1. DrSTSA

2. Wheeze
 A high-pitched whistling/musical sound produced by
the passage of air through narrowed airways/ bronchi
 Louder during expiration
 A manifestation of lower respiratory tract obstruction
 Site of obstruction may be anywhere from the
intrathoracic trachea to the small bronchi or large
bronchioles
 Sound is generated by turbulence in larger airways that
collapse with forced expiration

3. Wheezing in Children
 Episodic wheezing and cough are common in children
 Infants and young children (<3 years) are especially
prone to wheezing

4. Pathogenesis of Wheezing

5. Wheeze
 Acute
 Inhaled foreign body
 Acute infection
 Acute allergic reaction
 Recurrent
 Respiratory System
 Asthma
 Other causes*
• Non-respiratory system
 Heart failure (left to right shunts)
 GERD (milk inhalation)

6. Categories of Wheezing in children
<5 years
 Transient early wheezing
 Persistent early-onset wheezing
 Late-onset wheezing

7. Transient early wheezing
 Result from small airways being obstruct due to
inflammation secondary to viral infections.
 ↓ lung function from birth
 Risk factors: mother smoking during and/ or
after pregnancy and prematurity
 Common in ♂
 Resolves by 5 years old

8. Non atopic wheezing
 Have normal lung function in early life
 Lower respiratory illness due to viral infection
leads to ↑ wheezing during the 1st 10 years of life.
 cause less severe persistent wheezing
 symptoms improve during adolescence

9. Ig E-mediated wheezing
(atopic asthma)
 Lung function – normal at birth
 Recurrent wheeze develops with allergic sensitisation
 ↑ blood Ig E & positive skin prick tests to common
allergens
 Persistence of symptoms & ↓ lung function later in
childhood.
 Risk factors:
 Positive family history
 Allergy
 History of eczema

10. Other causes of recurrent wheeze
in infancy
 Recurrent aspiration of feeds
 Cystic fibrosis
o Inhaled foreign body
 Congenital abnormality of lung, airway or heart
 Idiopathic
 Cow’s milk protein intolerance

11. History Taking
Wheeze
 Age of onset
 Duration-Acute or recurrent
 Precipitating factors
 URTI symptoms
 Contact with URTI patient
 Triggers for asthma - ( A,V,C,D,E,F)
 History of atopy
 Associated symptoms
 Rapid breathing
 Cough- dry or productive? Sputum colour?
 Chest tightness
 Nausea or vomiting
 Cyanosis

12.  Pattern of symptoms
 Daytime/ nocturnal symptoms
 Exercise induced
 Severity
 On any medication? Types?
 Relieved with medication
 Restriction of daily activities
 Sleep disturbances

13.  Systemic Review
 General condition - LOA, LOW
 Atopy - angioedema, allergic rhinitis, allergic
conjunctivitis, eczema, urticaria
 Past Medical History
 Number of admission to the hospital
 Number of admission due to similar problem
 Last admission due to similar problem
 Duration of stays
 Medication given and discharge medication
 History of prolonged URTI symptoms

14.  Birth History
 Antenatal: intrauterine infection
 Intrapartum: Prematurity
 Postnatal: Prolonged labour, NNJ, congenital pulmonary disease
 Immunization History
 Family History
 Asthma
 Atopy
 CHD
 Cystic fibrosis
 Social History
 School performance
 Daily activities
 Social interaction
 Anyone smoking at home
 Location of house
 Environment condition: Pets, flower, dust
 Drug and Allergy History

15. Physical Examination
 General condition: alert, conscious, drowsiness, irritability
 Signs of respiratory distress
 Sitting propped up
 Shortness of breath
 Use of accessory muscles
 Audible wheeze
 Central cyanosis
 Vital signs
 Anthropometry measurements
 O2 therapy: : nasal prong, face mask, high-flow
mask, nebulizer
 Speech: sentences, phrases or words

16.  Hands
 Clubbing of fingernails
 Peripheral cyanosis
 Head
 Ears – inflammation, discharge
 Nose – nasal discharge
 Throat - inflammation, tonsil enlargement
 Tongue – central cyanosis
 Neck
 Lymph nodes
 Tracheal shift

