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Respiratory Top Tips CHINEDU NWOKORO 13 th June 2019 Practical Paediatrics Update

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Page 1: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Respiratory Top Tips

CHINEDU NWOKORO13th June 2019

Practical Paediatrics Update

Page 2: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Outline

◼ Chronic Cough

◼ Wheezy infants and preschoolers (when is it asthma?)

◼ Investigation and Pitfalls

◼ Clinical Cases

Page 3: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

What is a normal cough frequency?

◼ Mean 11 cough epochs / 24 hours with no preceding RTI (range 1-34)

◼ Munyard P, Bush A Arch Dis Child 1996; 7:531-4

Page 4: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

What is a normal cough frequency?

◼ Mean 11 cough epochs / 24 hours with no preceding RTI (range 1-34)

◼ Nocturnal cough is suspicious…

◼ Munyard P, Bush A Arch Dis Child 1996; 7:531-4

◼ Most cough related to acute RTI resolves within 1-3 weeks (90% <3 weeks) (non-asthmatics)

◼ Hay AD Fam Pract. 2003 Dec;20(6):696-705 (preschool)◼ Butler CC BMJ 2003; 327: 1088-1089 (6m-12y)

Page 5: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Chronic cough - Respiratory infections

What is normal ?

◼ 6-10 RTIs / year (age 0-4 yrs)

◼ 2.5-5 RTI / year (age 10-14 yrs)

◼ Most resolve without treatment◼ Monto AS Epidemiol Rev 1994; 16(2): 351-73 (review article)

Page 6: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

What is a chronic cough?

◼ Adults > 8 weeks (BTS 2006)

◼ Children no universal definition - range >3-12 weeks

◼ Primary care children 80% with chronic cough have 5 or more consultations

◼ Marchant JM et al Chest 2008;134:303-9◼ Morrice AH Eur Resp J 2004; 24:481-492◼ Chang AB J Asthma 2001; 38: 299-309

Page 7: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Chronic Cough – History - 1

◼ How and when did cough start? (NNU/ v.acute/ RTI)

◼ What is nature of the cough? (wet/honk/paroxysmal)

◼ Is cough an isolated symptom? (wheeze/SOB/fever/thriving)

◼ What triggers cough? ( cold air/exercise/feeding/lying down)

◼ Coughing during sleep? (not much with habit cough)

◼ What treatment given and what effect?

◼ Antibiotics (which? How long? Taken properly?)

◼ Inhalers (which? Doses? Technique?)

Page 8: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Chronic Cough – History - 2

◼ Normal viral RTI and GI illness?

◼ Dysphagia/vomiting

◼ Are there symptom free episodes?

◼ Exposure to other children? (nursery/siblings)

◼ Atopy? pets? HDM? Hay Fever?

◼ Cigarette smoke exposure

◼ Damp - fungal spores

◼ (Ab)Normal birth history / neonatal RDS

◼ Relevant family history

Page 9: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Chronic cough – Red Flags

What’s not normal?

◼ Persistent wet cough – at least 4 weeks

◼ No symptom free intervals

◼ Poor weight gain and growth

◼ Persistent or focal signs in the chest / clubbing

◼ Other infections at other sites (ear discharge)

◼ Unusual organisms

◼ Abnormal CXR

Page 10: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Chronic Cough - Differentials

Dry coughAtopyHarrison SulcusWheezeFHExercise/Noct sx

RhinitisThroat clearingHayfever

Wet coughPoor growthSteatorrhoeaClubbingOther infxns

RefluxExercise/noct sxDysphagiaFood aversion

Brassy/BarkingHx of TOFistulaLymphadenopathy

No clinical signsDistractibilityQuiet nights“Abnormal” cough

Dry coughClubbingBreathlessnessRestrictive spiroHypoxaemia

ProgressiveWeight lossfever/night sweatsHaemoptysisLymphadenopathy

WHEEZE +ASTHMA

UACS

BRONCHIECTASIS

ASPIRATION LUNG DISEASE

MALACIACOMPRESSIONNARROWING

FOREIGN BODY

PSYCHOGENIC/ HABIT COUGH

INTERSTITIAL LUNG DISEASE/

FIBROSIS

TUBERCULOSISLYMPHOPROLIF

DISEASE

Page 11: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Post-Pertussis Chronic Cough

◼ Classic (severe) pertussis:

◼ Incubation 7-10d (coryzal stage)

◼ ≥ 21 d paroxysmal cough + whoops/vomiting

◼ Lymphocytosis.

