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Wheezy babyWheezy baby
Dr Malena Cohen-CymberknohDr Malena Cohen-CymberknohDep. Of Pediatrics, Ped. Pulmonology and CF Dep. Of Pediatrics, Ped. Pulmonology and CF
CenterCenter
Hadassah Medical CenterHadassah Medical Center
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What is wheezing?What is wheezing?
Best characterized as a continuous, “musical” sound
Most often heard on expiration, but it may occur in both phases of respiration
The sound is the result of flow limitation in large or medium-sized airways
Obstruction of the airways may be due to intraluminal or extraluminal causes
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Causes of wheezingCauses of wheezingIntraluminal obstruction, caused by:• smooth muscle constriction• mucosal edema• hypersecretion of mucus or cellular infiltrate
airway inflammation or infection• foreign body aspiration• tumors
Extraluminal obstruction, caused by external compression by:• vascular structures • enlarged lymph nodes• pulmonary cysts• tumors
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What is wheezing?What is wheezing?
A common symptom that is typically associated with asthma, but…..
Not everyone who wheezes has asthma!
Occurs when lower airways are narrow or constricted- breathing feels difficult and there is a whistling sound in the chest on breathing out
Very common in the first few years of life: infant's airways are small and a respiratory tract infection
For most children wheezing is temporary and does not mean that they have asthma
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Causes of wheezing in childhoodCauses of wheezing in childhood
AcuteAcute
Asthma
Bronchial edema/hypersecretion- Infection (bronchiolitis, ILD, pneumonia)- Inhalation of irritant gases or particulates- Increased pulmonary venous pressure- Cholinergic drugs
Aspiration- Foreign body- Gastric contents (reflux, H-type TEF)
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Causes of wheezing in childhoodCauses of wheezing in childhoodChronic or recurrentChronic or recurrent
Reactive airway disease Hypersensitivity reactions- ABPA Dynamic airways collapse
- Bronchomalacia, tracheomalacia, vocal cord dysfunction Airway compression by mass or blood vessel
- Vascular ring/sling- Anomalous innominate artery- Pulmonary artery dilatation (absent pulmonary
valve)- Bronchial or pulmonary cysts- Lymph nodes or tumors
Aspiration- Foreign body- GER (gastroesophageal reflux)- TEF (repaired or unrepaired)
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Causes of wheezing in childhoodCauses of wheezing in childhood Chronic or recurrent- cont’dChronic or recurrent- cont’d
Bronchial hypersecretion/failure to clear secretions- Bronchitis- Bronchiectasis (CF, PCD, Immunodeficiencies) - Vasculitis- Others: lymphangiectasia, Alpha-1-antitrypsin
def.)
Intrinsec airway lesions- Endobronchial tumors- Endobronchial granulation tissue- Bronchial or tracheal stenosis - Bronchiolitis obliterans- Sequelae of BPD- Sarcoidosis
Congestive heart failure
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Causes of wheezing in childhoodCauses of wheezing in childhood
Chronic or recurrentChronic or recurrent
Congenital anomaliesCongenital anomalies::
•Tracheomalacia•Bronchomalacia•Vascular ring•Vascular sling•Anomalous innominate artery
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TracheomalaciaTracheomalacia
The walls of the trachea are floppy,instead of being rigid
Symptoms:
Breathing noises, may change with position and improve during sleep
Get worse with coughing, crying, feeding, or upper respiratory infections
High-pitched breathing, noisy breaths
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BronchomalaciaBronchomalacia
Weak cartilage in the walls of the bronchial tubes, in children <6 months
There is collapse of a main stem bronchus on expiration
Two types of bronchomalacia: - Primary- due to a deficiency in the cartilaginous rings - Secondary- may occur by extrinsic compression from an
enlarged vessel, a vascular ring or a bronchogenic cyst
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Vascular ringVascular ring
Is a congenital condition in which the anomalous configuration of the arch and/or associated vessels surrounds the trachea and esophagus, forming a complete or incomplete ring around them
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Vascular slingVascular sling
