Management of Respiratory
Problems in Children
DR SADASIVAM SURESH
Learning objectives:
•Increase understanding of common respiratory disorders in children
•To be able to recognise common respiratory symptoms and
presentations in a child under 2 years of age
•To understand the ongoing management and surveillance in paediatric
asthma
•Investigations in children with respiratory problem - a systematic
approach
•Multidisciplinary management in chronic conditions.
•Antibiotics and physiotherapy - synergy in management of chronic
respiratory conditions
Chronic Cough in Children
Road Map
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Definition
Clinical presentation
Differential diagnosis
Investigations
Management
Mechanism of Cough
Definition
• Chronic cough – daily cough for more than 4
weeks
• Dry Cough - Discussed separately
• Moist cough
– This presentation
Figure 1 Differentiated cough patterns.
Marais, B J et al. Arch Dis Child 2005;90:1162-1165
Copyright ©2005 BMJ Publishing Group Ltd.
Clinical Presentation
• Cough as a symptom
– Associated symptoms
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Wheeze
Pyrexia
Diurnal variation
Exercise & activity
Sleep
– Other systemic symptoms
• Reflux
• Cardiac
• Congenital abnormality
Suppurative Cough
Decision Tree
Investigations
Management points
• Value of CXR
– Follow-up CXR & timing
• Chronic Bronchitis of unknown aetiology
– Physiotherapy
– Prolonged course of antibiotics
• Role of Bronchoscopy
• Sequential investigation
Family/Patient preference
Cough Benefits
Bronchiolitis
Croup
What is it and what to do about it.
bronchiolitis
• Affects infants, males = females
• At risk - bottle fed, crowding
- CHD, CNLD
• Causes
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RSV
Human metapneumovirus
Influenza
parainfluenza (3)
adenovirus
Figure 1 Comparison of the frequency of detection of human metapneumovirus (hMPV) with
other respiratory viral pathogens. RSV, respiratory syncytial virus.
Garcia-Garcia, M L et al. Arch Dis Child 2006;91:290-295
Copyright ©2006 BMJ Publishing Group Ltd.
Figure 4 Age distribution of hMPV and RSV single infections.
Garcia-Garcia, M L et al. Arch Dis Child 2006;91:290-295
Copyright ©2006 BMJ Publishing Group Ltd.
Figure 3 Monthly distribution of hMPV and RSV single infections.
Garcia-Garcia, M L et al. Arch Dis Child 2006;91:290-295
Copyright ©2006 BMJ Publishing Group Ltd.
RSV
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Predominant pathogen
2 strains - A and B
All children exposed by 3 years
Spreads from nasopharynx to lungs
Kills respiratory epithelial cells
In vitro - large syncytia
Pathogenesis
• Ciliated epithelial necrosis
• Mononuclear cell infiltrate, oedema, mucous
plugs
• CXR - hyperinflation and patchy infiltrates,
collapse
• Repair - cilia by day 15
Clinical
• Incubation - 5 days
• Coryza
• tachypnoea, wheeze, crackles, hypoxia - 1 to 3
weeks
• Bacterial superinfection rare (1-2%)
• Residual symptoms
diagnosis
• Clinical
• NPA - respiratory viruses
Management
• Oxygen - saturations < 94%
• Fluids - oral feeds, NG feeds, IV fluids,
ventilation
• NOT - antibiotics, steroids, bronchodilators,
physiotherapy
• Ribavirin - expensive antiviral, no proven
efficiency
RSV prevention
• RSV immunoglobulin - monthly injection
during winter, CNLD
• Oxygen dependent, < 2 years
• Decreases hospital admissions (NNT 17) and
ICU admission (NNT 50)
• IMPACT study
Croup - laryngotracheobronchitis
• Changing epidemiology
• Viral cause - most common:
– Parainfluenza
symptoms
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Barking cough
Stridor
Hoarse voice
+/- URTI symptoms
BEWARE
• <4 months: structural airway lesions
• High fevers
• Day time onset
treatment
• Humidification - placebo effect
• Steroids - parenteral, oral, nebulized
Rapid onset of therapeutic effect improvement within 1-2 hours and sustained
• Nebulized adrenaline
• intubation
Admit if
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Stridor at rest
Needed nebulized adrenaline
< 12 months
Past Hx severe croup
High risk child eg Down syndrome
Under 2 years
•Stridor
-Laryngomalacia
-Congenital lesion
- biphasic
•Congenital lung lesions
-CCAM
Asthma in children
Thanks to
Dr Scott Burgess PhD FRACP
Outline
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What is asthma
Pre-school wheeze
Montelukast (Singulair)
Inhaled corticosteroids
LABAs
Difficult asthma / when to refer
Managing acute asthma in general practice
What is asthma?
