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Pediatric Respiratory Medicine

4 Seasons Lecture

• Bon Appétit !

Objectives

1. Differences between children and adults in

respiratory medicine.

2. Wheezy child

3. Recurrent cough in children3. Recurrent cough in children

4. Respiratory emergencies in children &

protocol of management.

Pediatric Respiratory MedicineChildren are not small Adults!

Part 1

Dr. Malak Shaheen

(PhD Pediatrics, FCCP)

Overview of differencesAnatomical/ physiological

Psychosocial Differences

Wheezy Child

By

Malak Shaheen

Part 2

Malak Shaheen

(MD Pediatrics)

Symptoms, signs and clinical presentations of childhood asthma

Reported wheeze not always reliable

Good evidence that ‘doctor-diagnosed asthma’ based on reported symptoms includes children without asthmasymptoms includes children without asthma

Reported isolated cough reliable – is not asthma

Skin Prick Test if uncertain

Spectrum of disorders

Birth 1 year 5 years Adolescence

Spectrum of disorders

Birth 1 year 5 years Adolescence

Bronchiolitis Pre-school wheeze Asthma in school children

Spectrum of disorders

Birth 1 year 5 years Adolescence

Bronchiolitis Pre-school wheeze School children

RSV, adeno,

rhino50:50 atopic 90:10 atopic

Spectrum of disorders

Birth 1 year 5 years Adolescence

Bronchiolitis Pre-school wheeze School childrenBronchiolitis Pre-school wheeze School children

RSV, adeno 50:50 non-atopic:atopic 90:10 atopic

Mucosal inflammation

Little smooth muscleSmall

Airways;

Neutrophils;

Mucosal

inflam+

SM

Normal airways;

Eosinophils;

SM + muc inflam

SM very important

Clinical features

Birth 1 year 5 years Adolescence

Bronchiolitis Pre-school Schoolchildren

URTI URTI or allergens Allergens, URTI, exercise, cold air

Crackles and wheeze

Martinez description of phenotypesMartinez description of phenotypes

Martinez FD N Engl J Med. Martinez FD N Engl J Med. 1995 1995 Jan Jan 1919;;332332::133133--88. .

D.D. of wheezy infant

• 1. Infections (viral, other include chlamydia, TB, ….)

• 2. Asthma (3 phenotypes)

• 3. Anatomic abnormalities of airways (central, intrinsic or extrinsic)(central, intrinsic or extrinsic)

• 4. Inherited (CF or Immunodefeciency)

• 5. Aspiration Syndroms

• 6. Interstitial lung dis ( include; BO)

• 7. Foreign Body

Wheezing phenotypes(response to corticosteroids1)

• Post-bronchiolitis wheeze

Those with a family history of atopy respond to ICS 2

• Non-atopic viral wheezing

Different cell profile in airways 3

Little evidence for response to ICS 4Little evidence for response to ICS 4

• Atopic asthma

Good response to ICS

1. Ranganathan & McKenzie Minerva Pediatr. 2003 55:357-67

2. Chavasse RJ et al Arch Dis Child 2001; 85:143-8

3. Marguet C et al Am J Respir Crit Care Med 1999; 159:1533-40

4. Pao CS et al Am J Respir Crit Care Med 2001; 163:1278-82

Wheezing phenotypes –continued

• Chronic lung disease of prematurity

Response to ICS unproven

• Wheezing related to CF• Wheezing related to CF

Response to ICS unproven 1

• Obesity related wheeze

No more atopic than healthy community 2

1. Balfour-Lynn IM Thorax 2002; 57:742-8

2. Schachter LM et al Thorax 2001; 56:4-8

Evaluation of wheeze

Problems with reported symptoms

• Some parents confuse symptoms1,2

• Recollection of symptoms changes3

• Parents’ and children’s reports differ4• Parents’ and children’s reports differ4

• No translation of ‘wheeze’ in some languages5

1. Lee et al 1983 BMJ; 286: 1256-8

2. Fuller et al 1998 ERJ; 12 (2): 426-31

3. Peat et al 1992 Chest; 102: 153-7

4. Wong et al 1998 Arch Dis Child; 78: 379-80

5. Pararajasingam 1992 Thorax; 47: 529-32

Do parents know what wheeze is?

