Wheeze and coughs Flashcards
Cough
“A forced expulsive manoeuvre, usually against a closed glottis with a characteristic sound”
Chronic = daily cough for over 8 weeks
Recurrent = cough for >2wks more than twice yearly
Wheeze
A polyphonic expiratory, high pitched whistling sound due to lower large airway obstruction
Causes of Cough without wheeze
URTI - most commonly viral - most common cause (10% of young children) - unrelated to colds and without wheeze
can also be caused by TB or Sinusitis
Causes of Wheeze without cough
Viral induced wheeze
Mediastinal mass or cancer
Causes of both cough and wheeze
Cystic fibrosis Asthma
Bronchiolitis Pneumonia
Croup GORD
Features of asthmatic wheeze (4,4)
Multi-trigger wheeze - Diurnal variation (nocturnal), exertion, cold air, viral illness
Atopy –> Food allergies, eczema, rhinitis and FH
Features of a viral wheeze
Viral illness prodrome –> develops into wheeze
If under 1yr may be bronchiolitis, if older viral induced wheeze
Risk factors for cough and wheeze
Parental Smoking – biggest single factor - 50% of children <11yrs when both parents smoke
Dampness in home, air pollution, SE status
Allergic responses - house dust mites, pollen, cats or dogs
Asthma treatment ladder for children under 5yrs
Step 1 - Inhaled short acting Beta-2 agonists PRN (salbutamol)
Step 2 - Add inhaled steroids 200-400mcg/day
Step 3 - Add leukotriene R antagonist to steroid or visa versa
Step 4 - Refer to resp paediatrician (if <2yrs consider skipping stage 3)
Complications of viral respiratory Illness
Tonsilitis - painful to swallow leading to dehydration
Obstructive sleep apnoea
Middle ear infection/effusion
Hearing loss and Glue ear
GORD
Commonest in infants and the overweight - occurs after meals and when lying down - sandifer’s syndrome, feeling of ‘globus’ in the throat
Complications –> feeding aversion and strictures
Sandifer’s syndrome
A combination of GORD and neurological movement disorder (spasmodic torticolis, dystonia and hypotonia)
Treatment of the reflux generally leads to remission of symptoms
Tuberculosis in children
Lymph nodes obstruct airways - cause cough
Night sweats and weight loss —> haemophtysis is unlikely in children
Check travel and family history
Cystic fibrosis
Chronic moist cough with phlegm - systemic signs and history
Should now be screen when neonate
Associated with Mec ileus, recurrent chest infections, malabsorption (steatorrhoea, FTT), liver disease. Also: short, DM, delayed puberty, rectal prolapse, nasal polyps, infertility (male) or subfertility (female).
Aspirated foreign body
Especially in younger children
Sudden onset cough or wheeze
Mediastinal causes of wheeze in children
Usually T cell lymphoma most commonly in teenagers with weight loss
Congential causes of cough or wheeze (6)
Tracheobronchomalacia or vascular rings (will give stridor)
Tracheo-oesophageal fistula or Laryngeal clefts (cough after feeding)
Primary ciliary dyskineasia or psychogenic cough
Physical examination of wheeze (6)
Finger clubbing or chest wall deformities (pectus excavatum or caraium )
Check air entry – equal?, normal or reduced? Wet or dry crepitations, resonance, Wheeze (general or localised)
Signs of respiratory distress (7)
Increased respiratory rate Head bobbing
Recession (subcostal or intercostal) Expiratory grunting
Nasal flaring Tracheal tug
Signs of tiring
Facial Signs of allergy
Allergic salute (wiping the nose upwards) Allergic shiners (dark circles under the eyes due to sinus congestion) Dennie-Morgan folds (extra suborbital folds due to oedema in atopic dermatitis)
Glue Ear
Otitis media with effusion (see ENT deck)
ENT exam in children
Big tonsils compared to adults
Mouth breathing – suggest nasal obstruction (polyps, Nasal haematoma, swollen turbinates)
