Pediatric Respiratory disease
WHAT DOES THE WHEEZING MEAN
Objectives
Review the evaluation of wheezing in children
Review diagnosis and treatment of asthma
Review diagnosis and treatment of bronchiolitis
Review diagnosis and treatment of Pneumonia
Case
2 year old male comes in with cough, wheezing, low-
grade fever, and poor feeding x 2 days
Family h/o asthma in dad
Personal h/o eczema
Attends daycare
Mom smokes in house
by the way. . . Its January
Wheezing--pathophysiology
By age 6 almost half of all children will have had a
wheezing episode
Caused by rapid passage of air through narrowed
airways
Children wheeze more because airways are smaller--
-therefore, increased resistance
Infants have less elastic tissue recoil
Fewer collateral airways
Differential Diagnosis
Common Rare
Wheezing in Children
Common Uncommon
Allergies Bronchiolitis obliterans
Asthma Congenital vascular
GERD abnormalities
Infections CHF
Bronchiolitis CF
Bronchitis Immunodeficiency
Pneumonia Mediastinal masses
URI Tracheobronchial anomalies
OSA Tumor
Vocal Cord Dysfunction
Foreign body aspiration
Bronchopulmonary
Dysplasia
History is Key
How long ago did wheezing start?
Pattern?
Associated with cough?
Associated with feeding?
Associated with multiple respiratory illnesses?
Associated with a specific season?
Better or worse with change in position?
Family history of wheezing?
How sick is the child?
Appearance is key
Nasal flaring
Grunting
Retractions
Stridor
Lethargy
Cyanosis
Diagnostic Testing
Presumptive Diagnosis Diagnostic Test
GERD pH probe/bar. Swallow
Tracheomalacia Bronchoscopy/CT/MRI
Pneumonia CXR
Vascular ring CT/MRI/Angiography
Cardiac disease Echo
CF Sweat chloride
RSV/Croup CXR/nasal swab
Epiglottitis Neck radiography
Foreign body aspiration Bronchoscopy
Asthma PFT/trial of albuterol
AsthmaBurden of Disease
Most common chronic illness in childhood
Condition causing most pediatric admissions
3xs the school absence as non-asthmatics
More prevalent and more severe in black children
Asthma and Wheezing
The most common cause of wheezing in young
children is viral respiratory infection
But
The strongest predictor for wheezing that develops
into asthma is ATOPY
Asthma and Wheezing
2 possible syndromes
Transient wheezing Early-onset Asthma
Smaller airway caliber Atopy
No bronchial Bronchial
hyperresponsiveness hyperresponsiveness
Resolves by age 6 Significant
deterioration in lung
function by age 6.
Is it Asthma??
Clinical index to define asthma risk in wheezers <6
yo
Early wheezer plus one of 2 major or 2 of 3 minor
criteria
Asthmaclinical index
Major Criteria Minor criteria
Parental asthma Allergic rhinitis
Personal eczema Wheezing apart from
colds
Eosinophilia >4%
Asthma--Prevention
Smoking cessation in pregnant women!!!!
Also---link with moms vit E intake
Children born of mothers with the lowest vitamin E intake
were 3.47 xs more likely to have asthma as those with the
highest
AsthmaRisk factors
Family historyespecially maternal
Smokingboth prenatal and current
Males
Dust mite exposure
Prematurity/low birth weight/bpd
Low socioeconmic status
Personal allergy history
Urban setting
Hospitalized for RSV
Asthma--Diagnosis
Demonstrating reversible airway obstruction
confirms the diagnosis.
Peak flow or spirometry in children old enough
Difficult to do this in pre-school children
Diagnosis often delayed
Spirometry Findings--Asthma
Pre-bronchodilator and 15-20 minutes post
Airflow obstruction >/= 20% with serial
measurements
Increase in forced expiratory volume in one second
(FEV1) of 12% or more after bronchodilator therapy
Therapy Goals
Reduce wheeze and cough
Reduce acute exacerbations
Minimize adverse effects of treatments, sleep
disturbances, and absences from school
Asthma Symptom Lung function Meds required
Classification frequency
Mild intermittent 2 days or PEF or FEV1 No daily meds
less/week 80% or more of needed
2 nights or predicted
less/month
Mild persistent More than 2 d/w Same Low-dosage
Less than 1x/d inhaled
More than 2 corticosteroid
nights/month
Moderate Daily PEF or FEV1 60- low dosage
persistent More than 1 80% of predicted inhaled
night/week corticosteroid
and long acting
beta2 agonist, or
medium dosage
inhaled
corticosteroid
Sever persistent Daytime- PEF or FEV1 High-dosage
continual 60% or less of inhaled
Nighttime- predicted corticosteroid
frequent and long-acting
Quiz
In an acute asthma exacerbation, what 3 medicines
should you consider?
