THE CHILD WITH NOISY BREATHING ASTHMA

Asthma and wheeze Aetiology Transient early wheezing Non-atopic wheezing IgE-mediated wheezing (atopic asthma) - normal lung function early in life - recurrent wheeze develop w allergic sensitisation - increased blood IgE + positive skin prick test - hv persistent symptoms + decreased lung function later in childhood - FHx of asthma/ allergy - Hx of eczema

RF

Causes of recurrent wheeze in infancy

- infant wheezer - normal lung function early in - virus life associated - LRTI d/t viral (wheezy bronchitis) infxn (RSV) - small airways increased being more wheezing during likely to the 1st 10 years obstruct d/t of life inflammation - Less severe 20 to viral persistent infxn wheezing - decreased - Symptoms lung function improve during from birth adolescence - mom smoking during / after pregnancy - prematurity transient early wheezing non atopic wheezing in preschool child IgE mediated wheezing (atopic asthma) Recurrent aspiration of feeds CF Cows milk protein intolerance Inhaled FB Congenital abnormality of lung, airway or heart idiopathic

Pathophysiolog y

Atopy and allergy

Diagnosis

Investigations

Management

- asthma - eczema - allergic rhinitis - allergic conjunctivitis - urticaria + angioedema - food + drug allergies Symptoms: - hx of recurrent wheeze - w exacerbations usually precipitated by viral infxn - how frequent are the symptoms? - How much school has been missed d/t asthma? - Are sport + general activities affected by asthma? - How often is sleep disturbed by asthma? - How severe are the interval symptoms between exacerbation Signs: - hyperinflation of the chest - generalised polyphonic expiratory wheeze long-standing asthma - prolonged expiratory phase - Harrisons sulci (onset on infancy) - Eczema examn of nasal mucosa for allergic rhinitis - Growth - Wet cough, sputum production, clubbing, poor growth bronchiectasis or CF - clinical diagnosis, no Ix needed - skin prick testing to identify the allergens - chest x ray normal - PEFR for child >5 years old; depends on diurnal variabilty (morning PEFR usually lower than evening) and day-to-day variability Aim - Allow child to lead a normal life by controlling symptoms + exacerbations - Minimising treatment + SE - Optimising pulmonary function Bronchodilator Short acting - Salbutamol, terbutaline B2-agonist - rapid onset of action (reliever) - effective for 2-4 hours - used as required for increased symptoms, and in high doses for acute asthma attack - have few SE. Anticholinergi - Ipratropium bromide c - Given to young infant when other bronchodilator is bronchodilato ineffective r - Used in tx of severe acute asthma Preventive/ prophylactic treatment Inhaled - patho: decrease airway inflammation decreased steroids symptoms, asthma exacerbations + bronchial (preventer) hypersensitivity - Increasingly used in conjunction w inhaled LABA. - SE: impaired growth, adrenal suppression + altered bone metabolism (when high dose used, generally no significant SE)

Long acting B2-agonists (LABA)

Leukotriene inhibitor Methylxanthi nes

Oral steroids

- salmeterol, formoterol - effective for 12 hours - used in conjunction w regular inhaled corticosteroids (not used in acute asthma + not be used w/o corticosteroid) - useful in exercise induced asthma - orally - montelukast - as add on therapy when inhaled steroids w LABA fail to control symptoms - slow release oral Theophylline - high incidence of SE: vomiting, insomnia, headache, poor concentration - blood level need to monitored - rarely used - prednisolone - useful in severe persistent asthma where other tx has failed - given on alternate days to minimise the SE on height

Monitor: - peak flow diary - severity + frequency of symptoms - exercise tolerance - interference with life, time off school - is sleep disturbed? - Use of preventer + reliever medication are they appropriate? - Inhaler technique - Consider triggers: allergic rhinitis, allergens, stress

Acute asthma

Clinical features: - wheeze + tachypnoea (RR >50/min in children 2-5 years, >30/min in children 5 years) but poor guide to severity - increasing tachycardia (>130/min in children 2-5 years, >120/min in children 5 years) better guide to severity - the use of accessory muscle + chest recession also better guide to severity - the presence of marked pulsus paradoxus (abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration) indicates moderate to severe in children but is difficult to measure accurately unreliable - if SOB interferes w talking attack is severe - cyanosis, fatigue, drowsiness late signs = life threatening asthma, may hv silent chest on auscultation as little air is being exchanged Severity may be underestimated by clinical examn alone. So: - Arterial SaO2 should be measured w pulse oximeter SaO2<92% = severe/ life threatening asthma - PEFR routinely measured in school age children

Criteria for hosp admission

if, after high dosed inhaled bronchodilator therapy, they: - Not responded adequately persisting SOB, tachypnoea - Exhausted - Marked reduction in predicted PEFR - Have a reduced O2 saturation (<92% in air) Chest Xray - indications: - severe dyspnoea - unusual features (asymmetry of chest sign pneumothorax, lobar collapse) - sign of severe infection In children - ABG indicated in life threatening / refractory cases As above assessment and management of acute asthma Need to know: - when drugs should be used (regularly or as required)