Asthma treatment ladder for children 5-12yrs
(Step 1+2 as <5s but steroid 200-800mg)Step 3 - Add long-acting B2 agonist.Step 4 - Steroid to 2000mcg + leukotriene R antagonist, theophylline, consider adding B2 agonist tablet. Step 5 - Add daily steroid tablet - optimise other drugs to minimise steroid tablets
Differentials for chronic cough
Asthma or Rhinosinusitis (upper airway cough syndrome)
Protracted bacterial bronchitis or Post-infectious cough
GORD or other (10%)
Asthma
Cough with wheeze + chest tightness
If cough without wheeze = cough variant asthma –> nocturnal exacerbations, triggered by exercise and cold air
Decreased exercise tolerance
Rhinosinusitis
Nasal obstruction or congestion - rhinorhoea, sneezing, purulent nasal discharge, post-nasal drip, repetitive throat clearing
Protracted bacterial bronchitis
Bronchoalveolar lavage –> check cytology for neutrophilia, culture (Hib - 50%, moraxella catarrhalis - 20%, strep pneumoniae 30%
Should response to antimicrobials within ten days
Post infectious cough
Transient airway hyper-reactivity and inflammation
Due to: Viruses (RSV and Parainfluenza) or Bacteria (chlamydia pneumonia or pertussis)
Management of non-specific cough
Watchful waiting up to 8 weeks
In many cases removing smoking is enough
Management of rhinosinusitis
Allergen avoidance
Trials of long-acting anti-histamines +
Intranasal steroids
Management of protracted bacterial bronchitis
Sputum culture before treatment
If pertussis start a macrolide antibiotic early (end in mycin)
Management of GORD
May not require empirical treatment - if pH shows reflux start treatment on full dose PPI for 1-2mths (if responds switch to low dose, if not double dose). Otherwise consider prokinetic or H2 antagonists –> consider fundoplication
Management of aspirated foreign body
Urgent bronchoscopy
Causes of wheeze in under 5s
Typical –> transient early, nonatopic/viral or atopic wheeze.
Atypical –> GORD, congenital abnormalities, cystic fibrosis, cardiac disease, Foreign bodies, TB, bronchopulmonary dysplasia, immunodeficiency, primary ciliary diskineasia, Mediastinal mass/Ca
Transient early wheeze
Starts in infancy - up to 3yrs
Related to reduced pulmonary function up to 16yrs
RFs –> prematurity, male, exposure to other children, exposure to tobacco smoke
Non-atopic wheeze
recurrent viral infections - normal lung function but with intermittent airway obstruction
Persistent atopic wheeze
Discrete attacks with symptom free intervals - worse at night
FH of asthma or atopy – Elevated IgE and blood eosinophilia
responds to bronchodilators and corticosteroids – early form/develops into asthma as airways remodel
Asthma phenotypes (5)
Concordant disease - Benign asthma or Early onset asthma
Discordant symptoms – obese non-eosinophilic or early symptomatic
Discordant inflammation - Eosinophilic inflammation predominant
Obese non-eosinophilic asthma
Late onset, in obese females, high symptom expression compared to eosinophil infiltration
Benign asthma
Mixed middle aged patients
Well controlled symptoms and inflammation
Benign prognosis
Early onset asthma
Standard Asthma - concordant levels of symptoms, inflammation and airway dysfunction
Early symptomatic asthma
Early onset with atopy in patients with normal BMI
Very high symptom expression compared to the level of inflammation
Eosinophilic inflammation predominant asthma
Late onset with a male preponderance - Few daily symptoms but active eosinophilic inflammation
Infections in cystic fibrosis
Staph aureus
Pseudomonas aeruginosa
Burkholderia (pseudomonas) cepacia
Aspergillus
High white cell count in child with respiratory issue
Neutrophilia- pneumococcus
Lymphocytosis- pertussis
