Wheeze in Children

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Wheeze in Children

  1. 1. Wheezing in children<br />Dr Divya Nair<br />Department of Pediatrics,<br />Mahavir Hospital & Research Centre,<br />Hyderabad.<br />
  2. 2. Introduction<br />Wheeze is a continuous & musical sound that <br /> originates from oscillations in narrowed <br /> airways<br />Mostly heard in expiration due to critical <br /> airway obstruction<br />Sign of lower (intra-thoracic) airway <br /> obstruction <br />
  3. 3. If there is widespread narrowing of airways <br /> leading to various levels of obstruction to <br /> airflow (eg. asthma), polyphonic wheeze is <br /> heard i.e. sounds of various pitches<br />Monophonic wheeze (single pitch) is produced <br /> in larger airways during expiration eg. distal <br />tracheomalacia, bronchomalacia<br />
  4. 4. Infants & children are prone to wheeze due to different set of lung mechanics ( as compared to older children & adults)<br />Obstruction to airflow  airway caliber<br /> compliance of lung<br /> 1) Resistance = 1/ ( radius of tube)4<br /> In children < 5 years, small caliber peripheral <br /> airways can contribute upto 50% of airway <br /> resistance<br />Marginal additional narrowing can cause further <br /> flow limitation & subsequent wheeze<br />
  5. 5. 2) Compliant chest walls, especially in newborns, <br /> leads to intra-thoracic airway collapse due to <br /> inward pressure produced in expiration<br />3) Differences in tracheal cartilage composition & <br /> airway muscle tone causes further increase in <br /> airway compliance<br />
  6. 6. All these mechanisms combine to make the <br /> Infant more susceptible to airway collapse<br /><br /> Increased resistance<br /><br /> Subsequent wheeze <br /> Many of these are outgrown in the 1st year <br /> of life itself <br />
  7. 7. 4) Immunologic & molecular influences:<br />Infants have increased levels of lymphocytes & <br />neutrophils in BAL fluid<br />Variety of inflammatory mediators have been <br /> implicated eg. Histamine, leukotrienes, <br /> interleukins, etc<br />Fetal & early post-natal “programming” affects the <br /> structure & function of fetal lung by factors <br /> including fetal nutrition, fetal & neonatal exposure <br /> to maternal smoking<br />
  8. 8. DD’s of wheezing:<br /> 1) INFECTION:<br /> Viral : RSV (Bronchiolitis)<br /> Human metapneumovirus<br /> Influenza, Parainfluenza<br /> Adenovirus<br /> Rhinovirus<br /> Others: TB<br /> Chlamydia trachomatis<br />Histoplasmosis<br />
  9. 9. 2) ASTHMA:<br />i) Transient wheezer - risk factor is primarily <br /> diminished lung size<br /> ii) Persistent wheezers – initial risk factors being <br /> passive smoke exposure, maternal asthma <br /> history, persistent rhinitis, eczema <1yr age, <br /> increased IgE in 1st yr of life<br /> At an increased risk of developing clinical <br /> asthma<br /> iii) Late onset wheezer<br />
  10. 10. 3) Anatomic abnormalities: <br /> a) Central airway abnormalities:<br /> - Malacia of larynx, trachea, bronchi<br /> - Tracheoesophageal fistula ( H type)<br /> - Laryngeal cleft (leading to aspiration)<br />b) Extrinsic airway anomalies (leading to com- <br />pression):<br /> - Vascular ring/ sling<br /> - MediastinalLN’pathy (infection/ tumor)<br /> - Esophageal foreign body<br />
  11. 11. c) Intrinsic airway anomalies:<br /> - Airway hemangioma<br /> - Cystic adenomatoid malformation<br /> - Bronchial/ lung cyst<br /> - Congenital lobar emphysema<br /> - Aberrant tracheal bronchus<br /> - Sequestration<br /> - CHD with L R shunt ( pulmonary edema)<br /> - Foreign body<br />
  12. 12. 4) Immunodeficiency states:<br /> - IgA deficiency<br /> - B cell defiency<br /> - AIDS<br /> - Bronchiectasis<br /> 5) Mucociliary clearance disorders:<br /> - Cystic fibrosis<br /> - Primary ciliarydyskinesias<br /> - Bronchiectasis<br />
  13. 13. 6) BronchopulmonaryDysplasia<br /> 7) Aspiration Syndromes<br /> - GERD<br /> - Pharyngeal/ swallow dysfunction<br /> 8) Interstitial lung disease<br /> 9) Heart Failure<br /> 10) Anaphylaxis<br /> 11) Inhalation Injury – Burns<br />12) WALRTI, Wheeze a/w URTI<br />13) Drugs: Ibuprofen, Aspirin, Rifampicin, Erythromycin<br />