◼ ’Whoop’ may be absent, partic. young infants

◼ “100 day cough” – can last weeks – months

◼ Laryngeal sensory neuropathy → persistence

◼ Usu nil rx – can use Pregabalin/gabapentin/amytrypt

Page 12: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Post-Pertussis Chronic Cough

◼ Vaccination → milder disease

◼ Whoop is absent (6% only)

◼ Non-specific, wet/dry “100-day cough”

◼ Under-diagnosed in adults and adolescents, who may be reservoirs for infection of unvaccinated infants.

◼ Up to 80% of infections in unvaccinated children were acquired from siblings and parents (n.b. vacc in utero)

Page 13: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Post-Pertussis Chronic Cough

Pertussis seropositivity

- Cough duration- Sleep disturbance- Parental concern

Page 14: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Post-Pertussis Chronic Cough

Cough duration is significantly longer in pertussis than mycoplasma

- 118 days vs 39 days

Page 15: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Chronic cough – Persistent bacterial bronchitis

◼ Persistent wet cough

◼ Investigate if red flags/pointers

◼ Can’t investigate everyone…

◼ 100 children, cough > 3 weeks

◼ Hx, Ex, Serial investigation

Page 16: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Chronic Cough - Persistent bacterial bronchitis

◼ ‘Specific cough’ 69

◼ Persistent bacterial bronchitis 45

◼ Bronchiectasis 6

◼ Asthma 4

◼ Eosinophilic bronchitis 4

◼ Aspiration 5

◼ Mycoplasma 2

◼ B.Pertussis 1

◼ TB 1

◼ Bronchiolitis obliterans 1

◼ ‘Non-specific cough’ 31

◼ Natural resolution 24

◼ Upper airway CS 3

◼ Gastro-Oe reflux 3

◼ Habit cough 1

◼ 20/29 (70%) dry cough resolved spontaneously

◼ 14/71 (20%) wet cough resolved spontaneously

◼ Most important pointers:

◼ wet cough

◼ abnormal chest findings

◼ CXR abnormalities

Page 17: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Persistent bacterial bronchitis: Outcome/16s

◼ Commonest organisms – haemophilus/strep

◼ Median age 3.7 years

◼ Risk of progression to bronchiectasis – swab + treat

◼ Suggest 1/12 co-amoxiclav

◼ If not responsive, look harder for reasons (see prev)

◼ Newer diagnostic methods – 16s PCR

Page 18: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Chronic cough and asthma

◼ Cough-variant asthma – dubious diagnosis

◼ Does it respond to asthma meds?

◼ Asthmatic physiology?

◼ Differentials? (GORD, UACS, OSA)

◼ Night cough in a non-atopic child – rarely asthma

Page 19: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

◼ Rhinitis

◼ Aeroallergen sensitivity → nasal steroid, antihist

◼ GORD →

◼ Foreign body

◼ Poor asthma control

◼ Hearing deficit and laryngitis

◼ Polyps

◼ Assoc asthma, aspirin sensitivity, montelukast resp

◼ Aeroallergen sensitivity

◼ Exclude CF/PCD/Foreign body/Immunodeficiency

Chronic Cough – The Nose

Page 20: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Chronic cough and GORD

◼ 40% adults with chronic cough have GORD

◼ In children: Cause and effect difficult to prove

◼ Imaging, ?aspiration?

◼ Cough reflux? Reflux vs Reflex theory?

◼ No studies have demonstrated symptom improvement with medical or surgical treatment

◼ Asthma and acid blockade experience – poorly controlled

asthma not helped by empirical reflux meds even in those with proven reflux

◼ Trial of therapy (Gaviscon, PPI, H2 antagonist, Prokinetic macrolide, domperidone???), consider:

◼ Allergy, Impedance, J feeding, Fundoplication,

Page 21: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Chronic cough - Recurrent aspiration

◼ Bulbar problems, laryngeal abn, H-type TOF, GOR

◼ Predominantly right sided CXR signs

◼ Ba swallow/pH-Impedance study/SLT +/- ENT review

◼ Bronchoscopy/MLB - oedematous airways

Bronchial lavage - fat laden alveolar macrophages

◼ Isotope scan (milk scan)

◼ Bulbar EMG (even if anatomical anomaly), MRI if indicated

◼ Case AO: diagnosis of brainstem tumour from SLT Ix of chronic feed-related cough

Page 22: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Chronic cough - recurrent aspiration

H-ToF: coughing, choking with feeds, noisy breathing, abdominal distension (Post-repair TOF cough, residual GOR)

Page 23: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Chronic cough and CF

