Approach to the Approach to the Wheezing Child Wheezing Child - PDF document

The Problem: “Wheezing” The Problem: “Wheezing” Approach to the Approach to the Wheezing Child Wheezing Child • Very common • Multiple sounds and • Multiple sounds and descriptions Elizabeth D. Allen, M.D. • Broad differential Pediatric Pulmonology Children’s Hospital Uncommon Causes of Uncommon Causes of Educational Goals Educational Goals Childhood Wheezing Childhood Wheezing • Large airway obstruction (congenital) • List causes of wheezing in children � Vascular ring • Outline a strategy for the initial assessment � Tracheomalacia and treatment of a typical child with and treatment of a “typical” child with � Tracheal stenosis � T h l t i wheezing • Large airway obstruction (acquired) • Outline a strategy for addressing sub- � Foreign body optimal responders � Mediastinal mass � Endobronchial tumor • Recognize wheezing child “red flags” • Abnormal GI - airway anatomy 1

Uncommon Causes of Uncommon Causes of Common Causes of Childhood Common Causes of Childhood Childhood Wheezing Childhood Wheezing Wheezing Wheezing • Recurrent • Persistent airway infection states � ASTHMA, ASTHMA, ASTHMA � Cystic fibrosis � Cystic fibrosis � “Infantile asthma” & post-RSV wheezing � � Immunoglobulin deficiency � Asthma complicated by persistent triggers � Dysmotile cilia syndromes � Aspiration disorders (Infants) • Cardiac failure � Vocal Cord Dysfunction (Older child) Goals of Initial Goals of Initial Common Causes of Childhood Common Causes of Childhood Wheezing Wheezing Evaluation Evaluation • Screen for “red flags” • Single episode � VIRAL • Assess for symptom pattern c/w asthma � “First event” asthma presentation • Screen for alternate clinical problems which might cause wheeze, or make asthma control difficult 2

Tools for Evaluation: Tools for Evaluation: Tools for Evaluation: Tools for Evaluation: a Good History a Good History a Good History a Good History • Triggers • Description of onset � URI’s, cold air, exercise, allergen � Present since birth exposure, smoke exposure � Eating, lying down � Onset in infancy � “No apparent reason” � Onset in later childhood � It never changes � Began following choking episode Tools for Evaluation: Tools for Evaluation: Tools for Evaluation: Tools for Evaluation: a Good History a Good History a Good History a Good History • Description of wheeze • Past Medical History � Inspiratory v.s. expiratory � Neonatal history � Neonatal history � Intermittent v.s. daily � State of birth (CF screening?) • Associated symptoms � Major health issues � Rattling • Family history � Cough • Social history (smoke exposure, pets) � Retractions 3

Tools for Evaluation: Tools for Evaluation: Tools for Evaluation: Tools for Evaluation: a Good History a Good History a Good Physical Exam a Good Physical Exam • ROS • Presence of: � GERD markers/ feeding difficulty g y � Non-physiologic heart murmurs � Chronic nasal discharge � Liver enlargement � Eczema � Clubbing � Poor growth � Chronic diarrhea Tools for Evaluation: Tools for Evaluation: Initial Testing: CXR Initial Testing: CXR a Good Physical Exam a Good Physical Exam • Typical: normal, peribronchial • General growth/health thickening, • Upper respiratory infection signs pp p y g hyperinflation hyperinflation • Upper respiratory allergy signs • Atypical: • Pulmonary exam Asymmetric inflation, � High pitched versus rhonchorous sounds large heart, dense or extensive infiltrates � Variability of sound � Location of sound* *Persistent unilateral location 4

Initial Testing: PFT’s Initial Testing: PFT’s Initial Assessment Initial Assessment Red Flags: Red Flags: • Obstructive changes on initial spirometry • Initial symptoms associated with choking that improve following episode a bronchodilator • Poor growth, clubbing, chronic diarrhea • Poor growth clubbing chronic diarrhea establishes an asthma • Findings suggestive of heart failure diagnosis • Monotonous wheezing, truly “present from • Spirometry can also birth” help estimate asthma severity • Atypical CXR Initial Approach: Initial Approach: PFT Testing Limitations PFT Testing Limitations Trial of Asthma Therapy Trial of Asthma Therapy • Most asthmatics develop symptoms prior to age 5 • Bronchodilators* years. • Oral steroids* • Most cannot perform quality Most cannot perform q alit • (Controller therapy) spirometry until age 6 years • Childhood asthmatics * Failure to respond usually have normal to combination spirometry when “well” suggests problem is NOT asthma 5

