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.