2. Wheeze
A high-pitched whistling/musical sound produced by
the passage of air through narrowed airways/ bronchi
Louder during expiration
A manifestation of lower respiratory tract obstruction
Site of obstruction may be anywhere from the
intrathoracic trachea to the small bronchi or large
bronchioles
Sound is generated by turbulence in larger airways that
collapse with forced expiration
3. Wheezing in Children
Episodic wheezing and cough are common in children
Infants and young children (<3 years) are especially
prone to wheezing
5. Wheeze
Acute
Inhaled foreign body
Acute infection
Acute allergic reaction
Recurrent
Respiratory System
Asthma
Other causes*
• Non-respiratory system
Heart failure (left to right shunts)
GERD (milk inhalation)
6. Categories of Wheezing in children
<5 years
Transient early wheezing
Persistent early-onset wheezing
Late-onset wheezing
7. Transient early wheezing
Result from small airways being obstruct due to
inflammation secondary to viral infections.
↓ lung function from birth
Risk factors: mother smoking during and/ or
after pregnancy and prematurity
Common in ♂
Resolves by 5 years old
8. Non atopic wheezing
Have normal lung function in early life
Lower respiratory illness due to viral infection
leads to ↑ wheezing during the 1st 10 years of life.
cause less severe persistent wheezing
symptoms improve during adolescence
9. Ig E-mediated wheezing
(atopic asthma)
Lung function – normal at birth
Recurrent wheeze develops with allergic sensitisation
↑ blood Ig E & positive skin prick tests to common
allergens
Persistence of symptoms & ↓ lung function later in
childhood.
Risk factors:
Positive family history
Allergy
History of eczema
10. Other causes of recurrent wheeze
in infancy
Recurrent aspiration of feeds
Cystic fibrosis
o Inhaled foreign body
Congenital abnormality of lung, airway or heart
Idiopathic
Cow’s milk protein intolerance
11. History Taking
Wheeze
Age of onset
Duration-Acute or recurrent
Precipitating factors
URTI symptoms
Contact with URTI patient
Triggers for asthma - ( A,V,C,D,E,F)
History of atopy
Associated symptoms
Rapid breathing
Cough- dry or productive? Sputum colour?
Chest tightness
Nausea or vomiting
Cyanosis
12. Pattern of symptoms
Daytime/ nocturnal symptoms
Exercise induced
Severity
On any medication? Types?
Relieved with medication
Restriction of daily activities
Sleep disturbances
13. Systemic Review
General condition - LOA, LOW
Atopy - angioedema, allergic rhinitis, allergic
conjunctivitis, eczema, urticaria
Past Medical History
Number of admission to the hospital
Number of admission due to similar problem
Last admission due to similar problem
Duration of stays
Medication given and discharge medication
History of prolonged URTI symptoms
14. Birth History
Antenatal: intrauterine infection
Intrapartum: Prematurity
Postnatal: Prolonged labour, NNJ, congenital pulmonary disease
Immunization History
Family History
Asthma
Atopy
CHD
Cystic fibrosis
Social History
School performance
Daily activities
Social interaction
Anyone smoking at home
Location of house
Environment condition: Pets, flower, dust
Drug and Allergy History
15. Physical Examination
General condition: alert, conscious, drowsiness, irritability
Signs of respiratory distress
Sitting propped up
Shortness of breath
Use of accessory muscles
Audible wheeze
Central cyanosis
Vital signs
Anthropometry measurements
O2 therapy: : nasal prong, face mask, high-flow
mask, nebulizer
Speech: sentences, phrases or words
21. Asthma (Protocol)
Chronic airway inflammation leading to ↑ airway
responsiveness that leads to recurrent episodes of
wheezing, breathlessness, chest tightness and
coughing particularly night / early morning.
often associated with widespread but variable
airway obstruction that is often reversible either
spontaneously or with treatment.
