Wheezy babyWheezy baby

Dr Malena Cohen-CymberknohDr Malena Cohen-CymberknohDep. Of Pediatrics, Ped. Pulmonology and CF Dep. Of Pediatrics, Ped. Pulmonology and CF

CenterCenter

Hadassah Medical CenterHadassah Medical Center

What is wheezing?What is wheezing?

Best characterized as a continuous, “musical” sound

Most often heard on expiration, but it may occur in both phases of respiration

The sound is the result of flow limitation in large or medium-sized airways

Obstruction of the airways may be due to intraluminal or extraluminal causes

Causes of wheezingCauses of wheezingIntraluminal obstruction, caused by:• smooth muscle constriction• mucosal edema• hypersecretion of mucus or cellular infiltrate

airway inflammation or infection• foreign body aspiration• tumors

Extraluminal obstruction, caused by external compression by:• vascular structures • enlarged lymph nodes• pulmonary cysts• tumors

What is wheezing?What is wheezing?

A common symptom that is typically associated with asthma, but…..

Not everyone who wheezes has asthma!

Occurs when lower airways are narrow or constricted- breathing feels difficult and there is a whistling sound in the chest on breathing out

Very common in the first few years of life: infant's airways are small and a respiratory tract infection

For most children wheezing is temporary and does not mean that they have asthma

Causes of wheezing in childhoodCauses of wheezing in childhood

AcuteAcute

Asthma

Bronchial edema/hypersecretion- Infection (bronchiolitis, ILD, pneumonia)- Inhalation of irritant gases or particulates- Increased pulmonary venous pressure- Cholinergic drugs

Aspiration- Foreign body- Gastric contents (reflux, H-type TEF)

Causes of wheezing in childhoodCauses of wheezing in childhoodChronic or recurrentChronic or recurrent

Reactive airway disease Hypersensitivity reactions- ABPA Dynamic airways collapse

- Bronchomalacia, tracheomalacia, vocal cord dysfunction Airway compression by mass or blood vessel

- Vascular ring/sling- Anomalous innominate artery- Pulmonary artery dilatation (absent pulmonary

valve)- Bronchial or pulmonary cysts- Lymph nodes or tumors

Aspiration- Foreign body- GER (gastroesophageal reflux)- TEF (repaired or unrepaired)

Causes of wheezing in childhoodCauses of wheezing in childhood Chronic or recurrent- cont’dChronic or recurrent- cont’d

Bronchial hypersecretion/failure to clear secretions- Bronchitis- Bronchiectasis (CF, PCD, Immunodeficiencies) - Vasculitis- Others: lymphangiectasia, Alpha-1-antitrypsin

def.)

Intrinsec airway lesions- Endobronchial tumors- Endobronchial granulation tissue- Bronchial or tracheal stenosis - Bronchiolitis obliterans- Sequelae of BPD- Sarcoidosis

Congestive heart failure

Causes of wheezing in childhoodCauses of wheezing in childhood

Chronic or recurrentChronic or recurrent

Congenital anomaliesCongenital anomalies::

•Tracheomalacia•Bronchomalacia•Vascular ring•Vascular sling•Anomalous innominate artery

TracheomalaciaTracheomalacia

The walls of the trachea are floppy,instead of being rigid

Symptoms:

Breathing noises, may change with position and improve during sleep

Get worse with coughing, crying, feeding, or upper respiratory infections

High-pitched breathing, noisy breaths

BronchomalaciaBronchomalacia

Weak cartilage in the walls of the bronchial tubes, in children <6 months

There is collapse of a main stem bronchus on expiration

Two types of bronchomalacia: - Primary- due to a deficiency in the cartilaginous rings - Secondary- may occur by extrinsic compression from an

enlarged vessel, a vascular ring or a bronchogenic cyst

Vascular ringVascular ring

Is a congenital condition in which the anomalous configuration of the arch and/or associated vessels surrounds the trachea and esophagus, forming a complete or incomplete ring around them

