United Airways Module

A Module For The Practicing PediatricianUnder The IAP Presidential Action Plan 2018

TeamDesignation Name

Chairperson Dr Santosh SoansCo-chairperson Dr Sachidanand Kamath IAP Coordinator Dr Bakul ParekhNational Coordinator Dr Jose OusephJoint National Coordianator Dr Salim A KhatibNational Scientific Convener Dr S Balasubramanian Jt. National Scientific Convener Dr S. Nagabhushana

Zonal ConvenersSouth Zone Dr Krishna Mohan RWest Zone Dr Rajendra C DevNorth Zone Dr Ashwani Kumar KamdarEast Zone Dr Santanu DebCentral Zone Dr Paka R Rajender

Contributors• Dr Barnali Bhattacharya• Dr Basavaraj• Dr Dhiren Gupta• Dr Ira Shah• Dr Indu Khosla• Dr Gautam Ghosh• Dr NC Gowrisankar• Dr Jagdish Chinnappa• Dr Jagdish Dhekne• Dr Jeeson Unni• Dr E Mahender• Dr Prabhakar murthy

• Dr Srinivas Gunda• Dr Subba Rao SD • Dr Sumanth Amperayani• Dr Sushil K Kabra• Dr Subramanya NK• Dr Salim A Khatib• Dr Tanu Singhal• Dr Thangavelu S• Dr Upendra K• Dr Vijay Yewale• Dr Vineet Sehgal

• Dr Pankaj Vaidya• Dr Pallab Chatterjee• Dr Pritish Nagar • Dr Palaniraman R• Dr P Ramachandran• Dr Sanjay Natu• Dr Sanjay Bafna• Dr Somu Sivabalan• Dr Sharath Balaji• Dr Shishir Modak• Dr Shivakumar• Dr Srikanta JT

Under Five Wheezing

Learning Objectives• Causes of Under-Five wheezing

• Identify the present severity by clinical evaluation

• Evidence based individualized management

and close follow up

Food for Thought

• Almost 50% of children wheeze in their first 3 years

• But only 20% will experience continued wheezing, thereafter

• Ref:Martinez et al. N Engl J Med 1995; 332:133-8

Three Basic Questions ?• Is it Asthma?

• Does he need Controllers? (if so, which one and for how long?)

• Can We predict long term outcome?Z

Baby J• 8 month old baby girl, • 33 weeker ventilated at birth• Nasal discharge for 4 days• Respiratory distress for 1 day• Refusal to feed

• Anything else in history?

Baby J• Family history - Father smoker; • Elder sibling currently suffering from cold

• On examination - RR 70/min; temp 38 C• SpO2 - 86% in room air• Subcostal indrawing present• B/L scattered Wheeze and crackles present

Chest X-ray

Possibilities?

Diagnosis Acute Bronchiolitis

Acute Bronchiolitis

• First episode in a baby, 1 - 24 months• In clusters (during rainy seasons and winter)• Start with URI; fever & coryza• Followed by lower respiratory tract signs & symptoms on day 2-3,

peaks by day 5-7• Usually self limiting; resolves over 7-10 days Sometimes -

symptoms may persist up to 4 weeks

Treatment of Bronchiolitis• Bedrock of treatment - supportive care

• Adequate hydration - IV fluids, Oro-gastric feed• Respiratory support• Nasal saline drops, nasal suctioning• Supplemental Oxygen - maintain SpO2 > 92%• Monitor for disease progression

Treatment of Bronchiolitis• Bronchodilators

• Clinical practice guidelines of AAP and SIGN recommend that bronchodilators NOT be used routinely in management

• Adrenaline - 0.1-0.3 mL/kg of 1:1000 adrenaline diluted in 3 mL normal (0.9%) salineIf no clinical response is evident within one hour, discontinue

• If definite response to Adrenaline is found and if hospitalization indicated ➔ continue as needed every 4-6 hrs. until the child clinically improves

• Nebulized hypertonic saline - Has shown promise as an alternative option

The majority of studies are with 3% saline and some with 5% saline, either alone or in combination with Adrenaline

Baby R

• R, who is 1 year old , has recurrent episodes of wheeze every month

• Each episode starts with fever, cold and running nose

• She attends a crèche as both parents are working

• Anything else in history?

Continued...• Each episode lasts for around 10 days• Normal during the intervening period• No family history of atopy/asthma. Father smoker• On examination - Active, afebrile• RR 55/min, SpO2 96% in room air• Nasal congestion with clear discharge• B/L scattered wheeze present

Possibilities?

What’s the Diagnosis?

• What is wrong ? ask her parents…

• Is it ‘Asthma’? exclaims her mother…

Fundamentally

• From the therapeutic and prognostic standpoint, preschool wheezing is not ONE uniform entity

• Instead, population of preschool wheezers represent a mixed bag of various phenotypes

• Further, some can cross over with time

Are Under 5 Children Different??

Episodic (Viral) Wheezer

• Discrete episodes with viral fever / URTI• Well between episodes• No personal / family history of atopy

• Management• Inhaled bronchodilator as necessary

Baby R presently fits in to this category

Management of Episodic (Viral) Wheeze• Intermittent or Episodic wheezing of any severity may represent

• an isolated viral – induced wheezing episode,

• an episode of seasonal or Allergen induced asthma

• unrecognized uncontrolled asthma.

• The initial treatment of wheezing is identical for all these

• SABA every 4 to 6hrly as needed for one or more days until symptoms disappear

Management of Episodic (Viral) Wheeze• Controllers – Inhaled or oral

• Inhaled Steroids – 1. Uncontrolled respiratory symptoms2. Frequent wheezing episodes( > 3 episodes in a season)3. Less frequent but more severe viral induced wheeze4. associated risk factors of asthma present

• Oral steroids – • Generally reserved for atopic wheezing infants thought

to have asthma that is refractory to other medications 

when in doubt ……

“If diagnosis of asthma is in doubt and inhaled SABA therapy needs to be repeated frequently, more than

every 6 to 8 weeks,

a trial of regular controller treatment should be considered to confirm

whether the symptoms are due to asthma”

Does LTRA help?

