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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

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Wheezing in Children

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  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

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