approaching treatment and management of wheezing in children

1. WHEEZING IN CHILDREN
APPROACHING TO
DIAGNOSE AND
MANAGEMENT

2. OUTLINE
• Introduction
• Epidemiology
• Clinical Assessment
• Differential Diagnosis
• Diagnostic Tools
• Asthma Management
• Non-Asthmatic Wheezing
• Prevention
• Case Studies
• Conclusion

3. INTODUCTION
DEFINITIONS AND PHENOTYPES
• Wheeze: continuous high-pitched sound (generated by bronchial wall
vibrations that occurs when respiratory effort exceeds that required to achieve
maximal airflow within the airway),
• Three common phenotypes
(a) transient early wheeze: occurs before the age of 3 years and resolves by
age of 6 years without lung function impairment
(b) late-onset wheeze: develops after 3 years of age and persists in
childhood, it is linked to atopy, and, in some studies, it is associated to reduced
lung function and high bronchial hyper responsiveness
(c) persistent wheeze: starts in early life before 3 years of age and it is
associated with atopy, high IgE level early allergen sensitization and diminished
lung function by school age
Fainardi V, Santoro A, Caffarelli C. Preschool Wheezing: Trajectories and Long-Term
Treatment. Front Pediatr. 2020;8:240. Published 2020 May 12

5. A simple model for understanding the causes of paediatric wheeze Edward Snelson Published: May 2019

7. Burden of preschool wheeze and progression to asthma in the UK: Population-based cohort 2007 to 2017
Bloom, Chloe I. et al.
Journal of Allergy and Clinical Immunology, Volume 147, Issue 5, 1949 - 1958

8. PATHOGENESIS OF WHEEZING

9. PATHOGENESIS
How to recognise the symptoms of pre-school wheeze in practice, and advise parents and carers on where effective management differs from that of childhood asthma.
Respiratory tract diseases 01 March 2021.By Sukeshi Makhecha (https://pharmaceuticaljournal.com/author/sukeshi-makhecha) & Sejal Saglani (https://pharmaceuticaljournal.com/author/sejal-saglani) .
Corresponding author Sukeshi Makhecha (https://pharmaceutical-journal.com/author/sukeshi-makhecha) .

10. Int J Pediatr Adolesc Med. 2019 Jun; 6(2): 68–73.
Published online 2019 Mar Int J Pediatr Adolesc Med. 2019 Jun; 6(2): 68–73.

11. EPIDEMIOLOGY
• Asthma is a common respiratory disease affecting up to 235 million people
worldwide.
• The prevalence of asthma varies due to the difficulty in assessing its severity. The
reported worldwide prevalence is between 5.2% and 9.4%.
• In Malaysia it is estimated to be 4.2% based on the third National Health and
Morbidity Survey in 2006.
• According to the WHO data published in 2014, asthma deaths in Malaysia reached
1,642 or 1.29% of total deaths
*Press statement by DG Dr Noor Hisham, 3 Mei 2018

12. CLINICAL ASSESSMENT
DIFFERENTIAL DIAGNOSIS

13. HISTORY TAKING
a) Confirm if it is really a wheeze or other upper or lower airway noise
► Ask parents to demonstrate the noisy breathing or you could demonstrate it to them
to
confirm or ask them to bring video in clinic
►Ask parents if they could feel vibrations or rattly noise on the chest
► Ask parents if they can localise the noisy breathing (throat or upper chest)
b) Confirm whether or not it responds to salbutamol
► Wheeze indicates partial airway obstruction but is not always because of
bronchospasm
-Airway narrowing by secretions and airway wall oedema will produce a
wheeze,which does not respond to bronchodilators.
-Airway malacia, fixed intrinsic or extrinsic narrowing also leads to
bronchodilato unresponsive wheeze.
c) Ask if there is history of shortness of breath with wheeze
d) Ask if there is any associated history of cough

14. e) Establish frequency, persistence and severity of episodes: history of onset,
duration and progress of wheezy episodes
f) Check if there was history of an initiating event
g) Check if there are any triggers
h) Check for interval symptoms
i) Exclude other cause of wheeze with a relevant systemic history
j) Take a detailed allergy history
k) Medical history: treatment- nebulization, antibiotics, oral steroids
l) Birth history: neonatal respiratory or bowel problems