17. Respiratory System
 Inspection
 Use of accessory muscles : suprasternal, intercostal retraction
 Harrison’s sulcus
 Chest deformities
 pectus carinatum
 Pectus cavum
 Hyperinflacted chest
 Signs of atopy : eczema, dry skin
 Palpation
 Trachea shift ( older child)
 Chest expansion
 Vocal Fremitus
 Apex beat
 Percussion : Hyperresonance
Percussion is usually normal unless there are foreign body, lung collapse, mediasternal
masses

18.  Auscultation
 Respiratory
 Air entry
 Prolonged inspiratory or expiratory phase
 Vesicular breath sound
 Added sounds : Rhonchi or crepitations
 Cardiovascular
 S1 and S2
 Additional sounds
 Palpation of abdomen - hepatomegaly

19. Investigations
1. Laboratory
 FBC : to look for infection, eosinophilia
 BUSE : hydration status, fluid maintenance
 ABG : to look for respiratory failure if severe condition
 Throat swab or sputum for culture and sensitivity
2. Imaging
 Chest X-Ray
 Foreign body
 Pneumothorax, lobar collapse, mass
 Infection
3. Bronchoscopy

20. Bronchial Asthma

21. Asthma (Protocol)
 Chronic airway inflammation leading to ↑ airway
responsiveness that leads to recurrent episodes of
wheezing, breathlessness, chest tightness and
coughing particularly night / early morning.
often associated with widespread but variable
airway obstruction that is often reversible either
spontaneously or with treatment.

22. Pathophysiology
Genetic
Environmental factors
predisposition
Bronchial inflammation
Bronchial hyperactivity + trigger Trigger factors:*
factors • Common viral infections of
resp: tract
•Allergens
Oedema •Cig smoking,Coldair,Chemic
al irritants
Bronchoconstriction
•Dust
↑ mucus production •Exercise,Emotional upset
•Food
Airways narrowing
Symptoms: cough , wheeze , breathlessness
& chest tightness

23. Risk factors
 Allergic rhinitis
 Atopic dermatitis
 Allergy- food
 Bronchiolitis,Pneumonia
 Severe LRTI
 Male
 LBW
 Exposure to tobacco smoke
 Parental Asthma

24. History taking
 Current symptoms
 Pattern of symptoms
 Precipitating factors
 Prolonged URTI Symptom
 Present Treatment
 Previous hospital admission
 Response to prior Treatment
 Typical exacerbations
 History of atopy
 Home/school environment
 Impact on lifestyle: school, sports, sleep
 Family history

25. Physical Exam:
Growth & nutrition
Signs of acute exacerbation:
• Drowsiness,fatigue
• Tachypnoea
• Tachycardia
• Hyperinflated chest
Signs of chronic illness: • Accessory muscles
• Cyanosis
• Harrison sulci • Pulsus paradoxus
• Hyperinflated chest • Prolonged expiratory
phase, wheeze
• Eczema/dry skin • Silent chest
• Hypertrophied turbinates • Rhonchi

26. Tests for Diagnosis and Monitoring
of Asthma
 Spirometry – FEV1 and FVC
 PEFR
 To confirm the diagnosis of asthma ( improvement of >15%
after bronchodilator)
 useful for assessing the severity of asthma
 response of the patient to therapy
 Normal value are available & relate to height
 To identify environmental (including occupational) causes of
asthma symptoms
 Skin prick test with allergens
 Exercise challenge

28. Peak Flow Meter
http://www.nhs.uk/Pathways/asthm
a/Pages/Diagnosis.aspx

30. Management of acute asthma
Assessment of Severity
Initial (Acute assessment)
 Diagnosis
- Symptoms e.g. cough, wheezing, breathlessness
 Triggering factors
- Food, weather, exercise, infection, emotion, drugs, aeroallergens
• Severity
- Respiratory rate, colour, respiratory effort, conscious level