Asthma is characterised by four key features:
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2.
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Symptoms
Bronchoconstriction
Bronchodilation
Inflammation
What is asthma?
Asthma is characterised by four key features:
1. Symptoms
2. Bronchoconstriction
3. Bronchodilation
4. Inflammation
Wheeze:
• Due to vibration of airways as gas flows through them
• Most commonly expiratory
• Parents often become confused by rattle from large airway
secretions.
What is asthma?
Asthma is characterised by four key features:
1. Symptoms
2. Bronchoconstriction
3. Bronchodilation
4. Inflammation
Cough:
• Cough is a common feature of asthma
• However, a chronic isolated cough is not asthma and will not
respond to salbutamol and ICS.
What is asthma?
Asthma is characterised by four key features:
1.
2.
3.
4.
Symptoms
Bronchoconstriction
Bronchodilation
Inflammation
Bronchoconstriction:
• Narrowing of airways in response to a trigger
• Basis of challenge testing and can be helpful in difficult diagnosis.
What is asthma?
Asthma is characterised by four key features:
1. Symptoms
2. Bronchoconstriction
3. Bronchodilation
4. Inflammation
Bronchodilation – reversible airways narrowing
Improvement in work of breathing and lung function following
salbutamol
Again very helpful – lung function testing when child is unwell.
What is asthma?
Asthma is characterised by four key features:
1. Symptoms
2. Bronchoconstriction
3. Bronchodilation
4. Inflammation
Inflammation – most commonly eosinophilic
Basis of steroid treatment
Difficult to test – exhaled nitric oxide and induced sputum
Little known about inflammation in preschool wheeze.
Pre-school wheeze
• Small children have small air-pipes
• Poiseuille’s law: flow is proportional to 4th power of the
radius of the pipe
– Small changes in the size of the pipes results in big changes in
flow
• Viral induced oedema can cause wheeze independent of
smooth muscle constriction
• Half of all children wheeze at some point
• Infants whose mother’s smoke have narrower small airways
• Some infants have narrower airways and wheeze with viral
infections but grow out of the tendency to wheeze with
time – transient wheezers.
Pre-school wheeze
• Pragmatically we divide children into:
– Viral induced wheeze [viral exacerbations only]
– Multi-trigger wheeze [viral exacerbations as well as symptoms with
exercise, at night, exposure to smoke and allergens] (Brand 2008)
• Mixed evidence regarding oral steroids in pre-school wheeze
– Probably little and more likely no benefit (Csonka 2003 and Panickar
2009)
– No benefit from parent initiated oral steroid in preschool wheeze
(Vuillermin 2011)
• No benefit from ICS in viral induced wheeze (Wilson 1995)
• Modest benefit from ICS in children with multi-trigger wheeze [treat 7
children to prevent 1 exacerbation] (Castro-Rodriguez 2009)
• ICS do not modify disease progress at any age.
Montelukast (Singulair)
• Leukotreine receptor antagonist block receptors on smooth muscle and
other cells, preventing the action of these mediators
• The effects are modest:
– Preschool wheeze – 9 children to prevent exacerbation and 19 to prevent
medical review, no effect on hospitalisation rates
– School aged wheeze – more effective but not as effective as ICS
• Modest effect as add on to low dose ICS (not supported by PBS for this
role)
• Side-effects are very uncommon
• Consider as first line for school aged children whose parents don’t want
ICS (although low does ICS don’t have measurable side effects)
• Role in exercise induced asthma.
Inhaled corticosteroids steroids (ICS)
• When to start?
