1 / 36

Wheezing in Children

Wheezing in Children. Prof RJ Green Department of Paediatrics. Adventitious Airway Sounds. Snoring Stridor Wheezing Crepitations. Airway Diameter. Cause of Wheezing. Not from obstruction of small airways – Surface area too large

elga
Télécharger la présentation

Wheezing in Children

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. Wheezing in Children Prof RJ Green Department of Paediatrics

  2. Adventitious Airway Sounds • Snoring • Stridor • Wheezing • Crepitations

  3. Airway Diameter

  4. Cause of Wheezing • Not from obstruction of small airways – Surface area too large • From increased intrathoracic pressure + decreased large airway pressure = vibration of airway wall in large airways (Generations 1-5)

  5. Wheezing • Sign of lower (intra-thoracic) airway obstruction • Small airways

  6. Air Trapping • Hyperinflated chest • Barrel shaped • Loss of cardiac dullness • Liver pushed down • Hoover sign

  7. Hoover Sign • Normal diagphragm movement • Hyperinflation = diaphragm flattened • Diaphragm contraction = paradoxical inward movement of lower interrcostal area during inspiration

  8. Acute Wheezing • Asthma • Bronchiolitis • Foreign body

  9. Bronchiolitis 10

  10. What Is Bronchiolitis? • Bronchiolitis is acute inflammation of the airways, characterised by wheeze • Bronchiolitis can result from a viral infection • Respiratory Syncytial Virus (RSV) may be responsible for up to 90% of bronchiolitis cases in young children Hall CB, McCarthy CA.In: Principles and Practice of Infectious Diseases 2000:1782-1801; Panitch HB et al. Clin Chest Med 1993;14:715-731 11

  11. In a clinical study in Argentina, RSV was the most common virus isolated from a sample of children aged <5 years with acute lower respiratory infection RSV 0.7% 6.5% 6.8% Adenovirus 7.8% Parainfluenza 78.2% Influenza A Influenza B RSV Is a Common Virus CausingBronchiolitis in Children New viruses (Human Metapneumovirus, Bocca, Corona) Carballal G et al. J Med Virol 2001;64:167-174 12

  12. Chronic Wheezing • Thriving child – Happy wheezer • Child failing to thrive - Causes

  13. Exclude other conditions • Structural problems: bronchoscopy • URTD : Polysomnography, • Esophageal disease: Barium swallow, pH probes, scopes and gram • Primary ciliary dyskinesia: nasal ciliary motility, Exhaled NO, EM, saccharine test • TB: mantoux, induced sputum/ gastric lavage/ BAL = Culture, microscopy & PCR • Bronchiectasis: HRCT scan, BAL • CF: sweat test, nasal potentials, genotypes • Systemic immune deficiency: Ig subtypes, lymphocytes & neutrophil function, HIV • Cardiovascular disease: echo, angiography

  14. WHEEZING PHENOTYPES12 Longitudinal birth cohorts Original Tucson Group (Taussig L et al 1985) Persistent Atopic Non Atopic Transient

  15. TRANSIENT WHEEZERS • Commonest form of wheeze • Decrease lung function at birth • No airway hyper-responsiveness • Non Atopic • No immune responses to viruses • Resolves by 3 years • Wheeze in first year – better outcome • Wheeze 2-3 year – worse outcome due to maturity of immune system Affected by : • Teenage pregnancy & smoking • Male gender • Day care- infections

  16. STRUCTURAL CONSIDERATIONS • Lung Growth: Fetal 8 years • Affected by: • Temperature & O2 tension • Nutrition & Smoking • Functional disorders eg CDH • Prematurity • Growth factors-Gene repair • Drugs (B2 agonist/ C/S) • Risk factors for COPD • Mx: antioxidant, retinoids,MMPI

  17. PERSISTENT NON ATOPIC WHEEZER • Lung function abnormal at birth and reduced in later life • Non Atopic • Airway hyper-responsiveness • Peak flow variability • RSV induced wheeze due to alteration in airway tone BETTER OUTCOME THAN ATOPIC PERSISTENT WHEEZERS

  18. Immunology associated with RSV • Unknown - natural infection # total immunity • Re-infection by same strains by 6 weeks • Recurrent disease- all infected by 3yrs • Infancy-immature immune system • Maternal antibodies • Incomplete protection,worse in premature

  19. Prevalence of RSV Infection • n= 125 children followed from birth to 12m & 92 children followed from age 24-60m, virtually all were infected with RSV by 24 m 100.0% 97.1% 100 80 Children with RSV infection (%) 68.0% 60 40 20 0 0-12 13-24 25-36 Age (months) Glezen WP et al. Am J Dis Child 1986;140:543-546 20