Treatment Patient education

how to use the drug (inhaler technique) what each drug does (relief vs prevention) how often and how much can be used (frequency + dosage) - what to do if asthma worsens (management of acute attack) - when to start steroid at home + what dose to give signs of poorly controlled asthma: - increasing cough, wheeze, SOB - difficulty in talking, walking, sleeping - decreasing relief from bronchodilators Written personalised asthma action plan Choosing the 4-10 y.o: dry powder inhaler (terbutaline sulphate + salbutamol) or MDI w correct inhaler inhaler <4 y.o: MDI w spacer, use mask if <2y.o Nebuliser deliver high dose therapy + are used in sevre acute attacks CLASSIFICATION OF RESPIRATORY INFECTION URTI DDx: o Croup Viral laryngotracheitis (very common) Acute on chronic stridor ie from floppy larynx (laryngomalacia) Bacterial tracheitis (rare) o Rare causes Epiglottitis Inhalation of smoke and hot air in fires Trauma to the throat Retropharyngeal abcess Laryngeal FB Allergic laryngeal oedema (angioedema) Tetany d/t poor vit D intake Infectious mononucleosis Measles Diphtheria

ACUTE BRONCHOLITIS Introduction Clinical features - commonest serious respiratory infection in infancy - Respiratory Syncytial Virus (RSV) (80%) Symptoms: - coryzal symptoms precede a dry cough - wheeze - feeding difficulty a/w increasing dyspnoea reason for admission - recurrent apnoea is a serious complication in young infants - RF : premature infant who develop bronchopulmonary dysplasia, infants w congenital heart disease Signs: - apnoea in infants <4months - sharp, dry cough - cyanosis or pallor

Investigations

tacypnoea high pitched wheezes expiratory > inspiratory tachycardia hyperinflation of the chest: - sternum prominent - liver displaced downwards - subcostal + intercostal recession - Auscultation: - Fine end-inspiratory crackles - Prolonged expiration RSV can be identified rapidly on nasopharyngeal secretions demonstrating binding of fluorescent antibody Chest X ray - hyperinflation of the lungs (d/t small airways obstruction, air trapping + often focal atelectasis) - flattening of diaphragm - horizontal ribs - increased hilar hilar bronchial marking - note: Chest X ray rarely helpful in bronchiolitis ABG - required in most severe cases show lowered arterial O2 + CO2 tension - Supportive - Humidified O2 delivered via nasal cannulae/ into headbox conc required determined by pulse oximetry - Infant is monitored for apnoea - Fluids via NG tube or IV - (Mist, antibiotics, steroid not helpful) - Can give nebulised bronchodilators ie salbutamol or ipratropium hv not shown to reduced the severity + duration of illness - Mechanical ventilation - RSV highly infectious infection control measure good hand hygiene to prevent cross infection to other infant - recover from acute infection within 2 weeks - monoclonal antibody to RSV (palivizumab, given monthly by IM) reduces no. of hosp admission in high risk preterm infants

Management

Prognosis Prevention CROUP Definition Causative organism Pathophysiolog y Epidemiology Clinical features

Croup is breathing difficulty and a "barking" cough. d/t swelling around the vocal cords. common in infants and children parainfluenza viruses (the commonest) metapneumovirus RSV Influenza mucosal inflammation and increased secretion affecting the larynx, trachea and bronchi the oedema of subglottic area is potentially dangerous in young children bcoz it may result in critical narrowing of trachea 6 months to 6 years old ( the peak incidence in the 2nd year of life) Commonest in autum barking cough

Management

- harsh stridor - hoarseness - preceded by fever and coryza - the symptoms start at night and worse at night Mild viral croup - manage at home - when upper airway obstruction is mild, the stridor + chest recession disappear when child at rest - parents give close monitoring for signs of increasing severity Admit or not? - severity of illness - time of day - ease of access to hospital - the childs age (low threshold for admission for those <12 months old) - parental understanding + confidence about the disorder Medical - inhalation of warm moist air widely used but unproven benefit - oral dexametahsone, oral prednisolone + nebulised steroids (budesonide) reduce the severity + duration of croup + need for hospitalisation - nebulised epinephrine (adrenaline) give transient improvement in: - severe upper airways obstruction - children w clinical features of severe croup - SaO2 <93% in air (give together O2 by face mask + close monitoring) - Tracheal intubation

ACUTE EPIGLOTTITIS Causative organism Pathophysiolog y Epidemiology Clinical features H. influenza type b - (introduction of universal Hib immunisation lead to decrease of incidence of epiglottitis) Intense swelling of epiglottis and surrounding tissue a/w septicaemia Children aged 1-6 years but affects all age group - high fever in an ill, toxic-looking child - an intensely painful throat that prevents the child from speaking or swallowing; saliva drools down the chin - soft inspiratory stridor + rapidly increasing respiratory difficulty over hours - the child sits immobile, upright, w an open mouth to optimise the -

airway CROUP Over days yes Severe, barking yes no unwell <38.5oC Harsh, rasping hoarse EPIGLOTTITIS Over hours No

Investigation Management

Absent or slight No Yes Toxic, very ill >38.5 oC Soft, whispering Muffled, reluctant to speak Should not attempt to lie child down or examine the throat w spatula or perform a lateral neck X ray can precipitate total airway obstruction - Hospital admission - Senior anaesthetist, paediatrician + ENT surgeon tx initiated w/o delay - Transferred to ICU - Intubate the child under GA (rarely possible, urgent tracheostomy is life saving) - After airway secured blood taken for C+S , IV antibiotic (cefuroxime) started (given for 3-5 days) - Tracheal tube remove after 24 gours - Child recover within 2-3 days - Prophylaxis Rifampicin (for close household contact)

Onset Preceding coryza Cough Able to drink Drooling saliva Appearance Fever Stridor Voice, cry

LARYNGOMALACIA Definition and pathophysiolog y Clinical features - the soft, immature cartilage of the upper larynx collapses inward during inhalation causing airway obstruction

partial airway obstruction, most commonly causing a characteristic high-pitched squeaking noise on inhalation (inspiratory stridor).

feeding difficulties

stridor