◼ Neonatal Screening: IRT + DNA (4 mutations)

– Immunoreactive Trypsin as screening test

◼ 5% false negative results from CF NBS programme

- Not all ‘mild’ / ’atypical’ (SPIDs) / CFTR variants

◼ Don’t forget the sweat test

◼ Sweat chloride

◼ >30 mmol/l (<6m)

◼ >40 mmol/L (>6m)

◼ >60 - diagnostic

◼ Realistically >30 → further testing

Page 24: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Chronic cough and CF – A Case

◼ TC – 13 years old, chronic “asthma”

◼ Born like:

◼ Presents like:

◼ Cough

◼ Wheeze

◼ Exercise limitation

◼ Reduced FEV1

◼ Admitted to local with “LRTI”

Page 25: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Chronic cough and CF – A Case

◼ Closer investigation

◼ Cachectic and stunted (wt 30kg @ 13y)

◼ Clubbed, Lifelong steatorrhoea, Wet cough, sputum

◼ Exercise capacity 30y (when well)

◼ FEV1 33%, nocturnal hypoxaemia

◼ Sweat [Cl-] = 95mmol/L, Stool elastase = <200mcg/g

◼ x2 CF genes → Dx confirmed

◼ A lifetime of mismanagement

◼ What happened???

Page 26: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Chronic cough and CF – A Case

◼ Engaged with treatment

◼ Started on CFTR modifier

◼ 6 months of treatment

30kg

FEV1 33%

Clubbed

Invalided

60kg

FEV1 99%

No clubbing

Sporty++

◼ Take a good history!!!

Page 27: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Chronic cough - and structural abnormality

◼ Tracheo – broncho – malacia (ToF-cough)

◼ Airway collapse during expiration /coughing

◼ Impaired airway clearance

◼ 30% of children (0-3) with persistent wet cough

have (some degree of) tracheomalacia (Zgherea)

◼ 74% of <5 with ++bact on BAL had malacia (Kompare)(retro review 70 kids – ++bugs on BAL for cough/wheeze/noisy resps)

◼ Airway compression / collapse (lymphadenopathy?)

◼ Other congenital abnormality (vascular ring)

Zgherea D Paediatrics 2012, Kompare J Paediatrics 2012

Page 28: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Chronic cough & tracheomalacia

Page 29: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Vascular ring causing chronic cough

Page 30: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Habit/Psychogenic cough

◼ Honking noise : theatrical

◼ Predominantly daytime but not exclusively

◼ Up to several times per minute

◼ May last for months ? Following infective trigger

◼ Exhausted / off school / headaches / abdominal pain

◼ Management

◼ Convince the parent – then convince the child

◼ Spirometry, FeNO, Distractibility

◼ Demonstrate, reassure, downplay

◼ Breathing control (SLT/Physio/Psychol)

Page 31: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Primary Ciliary Dyskinesia

Page 32: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Primary Ciliary Dyskinesia - features

◼ Neonatal breathing problems – 75%

◼ Situs inversus / dextrocardia 50%

◼ Mucousy (nasal) babies - difficult to feed

◼ Cough – leading to bronchiectasis in adulthood

◼ Polyps

◼ Can be misdiagnosed as asthma

◼ (rhinitis, polyps, cough and wheeze)

◼ Hearing problems

◼ Avoid grommets (Hearing aids/bone conduction)

◼ Nasal NO, Nasal brushings, Genetics

◼ Hydrocephalus, dev delay, infertility

Page 33: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Pulmonary TB in children

◼ Symptoms

◼ cough, fever, night sweats, fatigue, malaise, anorexia, weight loss

◼ Children often asymptomatic

◼ Investigations

◼ Rarely produce sputum → GW/IS, TST, IGRA

◼ Red flags:

◼ ‘Acute’ CXR/effusion in relatively well child

◼ Older children w. effusion (Whitechapel at least!)

◼ Exposure history (case: local child empyema ref)

Page 34: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

So what do you do?

◼ No red flags, intermittent symptoms, dry cough, CXR (N):

- watch and wait

◼ Persistent symptoms, wet cough, CXR abnormal?