What about Controller What about Controller ICS Delivery in Young ICS Delivery in Young Therapy Trial? Therapy Trial? Children Children • Clear response/improvement to controller therapy can help establish a diagnosis of • Nebulized • MDI/Spacer asthma in a child with typical symptoms steroids Devices Controller Therapy Trial Controller Therapy Trial Asthma Therapy Responders: Asthma Therapy Responders: Ongoing Management Ongoing Management Limitations Limitations A failure of improvement may indicate: • Establish clear plan for response to acute � Medication chosen was not “potent” symptoms enough h • If symptoms are frequent (or repeatedly • Montelukast trials severe) begin controller therapy • Low dose ICS trials • Titrate controller therapy according to disease severity/level of control � Medication was not used long enough � Medication was not actually inhaled 6

Approach to Initial Responders Who are in Approach to Initial Responders Who are in Advanced Approach: Infants Advanced Approach: Infants Poor Control Poor Control • Review adequacy of controller dosing • Trial of GERD Therapy (BID PPI) • Review medication usage • Videoswallow study • Videoswallow study � Technique problems • UGI? � Compliance problems • Sweat test • In older child, obtain PFT’s • Allergy testing Advanced Approach: Advanced Approach: Approach to Ongoing Poor Control, and Approach to Ongoing Poor Control, and “Partial Responders” “Partial Responders” Older Child Older Child • Advanced Approach: Look for and address • Trial of GERD Therapy (up to BID PPI) problems that persistently irritate airways: • Prolonged antibiotics for sinus disease P l d tibi ti f i di � Smoke exposure • Sinus CT � Infants: dysphagia, GERD, food allergy • Allergy testing � Older children: Allergen exposure, chronic • Pulmonary function testing sinusitis, GERD 7

Treatment Red Flags – Treatment Red Flags – Approach to the Approach to the Consider Referral Consider Referral Wheezing Child Wheezing Child • Failure to respond to beta-agonist and oral steroid trial • Failure to achieve control despite: F il t hi t l d it Meredith N. Merz, M.D. � Adequate controller therapy Pediatric Otolaryngology � Addressing common complicating Nationwide Children’s Hospital Columbus, Ohio disorders • Persistently abnormal lung function studies Nonbronchospasm Related Nonbronchospasm Related Summary Summary Wheezing Wheezing • When symptoms are atypical, consider other • Wheezing is common in childhood causes for persistent wheezing: • Recurrent wheezing is usually due to asthma � Wheezing that is poorly responsive to medical • Initial approach establishes whether the history, treatment and therapeutic response, is consistent with � Wheezing that returns after withdrawal of asthma medications • If asthma therapy is unsuccessful, look for � Unilateral wheezing common inflammation-contributing co- � Barky/ Croupy cough, especially in a young infant morbidities � Symptoms that are worse during eating • Watch for red flags - if found, consider referral � Reflex apnea � Recurrent pneumonias or infections 8

Nonbronchospasm Related Nonbronchospasm Related Normal Airway Normal Airway Wheezing Wheezing • Anatomic: • Neurologic: � Primary � Vocal cord paralysis Tracheomalacia T h l i � Vocal cord � Secondary dysfunction Tracheomalacia • Other: � Tracheal stenosis � Airway Foreign Body � Tracheal masses � Bronchomalacia Diagnostic Evaluation Diagnostic Evaluation Tracheomalacia Tracheomalacia • Classification system described by • Nasopharyngoscopy allows evaluation to the Benjamin in 1984: level of the larynx and limited evaluation of I. Primary tracheomalacia the subglottic airway II. Secondary tracheomalacia • Rigid bronchoscopy allows evaluation of the g y A T A. Tracheoesophageal fistula and h h l fi t l d tracheal and bronchial airways esophageal atresia B. External compression (vascular/ cardiac/ neoplastic) C. Boney thorax abnormality (i.e. pectus excavatum) • Imaging may be useful in some cases D. Dyschondroplasia � 3-D Reconstructions 9