Vascular slingVascular sling

The left pulmonary artery arises from the right pulmonary artery, crossing to the left side, and insinuates itself between the trachea and esophagus, forming a 'sling' around the trachea

Innominate arteryInnominate artery

An artery that arises from the arch of the aorta and divides into the right subclavian and right carotid arteries. (also called brachiocephalic artery, brachiocephalic trunk)

It appears to originate from a more It appears to originate from a more distal and leftward position on the arch distal and leftward position on the arch than normalthan normal

As it takes its course from left to right, As it takes its course from left to right, it crosses the trachea anteriorly and in it crosses the trachea anteriorly and in doing so may produce compression of doing so may produce compression of the tracheathe trachea

Anomalous innominate arteryAnomalous innominate artery

Other common causes of Other common causes of wheezingwheezing

Acute:Acute:BronchiolitisBronchiolitis

AsthmaAsthma

GERGER

Foreign body aspirationForeign body aspiration

Chronic:Chronic:BronchiectasisBronchiectasis

Interstitial lung diseaseInterstitial lung disease

BronchiolitisBronchiolitis

BronchiolitisBronchiolitis

Usually affects children under the age of 2 y, with a peak age of 3 to 6 months

Is seasonal and appears more often in the fall and winter months

It is caused by a virus (RSV most common). Other viruses: hMPV, influenza, parainfluenza, coronavirus, adenovirus and rhinovirus

Bronchiolitis- Bronchiolitis- contcont..

It starts like a cold, with a runny nose, fever and mild cough

Wheezing and tachypnea are common

Most cases are mild and get better without treatment, but in young babies can be severe, occasionally requiring hospitalization

Treatment: supportive therapy, inhalations with HS, (epinephrin, steroids, β2 agonists???)

AsthmaAsthma

Most common chronic disease in childhood

High prevalence (more than 10% in <18yrs.)

Asthma exacerbations are a major cause of morbidity for patients of all ages

80% of asthmatics develope symptoms before the age of 5 years

AsthmaAsthma

Never wheezed51%

Transient 20%

Persistent 14%Late

15%

Never wheezed by age of 6y

Transient: wheeze <3y,no wheeze by 3yPersistent: wheeze <3y,wheeze at 6yLate: no wheeze <3y,wheeze at 6y

Martinez et al. NEJM 1995

n=826

Asthma and wheezing in first 6 Asthma and wheezing in first 6 yearsyears

most likely to experience asthma- like symptoms that persist into adolescence and adult life, particularly those with atopic features

Viruses are detected in up to 85% of Viruses are detected in up to 85% of wheezing exacerbations:wheezing exacerbations:

RhinovirusRhinovirus Respiratory syncytial virus (RSV)Respiratory syncytial virus (RSV)CoronavirusCoronavirusInfluenza virusInfluenza virusParainfluenza virusesParainfluenza viruses

Seasonal correlations between rates of Seasonal correlations between rates of upper respiratory infections (URIs) and upper respiratory infections (URIs) and hospital admissions for asthmahospital admissions for asthma

Viral infection-a common cause of Viral infection-a common cause of wheezing exacerbations in childrenwheezing exacerbations in children

Johnston SL et al. BMJ 1995;Johnston SL et al. AJRCCM 1996;Pattemore PK et al. Clin Exp Allergy 1992

Asthma exacerbation- Asthma exacerbation- most important triggersmost important triggers

Viral infections (85%)- URTI

Drugs-aspirin, blocker

Irritants-smoking, air pollution

Allergy-cat, dog, cockroach

Exercise

Weather

Mendelson (1946) was first to associate respiratory disease as a consequence of GER

He described an “asthma-like” syndrome following GER and aspiration of acidic gastric contents during the induction of obstetric anesthesia

Gastroesophageal Reflux (GER)

Gastroesophageal Reflux (GER)Gastroesophageal Reflux (GER)