- 4 week course PO abx (aug/clari)

- If not-improved/improved but relapse

- Investigate further:

Page 35: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

General Interventions

◼ Ensure fully immunised (incl flu), vitamin D replete

◼ Consider antibiotic prophylaxis (azithro MWF 10mg/kg)

◼ Lifestyle (exercise, ETS, damp, allergen, ?physio req)

◼ Nutrition (monitor growth, adequate hydration, calories)

◼ Monitoring (depends on cause/severity)

◼ Symptoms, spirometry, anthropometry, saturations

◼ Cough swab/sputum (every clinic)

◼ Consider annual CXR

◼ Normal immunity can change… (CVID)

Page 36: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Key references

◼ BTS Guideline

Recommendations for the assessment and management of cough in children

M Shields, A Bush et al for BTS 2007/8

◼ Chang AB et al

A cough algorithm for chronic cough in children

Pediatrics 2013: 131: e1576 – 83

◼ Shields MD et al

The difficult coughing child

Cough 2013:9;

Page 37: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Wheezy infants & pre-schoolers

◼ When is it asthma? When does it matter?

40% of children wheeze in the first year of life – only 30%

pre-school kids with recurrent wheeze have asthma at age

6yrs.

◼ What is meant by wheezing?

◼ What do parents mean by wheezing?

◼ Where does it come from?

Page 38: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

◼ Turbulent, high velocity airflow in small airways

◼ Expiratory whistling sound

◼ Differentiate from:

◼ Inspiratory sounds (stridor, snoring/stertor)

◼ Ruttles, crepitations

◼ Mimic/Model it

◼ Smartphone recordings

Where does wheeze come from?

Page 39: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Causes of wheeze

◼ Broncho-constriction

◼ Asthma/multitrigger wheeze

◼ Episodic viral wheeze

◼ Dynamic large airway collapse (malacic segments)

◼ Bronchial oedema + secretions (infection, cardiac)

◼ (Intrathoracic) Large airway obstruction (LNs etc.)

◼ Reflux and aspiration, chronic suppurative lung dis

Page 40: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

What is the chance of this being asthma?

Page 41: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

A primary care approach to asthma mx?

Suspected AsthmaEpisodic cough & wheeze, viral/nocturnal/exercise symptoms, Salbutamol response

Diurnal/Symptomatic variation in lung function (PEFR/FEV-1), Other Atopy

Troublesome SymptomsSalbutamol used > 3 days/week

Disturbed sleep, School absence, Exercise limitationHospitalisation, Requires oral steroids, ACT Score <19, PEFR < 80% predicted

Initiate Preventer Treatment Age < 5 – Clenil Modulite 100mcg BD via MDI and spacer (mask or mouthpiece)

Age >5 – Clenil Modulite 200mcg BD via MDI and spacer (mouthpiece), PRN SalbutamolAssess ACT Score, PEFR after 3 months

Symptoms PersistAge < 5 – Add montelukast 4mg OD

Age > 5 – Start Seretide 50, TT BD via MDI + spacer

Reassess ACT Score, PEFR

Symptoms Persist?

Symptoms Resolved?Reduce/Stop Treatment

Reassess ACT Score, PEFRRestart/escalate or Reduce/discontinue

MonitorACT, PEFR

Salbutamol Px, Prednisolone PxSchool Absence, ++USMA

Cause for Concern?

Increase Steroid dose/Add montelukast 5mgReassess ACT Score, PEFR

Symptoms Persist?

Refer Secondary Care*

NO

YES

Page 42: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

A primary care approach to asthma mx?

Suspected AsthmaEpisodic cough & wheeze, viral/nocturnal/exercise symptoms, Salbutamol response

Diurnal/Symptomatic variation in lung function (PEFR/FEV-1), Other Atopy

Troublesome SymptomsSalbutamol used > 3 days/week

Disturbed sleep, School absence, Exercise limitationHospitalisation, Requires oral steroids, ACT Score <19, PEFR < 80% predicted

Initiate Preventer Treatment Age < 5 – Clenil Modulite 100mcg BD via MDI and spacer (mask or mouthpiece)

Age >5 – Clenil Modulite 200mcg BD via MDI and spacer (mouthpiece), PRN SalbutamolAssess ACT Score, PEFR after 3 months

Symptoms PersistAge < 5 – Add montelukast 4mg OD

Age > 5 – Start Seretide 50, TT BD via MDI + spacer

Reassess ACT Score, PEFR

Symptoms Persist?

Symptoms Resolved?Reduce/Stop Treatment

Reassess ACT Score, PEFRRestart/escalate or Reduce/discontinue

MonitorACT, PEFR

Salbutamol Px, Prednisolone PxSchool Absence, ++USMA

Cause for Concern?

Increase Steroid dose/Add montelukast 5mgReassess ACT Score, PEFR

Symptoms Persist?