Acute Therapy
Beta 2 agonists mainstay of treatment
MDI with spacer is equally as effective as nebulized
therapy
Levalbuterol (xopenex)one RCT showed a decrease
in rate of hospitalization but no decrease in hospital
stay
No evidence to support oral/IV beta 2 agonists
Acute Therapy
Ipratropium Bromide (Atrovent)
The addition of atrovent to each nebulized treatment of
albuterol is more effective than albuterol alone in acute
exacerbation.
Acute Therapy
Systemic corticosteroids
If given within 45 minutes of acute exacerbation,
reduce the likelihood of hospital admission
No evidence that IV steroids are more effective
1-2 mg/kg/d for 3-10 days as burst
Methylprednisolone (Medrol)
Prednisolone (Prelone/Pediapred)
Prednisone
Quiz
T/F
Servent and Pulmicort are equally effective for
maintainance therapy in mild persistent asthma.
Long-Term Therapy
Inhaled steroids are mainstay
As a single agent, more effective than inhaled long-
acting beta2 agonists in improving symptoms and
lung function
Use lowest dose necessary to prevent reduction of
growth velocity
Inhaled Steroids
Beclomethasone QVAR
Budensonide Pulmicort
Flunisolide Aerobid
Fluticasone Flovent
Triamcinolone acetonide Azmacort
Long-Term Therapy
Leukotriene Inhibitors (Singulair)
Similar efficacy to inhaled steroids in one RCT
Likely due to better compliance with oral meds
Long-Term Therapy
Cromolyn Sodium (Intal)
Reduces symptom scores, asthma severity, bronchodilator use,
and improves lung function in children
Not as effective as inhaled corticosteroids
Insufficient evidence to recommend
Long-Term Therapy
Long-Acting Beta 2 agonist
Salmetrol (Servent)
Improves lung function
Conflicting evidence about whether it reduces rescue inhalers
Increases hyperreactivity
Not recommended as monotherapy
Quiz
T/F
Theophylline improved lung function in childhood
asthma.
Long-Term Therapy
Theophylline
Increased mean morning peak expiratory flow rate
Reduced mean number of nighttime attacks
NO significant difference between theophylline and inhaled
steroids in reduction of asthma symptoms
Increased use of short acting beta2 agonists and oral steroids
in children using
Not recommended because of risks of serious side effects
Long-Term Therapy
Immunotherapy
Can be used as an adjunct
Reduce presence of asthma and use of medication
1.7-15 percent range of adverse effects
Between 1985-1989, 17 related deaths
Other Interventions
Education
Educate to recognize and avoid triggers
Understand medications and proper use
Importance of compliance and monitoring
Proper education has been shown to improve lung function,
decrease school absenteeism, and visits to ED.
Reducing Triggers
Avoiding triggers (smoke, perfumes, cold air,
exercise, infections, beta blockers, pollen) should be
recommended
Removing carpet, using pillow and mattress covers,
air filtration systems is controversial.
Insufficient evidence to recommend for or against.
Quiz
2 yo presents with acute wheezing related to URI
that responds to a breathing treatment. How will
you deliver his beta 2 agonist at home?
Spacer Vs. Nebulizer
Has been studied in children as young as 10 months
and found to be as effective.
As effective in acute exacerbation
Lower cost
Lower pulse rates in children in ED
Key Recommendations
MDI with spacer as effective as nebulizer---A
Consider atrovent with beta2 agonist in acute
exacerbation---A
Oral corticosteroids should be given within 45
minutes of the onset of symptoms---A
Modest doses of inhaled steroids more effective than
long acting beta 2 agonists, cromolyn, and
leukotriene inhibitors for moderate persistent---A
Parents should be taught to avoid triggers, and
understand medications and compliance---A
Bronchiolitis
Acute inflammatory disease of lower resp. tract
Most commonly caused by RSV
Self limited
Median length of illness is 12 days!!