  14. 14. Etiology:<br /> I) ACUTE BRONCHIOLITIS:<br /> - It is acute inflammation of the airways <br /> - predominantly a viral disease<br /> - cause: RSV ( > 50%) , parainfluenza, <br /> adenovirus, mycoplasma, human metapneumovirus<br /> - more common in males, not breast fed, live in <br /> crowded conditions<br /> - older family members are source of infection<br /> - LRTI manifestations are minimal in older patients in <br /> whom bronchial edema is better tolerated <br />
  15. 15. - RSV infection leads to a complex immune response<br />i) Eosinophilsdegranulate release Eosinophilic<br /> Cationic Protein cytotoxic to airway epithelium<br /> ii) IgE antibody release may be related to wheezing<br /> iii) Other mediators: Chemokines (IL-8, Macrophage <br /> Inflammatory Protein); Leukotrienes , IF gamma<br /> - Characterized by bronchiolar obstruction with <br /> edema, mucus & cellular debris<br />
  16. 16. - Resistance in small airway is increased more in exhalation than <br /> inspiration  respiratory obstruction  early air trapping & <br />overinflation complete obstruction atelectasis<br /> - Hypoxemia occurs early in the course due to <br /> VQ mismatch<br /> - Hypercapnia develops due to severe <br /> obstructive disease and respiratory fatigue<br />
  17. 17. II) ALLERGY & ASTHMA:<br /> - Important cause of wheezing<br /> - Characterized by: <br /> airway inflammation,<br /> bronchial hyper-reactivity,<br /> reversibility of obstruction<br /> - 3 identified patterns: <br /> a) Transient early wheezer: 20% of population<br /> Before the age of 3yrs had wheezing at least <br /> once, with LRTI but never wheezed again<br />
  18. 18. b) Persistent wheezer: 14% of population<br /> Before 3yrs age had wheezing episodes<br /> still wheezing at 6yrs age<br />c) Late onset wheezer: 15% of population<br /> No wheezing by 3yrs but wheezing by <br /> 6yrs<br /> - The remaining 50% of children had never <br /> wheezed by 6yrs of age <br />
  19. 19. III) CHRONIC INFECTIONS:<br /> - Should be considered in infants who seem <br /> to fall out of range of a normal clinical <br /> course<br /> - Cystic fibrosis is a common cause<br /> - Persistent respiratory symptoms, digital <br /> clubbing, malabsorption, FTT, electrolyte <br /> abnormalities, resistance to bronchodilator <br /> therapy<br />
  20. 20. IV) CONGENITAL MALFORMATIONS:<br /> - Causes wheezing in early infancy<br /> - Findings can be diffuse or focal<br /> - Can be from an ext compression/ intrinsic abn<br /> - External vascular compression: vascular ring/ <br /> sling compressing trachea/ esophagus<br /> - CVS causes: massive cardiomegaly, LA <br /> enlargement, dilated pulmonary arteries<br /> - Pulmonary edema d/t CHF  lymphatic & <br /> bronchial vessel engorgement obstruction & <br /> edema of bronchioles Wheeze<br />
  21. 21. V) FOREIGN BODY ASPIRATION:<br /> - Can cause acute/ chronic wheezing<br /> - Common between 2mths- 4 yrs of age<br /> - Infants may present with atypical histories or <br /> misleading radiological/ clinical findings<br /> - D/d: asthma, other obstructive disorders<br /> - Esophageal FB can transmit pressure to <br /> membranous trachea  compromises the <br /> airway lumen<br />
  22. 22. VI) GASTROESOPHAGEAL REFLUX:<br /> - can cause direct aspiration into tracheo-<br /> bronchial tree<br /> - may trigger a vagal/ neural reflex <br /><br /> increased airway resistance <br /><br /> airway reactivity<br />
  23. 23. VII) TRAUMA & TUMORS:<br /> - rare causes of wheezing in children<br /> - trauma of any type to TB tree (aspiration/ burns/ scalds) <br /> inflammation of the airways  subsequent wheeze<br /> - SOL (lung/ extrinsic)  compression <br /> obstruction to airway <br />
  24. 24. Clinical Manifestations<br />HISTORY & PHYSICAL EXAMINATION<br /> - ODP & associated factors of wheezing:<br /> - Birth history: weeks of gestation, NICU admission, <br />h/o intubation/ O2 requirement, maternal <br /> complications eg. Infn- HSV, HIV; prenatal smoke <br /> exposure<br /> - Past medical history: co-morbid conditions eg. <br /> syndromes or association<br />