– Frequent exacerbations (every 4-6 weeks regularly)
– Persistent disease:
• Symptoms between exacerbations (waking at night, minimal exertion,
frequent wheeze)
• Using reliever 2-3 times per week (except for exercise)
• Abnormal lung function with bronchodilator response
• Medication and dose
– All inhaled steroids are much the same
– Start low or moderate (eg Fluticasone 100-250 ug/day) and wean as
able
– Steep dose response curve (most children controlled with 100
micrograms per day)
– Side-effects more likely as increase, especially at 500 ug/day or higher.
Inhaled corticosteroids steroids (ICS)
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• How to give?
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Puffer and spacer unless child refuses to use
Dry powder device only in those >= 7 years of age
Face mask only in those < 3 years of age
Must know how to use and demonstrate to child /
parent
– Check inhalation technique as regularly as you can
– Placebos and information on lung delivery can be
helpful
– Wash spacer in soapy water and air dry to reduced
static and increase delivery.
Long acting beta agonists (LABA)
Seretide / Symbicort
• Pre-school children: There are no trials of LABAs
in pre-school children and no indications for
prescription in this group (Do not prescribe to
pre-school children)
• LABA as add on to ICS: BTS guidelines
• LABA plus low dose ICS vs moderate dose ICS
• Safety and a note of caution: No evidence of
significant adverse effects when used in
combination with ICS. Adverse event profile in
younger children not well recorded.
Difficult asthma / when to refer
• Asthma that is not well controlled despite moderate dose ICS plus
add on medication eg Seretide 500 ug / day
• Previously - Difficult asthma clinic at Mater Children’s Hospital
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6 years and older
Poorly controlled asthma
Physician, nurse, scientists, psychologist and research assistant
Top 3 reasons: Not asthma, poor inhalation technique, poor
adherence
• Comprehensive Asthma Assessment and Management Program
• When to refer?
– Worried about diagnosis: Chronic moist cough, poor weight gain, focal
signs
– Not well controlled on Flixotide 250 ug per day and good inhalation
technique.
Managing acute asthma in your
practice
• Stay calm and keep them calm
• Call for help (000) if severe or dose not respond to first dose of
salbutamol
• Airway and oxygen (keep sats >94%)
• Given salbutamol [a lot] – Asthma foundation 4 puffs (but can give
up to 12puffs)
• Given oral prednisone 2mg/kg orally (no need for IV)
• If responds:
– Give written plan
– Ensure knows how to give medication
– Follow-up to review management
• Patient should go to hospital if needing reliever more than every 3
hours.
Lung function testing in General
Practice
• Who performs LFT in children?
• What are the barriers to performing lung
function testing?
Top Tips
• Confirm the diagnosis
– History of musical not rattly wheeze, wheeze not cough
– Review when unwell
– Lung function testing
• ICS
– Low or moderate dose (Flixotide 50ug twice daily or 125 ug twice
daily)
– Do not use LABA 1st line or in pre-school children
– Demonstrate use of spacer and check technique
• Check for concerns as well as provide general educational
information
• Provide asthma plan
• Ask about smoking / encourage stop smoking even if away from
child.
Lung Volumes
VT: Tidal Volume
IRV: Inspiratory reserve volume
ERV: Expiratory reserve volume
RV: Residual volume
VC: Vital capacity
IC: Inspiratory capacity
FRC: Functional reserve capacity
TLC: Total lung capacity
In summary:
Rapid flight through respiratory paediatrics
•Common presentations to general practice
•High percentage managed by general
paediatricians
•Definite role for tertiary specialists to treat,
empower, educate and advocacy
OUR VISION: To provide high quality holistic care in
paediatric respiratory and sleep medicine to children
and their families.
OUR MISSION: Q-Class will provide readily accessible
comprehensive care to children with respiratory and
sleep problems in a multidisciplinary setting and
promote ongoing health and well-being in partnership
with their family.
Helping Kids Breathe and Sleep Better
CASE STUDY - 1
CASE STUDY - 2
CASE STUDY - 3
CASE STUDY - 4
CASE STUDY 3 & 4
• Comment on the lung function values
• What is the likely diagnosis
• Comment on the mid expiratory flow values
CASE STUDY - 5
Comment on lung function values/loop
The residual volume is 230% predicted –likely diagnosis?
CASE STUDY -6
CASE STUDY 7
These are lung function value of a 32 year old adult
What more information would you like to know?
CASE STUDY - 8
Well controlled asthmatic what other history would you ask?