• With severe (needing hospital care) or frequent episodes (> 1/month)

• Consider LTRA as the second option• the first option being ICS

GINA 2015

Baby R continued...• Was advised inhaled salbutamol prn along with saline nasal

drops• Parents stopped sending her to the crèche• She responded well, only to return after 18 months• She is now going to school, but is still suffering from

recurrent episodes of wheeze, not always associated with cold or fever

• She is not completely well between episodes

The Saga Continues…..• She coughs on running and laughing, and refuses

to play with other kids as she did before• Also complains of tightness of the chest and has

disturbed sleep• On examination

• Active, alert. RR 60/min• SpO2 - 95% in room air• Bilateral scattered wheeze

Possibilities?

What have We understood so far ?

Symptom Based

Time Based

What do we Know now ?

Do Preschool Wheeze Phenotypes change over a period of Time??

The transient value of classifying preschool wheeze into episodic viral wheeze and multiple trigger wheeze

Acta paediatr 2010;56-60

Probability of Asthma Diagnosis or Response to Asthma Treatment in Children ≤5 years

Quantifying Severity and tailoring Management

Cough, Wheeze, Heavy breathing lasting < 10 days during URI

Cough, Wheeze, Heavy breathing lasting > 10 days during URI

Cough, Wheeze, Heavy breathing lasting > 10 days during URI

2-3 episodes per year

> 3 episodes per year > 3 episodes per yearSevere episodes night worsening

Asymptomatic in between

Occasional symptoms inbetween

Frequently symptomatic during playing, laughing crying

Family h/o atopy present

GINA 2015

In SummaryUnder 5 Wheeze

Episodic Viral Wheeze

SABA

Severe and Frequent Symptoms

SABA + ICS ?LTRA

Seasonal Allergic Wheeze Asthma

Classify severity & manage

Asthma Mimics

Investigate

Will Baby R ever qualify for being called as “Asthma” ?

What are features suggesting asthma in children ≤5 years

• Cough• Wheezing• Difficulty or heavy or shortness of breath• Reduced activity• Past or family history of atopy• Therapeutic trial with low dose ICS and as needed

SABA

GINA 2015

Factors associated with Progression from Infantile Wheezing to Childhood Asthma

• Allergen sensitisation (esp. ≤ 3 years)

• Parent with atopy and / or asthma

• Atopic dermatitis

• Wheeze onset after age 2 years

• Hospitalisation for RSV bronchiolitis in the first year of life

Baby P• 10 months old

• Brought with severe breathing difficulty

• Treated in local Nursing Home with iv fluids, iv antibiotics,

iv hydrocort, salbutamol nebs, budesonide nebs

• Anything else in history?

Baby P

• H/o persistent subcostal indrawing and noisy breathing

that started with a cold from 15 days of life

• Frequent vomiting and feeding difficulty

• Normal birth history

• No significant family history of atopy

• On inhaled Salbutamol and Budesonide since then

Profile• Active, afebrile; responding to stimuli • RR 80/min; • Suprasternal & subcostal indrawing+• B/l wheeze+; conducted sounds+• SpO2 96% in 3 litres oxygen by head box • Investigations WNL• What do you think?• What will you do now?

Bronchoscopy

• Showed presence of Tracheomalacia

Compare with normal looking trachea

What can mimic Wheezing?What can co-exist with

Asthma?

Some more Mimics……CLE FB GER

Some more Mimics……

Endobronchial TB

Infections• Recurrent resp. infections• Chronic rhino-sinusitis• Tuberculosis • Foreign body• Aspiration syndromes• Vocal cord dysfunction• Congenital problems

Others• Tracheomalacia• Cystic fibrosis• Immune deficiency• Congenital heart disease• Primary ciliary dyskinesia• Bronchopulmonary dysplasia

Points in History• Is it really wheeze?• Upper airway symptoms prominent; More noise and no cough -

Asthma unlikely• Symptoms beginning from 1st day of life• Sudden onset of symptoms• Chronic moist cough / sputum production• Irritable while feeding, arches back and vomits• Features of Systemic illness / immunodeficiency• Continuous unremitting symptoms• What happens during sleep?

Physical Examination

• Clubbing, weight loss, failure to thrive• Upper airway disease, tonsils, rhinitis• Unusually severe chest deformity• Fixed monophonic wheeze• Stridor (monophasic or biphasic)• Asymmetrical signs• Signs of cardiac or systemic disease

Pearls• Younger the child - Greater the possibility of alternate

diagnosis• Mimics & co-morbids - tend to confuse• Diagnosis is always clinical• Investigations - To r/o alternate diagnosis• Therapeutic 3 months’ ICS trial - confirms the diagnosis • Avoid triggers• Achieve control & maintain for sufficient periods

Beware!! (of the Mistakes we make)

• Noisy breathing wheezing

• Nebulization is not only the treatment modality for all

types of cough

• What if wheezing child does not respond to

bronchodilators?

• Inability to control recurrent wheezing - Think of alternate diagnosis

Take Home Messages

• Make sure it is wheeze (both by History & Exam)• Remember - Phenotypes are not 'water-tight compartments' - they

can change over time • There are as yet no disease modifying therapies• Consider atypical wheeze in child with unusual symptoms or poor

response to treatment • Investigate to rule out alternate diagnosis• Give your time to arrive at diagnosis and to convince parents

Thanks for the academic grant from