  25. 25. - Social history: <br /> Environmental history of smokers at home, <br /> number of siblings, occupation of inhabitants at <br /> home, pets, TB exposure<br /> - Family history: <br /> of CF, immuno-deficeincy, asthma in 1st degree <br /> relatives OR <br /> any other recurrent respiratory conditions should <br /> be obtained<br />
  26. 26. RISKS OF FAMILY HISTORY OF ATOPY<br /><ul><li>No family history :16%
  27. 27. Single parent atopy : 22%Maternal Atopy : 32 %
  28. 28. Both parents atopic : 50%</li></ul>(Aberdeen Study 1994)<br />
  29. 29. Pertinent medical history in wheezing infant:<br />Did the onset of symptoms begin at birth or thereafter?<br />Is the infant a noisy breather & when is it most prominent?<br />Is there a history of cough apart from wheezing?<br />Was there an earlier LRTI?<br />Have there been any emergency department visits, hospitalizations, or ICU admission for RD?<br />Is there a history of eczema?<br />
  30. 30. How is the infant growing & developing?<br />Is there associated failure to thrive?<br />Is there failure to thrive without feeding difficulties?<br />Are there s/o intestinal malabsorption including frequent , greasy, or oily stools?<br />Is there a maternal history of genital HSV infection?<br />What was the gestational age at delivery?<br />Was the patient intubated as neonate?<br />Does the infant bottle feed in the bed or crib, especially in propped position?<br />
  31. 31. Are there any feeding difficulties including choking, gagging, arching, or vomiting with feeds?<br />Any new food exposure?<br />Is there a toddler in the home or lapse in supervision in which foreign body aspiration could have happened?<br />Change in caregivers or chance or non accidental trauma? <br />
  32. 32. Physical examination:<br /> - Vitals especially RR, SPO2<br /> - Growth charts for s/o FTT<br /> - Upper airway s/oatopy: boggy turbinates , <br /> posterior oropharynxcobblestoning<br /> - Evaluate skin for eczema, hemangioma<br /> - Midline lesions may be associated with <br />intrathoracic lesions<br /> - Clubbing<br />
  33. 33. - S/O RD- Tachypnea, nasal flaring, tracheal <br /> tugging, SCR/ICR, excessive use of accessory <br /> muscles<br /> - Prolonged expiratory time, expiratory whistling <br /> sounds<br /> - Auscultation: aeration to be noted, expiratory <br /> wheeze, lack of audible wheeze due to complete <br /> airway obstruction<br /> - Trial of bronchodilators to evaluate change of <br /> wheezing<br /> - Stridor +/-. <br />
  34. 34. Air Trapping<br />Hyperinflated chest<br /> Barrel shaped<br /> Loss of cardiac dullness<br /> Liver pushed down<br /> Hoover sign<br /> Normal diagphragm movement<br /> Hyperinflation = diaphragm flattened<br /> Diaphragm contraction = paradoxical inward <br /> movement of lower interrcostal area during <br /> inspiration<br />
  35. 35. In Acute Bronchiolitis: <br /> - h/o exposure to older contact with URTI <br /> infant 1st develops mild URTI with sneezing & <br />rhinorrhea may be associated with <br /> decreased appetite & fever  gradually RD <br /> ensues with paroxysmal wheezy cough, <br />dyspnea, irritability<br />
  36. 36. - Apnea may be more prominent than <br /> wheezing early in the course of disease esp<br /> with very young infants ( < 2 mths ) or former <br /> premature infants<br /> - Degree of tachypnea doesn’t always correlate <br /> with degree of hypoxemia/ hypercarbia<br /> - Fine crackles/ overt wheezes present<br /> - Hyperinflation of lungs palpation of liver & <br /> spleen<br />
  37. 37. Diagnostic evaluation<br />Initial evaluation depends on likely etiology<br /> 1. Chest Xray: hyperinflation, SOL, <br />s/o chronic diseases like <br />bronchiectasis, focal infiltrates<br /> 2. Trial of bronchodilators-<br /> diagnostic & therapeutic in <br />bronchiolitis & asthma, won’t effect fixed obstruction<br /> May worsen wheezing in tracheal/ bronchomalacia<br /> 3. Baseline immunity in complicated cases <br />