Refer Secondary Care*

NO

YES

Page 43: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Asthma Prediction – the API

◼ Frequent wheezing >3x/year under 3 yrs of age and Either

◼ One major risk factor (parental asthma or child with eczema)

◼ Or Two of three minor risk factors

(eosinophilia > 4%, wheezing without colds, and allergic rhinitis).

◼ Risk of having subsequent asthma increased by 4.3 to 9.8 times

◼ Increased risk of asthma persistence

◼ Castro-Rodriguez JA: Am J Resp Crit Care Med 2000: 162: 1403-1406

Tucson Children’s Respiratory study

Page 44: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Asthma phenotypes - temporal

Martinez F D Pediatrics 2002;109:362-367 Tucson Arizona

Page 45: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Asthma phenotypes

◼ Transient early wheeze resolves by age 3

◼ not assoc. FH or atopy. +ve assoc with smoking, prematurity, increased airway compliance, smaller airways, multiple siblings, PFTs track growth

◼ Non-atopic wheeze – viral related esp. RSV

◼ May have lower lung function/ smaller airways at birth

◼ No atopy or +ve SPT – PFTs abnormal till 13yrs

◼ Persistent Wheeze

◼ early onset - before age 3 yrs associated with more severe, persistent symptoms, poor early PFT, early allergy

◼ Late onset wheeze – later atopic development

Page 46: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Simpler asthma adviceClassify according to symptom pattern

◼ Episodic viral wheeze

◼ Multiple trigger wheeze/Asthma

- type may change over time

◼ Target symptom control – can’t modify progression

◼ ICS preferred maintenance rx

◼ LTRA = add-on/intermittent therapy (recent metaanalysis – no benefit in preschoolers)

◼ Assess periodically for sx remission, heterogenity?

◼ Caution with use of oral steroids (no evidence)Castro-Rodriquez et al. Treatment of asthma in young children: evidence-based recommendations Asthma Research and Practice 2016 2:5

Bush A. Managing asthma in preschool children BMJ 2014;348;g15

Page 47: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Other factors

◼ Passive smoking

◼ Mould exposure

◼ Obesity

◼ Pollution

Page 48: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Pollution and wheeze

◼ Pollution - especially particulates and ozone linked to asthma exacerbation

◼ moving from high → low PM10 regions → slows

rate of LF decline

◼ Acute changes in ambient PM10 assoc c incrasthma sx

◼ Prevalence of asthma/allergies in children increasing

◼ Air pollution increases resp infection (PAFr) WHO Europe FACT SHEET 2007:3.1

Esposito S. Impact of air pollution on respiratory diseases in children with recurrent wheezing or asthma. BMC Pulmonary Medicine 2014, 14:130

Page 49: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Obesity and Wheeze

◼ Obesity has been associated with

- Asthma and wheeze

- Severity of asthma

- Poor asthma control

Obesity is a pro-inflammatory condition

Association with poor physical fitness and exercise symptoms also

Page 50: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Meds Update

• New Inhalers• Relvar Ellipta (12+)• (92/22 OD = 250/50 BD)• Spiriva Respimat (6+)• (5mcg = 2 puff OD)• Generics

• Dexamethasone• Azithromycin

Page 51: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Biologics - update

◼ Omalizumab (6+)

◼ Mepolizumab (6+)

Page 52: Respiratory Top Tips - Infomed Research & Training Limited · Asthma Prediction –the API Frequent wheezing >3x/year under 3 yrs of age and Either One major risk factor (parental

Important references

◼ Bush A. Managing asthma in preschool children BMJ 2014;348;g15

◼ R.J. Kurukulaaratchy Predicting persistent disease among children who wheeze during early life

Eur Resp J 2003;22: 767-771

◼ Castro-Rodriguez JA & Martinez FD

Tucson Children’s Respiratory study

◼ I.O.W. study, PIAMA study - Netherlands, ALSPAC –Avon,

◼ ISAAC 1991-2012

◼ Hussein, H.R., Gupta, A., Broughton, S. et al. Eur J Pediatr (2017). doi:10.1007/s00431-017-2936-6

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Top tips to take-away

Cough

◼ Early onset wet cough: consider underlying cause

◼ Chronic wet cough: treat – investigate if not better

◼ Cough alone: unlikely to be asthma

Wheeze

◼ Consider airway abnormality in early onset wheeze

◼ If child has regular symptoms and the diagnosis of asthma is ‘probable’ (cough + wheeze +/- SOB(Ex) +/- atopy)

– give 3/12 trial of preventer treatment

◼ Be prepared to re-think if no atopy & no Rx response

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Thank You – Questions?