The left pulmonary artery arises from the right pulmonary artery, crossing to the left side, and insinuates itself between the trachea and esophagus, forming a 'sling' around the trachea
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Innominate arteryInnominate artery
An artery that arises from the arch of the aorta and divides into the right subclavian and right carotid arteries. (also called brachiocephalic artery, brachiocephalic trunk)
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It appears to originate from a more It appears to originate from a more distal and leftward position on the arch distal and leftward position on the arch than normalthan normal
As it takes its course from left to right, As it takes its course from left to right, it crosses the trachea anteriorly and in it crosses the trachea anteriorly and in doing so may produce compression of doing so may produce compression of the tracheathe trachea
Anomalous innominate arteryAnomalous innominate artery
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Other common causes of Other common causes of wheezingwheezing
Acute:Acute:BronchiolitisBronchiolitis
AsthmaAsthma
GERGER
Foreign body aspirationForeign body aspiration
Chronic:Chronic:BronchiectasisBronchiectasis
Interstitial lung diseaseInterstitial lung disease
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BronchiolitisBronchiolitis
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BronchiolitisBronchiolitis
Usually affects children under the age of 2 y, with a peak age of 3 to 6 months
Is seasonal and appears more often in the fall and winter months
It is caused by a virus (RSV most common). Other viruses: hMPV, influenza, parainfluenza, coronavirus, adenovirus and rhinovirus
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Bronchiolitis- Bronchiolitis- contcont..
It starts like a cold, with a runny nose, fever and mild cough
Wheezing and tachypnea are common
Most cases are mild and get better without treatment, but in young babies can be severe, occasionally requiring hospitalization
Treatment: supportive therapy, inhalations with HS, (epinephrin, steroids, β2 agonists???)
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AsthmaAsthma
Most common chronic disease in childhood
High prevalence (more than 10% in <18yrs.)
Asthma exacerbations are a major cause of morbidity for patients of all ages
80% of asthmatics develope symptoms before the age of 5 years
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AsthmaAsthma
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Never wheezed51%
Transient 20%
Persistent 14%Late
15%
Never wheezed by age of 6y
Transient: wheeze <3y,no wheeze by 3yPersistent: wheeze <3y,wheeze at 6yLate: no wheeze <3y,wheeze at 6y
Martinez et al. NEJM 1995
n=826
Asthma and wheezing in first 6 Asthma and wheezing in first 6 yearsyears
most likely to experience asthma- like symptoms that persist into adolescence and adult life, particularly those with atopic features
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Viruses are detected in up to 85% of Viruses are detected in up to 85% of wheezing exacerbations:wheezing exacerbations:
RhinovirusRhinovirus Respiratory syncytial virus (RSV)Respiratory syncytial virus (RSV)CoronavirusCoronavirusInfluenza virusInfluenza virusParainfluenza virusesParainfluenza viruses
Seasonal correlations between rates of Seasonal correlations between rates of upper respiratory infections (URIs) and upper respiratory infections (URIs) and hospital admissions for asthmahospital admissions for asthma
Viral infection-a common cause of Viral infection-a common cause of wheezing exacerbations in childrenwheezing exacerbations in children
Johnston SL et al. BMJ 1995;Johnston SL et al. AJRCCM 1996;Pattemore PK et al. Clin Exp Allergy 1992
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Asthma exacerbation- Asthma exacerbation- most important triggersmost important triggers
Viral infections (85%)- URTI
Drugs-aspirin, blocker
Irritants-smoking, air pollution
Allergy-cat, dog, cockroach
Exercise
Weather
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Mendelson (1946) was first to associate respiratory disease as a consequence of GER
He described an “asthma-like” syndrome following GER and aspiration of acidic gastric contents during the induction of obstetric anesthesia
Gastroesophageal Reflux (GER)