  38. 38. Exclude other conditions<br /> 4) Structural problems: bronchoscopy<br /> 5) URTD : Polysomnography<br /> 6) Esophageal disease: Barium swallow, pH probes, Upper GI scopy<br /> 7) Primary ciliarydyskinesia: nasal ciliary motility, Exhaled NO,<br /> Electron Microscopy, saccharine test<br /> 8) TB: mantoux, induced sputum/ gastric lavage/ BAL = Culture,<br /> microscopy & PCR<br /> 9) Bronchiectasis: HRCT scan, BAL<br />
  39. 39. 10) CF: sweat test, nasal potentials, genotypes<br /> 11) Systemic immune deficiency: Ig subtypes, <br /> lymphocytes & neutrophil function, HIV<br /> 12) Cardiovascular disease: echo, angiography<br /> 13) Viral testing (PCR, viral culture) is helpful if diagnosis <br /> is uncertain.<br />
  40. 40. Treatment<br />1) Comfort the child – <br /> Try to keep your baby calm. Having a cough and a <br /> noisy wheeze frightens children and breathing is <br /> more difficult when they are upset. <br />2) Offer frequent liquids –<br /> Drinking less but more often may be easier<br />
  41. 41. 3) Bronchodilators:<br /> - administer inhaled short acting beta-2 agonist <br /> (egsalbutamol) & observe the response<br /> - Children < 3 yrs: inhaled medications by MDI <br /> with mask & spacer, if therapeutic benefit <br /> demonstrated<br /> - response is unpredictable<br /> - Therapy to be continued in all asthma <br /> patients with exacerbations with viral <br /> illness <br />
  42. 42. 4) Ipratropium bromide:<br /> - can be used as adjunct therapy<br /> - also useful in patients with significant tracheal or <br />bronchomalacia<br /> - Anticholinergic agent<br />5) Oral/ IV steroids:<br /> - used for atopic wheezing infants thought to have <br /> asthma i.e. refractory to other medications<br />
  43. 43. 6) Inhaled steroids:<br /> - appropriate for maintenance therapy in known reactive <br /> airways but not useful in acute illness<br /> - to be used if significant h/oatopy ( food allergy, eczema) <br /> present<br /> - maintenance treatment with inhaled steroids is <br /> recommended for multiple-trigger wheeze. <br />
  44. 44. 7) In acute bronchiolitis:<br /> - hospitalze<br /> - mainstay of treatment is supportive<br /> - hypoxemic child: cool humidified oxygen<br /> - avoid sedatives<br /> - keep head & chest elevated at 30 degree angle<br /> - NG tube feeds to avoid aspiration<br /> - respdecompensation tracheal intubation<br /> - Bronchodilators show modest short term <br /> improvement in clinical features<br /> - Nebulized epinephrine more effective <br />
  45. 45. 8) Montelukast is recommended for the treatment of <br /> episodic (viral) wheeze,to be started when symptoms of a <br /> viral cold develop<br /> 9) Ribavarine: antiviral administered by aerosol<br /> - Used for children with CHD/ CLD<br />10) No role of antibiotics unless secondary bacterial <br /> infection<br />
  46. 46. Prevention<br /> 1) Reduction in severity & incidence of ac. bronchiolitis due to <br /> RSV is possible through administration of pooled Hyperimmune<br /> RSV Intravenous Immunoglobulin (RSV IVIg, Respigam) and<br /> 2) Palivizumab, a monoclonal antibody to the RSV F protein, before & <br /> during RSV season<br /> It is recommended for children < 2yrs age with chronic lung disease <br /> (BPD) or prematurity<br />3) Inhaled corticosteroids and montelukast may be <br /> considered in preschool child with recurrent wheeze. <br />
  47. 47. 4) Avoid smoking –<br /> Smoking in the home or car increases the risk of respiratory <br /> problems in children<br />5) Educating parents regarding causative factors and <br /> treatment is useful. <br />6) Allergen avoidance may be considered when sensitisation<br /> has been established<br />7) Meticulous handwashing is the best measure <br /> to prevent nosocomial infection<br />
  48. 48. Prognosis<br />Approx 60% of infants who wheeze, will stop wheezing<br />Ac. Bronchiolitis: highest risk in 1st 2-3 days ; Case Fatality Rate < 1%<br /> Death  apnea, severe dehydration, uncompensated resp acidosis<br /> Mean duration of symp - 12 days<br /> High incidence of wheezing & asthma in children with h/o<br />bronchiolitis<br />CHD/ BPD/ Immuno-deficiency:<br /> More severe disease, higher morbidity & mortality<br />
  49. 49. THANK YOU<br />

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