40% will have subsequent wheezing through 5 years
of age
10% will continue to wheeze after 5
RSV accounts for 500 infant deaths/year in US
Bronchiolitis
Most at risk for hospitalization and significant
morbidity
Premature infants (<35 weeks gestation)
Chronic lung disease
Heart disease
Immune deficiency syndromes
Bronchiolitis--Prevention
Eliminating environmental tobacco smoke exposure
Limiting exposure to daycare and sick siblings
Handwashing
Palivizumab (synagis)
Quiz
T/F
Synagis should be given to all premature infants
during the first year of life.
Synagis
One large multicenter double-blind RCT
Reduction in hospitalization (not acute illness)
However, it has not been shown to be cost-effective regardless
of prematurity or presence of congenital heart disease
Cost of the medications and administration was more than six
times higher than the financial benefit
Synagis Prophylaxis
Infants and children<2 with known CLD
<28 weeks gestation
29-32 weeks gestation if RSV season during first 6
months of life
32-35 weeks if 2 risk factors present
Day-care
School-aged siblings
Exposure to environmental pollution
Abnormal airways
Severe neuromuscular problems
BronchiolitisPrecautions
Respiratory/Contact isolation
Vigorous handwashing
Providers must wear masks covering nose and eyes
BronchiolitisDiagnosis
Based on history and physical
Wide range of symptoms, from mild URI to
impending respiratory failure
Wheezing, retractions, low O2 sat, tachypnea, nasal
flaring
Signs of dehydration
History of exposure to URI
Lab studies
RSV swab, CXR, cultures, ABG, rapid flu should
NOT be routinely performed.
CXR if diagnosis not clear
In very young infants, RSV rapid viral testing may
prevent the full septic work-up
Bronchiolitis--Management
Supportive care
Adequate hydration
Supplemental oxygen if needed
Benefits of hospitalization are for careful monitoring
to maintain patent airway, adequate hydration,
oxygen, and to educate parents
Medications
Consider supplemental oxygen if O2 is consistently
<91%
Wean when consistently>94%
Scheduled albuterol should not be routinely used
2 RCTs no improvement on clinical scores or
hospitalization rates with albuterol nebs
Quiz
What medication can you give a trial of to an infant
with RSV bronchiolitis?
Medications
Single trial inhalation using racemic epinephrine is
an option
RCT showed better improvement in clinical scores
compared with albuterol or placebo
Predominantly transient effect (30-60 min)
If no improvement in appearance at 15-30 minutes ,
do not repeat
Medications
Antibiotics not indicated
Incidence of serious bacterial illness <2%
Antihistamines, decongestants, and nasal
vasoconstrictors not recommended
Steroids not recommended
Respiratory Care
Suctioning when clinically indicated
Before feeding
Prior to inhalation therapy
PRN
Normal saline nose drops may be used prior to suctioning
Chest physiotherapy and cool mist therapy have not been
shown to be helpful
Monitoring
Acute stage may warrant cardiac and respiratory
monitoring, especially in at risk infants
More severe progression of disease who present with
low initial oxygen saturation.
Spot checks of pulse ox are recommended
Continuous oximetry has been associated with
increased length of stay.
Indication for Hospitalization
Age less than 3 months
Gestational age at birth <34 weeks
Cardiopulmonary disease
Tachypnea >70/min
Lethargy
Oxygen sats <92% on room air
Increased work of breathing
Inability to maintain hydration
Quiz
When educating a parent about their childs RSV,
what should you tell them regarding the childs
length of illness?
A. 3-5 days
B. 7 days
C. 10 days-2 weeks and possibly longer
Family Education
Course of diseasemedian course of illness is 12
days.
9% still ill after 28 days
Suctioning to make breathing easier
Signs of worsening clinical status
Maintaining adequate hydration
Eliminating smoke exposure
Handwashing
CAP
We will focus on kids 60 days-17 years
Challenges
Ability to make clinical diagnosis
Differentiation of viral vs. bacterial
Inability to determine specific etiology
Selection of appropriate antibiotics
Community acquired pneumonia
Acquired outside of a hospital setting
Historical or physical evidence of an acute infectious
process
Fever
Respiratory distress
Radiological evidence of an acute infiltrate
Quiz
What is the most common cause of bacterial
pneumonia in a child 60 days-5 years?
CAP--Etiology
Bacterial causes
Strep pneumoniae 13-28% prior to Prevnar
Still the most common, however, vaccine has reduced invasive
disease.
Mycoplasma pneumoniae and Chlamydia
pneumoniae more common in school age children.
Etiology
Viral causes
Most common in children <5
RSV most common viral etiology in <3
Adenovirus, Parainfluenza, Influenza, and Human
metapneumovirus are also implicated frequently.
