dr julian vyas - gp cme north/sat_room7_0830... · pathway gpcme . parental use of terminology is...
TRANSCRIPT
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Dr Julian VyasRespiratory Paediatrician
Auckland
8:30 - 9:25 WS #97: Kids with Wheezing or Reflux?
9:35 - 10:30 WS #109: Kids with Wheezing or Reflux? (Repeated)
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GPCME
Wheeze or Reflux
- in children
Julian Vyas
Respiratory Paediatrician
STARSHIP HOSPITAL
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No Conflicts of Interest to Declare
GPCME
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Who is this?
What did he do?
Paediatric Update GPCME
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what is wheeze?
Definition:A wheeze is a high-pitched, musical, adventitious lung sound produced by
airflow through narrowed airways.
GPCME
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wheeze indicates turbulent i.e. abnormal airflow
through an airway.
Can be:
• acute or chronic
• focal or diffuse
• monophonic or polyphonic
what does “wheeze” mean?
Indicates
different
underlying
pathologies
W final
common
pathway
GPCME
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Parental use of terminology is unreliable
• whistling, squeaking, gasping, abnormal rate or style of breathing, or same as cough (1-5)
• Tokelau (Crane, ISAAC Study) - video questionnaire - “wheeze” also used for SOB, and (6)
cough
1: Elphick, ADC 20012: Michel, ERJ 20063: Elphick ERJ 20004: Cane ADC 20005: Cane, ADC 20016: Crane, ERJ 2003 Elphick, ADC 2001
what is wheeze?
terminology used by parents
to describe noisy breathing
GPCME
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what is wheeze?“Physician diagnosed wheeze”
Murray (2004): wheeze vs iPFT (sRAW) - <4y
• 458 children. 41% Parents reported wheeze in 1st year of life
• sRaw: signif incr in those w Dr confirmed wheeze vs never, or unconfirmed
(p<0.001)
A proportion of parents may have limited
understanding of what medical
professionals mean by the term ‘‘wheeze’’Murray, ADC, 2004, 89, 540
GPCME
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what is wheeze?
Elphick (2004): 2 “experienced” Drs -
compared wheeze heard by steth vs
computerised acoustic analysis• Both could discriminate between wheeze, crackles and
rattle
• W: Convergent Validity k=0.07 (-0.13 to 0.26) - “poor”
• R: CV k= 0.11 (-0.05 to 0.27) - “poor”
• C: CV k= 0.36 (0.18-0.54) - “fair”
• Wheeze: agreement between observers was poor
“stethoscope is unreliable for assessing
respiratory sounds in infants.”
“Physician diagnosed wheeze”
Elphick, ADC, 2004, 89,1059
GPCME
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how common is wheeze?
ALSPAC Study1: 26% of 6265 by 18/12
Tucson Study2: c33% by 3y
50% cumulative by 5y3
1:4 Kiwi kids have “asthma” —> 1:6 Kiwi adults
1. Henderson. Thorax 2008; 2. Martinez. NEJM, 1995; 3. Bisgaard, Ped Pulmonol 2007;
GPCME
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Who is this?
What did he do?
GPCME
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Causes of recurrent wheeze
Wheeze or Reflux
• Pre-school wheeze: VIW vs MTV vs asthma
• Asthma
• GOR ± aspiration
• CSLD/protracted bronchitis/ Bronchiectasis/ CF
• Structural airway disease: malacia, stenosis
GPCME
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Wheeze Phenotypes
MTW
Transient
Persistent
?EVW
GPCME
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Wheeze phenotypes
GPCME
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✴ Viral Induced wheeze: Wheeze during discrete time periods - often assoc with
viral RTI’s; Sx free between RTI’s; ? less ICS responsive.
✴ Multi trigger Wheeze: Wheeze with discrete exacerbations - as per episodic
wheeze; Sx between episodes; other triggers (exercise, smoke, allergens); ICS
responsive.
✴ Asthma: ongoing Sx beyond pre school, ICS responsive, known triggers, FH.
✴ PBB/CSLD/CF/Bx: moist cough, abN CXR when well, failure to
thrive/malabsorption, other sites of infection.
Wheeze Clinical Causes
GPCME
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✴ Reflux: ease of vomiting, hoarse voice, ? snoring, middle ear disease, post-
prandial Sx, Sx when recumbent, empirical response to GOR Rx
✴ Aspiration: cough w swallowing (diff foodstuffs), Sx with eating, assoc w:
✴ dyspnoea
✴ devel delay: CP, Down Sy,
✴ laryngeal abnormalities incl supraglottoplasty for laryngomalacia
✴ neuromuscular disease: Duchenne, SMA etc
✴ (T-O fistula - rare)
GPCME
Wheeze Clinical Causes
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Wheeze from reflux
GPCME
http://www.theasthmacenter.org/images/uploads/image/GERD.gif
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Reflux from wheeze!
GPCME
http://www.hon.ch/OESO/books/Vol_5_Eso_Junction/Articles/art088.html
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✴ Asthma
✴ Recurrent/ persistent cough or wheeze
✴ chronic bronchitis/COPD
✴ Bronchiectasis
✴ IPF/ ILD
✴OSA
✴ BOS - post lung transplant
GOR assoc lung diseases
GPCME
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GPCME
✴ vomits easily
✴ “at risk group” - CP, 213, etc
✴ symptoms when lying down
✴ back arching - Sandifer’s sy.
