LMCC Review Lecture Pediatric Respiratory Medicine

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LMCC Review LecturePediatric Respiratory
Medicine

• Joe Reisman MD, FRCP(C), MBA
• Pediatric Respirologist
• Chief of Pediatrics, CHEO
• Professor and Chairman, Department of Pediatrics
• Faculty of Medicine, University of Ottawa

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Normal Respiratory Rates
Age Respiratory Rate (breaths/min) Neonat
es 30-60 Infant 20-50 1 yr 20-40 2
yr 20-35 3 yr 15-30 Adolescent 12-18
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Asthma Definition

• Asthma is characterized by paroxysmal or
  persistent symptoms such as dyspnea, chest
  tightness, wheezing, sputum production and cough
  associated with variable airflow limitation and
  hyperresponsiveness to endogenous or exogenous
  stimuli
• Inflammation key to underlying mechanism for
  development and persistence of Asthma

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Not All that Wheezes is AsthmaDifferential
Diagnosis

• Infections
• Bronchiolitis
• Respiratory viruses
• Pertussis
• Sinusitis

• Inflammatory
• Asthma
• Tuberculosis
• Bronchopulmonary Dysplasia
• Cystic Fibrosis

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Not All that Wheezes is AsthmaDifferential
Diagnosis

• Aspiration
• Gastroesophageal reflux
• Palatopharyngeal dyscoordination
• Foreign body

• Congenital Malformations
• Vascular rings
• Congenital cysts etc.
• Miscellaneous
• Congestive heart failure
• Vocal chord adduction
• Psychogenic causes

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Clinical Features suggestive of an alternative
diagnosis to asthma
History Symptoms presenting in neonatal
period Requirement of ventilation in newborn
period Wheeze associated with feeding or
vomiting Sudden onset of cough/choking Steatorrhea
Stridor
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Clinical features suggestive of an alternative
diagnosis to asthma
Physical Examination Failure to
thrive Significant heart murmur Clubbing Unilatera
l signs
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Clinical features suggestive of an alternative
diagnosis to asthma
Investigations No reversibility of airflow
obstruction with bronchodilator Focal, persistent
or atypical radiographic findings
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Making the Diagnosis

• History, Physical, Supporting Investigations
• History of recurrent episodes of cough, wheeze,
  shortness of breath, chest tightness
• Evidence of Atopy (history, physical,
  eosinophilia, family history)
• Evaluate and exclude alternate diagnoses
• Pulmonary function testing (6 years and older)
• FEV1 and response to bronchodilator
• Response to Therapeutic Trial
• Short-acting bronchodilators
• Anti-inflammatory agents

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Types of Asthma in Young Children

• Early Onset, Transient
• Non-Atopic
• Outgrown in approximately 60 children
• Early Onset, Persistent
• Associated with Atopy
• Personal Atopy
• Family History of Atopy

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Guideline Recommendations regarding Diagnosis

• 1. Physicians must obtain appropriate patient
  and family history to assist them in recognizing
  the heterogeneity of wheezing phenotypes in
  pre-school aged children (Level III)
• 2. In children unresponsive to asthma therapy,
  physicians must exclude other pathology that
  might suggest an alternative diagnosis (Level IV)
• 3. The presence of atopy should be determined
  because it is a predictor of persistent asthma
  (Level III)

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Determination of Asthma Severity and Control

• Severity may only be able to be determined once
  adequate asthma control is achieved
• Asthma control should be assessed on a regular
  basis (continuity of care)
• Base assessment of control on following criteria

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Criteria for Determining whether Asthma is
Controlled
Parameter Frequency or Value
Daytime Symptoms lt 4 days/week
Night-time Symptoms lt1 night/week
Physical Activity Normal
Exacerbations Mild, infrequent
School Absence None
Beta-2 Agonist need lt4 doses/week
FEV1 or PEF gt90 personal best
PEF diurnal variation lt 10-15
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Therapeutic Goals

• Achieve and maintain acceptable asthma control
• If poor control, identify reasons
• Environment
• Education
• Drug and Dose
• Inhaler technique
• Compliance issues
• Once good control is achieved, gradually reduce
  medication to minimum that maintains control, and
  reassess over time

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General Management of Asthma

• If control is inadequate, reason or reasons
  should be identified, maintenance therapy should
  be modified
• Any new treatment should be considered a
  therapeutic trial and its effectiveness should be
  assessed after 4-6 weeks
• Inhaled corticosteroids should be introduced as
  initial maintenance therapy (Level I) even when
  patient reports symptoms fewer than 3 times per
  week
• Although less effective than low dose ICSs,
  (Level I) LTRAs are alternative if patient can
  not or will not use ICSs (Level II)
• If control is inadequate on low-dose ICSs, assess
  reasons for poor control and consider additional
  therapy with long-acting B2-agonists or LTRAs
  (Level I).
• Severe asthma may require systemic
  corticosteroids
• Asthma control and maintenance must be assessed
  regularly

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Frequent Reasons for Poor Asthma Control

• Insufficient patient education in terms of what
  asthma is, and how it is controlled
• Insufficient use of objective measures of airflow
  obstruction (PEF, FEV1), leading to over- or
  underestimation of asthma control
• Misunderstanding regarding role and side effects
  of medications
• Overuse of B2-agonists
• Insufficient use of anti-inflammatory agents,
  including intermittent use, inadequate use, or
  lack of use
• Inadequate assessment of patient adherence
• Lack of continuity of care

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Asthma Therapy

• Regularly assess
• Control
• Triggers
• Compliance
• InhalerTechnique
• Co-morbidity

