic (Ipratropium bromide)

Inhaled CorticosteroidsLeukotriene receptor agonist (oral)Theophylline

Prednisolone (Oral steroids) Anti-IgE injection (Omalizumab)



Mnemonics A - Adrenergics (Beta 2 Agonist)

- AlbuterolS - SteroidsT - TheophylineH - Hydration (IV)M - Mask O2 A - Anticholinergics

- Ipratropium bromide



Inhaler

N b li



Nebulizer

• Only used in acute asthma whereoxygen is needed in addition to inhaleddrugs.



Allergic Disorders Allergy - an “altered state of reactivity” to commonenvironmental antigens.Most patients with allergy produce IgE antibodies to theantigens; familial predisposition to allergic diseases

Allergic rhinitis Allergic conjuntivitisEctopic eczema

Urticaria AnaphylaxisFood and drug allergyInsect bite hypersensitivity



• Sudden onset• if the chest does not rise when ventilation is firstattempted.• The most serious complication is complete obstructionof the airway, recognized as sudden respiratory distressfollowed by inability to speak or cough.



Three stages of symptoms:1. Initial event — violent paroxysms of coughing,

choking, gagging, and persistent monophonic wheeze.

2. Asymptomatic interval — the foreign bodybecomes lodged, reflexes fatigue, and the immediateirritating symptoms subside.

3. Complications — obstruction, erosion, or infection.

Complications include lung abcess, fever, cough,hemoptysis, pneumonia, and atelectasis .



Most airway foreign bodies lodge in a bronchus (rightbronchus in ≈58% of cases); laryngeal or tracheallocations occur in ≈10% of cases.Bronchoscopyx-rayCT or MRI



Abdominal thrust usingHeimlich maneuver Back blows and chest thrusts



Infant younger than 1 yr

Conscious child - permits to coughspontaneously until coughing is noteffective (or aphonic), respiratorydistress and stridor increaseUnconscious - the airway is opened with the head-tilt/chin-lift maneuver,and ventilation is attempted.

If there is still no chest rise, acombination of 5 back blows and 5chest thrusts is administered.



Child older than 1 yr

A conscious child is administered a series of 5abdominal thrusts (Heimlich manoeuvre) with thechild standing or sitting.If the child is unconscious, this is done with the child

lying down.

1. Stand behind the patient2. Encircle arms around the upper part of the abdomen

just below the patient’s rib cage 3. Give a sharp, forceful squeeze, forcing the diaphragm

sharply into the thorax.



Obstructive emphysema (air trapping) and shiftof the mediastinum toward the opposite side.



Clinical Approach to a Child with Wheeze AgeGradual or sudden onset, durationTransient early wheezing or persistent and recurrent

wheezingPreterm, maternal smoking Allergens (dust mites, pollens, pets etc), other allergicdisorders, family history of allergic disorder, asthmaFeeds



ReferencesEuropean Respiratory Journals [Outcome of asthma :longitudinal changes in lung function]Illustrated Textbook of PaediatricsPaediatrics Protocols

a child with wheeze

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