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Wheezing in Children

Wheezing in Children. Mona Massoud, MD Emory University School of Medicine Family Medicine Residency 9/22/11. Introduction. Common presenting symptom of respiratory disease in children Could benign and self limiting or presenting symptom of significant respiratory disease

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Wheezing in Children

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  1. Wheezing in Children Mona Massoud, MD Emory University School of Medicine Family Medicine Residency 9/22/11

  2. Introduction • Common presenting symptom of respiratory disease in children • Could benign and self limiting or presenting symptom of significant respiratory disease • Common problems presented to PCP

  3. Incidence • 25-30% of infants will have one episode of wheezing. • By six years of age approximately half of children will have had at least one episode of wheezing

  4. Overview • Wheezing: Continuous coarse whistling sound produced by oscillation of narrowed or compressed respiratory airway. Inspiratory or expiratory/ High or low pitched. • Crackles (rales): Popping sound created when air is forced through respiratory passages. • Stridor: high-pitched harsh sound heard during inspiration, due to obstruction of upper airway.

  5. Wheezing type in childhood • Transient wheezer: One episode or few episodes of wheezing. No further episodes beyond 6 years. • Non-atopic wheezer: Wheeze during viral infections and continue to have recurrent airway obstruction during early school years. • IgE associated wheeze/asthma: Start to have symptoms later in life which continues into adulthood.

  6. Wheezing Type in Childhood

  7. Why do Children tend to wheeze more than Adults? • Children have smaller airway passages, therefore higher resistance • Less chest compliance • Elastic tissue recoil is lower than adults and fewer collateral airways-prone to obstruction and atelectasis

  8. Differential Diagnosis • Acute • Asthma • Bronchitis • Bronchiolitis • Laryngeotracheobronchitis (Croup) • Bacterial Tracheitis • FB aspiration • Esophageal FB

  9. Chronic or Recurrent Causes • Asthma • GERD • Retained foreign body • Cystic Fibrosis • Recurrent Aspiration • Primary ciliary dyskinesia • ILD • Immunodeficiency • Structural Causes: • Tracheo-bronchomalacia • Vascular rings • Tracheal web • Cystic lesions/lymphadenopathy/mediastinal masses

  10. Asthma • Affects approximately 5 million children in US • Chronic and reversible inflammatory disorder that produces airway hyper-responsiveness, airway inflammation and airflow limitation. • Immediate and delayed inflammatory response

  11. Classification of Asthma

  12. Asthma Control assessment

  13. Bronchiolitis • Children less than 2 yo, usually 3-6 m • Viruses-RSV (most common), adenovirus, influenza or parainfluenza • Fall and winter months • Begins as mild URI which can progress to increase respiratory distress • Rx: • Supportive therapy • Ribavirin in extremely ill children

  14. Croup vs Epiglottitis

  15. Approach to a wheezing child • Clinical History: • Wheeze description from parents Snoring, snoring, rattling or gargling noises • Patient age at onset of wheeze Distinguishes congenital vs non-congenital • Course: acute vs gradual Acute onset- FB aspiration

  16. Cont’d Q’s • Pattern of wheezing? • Episodic: asthma • Persistent: congenital • Response to bronchodilators? • Improvement: Asthma • Is Wheezing associated with multiple respiratory illnesses? • Cystic fibrosis and Immunodeficiency diseases

  17. Cont’d Q’s • Wheeze associated with feeding? GERD • Wheeze associated with cough? GERD, asthma, allergies • Change in position? Worsening or improvement Tracheomalacia • Family hx of asthma?

  18. Features that favors diagnosis of Asthma • Intermittent episodes of asthma • Presence of a trigger • URI • Allergens • Exercise • Seasonal variation • Family hx of asthma and/or atopy • Response to bronchodilators

  19. Clinical features that suggest a diagnosis other than asthma: • Hx of wheezing since birth or neonatal respiratory problems. • Hx of choking associated with SOB and coughing. • Symptoms that change with position. • Poor weight gain and recurrent infections. • Hx of progressive dyspnea, tachypnea, exercise intolerance. • Poor response to broncholdilators.

  20. Physical Examination • Vital signs including Sa02 % • Inspection: • Respiratory distress/ tachypnea/ cyanosis • Retractions or structural abnormalities (increased AP diameter, pectus excavatum, scoliosis) • HENT: allergic shiners/nasal polyps • Skin: eczema

  21. Cont’d PE • Palpation: chest wall asymmetry with expansion, tracheal deviation or supratracheal lymphadenopathy • Percussion: difference in vocal resonance and define position of diaphragm • Auscultation: • Location of wheeze • Character of wheeze • Other breath sounds associated with wheeze • Cardiac: presence of murmur or gallops

  22. Diagnostic Evaluation • CXR: AP and lateral views • Children with new onset wheezing of undetermined etiology • Chronic persistent wheezing not responding to treatment • Lateral decubitus views: FB aspiration • Chest radiography is not performed with every asthma exacerbation unless there is a specific indication

  23. CXR findings: • Hyperinflation: • Generalized: suggests diffuse air trapping • Asthma/ Cystic fibrosis/ Primary ciliary dyskinesia • Localized hyperinflation: • Structural abnormalities/ FB aspiration • Other findings: atelectasis, bronchiectasis, mediastinal masses, enlarged LN’s, cardiomegaly, enlarged pulmonary vessels or pulmonary edema.

  24. Status Asthmaticus

  25. Croup (Steeple Sign):

  26. FB occludes middle lobe bronchus Atelectasis of Rt middle lobe Hyperinflation of upper and lower lobes FB aspiration

  27. Other radiological studies: • Chest CT scan: • Mediastinal masses or LN’s • Vascular anomalies • Bronchiectasis • Barium Swallow: • GERD • TEF • Vascular rings • Swallowing dysfunction

  28. Vascular ring

  29. TEF

  30. Pulmonary Function Tests (PFT’s) • Airway obstruction assessment • PFT’s with inspiratory and expiratory flow-volume loops is is important in determining the degree, location of airway obstruction in addition to response to bronchodilators.

  31. Response to Treatment • Trial of inhaled bronchodilators • Improvement: reversible airway disease • Partial or negative response: asthma or other causes • Combination of inhaled CST +bronchodilators: if asthma is suspected in a patient with chronic or persistent symptoms

  32. Bronchodilator response

  33. Other Investigations • Sweat Chloride Test: Cystic fibrosis screening in children with chronic lung problems, failure to thrive and diarrhea • Immunoglobulin levels: Screen for immunodeficiencies. • Rapid antigen testing, viral cultures, sputum gram stain and culture. PPD in suspected cases.

  34. http://www.youtube.com/watch?v=VA9C_aCH7F0 • http://www.youtube.com/watch?v=EMKxnyPs7K8&feature=related • http://www.youtube.com/watch?v=Qbn1Zw5CTbA&feature=related

  35. References • http://www.aafp.org • http://www.uptodate.com/contents • http://emedicine.medscape.com • http://www.essentialevidenceplus.com • http://www.acaai.org/patients/resources/asthma/Documents/AZnhlbiGuidelines • http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001970/ • http://www.medcyclopaedia.com/library/radiology • http://pediatrics.aappublications.org/content/123/3/e519.long

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