✴ post prandial symptoms
✴ wheezing without typical asthma provoking factors - exercise cold, viral
URTI etc
✴ associated hoarse voice, stridor/croup,
✴ wheeze doesn't respond salbutamol
✴ NB: response to salbutamol does not refute Dx GOR
Clues towards GOR related Resp Sx
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Investigation
empirical treatment - see later
Ba study:
good sensitivity, poor specificity
neg predictive value low
impedance
GPCME
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Investigation
pH probe: +
predictive 98%, -
predict 50%
? non acid reflux-
? resp Sx more
common with non
acid reflux
GPCME
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Investigation
Impedance
manometry
GPCME
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Treatment:
GOR & VIW/MTW
GPCME
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Which of these was not a previously
recommended asthma treatment?
Stool of Camel or Crocodile
Thorn apple
Linctus of cat’s lung
Powdered millipede
Cigarettes
Squill - flower
Colonic irrigation
GPCME
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Treatment - GORInfants:
feed thickeners🙂
elevate head of cot 🙂 - nocturnal cough
gaviscon 🙂
omeprazole😐
domperidone😐
GPCME
no magic bullet
? start with 3,
wean if gain control
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Treatment - GOROlder children:
elevate head of bed 🙂 - nocturnal cough
gaviscon 🙂
omeprazole 🙂/😐
domperidone😐
macrolides 😐
GPCME
no magic bullet
? start with 3,
wean if gain control
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EVW/MTW:
no cig smoke exposure
? air pollution
? drugs to prevent development of asthma -
not yet
Treatment - VIW
GPCME
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EVW:
prn salbutamol - imps to assess if empirically beneficial
? intermittent leukotriene antagonists - ???
variable outcomes _ some benefits (decr time off day care/
parent work), but not reproducible.
Overall ? trial monteleukast in child with troublesome Sx.
? continue til child better.
Rx - VIW
1. AJRCCM 2007; 2. Ann Allergy Asthma Immunol 2011; 3. J Allergy Clin Immunol 2008; 4. Lancet Resp Med 2014
GPCME
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PHARMAC: SA 1421 July 2015
Treatment
GPCME
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no evidence to support use of ICS in pre
schoolers who do not wheeze
between viral RTI
Rx- ICS for EVW
1. AJRCCM 2007; 2. Ann Allergy Asthma Immunol 2011; 3. J Allergy Clin Immunol 2008
GPCME
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Oral steroids:
Studies - mild episodes - suggest no
benefit for OCS in preschool wheeze who
don't need admission 1,2
1. NEJM 2011; 2. NEJM 2009
GPCME
Rx- EVW
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EVW:
small study 7% HTS + salbut neb.
decr admission rate and LOS, not severity
? palivizumab - cost prohibitive, never tried in low risk
group
Treatment
GPCME
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N child, Hx intermittent wheeze only, well on exam, thriving. No signif morbidity w viral infections - REASSURANCE
Otherwise well, but Hx vomiting, arching, ? GOR; or upper airway disease - INITIAL Rx as per Dx
REFER (Gen Paeds, ENT) IF NO RESPONSE
Pragmatic approach1
Bush et al, BMJ 2014, 348
GPCME
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GPCME
Well child with recurrent wheeze only with viral infection - TREAT
Well child with recurrent wheeze w infection and at other times- TREAT
Pragmatic approach1
Bush et al, BMJ 2014, 348
Significant history:
cough <1/12, wet, chronic, sudden onset, continuous
clubbed, chest deformity, stridor, fixed wheeze, other sites of infection, systemic
disease - INVESTIGATE ? REFER
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Well child with wheeze only with viral infection
Well child with wheeze w infection and at other times
Pragmatic approach1
Bush et al, BMJ 2014, 348
GPCME
EVW: prn B2,
consider monteleukast - reassess after 4-8 w
No better- stop
consider alt DDx incl MTW, and other res disease
Acute: prednisone if needed admission/ of benefit previously
MTW: prn B2,
consider ICS - reassess after 4-8 w
No better- stop
consider alt DDx incl EVW, and other res disease
Acute: prednisone if needed admission/ of benefit before
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?GOR - If no better - revisit Dx, Refer/ seek advice.
? EVW/MTW - if no better stop Rx, DONT ESCALATE - consider alt Dx - ? refer as per
severity / are of Sx.
But…if wheeze returns/increases/return on cessation, restart and consider escalation of
treatment after further 4w Rx.
If continuing Inhaled Rx - aim over time for lowest dose for Sx control.
Avoid nebulisers for either wheeze phenotype
Pragmatic approach
GPCME
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EVW vs MTW• empirical b2’s
• no ICS for EVW
• consider monteleukast
• review and reassess
Dx/Rx
SUMMARY
GPCME
GOR• empirical Rx:
• thickeners
• raise cot/bed
• gaviscon
• omeprazole
• (? domperidone)
• Reassess Dx
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Questions
Stool of Camel or
Crocodile
Thorn apple
Linctus of cat’s lung
Powdered milipedes
Cigarettes
Squill - flower
Colonic irrigation
GPCME
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Answers
Rene Laennec.
invented the Stethoscope
Homer.
Iliad where first use of term
“Asthma”. Means “gagging painfully”
Stool of Camel or CrocodileThorn appleLinctus of cat’s lung Powdered milipedesCigarettesSquill - flowerColonic irrigation foxes lung
GPCME