Wheezy baby

1. Wheezy baby Dr Malena Cohen-Cymberknoh Dep. Of Pediatrics, Ped. Pulmonology and CF Center Hadassah Medical Center

2. 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

3. Intraluminal 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 Causes of wheezing

4. 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

5. Acute • 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 childhood

6. Chronic 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 childhood

7. Chronic 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 childhood

8. Causes of wheezing in childhood • Chronic or recurrent • Congenital anomalies: • Tracheomalacia • Bronchomalacia • Vascular ring • Vascular sling • Anomalous innominate artery

9. Tracheomalacia • 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

10. Bronchomalacia • 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

11. Vascular 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

12. Vascular 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

13. Innominate 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)

14. Anomalous innominate artery It appears to originate from a more distal and leftward position on the arch than normal As it takes its course from left to right, it crosses the trachea anteriorly and in doing so may produce compression of the trachea

15. Other common causes of wheezing Acute: • Bronchiolitis • Asthma • GER • Foreign body aspiration Chronic: • Bronchiectasis • Interstitial lung disease

16. Bronchiolitis

17. Bronchiolitis • 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

18. Bronchiolitis- cont. • 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???)

19. Asthma • 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

20. Asthma

21. Asthma and wheezing in first 6 years n=826 Transient 20% Never wheezed 51% Persistent 14% Late 15% Never wheezed by age of 6y Transient: wheeze <3y, no wheeze by 3y Persistent: wheeze <3y,wheeze at 6y Late: no wheeze <3y,wheeze at 6y most likely to experience asthma- like symptoms that persist into adolescence and adult life, particularly those with atopic features Martinez et al. NEJM 1995

22. Viral infection-a common cause of wheezing exacerbations in children • Viruses are detected in up to 85% of wheezing exacerbations: • Rhinovirus • Respiratory syncytial virus (RSV) • Coronavirus • Influenza virus • Parainfluenza viruses • Seasonal correlations between rates of upper respiratory infections (URIs) and hospital admissions for asthma Johnston SL et al. BMJ 1995;Johnston SL et al. AJRCCM 1996;Pattemore PK et al. Clin Exp Allergy 1992

23. Asthma exacerbation- most important triggers • Viral infections (85%)- URTI • Drugs-aspirin, blocker • Irritants-smoking, air pollution • Allergy-cat, dog, cockroach • Exercise • Weather

24. Gastroesophageal Reflux (GER) • 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

25. 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

26. Complications of GER • 1- Vomiting • Parental frustration • Iatrogenic weight loss from limitation on feeding to prevent vomiting • Weight loss/inadequate weight gain from excessive vomiting

27. Complications of GER- cont’d • 2- Esophagitis • Dysphagia • Chest pain, heartburn • Irritability/inconsolable crying in infants • Hematemesis, anemia, melena • Sandifer syndrome • Globus sensation • Barret esophagus • Esophageal stricture

28. Complications of GER- cont’d • 3- 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

29. Foreign 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

30. Foreign body aspiration • Distal to the obstruction, air trapping may occur • May lead to: • local emphysema • atelectasis • post-obstructive pneumonia • Other complications: • Necrotizing pneumonia • Abscess • Suppurative pneumonia Bronchiectasis

31. Bronchiectasis • 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

32. Interstitial lung disease (ILD) A group of lung diseases affecting the interstitium of the lung • alveolar epithelium • pulmonary capillary endothelium • basement membrane • perivascular tissue • perilymphatic tissue

33. ILD- Etiology (primary/secondary) • Idiopathic • Infection • Toxic (environmental or drugs) • Infiltration • Association with other conditions

34. Interstitial lung disease (ILD) The term ILD is used to distinguish these diseases from obstructive airways diseases

35. ILD- 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

36. ILD- 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

37. ILD- Infiltrative causes • Neoplastic diseases leukemia lymphoma Langherans cell histiocytosis • Storage diseases Nieman-Pick Gaucher • Congestion- Cardiac or renal diseases

38. ILD- Radiologic evaluation

40. 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