15. PHYSICAL EXAMINATION
• Examination and features suggestive of more complex underlying disease:
► Well/unwell
► Growth: faltering growth
► Abnormal voice/cry
► ENT examination:
-Inspiratory stridor
-Rhinitis, nasal polys
-Adenotonsillar hypertrophy
► Skin examination: dry skin/eczema
► Stigmata of chronic respiratory disease: (Any unexpected clinical findings)
- Abnormal shape of the chest
- Finger clubbing
- Focal signs
► Systemic examination

16. TITLE LOREM IPSUM DOLOR

17. Khetan, Renu; Hurley, Matthew; Neduvamkunnil, Abraham; Bhatt, Jayesh Mahendra (2017). Fifteen-minute consultation: an
evidence-based approach to the child with preschool wheeze. Archives of disease in childhood - Education & practice edition
archdischild-2016-311254

18. INVESTIGATIONS
1. Laboratory
⚫ FBC : to look for infection, eosinophilia
⚫ BUSE : hydration status, fluid maintenance
⚫ Blood gas : to look forrespiratory failure if severe
condition
⚫ Throat swab orsputum forcultureand sensitivity
2. Imaging
⚫ ChestX-Ray
⚫ Foreign body
⚫ Pneumothorax, lobarcollapse, mass
⚫ Infection
3. Bronchoscopy

19. MANAGEMENT OF ACUTE
ASTHMA
Assessmentof Severity
Initial (Acute assessment)
⚫ Diagnosis
- Symptoms e.g. cough, wheezing, breathlessness
⚫ Triggering factors
- Food, weather, exercise, infection, emotion, drugs,
aeroallergens
• Severity
- Respiratory rate, colour, respiratoryeffort, conscious
level

25. How to recognise the symptoms of pre-school wheeze in practice, and advise parents and carers on where effective management differs from that of childhood asthma.
Respiratory tract diseases 01 March 2021.By Sukeshi Makhecha (https://pharmaceuticaljournal.com/author/sukeshi-makhecha) & Sejal Saglani (https://pharmaceuticaljournal.com/author/sejal-saglani) .
Corresponding author Sukeshi Makhecha (https://pharmaceutical-journal.com/author/sukeshi-makhecha) .

27. CRITERIA FOR
ADMISSION
⚫Failure torespond tostandard home treatment
⚫Failureof thosewith mild or moderateacuteasthma to
respond to nebulised β2-agonists
⚫Relapsewithin 4 hrs of nebulised β2-agonists
⚫Severeacuteasthma

28. PREVENTION
⚫Identifying and avoiding the following
common triggers
⚫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

32. CONCLUSION
• Wheezes are very common in children, in whom they appear as heterogeneous
groups
• Wheezing phenotypes, most of which abate with age. Few groups continue to
wheeze during childhood, although exposure to environmental triggers is a poor
prognostic factor.
• Determining the appropriate level of investigation and treatment
• The level of education of a patient's parents is a very important factor in the
management of children with wheeze

33. REFERENCES
• Fainardi V, Santoro A, Caffarelli C. Preschool Wheezing: Trajectories and Long-Term
Treatment. Front Pediatr. 2020;8:240. Published 2020 May 12
• A simple model for understanding the causes of paediatric wheeze Edward
Snelson Published: May 2019
• Burden of preschool wheeze and progression to asthma in the UK:
Population-based cohort 2007 to 2017Bloom, Chloe I. et al. Journal of Allergy
and Clinical Immunology, Volume 147, Issue 5, 1949 – 1958
• How to recognise the symptoms of pre-school wheeze in practice, and advise
parents and carers on where effective management differs from that of
childhood asthma.
• Respiratory tract diseases 01 March 2021.By Sukeshi Makhecha
(https://pharmaceuticaljournal.com/author/sukeshi-makhecha) & Sejal
Saglani (https://pharmaceuticaljournal.com/author/sejal-saglani) .
• Pediatric Protocols
• Illustrated Textbook of Pediatric