Wheeze in Children

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  • 1. Wheezing in children
    Dr Divya Nair
    Department of Pediatrics,
    Mahavir Hospital & Research Centre,
    Hyderabad.
  • 2. Introduction
    Wheeze is a continuous & musical sound that
    originates from oscillations in narrowed
    airways
    Mostly heard in expiration due to critical
    airway obstruction
    Sign of lower (intra-thoracic) airway
    obstruction
  • 3. If there is widespread narrowing of airways
    leading to various levels of obstruction to
    airflow (eg. asthma), polyphonic wheeze is
    heard i.e. sounds of various pitches
    Monophonic wheeze (single pitch) is produced
    in larger airways during expiration eg. distal
    tracheomalacia, bronchomalacia
  • 4. Infants & children are prone to wheeze due to different set of lung mechanics ( as compared to older children & adults)
    Obstruction to airflow  airway caliber
     compliance of lung
    1) Resistance = 1/ ( radius of tube)4
    In children < 5 years, small caliber peripheral
    airways can contribute upto 50% of airway
    resistance
    Marginal additional narrowing can cause further
    flow limitation & subsequent wheeze
  • 5. 2) Compliant chest walls, especially in newborns,
    leads to intra-thoracic airway collapse due to
    inward pressure produced in expiration
    3) Differences in tracheal cartilage composition &
    airway muscle tone causes further increase in
    airway compliance
  • 6. All these mechanisms combine to make the
    Infant more susceptible to airway collapse

    Increased resistance

    Subsequent wheeze
    Many of these are outgrown in the 1st year
    of life itself
  • 7. 4) Immunologic & molecular influences:
    Infants have increased levels of lymphocytes &
    neutrophils in BAL fluid
    Variety of inflammatory mediators have been
    implicated eg. Histamine, leukotrienes,
    interleukins, etc
    Fetal & early post-natal “programming” affects the
    structure & function of fetal lung by factors
    including fetal nutrition, fetal & neonatal exposure
    to maternal smoking
  • 8. DD’s of wheezing:
    1) INFECTION:
    Viral : RSV (Bronchiolitis)
    Human metapneumovirus
    Influenza, Parainfluenza
    Adenovirus
    Rhinovirus
    Others: TB
    Chlamydia trachomatis
    Histoplasmosis
  • 9. 2) ASTHMA:
    i) Transient wheezer - risk factor is primarily
    diminished lung size
    ii) Persistent wheezers – initial risk factors being
    passive smoke exposure, maternal asthma
    history, persistent rhinitis, eczema <1yr age,
    increased IgE in 1st yr of life
    At an increased risk of developing clinical
    asthma
    iii) Late onset wheezer
  • 10. 3) Anatomic abnormalities:
    a) Central airway abnormalities:
    - Malacia of larynx, trachea, bronchi
    - Tracheoesophageal fistula ( H type)
    - Laryngeal cleft (leading to aspiration)
    b) Extrinsic airway anomalies (leading to com-
    pression):
    - Vascular ring/ sling
    - MediastinalLN’pathy (infection/ tumor)
    - Esophageal foreign body
  • 11. c) Intrinsic airway anomalies:
    - Airway hemangioma
    - Cystic adenomatoid malformation
    - Bronchial/ lung cyst
    - Congenital lobar emphysema
    - Aberrant tracheal bronchus
    - Sequestration
    - CHD with L R shunt ( pulmonary edema)
    - Foreign body
  • 12. 4) Immunodeficiency states:
    - IgA deficiency
    - B cell defiency
    - AIDS
    - Bronchiectasis
    5) Mucociliary clearance disorders:
    - Cystic fibrosis
    - Primary ciliarydyskinesias
    - Bronchiectasis
  • 13. 6) BronchopulmonaryDysplasia
    7) Aspiration Syndromes
    - GERD
    - Pharyngeal/ swallow dysfunction
    8) Interstitial lung disease
    9) Heart Failure
    10) Anaphylaxis
    11) Inhalation Injury – Burns
    12) WALRTI, Wheeze a/w URTI