  20. RSV-Induced Bronchiolitis May Consist of Several Phases Phase I Phase II Phase III Long term Persistent wheezing Acutephase Viralinfection Wheezing and asthma Days Weeks Months ( (Not to scale) 21

  21. Wheezing Often Persists Post Bronchiolitis Korppi M et al. Am J Dis Child 1993;146:628-631 • 83 children <2 years hospitalised with bronchiolitis, a large proportion had subsequent wheezing 100 76% 80 58% Children with wheezing (%) 60 40 20 0 1-2 (n=83) 2-3 (n=76) Age (years) 22

  22. 35 30% 30 25 20 15 10 3% 5 0 RSV (n=47) Control (n=93) RSV-Induced Bronchiolitis: Association With Asthma • n= 140, the incidence of asthma at 7.5 yrs was higher in children who had been infected with RSV compared with controls Children with asthma at age 7.5 years (%) Sigurs N et al. Am J Respir Crit Care Med 2000;161:1501-1507 23

  23. TIME COURSE OF RECURRENT LOWER RESPIRATORY SYMPTOMS Henry et al. 1985 Arch Dis Child Webb et al. 1985 Arch Dis Child Hall et al. 1984 J Pediatr

  24. Therapeutic Options:viral induced wheeze 25

  25. Options • Humidified oxygen: Beneficial • ?? Antibiotics -associated infection • ??Efficacy of Bronchodilators • Inhaled & oral B2 agonists • Inhaled ipratropium bromide • theophyllines • ??Use of corticosteroids • ?Use on leukotriene antagonists • ?Efficacy of immunoglobulin

  26. Effect of Montelukast on RSV-Induced Bronchiolitis • A RDBPC trial studied the effects of the LTRA montelukast on the post-infectious course of RSV-induced bronchiolitis • 130 infants aged 3-36 months were randomized to receive montelukast or placebo • Study treatment was montelukast 5 mg chewable tablets or matching placebo taken in the evening for 28 days • Symptoms were recorded by the caretakers on diary cards Bisgaard H. Am J Respir Crit Care Med 2003;167:379-383 27

  27. 30 Montelukast (n=61) Placebo (n=55) 20 p=0.015 10 0 28 0 7 14 21 Montelukast Improved the Symptoms of RSV-Induced Bronchiolitis • Montelukast significantly improved symptom-free days &nights (daily median) Median symptom-free days and nights (%) Days Missing data were considered to be symptomatic days. Bisgaard H. Am J Respir Crit Care Med 2003;167:379-383 28

  28. Montelukast : Reduced Exacerbations - Post RSV Bronchiolitis 25 18.2% 20 Patients with exacerbations (%) 15 10 6.6% 5 0 Montelukast Placebo * Withdrawal due to symptom severity, or attending emergency department or hospitalisation due to lung symptoms Bisgaard H. Am J Respir Crit Care Med 2003;167:379-383 29

  29. PERSISTENT ATOPIC WHEEZER • Lung function normal at birth but deteriorates with recurrent symptoms • Increased symptoms with increasing age • Airway liability • Atopic (increase IgE at 6-9m; increase cytokines) • Abnormal immune responses to viruses

  30. PREDICTORS + RISK FACTORS FOR PERSISTENT WHEEZE • Family history of Atopy • Viral infections • Allergens • Environmental factors • Household chemicals (OR 2.3 CI 1.2- 4.39) • Genetics • Multiple factors in combination

  31. RISKS OF FAMILY HISTORY OF ATOPY • No family history : 16% • Single parent atopy : 22%Maternal Atopy : 32 % • Both parents atopic : 50% (Aberdeen Study 1994)

  32. MULTIPLE FACTORS Triad of interactions Genetic variability Infections & environment Complex receptor interaction • Single factor PPV < 50% • Combination factors PPV 80% (German MAS 1990)

  33. 90% 50% 40% 20% Infant wheeze Infant wheeze + atopic eczema and/or other food allergies Infant wheeze with atopic parent (s) Infant wheeze + atopic parent + positive skin prick test + raised sIL-2R % OF INFANTS SUBSEQUENTLY DEVELOPING ASTHMA

  34. OUTCOME OF INFANT WHEEZING • Low birth weight • Pregnancy smoking • Male Sex • Affluence • Atopy • Low maternal age (first born) Infant wheeze With viral infection alone With various precipitants Remission in 80% Persistent asthma (with or without evidence of atopy) in 50-60% ?? COPD in adults

  35. Points on examination • LOW, FTT – systemic disease • UAO: Tonsils, Adenoids, Polyps, Rhinitis • Fixed Monophonic/asymmetric wheeze : foreign body • Chest deformity- chronic lung disease • Clubbing & Halitosis- chronic suppurative lung disease -bronchiectasis • Stridor – bronchomalacia, vascular ring mediastinal syndrome • signs of cardiac or systemic disease

More Related