CAP
Mixed etiologies are reported in 30-50% of children
with CAP
Strep pneumo and a virus
Strep pneumo and C. pneumonia
CAP--History
Age
Season
Immunization status (especially prevnar and
influenza)
Exposure to TB
CAP--PE
Respiratory rate over a full 60 seconds
A single clinical finding is not useful to determine if a
child has pneumonia, combinations are more helpful
Best indicators in children <5
Nasal flaring(<12 mo)
O2 sat < 94%
Tachypnea
Retractions
Best negative predictive valueabsence of tachypnea
WHO Criteria for Tachypnea
Age NL Respiratory Rates Tachypnea Threshold
2-12 months 25-40 50
1-5 years 20-30 40
>5 years 15-25 20
CAP
In acutely ill and febrile children, pneumonia may
present as pain referred to the abdomen or as fever
without a source.
CXR or Not
For children, CXR recommended when
Clinical findings are ambiguous
Complication such as pleural effusion suspected
Pneumonia prolonged and unresponsive to antimicrobials
CXR
Do not consistently alter management
Can not differentiate viral from bacterial
Classically ---lobar consolidation=bacterial
interstitial infiltrates =viral
However, both have been seen in all types of infections
Ordering of CXR is inversely proportional to
experience of clinician
CXR
It is recommended that CXR be considered in
children <5 with high fevers and high WBC of
uncertain source.
WBC
WBC count and differential helpful in the decision to
use antibiotics
Likelihood of a bacterial cause increases when
WBC>15,000, and especially >20,000.
More specific when associated with fever >39C
(102.2F)
Blood Cultures
Should not be routinely obtained
More helpful in more severe or unusual cases
Other Tests
CRP and ESR not helpful
PPD should be done if history of exposure or travel
to location where TB is prevalent.
Sputum gram stain can be considered in more severe
cases
Pleural cultures should be obtained prior to starting
antibiotic if effusion present.
Rapid antigen tests for RSV, parainfluenza,
influenza, and adenovirus can help determine
etiology for viral pneumonia, but are not necessary.
Quiz
What is the treatment of choice in 3yo with CAP?
Medicine and dosage??
Antibiotics
Based on age and severity of illness
Age 60 days-5 years
High dose amoxicillin (80-90mg/kg/day x 7-10 days)
Covers S. pneumo
Resistance of 16-35% to penicillins
High doses saturate penicillin binding proteins
PCN allergic can use macrolide or cephalosporin
Macrolides are not first line but can be added at 24-48 hours of
M/C. pneumonia suspected
A single dose of ceftriaxone is acceptable, prior to starting
orals, if child is unable to tolerate liquids.
Antibiotics
Age 5 and older
Macrolide is treatment of choice
7-10 days except azithromycin
15% S. pneumo resistant to macrolides
More severe disease
Combination of macrolide and B-lactam (high dose
amox or ceftriaxone)
Better coverage for resistance and mixed infections
Admission Criteria
O2 sat consistently < 91%
Severely dehydrated
Moderately dehydrated and unable to hydrate orally
after IV fluids
Moderate or severe respiratory distress
Failed outpatient antibiotics
Unsafe to send home
Follow-up
Follow-up key, especially when initial diagnosis
unclear
24-48 hours
In Summary
Asthma is the most likely cause of recurrent
wheezing in children <5.
The most common causes of wheezing in young
children are asthma, allergies, GERD, infections, and
OSA
Response to bronchodilators may help differentiate
asthma from other causes
CXR should be performed in recurrent wheezing or
unexplained wheezing not responsive to
bronchodilators
References
Cincinnati Childrens Evidence Based Guidelines for Bronchiolitis,
revised 11/05.
Cincinnati Childrens Evidence Based Guidelines for CAP, revised
11/05.
Courtney, Ursula, et al. Childhood Asthma: Treatment Update.
American Family Physician, May 15, 2005.
Kemp, James and Judith. Management of Asthma in Children.
American Family Physician, April 1, 2001.
Ostapchuk, Michael, et al. Community Acquired Pneumonia in
Infants and Children. American Family Physician, Sept. 1, 2004.
Steiner, Robert William Prasaad. Treating Acute Bronchiolitis
Associated with RSV. American Family Physician, Jan15, 2004.
Weiss, Lisa Noble. The Diagnosis of Wheezing in Children.
American Family Physician, April 15, 2008.