32. Criteria for Admission
 Failure to respond to standard home treatment
 Failure of those with mild or moderate acute asthma to
respond to nebulised β2-agonists
 Relapse within 4 hrs of nebulised β2-agonists
 Severe acute asthma

33. Monitor vital s/-
Pulse,SpO2 ,colour,ABG,PEFR
Definitive Treatment
1. O2 therapy (SpO2 >95%)
2. Bronchodilator therapy
• β2-agonists
• Ipratropium bromide
• Aminophylline
3. Maintenance therapy
Supportive Treatment
1.Hydration & fluid maintenance
2.+/- antibiotics
(ONLY if bacterial infection suspected)

35. GINA 2009…..Under 5

37. >5 years

39. Upon Discharge
 Review asthma medications
 Provide Asthma Action Plan
 How to recognize worsening asthma
 How to treat worsening asthma
 How & when to seek medical attention
 Schedule regular follow-ups to monitor asthma control

40. Asthma Education
 To provide the person with asthma, their family and other
caregivers with suitable information and training so that they
can keep well and adjust treatment according to a medication
plan developed with the health care professional
 Asthma Education should include :
 What is asthma?
 Types of treatment available
 Drugs – “relievers” & “controllers”
 Inhalation devices – how to use them
 Trigger factors and how to avoid them
 Personal Asthma Action Plan

41. Prevention
 Identifying and avoiding the following common
triggers may be useful
 Environmental allergens (house dust mites, animal
dander, insects, mould and pollen)
 Cigarette smoking
 Respiratory tract infections
 Food allergy – uncommon trigger, occurring in 1-2% of
children
 vigorous exercise –should not restrict

42. Assessment of level of control
Management based on control
Drug therapy –types,dosages,delivery

43.  Assessment of severity
 Classification based on frequency, chronicity and severity of
symptoms
 Management according to severity:
Daytime Limitatio Nocturnal Need for Lung Exacerba
symptoms of symptoms/ reliever function tions
activites awakening tests
s
Controlled None None None None None None
All of the
following:
Partly >2 / week Any Any 2/week <80% ≥1 a year
controlled predicted
any measure or
present in
personal
any wk
best
Uncontroll ≥3 features of partly controlled asthma present in any week 1/week
ed

44. Management of Chronic Asthma
 Goal:
 Achieve and maintain control of symptoms
 Maintain normal activity levels, including exercise
 Maintain pulmonary function as close to normal as
possible
 Prevent asthma exacerbations
 Avoid adverse effects from asthma medications
 Prevent asthma mortality

45. Treatment of Chronic asthma

46. Chronic asthma
NOTE:
1. Patients should commence treatment at the step most
appropriate to the initial severity.
A short rescue course of prednisolone may help establish
control promptly.
2. Explain to parents and patient about asthma and all therapy
3. Ensure both compliance and inhaler technique optimal before
progression to next step.
4. Step-up; assess patient after 1 month of initiation of treatment
and if control is not adequate, consider step-up after looking
into factors as in 3
5. Step-down; review treatment every 3 months and if control
sustained for at least 4-6 months, consider gradual treatment
reduction.

47. Drugs
Nebulizer
MDI
Nebulizer
MDI
MDI
Oral,IV
Oral

48.  Delivery Systems

49. Pressurized metered-
dose inhaler
Dry
Nebulizer powder
inhaler

51. GINA 2009……Under 5

52. …..GINA2009 (> 5 years)

53. GINA 2009

55. Monitoring
 Assessment during follow-up
 Assess severity
 Response to treatment
 Interval symptoms
 Frequency and severity of acute exacerbation
 Morbidity secondary to asthma
 Quality of life
 PER monitoring on each visit
 Compliance
 Frequency, technique, reason and excuses
 Education
 Technique, factual information, written action plan, PEF monitoring
may not be practical for all asthmatics but is essential especially for
those have poor perception of symptoms and those with life
threatening attacks

57. References
 Pediatric Protocols
 Illustrated Textbook of Pediatric
 GINAReport 2009
 GINA_Under 5 Report 2009
 Nelson Textbook of Pediatric 18th Edition, chapter 381