    13) Drugs: Ibuprofen, Aspirin, Rifampicin, Erythromycin
  • 14. Etiology:
    I) ACUTE BRONCHIOLITIS:
    - It is acute inflammation of the airways
    - predominantly a viral disease
    - cause: RSV ( > 50%) , parainfluenza,
    adenovirus, mycoplasma, human metapneumovirus
    - more common in males, not breast fed, live in
    crowded conditions
    - older family members are source of infection
    - LRTI manifestations are minimal in older patients in
    whom bronchial edema is better tolerated
  • 15. - RSV infection leads to a complex immune response
    i) Eosinophilsdegranulate release Eosinophilic
    Cationic Protein cytotoxic to airway epithelium
    ii) IgE antibody release may be related to wheezing
    iii) Other mediators: Chemokines (IL-8, Macrophage
    Inflammatory Protein); Leukotrienes , IF gamma
    - Characterized by bronchiolar obstruction with
    edema, mucus & cellular debris
  • 16. - Resistance in small airway is increased more in exhalation than
    inspiration  respiratory obstruction  early air trapping &
    overinflation complete obstruction atelectasis
    - Hypoxemia occurs early in the course due to
    VQ mismatch
    - Hypercapnia develops due to severe
    obstructive disease and respiratory fatigue
  • 17. II) ALLERGY & ASTHMA:
    - Important cause of wheezing
    - Characterized by:
    airway inflammation,
    bronchial hyper-reactivity,
    reversibility of obstruction
    - 3 identified patterns:
    a) Transient early wheezer: 20% of population
    Before the age of 3yrs had wheezing at least
    once, with LRTI but never wheezed again
  • 18. b) Persistent wheezer: 14% of population
    Before 3yrs age had wheezing episodes
    still wheezing at 6yrs age
    c) Late onset wheezer: 15% of population
    No wheezing by 3yrs but wheezing by
    6yrs
    - The remaining 50% of children had never
    wheezed by 6yrs of age
  • 19. III) CHRONIC INFECTIONS:
    - Should be considered in infants who seem
    to fall out of range of a normal clinical
    course
    - Cystic fibrosis is a common cause
    - Persistent respiratory symptoms, digital
    clubbing, malabsorption, FTT, electrolyte
    abnormalities, resistance to bronchodilator
    therapy
  • 20. IV) CONGENITAL MALFORMATIONS:
    - Causes wheezing in early infancy
    - Findings can be diffuse or focal
    - Can be from an ext compression/ intrinsic abn
    - External vascular compression: vascular ring/
    sling compressing trachea/ esophagus
    - CVS causes: massive cardiomegaly, LA
    enlargement, dilated pulmonary arteries
    - Pulmonary edema d/t CHF  lymphatic &
    bronchial vessel engorgement obstruction &
    edema of bronchioles Wheeze
  • 21. V) FOREIGN BODY ASPIRATION:
    - Can cause acute/ chronic wheezing
    - Common between 2mths- 4 yrs of age
    - Infants may present with atypical histories or
    misleading radiological/ clinical findings
    - D/d: asthma, other obstructive disorders
    - Esophageal FB can transmit pressure to
    membranous trachea  compromises the
    airway lumen
  • 22. VI) GASTROESOPHAGEAL REFLUX:
    - can cause direct aspiration into tracheo-
    bronchial tree
    - may trigger a vagal/ neural reflex

    increased airway resistance

    airway reactivity
  • 23. VII) TRAUMA & TUMORS:
    - rare causes of wheezing in children
    - trauma of any type to TB tree (aspiration/ burns/ scalds)
     inflammation of the airways  subsequent wheeze
    - SOL (lung/ extrinsic)  compression 
    obstruction to airway
  • 24. Clinical Manifestations
    HISTORY & PHYSICAL EXAMINATION
    - ODP & associated factors of wheezing:
    - Birth history: weeks of gestation, NICU admission,
    h/o intubation/ O2 requirement, maternal
    complications eg. Infn- HSV, HIV; prenatal smoke
    exposure
    - Past medical history: co-morbid conditions eg.