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Gastroesophageal Reflux (GER)Gastroesophageal Reflux (GER)
Normal physiological process in a healthy infants, children and adults
50% infants (0-3 m) and 2/3 old-infants (4-6 m) vomit at least once a day
Prevalence of vomiting decreases dramatically >8 mos. of age
Typically resolved by 18-24 mos. of age, and no evaluation or treatment is necessary
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Complications of GERComplications of GER
1- Vomiting
Parental frustration
Iatrogenic weight loss from limitation on feeding to prevent vomiting
Weight loss/inadequate weight gain from excessive vomiting
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Complications of GER- cont’dComplications of GER- cont’d
2- Esophagitis2- Esophagitis
DysphagiaDysphagia Chest pain, heartburnChest pain, heartburn Irritability/inconsolable crying in infantsIrritability/inconsolable crying in infants Hematemesis, anemia, melenaHematemesis, anemia, melena Sandifer syndromeSandifer syndrome Globus sensationGlobus sensation Barret esophagusBarret esophagus Esophageal strictureEsophageal stricture
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Complications of GER- cont’dComplications of GER- cont’d
3- Respiratory disorders3- Respiratory disorders
Cough, hoarseness, stridor Apnea, ALTE Bronchospasm or wheezing Asthma: can be worsened by GER-
High prevalence of GER in asthma (50%) Recurrent pneumonia (GER + aspirations) Pulmonary fibrosis
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Foreign body aspirationForeign body aspiration
Can be a life-threatening emergency
More frequent: 1-3 years
Local inflammation, edema, cellular infiltration, ulceration, and granulation tissue formation may contribute to airway obstruction, making removal of the object by bronchoscopy more difficult
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Foreign body aspirationForeign body aspiration
•Distal to the obstruction, air trapping may occur
•May lead to:local emphysemaatelectasispost-obstructive
pneumonia
•Other complications:Necrotizing pneumoniaAbscessSuppurative pneumonia Bronchiectasis
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BronchiectasisBronchiectasis
Localized, irreversible dilation of part of the bronchial tree
Airflow obstruction and impaired clearance of secretions
Sputum retained in the dilated areas, cannot being pushed upward
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A group of lung diseases affecting the interstitium of the lung
• alveolar epithelium• pulmonary capillary
endothelium• basement membrane• perivascular tissue• perilymphatic tissue
Interstitial lung disease (ILD)Interstitial lung disease (ILD)
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ILD- Etiology (primary/secondary)ILD- Etiology (primary/secondary)
Idiopathic InfectionToxic (environmental or drugs)InfiltrationAssociation with other
conditions
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Interstitial lung disease (ILD)Interstitial lung disease (ILD)
The term ILD is used to distinguish these diseases from obstructive airways diseases
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ILD- Infectious causesILD- Infectious causes
Bacteria- Mycoplasma, Chlamydia, Legionella, Mycobacterium
Virus- CMV, EBV, RSV, Adenovirus, Influenza, Parainfluenza, Measles
Fungi- Aspergillus, Candida, Histoplasma
Parasite- PCP (Pneumocystis jiroveci), Visceral larva migrans
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ILD- Toxic causesILD- Toxic causes
Environment Inorganic dust (silica, asbestos) Organic dust hypersensitivity pneumonitis (exposition to
birds, pigeons, doves, parakeet-look for pecipitins (Atg-Ab complex)
Drugs Antineoplastic (Cyclophosphamide, Azathioprine, MTX,
Bleomycin) Penicillamine, Gold
Radiation therapy
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ILD- Infiltrative causesILD- Infiltrative causes
Neoplastic diseasesleukemialymphomaLangherans cell histiocytosis
Storage diseasesNieman-PickGaucher
Congestion- Cardiac or renal diseases
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ILD- Radiologic evaluationILD- Radiologic evaluation
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Childhood vs. adult asthma Childhood vs. adult asthma
Childhood asthma• Boys twice as girls• Transient Peripheral airway
resistance
Adult asthma • Women twice as men• Persistent Peripheral + central
airway resistance