26. Tests for Diagnosis and Monitoring
of Asthma
Spirometry – FEV1 and FVC
PEFR
To confirm the diagnosis of asthma ( improvement of >15%
after bronchodilator)
useful for assessing the severity of asthma
response of the patient to therapy
Normal value are available & relate to height
To identify environmental (including occupational) causes of
asthma symptoms
Skin prick test with allergens
Exercise challenge
32. Criteria for Admission
Failure to respond to standard home treatment
Failure of those with mild or moderate acute asthma to
respond to nebulised β2-agonists
Relapse within 4 hrs of nebulised β2-agonists
Severe acute asthma
39. Upon Discharge
Review asthma medications
Provide Asthma Action Plan
How to recognize worsening asthma
How to treat worsening asthma
How & when to seek medical attention
Schedule regular follow-ups to monitor asthma control
40. Asthma Education
To provide the person with asthma, their family and other
caregivers with suitable information and training so that they
can keep well and adjust treatment according to a medication
plan developed with the health care professional
Asthma Education should include :
What is asthma?
Types of treatment available
Drugs – “relievers” & “controllers”
Inhalation devices – how to use them
Trigger factors and how to avoid them
Personal Asthma Action Plan
41. Prevention
Identifying and avoiding the following common
triggers may be useful
Environmental allergens (house dust mites, animal
dander, insects, mould and pollen)
Cigarette smoking
Respiratory tract infections
Food allergy – uncommon trigger, occurring in 1-2% of
children
vigorous exercise –should not restrict
42. Assessment of level of control
Management based on control
Drug therapy –types,dosages,delivery
43. Assessment of severity
Classification based on frequency, chronicity and severity of
symptoms
Management according to severity:
Daytime Limitatio Nocturnal Need for Lung Exacerba
symptoms of symptoms/ reliever function tions
activites awakening tests
s
Controlled None None None None None None
All of the
following:
Partly >2 / week Any Any 2/week <80% ≥1 a year
controlled predicted
any measure or
present in
personal
any wk
best
Uncontroll ≥3 features of partly controlled asthma present in any week 1/week
ed
44. Management of Chronic Asthma
Goal:
Achieve and maintain control of symptoms
Maintain normal activity levels, including exercise
Maintain pulmonary function as close to normal as
possible
Prevent asthma exacerbations
Avoid adverse effects from asthma medications
Prevent asthma mortality
46. Chronic asthma
NOTE:
1. Patients should commence treatment at the step most
appropriate to the initial severity.
A short rescue course of prednisolone may help establish
control promptly.
2. Explain to parents and patient about asthma and all therapy
3. Ensure both compliance and inhaler technique optimal before
progression to next step.
4. Step-up; assess patient after 1 month of initiation of treatment
and if control is not adequate, consider step-up after looking
into factors as in 3
5. Step-down; review treatment every 3 months and if control
sustained for at least 4-6 months, consider gradual treatment
reduction.
55. Monitoring
Assessment during follow-up
Assess severity
Response to treatment
Interval symptoms
Frequency and severity of acute exacerbation
Morbidity secondary to asthma
Quality of life
PER monitoring on each visit
Compliance
Frequency, technique, reason and excuses
Education
Technique, factual information, written action plan, PEF monitoring
may not be practical for all asthmatics but is essential especially for
those have poor perception of symptoms and those with life
threatening attacks
56.
57. References
Pediatric Protocols
Illustrated Textbook of Pediatric
GINAReport 2009
GINA_Under 5 Report 2009
Nelson Textbook of Pediatric 18th Edition, chapter 381
Notas do Editor
Continuous ossilation,E>I coz airway nlly dilate during I,,absence in severe cond:--therefore poor guide to severity
Airway narrowing start fm inflamm;of bronchus/bronchiolesaccumula ;of cells(N,L,E)congestion/oedemanarrowing of wall of bronch,hypertrophy of s/m ,cell produce↑mucous,plug formation
Older age- Pul parasitic infestation,Hypersensitivitypneumonitis,T.B,Immunedef,Pciliarydyskinesia
Dry& moist =p’ia,Nocturnal = asthma
Evidence of poor wt gain suggests Immune def,CF and GOR
Chronic inflamm;is precipitated by E and G .Bronchoconstriction is strongly linked to airway hyper-responsiveness to *-irritentexposure,cold/dry air ..etc..Inflamm mediators – E,Cytokines,chemokines, NK ,mast cells(proinflamm cells)inflamm process
LFT=spirogram(FEV1,FVC,..)PEF,Flow-volume-loopFEV1/FVC =0.8(80%) useful in determin:ofobst and restrict d/sPEFR morning /evening variation >20% is consistent with asthma,morning dip is s/- of (worsening)uncontrolled asthma
Spirometric findings
DX,Severityass,Response to Tx, Compliance,PEFR diary
Attend school regularly,can participate in sport,sleep well without disturbance