    syndromes or association
  • 25. - Social history:
    Environmental history of smokers at home,
    number of siblings, occupation of inhabitants at
    home, pets, TB exposure
    - Family history:
    of CF, immuno-deficeincy, asthma in 1st degree
    relatives OR
    any other recurrent respiratory conditions should
    be obtained
  • 26. RISKS OF FAMILY HISTORY OF ATOPY
    • No family history :16%
    • 27. Single parent atopy : 22%Maternal Atopy : 32 %
    • 28. Both parents atopic : 50%
    (Aberdeen Study 1994)
  • 29. Pertinent medical history in wheezing infant:
    Did the onset of symptoms begin at birth or thereafter?
    Is the infant a noisy breather & when is it most prominent?
    Is there a history of cough apart from wheezing?
    Was there an earlier LRTI?
    Have there been any emergency department visits, hospitalizations, or ICU admission for RD?
    Is there a history of eczema?
  • 30. How is the infant growing & developing?
    Is there associated failure to thrive?
    Is there failure to thrive without feeding difficulties?
    Are there s/o intestinal malabsorption including frequent , greasy, or oily stools?
    Is there a maternal history of genital HSV infection?
    What was the gestational age at delivery?
    Was the patient intubated as neonate?
    Does the infant bottle feed in the bed or crib, especially in propped position?
  • 31. Are there any feeding difficulties including choking, gagging, arching, or vomiting with feeds?
    Any new food exposure?
    Is there a toddler in the home or lapse in supervision in which foreign body aspiration could have happened?
    Change in caregivers or chance or non accidental trauma?
  • 32. Physical examination:
    - Vitals especially RR, SPO2
    - Growth charts for s/o FTT
    - Upper airway s/oatopy: boggy turbinates ,
    posterior oropharynxcobblestoning
    - Evaluate skin for eczema, hemangioma
    - Midline lesions may be associated with
    intrathoracic lesions
    - Clubbing
  • 33. - S/O RD- Tachypnea, nasal flaring, tracheal
    tugging, SCR/ICR, excessive use of accessory
    muscles
    - Prolonged expiratory time, expiratory whistling
    sounds
    - Auscultation: aeration to be noted, expiratory
    wheeze, lack of audible wheeze due to complete
    airway obstruction
    - Trial of bronchodilators to evaluate change of
    wheezing
    - Stridor +/-.
  • 34. Air Trapping
    Hyperinflated chest
     Barrel shaped
     Loss of cardiac dullness
     Liver pushed down
     Hoover sign
    Normal diagphragm movement
    Hyperinflation = diaphragm flattened
    Diaphragm contraction = paradoxical inward
    movement of lower interrcostal area during
    inspiration
  • 35. In Acute Bronchiolitis:
    - h/o exposure to older contact with URTI 
    infant 1st develops mild URTI with sneezing &
    rhinorrhea may be associated with
    decreased appetite & fever  gradually RD
    ensues with paroxysmal wheezy cough,
    dyspnea, irritability
  • 36. - Apnea may be more prominent than
    wheezing early in the course of disease esp
    with very young infants ( < 2 mths ) or former
    premature infants
    - Degree of tachypnea doesn’t always correlate
    with degree of hypoxemia/ hypercarbia
    - Fine crackles/ overt wheezes present
    - Hyperinflation of lungs palpation of liver &
    spleen
  • 37. Diagnostic evaluation
    Initial evaluation depends on likely etiology
    1. Chest Xray: hyperinflation, SOL,
    s/o chronic diseases like
    bronchiectasis, focal infiltrates
    2. Trial of bronchodilators-
    diagnostic & therapeutic in
    bronchiolitis & asthma, won’t effect fixed obstruction
    May worsen wheezing in tracheal/ bronchomalacia
    3. Baseline immunity in complicated cases
  • 38. Exclude other conditions
    4) Structural problems: bronchoscopy
    5) URTD : Polysomnography
    6) Esophageal disease: Barium swallow, pH probes, Upper GI scopy
    7) Primary ciliarydyskinesia: nasal ciliary motility, Exhaled NO,
    Electron Microscopy, saccharine test
    8) TB: mantoux, induced sputum/ gastric lavage/ BAL = Culture,
    microscopy & PCR
    9) Bronchiectasis: HRCT scan, BAL
  • 39. 10) CF: sweat test, nasal potentials, genotypes
    11) Systemic immune deficiency: Ig subtypes,
    lymphocytes & neutrophil function, HIV
    12) Cardiovascular disease: echo, angiography
    13) Viral testing (PCR, viral culture) is helpful if diagnosis
    is uncertain.