Normal physiological process in a healthy infants, children and adults

50% infants (0-3 m) and 2/3 old-infants (4-6 m) vomit at least once a day

Prevalence of vomiting decreases dramatically >8 mos. of age

Typically resolved by 18-24 mos. of age, and no evaluation or treatment is necessary

Complications of GERComplications of GER

1- Vomiting

Parental frustration

Iatrogenic weight loss from limitation on feeding to prevent vomiting

Weight loss/inadequate weight gain from excessive vomiting

Complications of GER- cont’dComplications of GER- cont’d

2- Esophagitis2- Esophagitis

DysphagiaDysphagia Chest pain, heartburnChest pain, heartburn Irritability/inconsolable crying in infantsIrritability/inconsolable crying in infants Hematemesis, anemia, melenaHematemesis, anemia, melena Sandifer syndromeSandifer syndrome Globus sensationGlobus sensation Barret esophagusBarret esophagus Esophageal strictureEsophageal stricture

Complications of GER- cont’dComplications of GER- cont’d

3- Respiratory disorders3- Respiratory disorders

Cough, hoarseness, stridor Apnea, ALTE Bronchospasm or wheezing Asthma: can be worsened by GER-

High prevalence of GER in asthma (50%) Recurrent pneumonia (GER + aspirations) Pulmonary fibrosis

Foreign body aspirationForeign body aspiration

Can be a life-threatening emergency

More frequent: 1-3 years

Local inflammation, edema, cellular infiltration, ulceration, and granulation tissue formation may contribute to airway obstruction, making removal of the object by bronchoscopy more difficult

Foreign body aspirationForeign body aspiration

•Distal to the obstruction, air trapping may occur

•May lead to:local emphysemaatelectasispost-obstructive

pneumonia

•Other complications:Necrotizing pneumoniaAbscessSuppurative pneumonia Bronchiectasis

BronchiectasisBronchiectasis

Localized, irreversible dilation of part of the bronchial tree

Airflow obstruction and impaired clearance of secretions

Sputum retained in the dilated areas, cannot being pushed upward

A group of lung diseases affecting the interstitium of the lung

• alveolar epithelium• pulmonary capillary

endothelium• basement membrane• perivascular tissue• perilymphatic tissue

Interstitial lung disease (ILD)Interstitial lung disease (ILD)

ILD- Etiology (primary/secondary)ILD- Etiology (primary/secondary)

Idiopathic InfectionToxic (environmental or drugs)InfiltrationAssociation with other

conditions

Interstitial lung disease (ILD)Interstitial lung disease (ILD)

The term ILD is used to distinguish these diseases from obstructive airways diseases

ILD- Infectious causesILD- Infectious causes

Bacteria- Mycoplasma, Chlamydia, Legionella, Mycobacterium

Virus- CMV, EBV, RSV, Adenovirus, Influenza, Parainfluenza, Measles

Fungi- Aspergillus, Candida, Histoplasma

Parasite- PCP (Pneumocystis jiroveci), Visceral larva migrans

ILD- Toxic causesILD- Toxic causes

Environment Inorganic dust (silica, asbestos) Organic dust hypersensitivity pneumonitis (exposition to

birds, pigeons, doves, parakeet-look for pecipitins (Atg-Ab complex)

Drugs Antineoplastic (Cyclophosphamide, Azathioprine, MTX,

Bleomycin) Penicillamine, Gold

Radiation therapy

ILD- Infiltrative causesILD- Infiltrative causes

Neoplastic diseasesleukemialymphomaLangherans cell histiocytosis

Storage diseasesNieman-PickGaucher

Congestion- Cardiac or renal diseases

ILD- Radiologic evaluationILD- Radiologic evaluation

Childhood vs. adult asthma Childhood vs. adult asthma

Childhood asthma• Boys twice as girls• Transient Peripheral airway

resistance

Adult asthma • Women twice as men• Persistent Peripheral + central

airway resistance