• How do you know your child is wheezy?

>20% parents of wheezers do not mention sound 1

• Videos of stridor, wheeze and nasal congestion

Disagreement between what audio-videos show and what

parents call the noise in 20% 2

1. Cane RS et al Arch Dis Child 2001; 84:31-4

2. Young B et al Arch Dis Child 2002; 87; 131-4

What is ‘doctor-diagnosed’ asthma?

• A term used in epidemiology

• Never validated

• Do children with ‘doctor-diagnosed’ asthma • Do children with ‘doctor-diagnosed’ asthma (DDA) have the same attributes as those with ‘doctor-observed’ wheeze (DOW)? 1

1. Chan EY et al ERS abstract 2003

2. Lowe L BMJ 2004 328: 1026-7

Attributes of DDA and DOW

• Skin-prick test positivity 1 Total IgE SD score

(schoolchildren)Controls 19% -0.04

DDA 51% 0.4

DOW 82% 1.25

• Specific airway resistance 2• Specific airway resistance 2

Controls = DDA < DOW

1.Chan et al In press

2.Lowe et al Arch Dis Child 2004 89:504

Letter• Dear ER doctorThis child’s parents give a history of difficulty in breathing.

I have asked them to bring her up when they next notice it. when they next notice it.

Please could you examine her for upper airway noise and/or wheeze and document this. If she is wheezy please record the response to a bronchodilator and let me know the results.

Any tests?

1. Knowledge of atopic status helps

2. Bronchodilator responsiveness testing has a good diagnostic profile

(80% sensitivity and specificity for previous (80% sensitivity and specificity for previous wheeze)

3. Chest radiography, sweat testing, pH study

and bronchoscopy only for true persistent wheezing

4. Immune deficiencies present with pneumonia not wheezing

60%

80%

100%

Perc

ent

po

sitiv

e

Non-wheezers

Wheezers

40%

60%

80%

100%

Perc

ent

po

sitiv

e

Non-wheezers

Wheezers

SPT positivity to one or more common aeroallergens

0%

20%

40%

0 2 4 6 8 10

Age (years)

Perc

ent

po

sitiv

e

Wheezers

0%

20%

0 2 4 6 8 10

Age (years)

Perc

ent

po

sitiv

e

TotalTotal IgEIgE in 2 in 2 --10 year old children in 10 year old children in

East London East London 11

20%

25%

pro

po

rtio

n in

po

pu

lati

on

Healthy n=253Healthy n=253

Coughers n=87Coughers n=87

WheezersWheezers n=183n=183

0%

5%

10%

15%

-2.5 -2 -1 .5 -1 -0.5 0 0.5 1 1.5 2 2.5 3 3.5 4

z scores for log IgE

pro

po

rtio

n in

po

pu

lati

on

sam

ple

1.Chan E et al,1.Chan E et al, ClinClin Exp Allergy, 2003.Exp Allergy, 2003.

pH Study

• GORD in preschool children with wheeze is evident in 64% of them.

• pH study vs. Fat-laden macrophages ?

Bronchoscopy

• Performed safely

• Yield potentially relevant

informationsinformations

• Structural airway

abnormalitys

• Eosinophilic airway

inflammation

• Bacterial infections

Management of Acute wheezingManagement of Acute wheezing

Medical treatment of moderate to severe bronchiolitis

• Stop feeding– Babies obligate nasal breathers

– Increase work of breathing

– May increase chance of vomiting

– NG tubes increase total airway resistance

– Why block a small hole?

Acute wheeze

– Why block a small hole?

• Do not disturb

• Drugs only have brief value and reserved for MILD disease where feeding is possible Bronchodilators produce modest short-term improvement in clinical features of mild or moderately severe

bronchiolitis. Arch Pediatr Adolesc Med. 1996 Nov;150(11):1166-72.

• Result in tachycardia

• CXR only if need PICU

Ipratropium?• ‘There is not enough evidence to support the

uncritical use of anti-cholinergic therapy for

wheezing infants – under 2 years’

Acute wheeze

Cochrane Database Syst Rev. 2002;(1):CD001279.