  • 40. Treatment
    1) Comfort the child –
    Try to keep your baby calm. Having a cough and a
    noisy wheeze frightens children and breathing is
    more difficult when they are upset.
    2) Offer frequent liquids –
    Drinking less but more often may be easier
  • 41. 3) Bronchodilators:
    - administer inhaled short acting beta-2 agonist
    (egsalbutamol) & observe the response
    - Children < 3 yrs: inhaled medications by MDI
    with mask & spacer, if therapeutic benefit
    demonstrated
    - response is unpredictable
    - Therapy to be continued in all asthma
    patients with exacerbations with viral
    illness
  • 42. 4) Ipratropium bromide:
    - can be used as adjunct therapy
    - also useful in patients with significant tracheal or
    bronchomalacia
    - Anticholinergic agent
    5) Oral/ IV steroids:
    - used for atopic wheezing infants thought to have
    asthma i.e. refractory to other medications
  • 43. 6) Inhaled steroids:
    - appropriate for maintenance therapy in known reactive
    airways but not useful in acute illness
    - to be used if significant h/oatopy ( food allergy, eczema)
    present
    - maintenance treatment with inhaled steroids is
    recommended for multiple-trigger wheeze.
  • 44. 7) In acute bronchiolitis:
    - hospitalze
    - mainstay of treatment is supportive
    - hypoxemic child: cool humidified oxygen
    - avoid sedatives
    - keep head & chest elevated at 30 degree angle
    - NG tube feeds to avoid aspiration
    - respdecompensation tracheal intubation
    - Bronchodilators show modest short term
    improvement in clinical features
    - Nebulized epinephrine more effective
  • 45. 8) Montelukast is recommended for the treatment of
    episodic (viral) wheeze,to be started when symptoms of a
    viral cold develop
    9) Ribavarine: antiviral administered by aerosol
    - Used for children with CHD/ CLD
    10) No role of antibiotics unless secondary bacterial
    infection
  • 46. Prevention
    1) Reduction in severity & incidence of ac. bronchiolitis due to
    RSV is possible through administration of pooled Hyperimmune
    RSV Intravenous Immunoglobulin (RSV IVIg, Respigam) and
    2) Palivizumab, a monoclonal antibody to the RSV F protein, before &
    during RSV season
    It is recommended for children < 2yrs age with chronic lung disease
    (BPD) or prematurity
    3) Inhaled corticosteroids and montelukast may be
    considered in preschool child with recurrent wheeze.
  • 47. 4) Avoid smoking –
    Smoking in the home or car increases the risk of respiratory
    problems in children
    5) Educating parents regarding causative factors and
    treatment is useful.
    6) Allergen avoidance may be considered when sensitisation
    has been established
    7) Meticulous handwashing is the best measure
    to prevent nosocomial infection
  • 48. Prognosis
    Approx 60% of infants who wheeze, will stop wheezing
    Ac. Bronchiolitis: highest risk in 1st 2-3 days ; Case Fatality Rate < 1%
    Death  apnea, severe dehydration, uncompensated resp acidosis
    Mean duration of symp - 12 days
    High incidence of wheezing & asthma in children with h/o
    bronchiolitis
    CHD/ BPD/ Immuno-deficiency:
    More severe disease, higher morbidity & mortality
  • 49. THANK YOU