….and of pre-school moderate to severe pre-school wheeze

• Smooth muscle now present

• The younger the child the less there is

• No evidence of value of corticosteroids in pre-school child

– But still recommended (prednisolone)

Acute wheeze

– But still recommended (prednisolone)

• Bronchodilators help - the older the child, the better they help

• Can add ipratropium to beta-agonists BUT not useful for non-severe attacks 1

1. AJCCRM 2003;2(2):109-15

Summary - wheeze

• Ask the parent to describe the symptoms

• Try not to use the word wheeze

• If unclear, skin prick test• 16% of preschool non-wheezers SPT positive • 16% of preschool non-wheezers SPT positive

• 43% wheezers positive 1

• 19% of schoolchildren non-wheezers SPT positive

• 80% wheezers are positive

• Diagnostic profile better than bronchodilator responsiveness

• Examine pre-school children when parents think they are wheezy or when they have a cold!

1. Chan et al 2005 Ped Pulmonol In press

Childhood Recurrent Cough

Part 3

childshaheen@yahoo.com

By

Dr Malak Shaheen

Recurrent Isolated Cough

• Persistent isolated cough often confused and treated as asthma1

• Parents know when children are coughing, when it gets better or worse but not by how much 2

• Usually worse at night 2

• Do not lose sleep (parents might) 2• Do not lose sleep (parents might) 2

• Same atopic status as healthy children 3,4

1. Chang AB Arch Dis Child 1999; 80:211-3

2. Fuller P et al Eur Respir J 1998; 12:426-1

3. McKenzie SA et al Eur Respir J 2000; 15:833-8

4. McKenzie SA et al Eur Respir J 2001; 18:977-81

Causes of recurrent cough

• 1. BHR (? Asthma)

• 2. Post nasal drainage

• 3. Aspiration syndroms• 3. Aspiration syndroms

• 4. Recurrent chest infections

• 5. Idiopathic pulmonary hemosiderosis

TotalTotal IgEIgE in 2 in 2 --10 year old children in 10 year old children in

East London East London 11

20 %

25 %

pro

po

rtio

n in

po

pu

lati

on

Healthy n=253Healthy n=253

Coughers n=87Coughers n=87

WheezersWheezers n=183n=183

0 %

5 %

10 %

15 %

-2.5 -2 -1 .5 -1 -0.5 0 0. 5 1 1.5 2 2 .5 3 3.5 4

z scor e s for log I gE

pro

po

rtio

n in

po

pu

lati

on

sam

ple

1.Chan E et al,1.Chan E et al, ClinClin Exp Allergy, 2003.Exp Allergy, 2003.

Summary - cough• Isolated cough unlike asthma

• Most get better in 2 weeks

• Look out for bronchiectasis

• No good treatment • No good treatment

– modest response to high-dose (unlicensed)

fluticasone

– Do not respond to bronchodilator

Pediatric Respiratory

Emergencies

Part 4

Dr. Malak Shaheen

(PhD Pediatrics, MSc Critical Medicine)

Remember!

Not all respiratory distress

caused by respiratory causes.

How to differentiate?

Do you know non respiratory causes?

Remember!

The only way to confirm

RF is to perform Arterial

Blood gases (ABG)Blood gases (ABG)

Summary

Reported wheeze not always reliable

Good evidence that ‘DDA’ based on Good evidence that ‘DDA’ based on reported symptoms includes children without asthma

Investigate !

True or false?

1. Children with isolated cough are non-atopic

2. Inhaled corticosteroids are the recommended treatment for isolated cough

3. 50% pre-school wheezy children are atopic3. 50% pre-school wheezy children are atopic

4. Ipratropium is the drug of choice in the management of bronchiolitis

5. Infants with bronchiolitis should all have a chest radiograph

A 4yo child has night-time cough and no other symptoms

You would tell his parents

1. He is likely to have asthma

2. He is probably allergic2. He is probably allergic

3. He should have a sweat test

4. The cough is likely to improve in the next 3 weeks

5. Anti-reflux treatment is helpful

Further Readings ….

Further Readings ….

Second edition - 2015

Thank YouThank YouThank YouThank You

childshaheen@yahoo.com

Good luck!Good luck!