Pred
Adjust maintenance therapy
Add-on therapy
Inhaled Corticosteroids
Fast-acting bronchodilator on demand
Environmental control Education, Written action
plan, and Follow-up
Moderately Severe
Severe
Moderate
Very mild
Mild
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First Line Maintenance Therapy

• Physicians should recommend inhaled
  corticosteroids (ICSs) as the best option for
  anti-inflammatory therapy monotherapy for
  childhood asthma (Level I)
• There is insufficient evidence to recommend
  leukotriene receptor antagonists (LTRAs) as
  first-line monotherapy for childhood asthma
  (Level I). For children who can not or will not
  use ICSs, LTRAs represent an alternative (Level
  II)

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ICS Benefits (Budesonide)

• Clinical measures of control strongly favored
  Budesonide over Placebo
• Symptoms
• Rescue medication use and prednisone courses
• Episode-free days
• Hospitalizations and urgent care
• Initiation of beclomethasone or additional asthma
  medication
• CAMP Study, NEJM Oct 13, 2000

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Growth Effects of Budesonide

• Budesonide growth effect
• Led to limited, small, and apparently transient
  reduction in growth velocity
• Projected final height by bone age similar to
  Placebo

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ICS Safety

• Other safety issues for Budesonide
• No adverse effect on bone density
• No association with cataracts
• No adverse effect on sexual maturation
• No adverse effect on psychological growth

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Add-on Therapies

• Long-acting B2-agonists are not recommended as
  maintenance monotherapy for asthma (Level I)
• After reassessment of compliance, control of
  environment and diagnosis, if asthma is not
  optimally controlled with low doses of ICSs,
  therapy should be modified by the addition of a
  long-acting B2-agonist (Level I)
• Alternatively, addition of an LTRA or increasing
  to a moderate dose of ICS may be considered
  (Level1)

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Inhalation Devices

• At each contact, health care professionals should
  work with patients and their families on inhaler
  technique (Level I)
• When prescribing MDIs, physicians should
  recommend use of a valved spacer, with mouthpiece
  when possible, for all children (Level II)
• Dry powder breath-actuated devices offer a
  simpler form of maintenance therapy in children
  over 5 years of age (Level IV)
• Children tend to auto-scale their inhaled
  medication dose and the same dose of maintenance
  medication can be used at all ages for all
  medications (Level IV)
• Physicians, educators and families should be
  aware that jet nebulizers are rarely indicated
  for the treatment of chronic or acute asthma
  (Level I)

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Prevention Strategies for AsthmaPrimary
Prevention

• With conflicting data on early life exposure to
  pets, no general recommendations can be made with
  regard to pets for primary prevention of allergy
  and asthma (Level III). Families with
  bi-parental atopy should avoid having cats or
  dogs in the home (Level II)
• There are conflicting and insufficient data for
  physicians to recommend for or against
  breastfeeding specifically for the prevention of
  asthma (Level III). Due to its many other
  benefits, breastfeeding should be recommended

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Prevention Strategies for AsthmaSecondary
Prevention

• Health care professionals should continue to
  recommend the avoidance of tobacco smoke in the
  environment (Level IV)
• For patients sensitized to house dust mites,
  physicians should encourage appropriate
  environmental control (Level V)
• In infants and children who are atopic, but do
  not have asthma, data are insufficient for
  physicians to recommend other specific preventive
  strategies (Level II)

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Our Patients and their Parents Still Smoke..
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50 of Children with Asthma are Sensitive to
House Dust Mite
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Prevention Strategies for AsthmaTertiary
Prevention

• Allergens to which a person is sensitized should
  be identified (Level I), and a systematic program
  to eliminate, or at least to substantially
  reduce, allergen exposure in sensitized people
  should be undertaken (Level II)

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EDUCATION
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Education and Follow-up

• Asthma control criteria should be assessed at
  each visit (Level IV). Measurement of pulmonary
  function, preferably by spirometry, should be
  done regularly (Level III) in adults and children
  over 6 years of age
• Socioeconomic and cultural factors should be
  taken into account in designing asthma education
  programs (Level II).
• School age children may benefit from education
  programs separate from their parents

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OXYGEN
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Asthma Rx
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Differential Diagnosis of Croup

• Epiglottitis
• Bacterial Tracheitis
• Foreign Body in Airway or Esophagus

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Management of Croup

• Avoid agitation as much as possible
• Mild croup may be managed at home with p.o.
  fluids and humidity
• Warn parents croup may be
• Worse at night
• May clear in cold air outside

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Management of Croup contd

• Stridor at rest, moderate chest wall retractions,
  and an anxious, restless child are all indicators
  of moderate to severe disease and signal need for
  hospitalization
• Nurse in Oxygen (usually 30-40)
• If concerned about degree of respiratory failure,
  arterial blood gas indicated

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Management of Croup contd

• Racemic epinephrine 0.5 mL of 2.25 solution in 3
  mL normal saline by inhalation X 1 dose may
  provide relief
• Effect may last 30-60 minutes may repeat q1-2h
• Dexamethasone 0.6 mg/kg (MAX 12 mg) (PO, IM, IV)
  X 1 dose
• A child who has received racemic epinephrine
  should be admitted for observation

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Management of Croup contd

• If there is a question of impending respiratory
  failure, obtain arterial blood gases
• A rising respiratory rate correlates well with a
  falling PaO2
• Hypercapnea (rising PaCO2) occurs late in upper
  respiratory tract obstruction and is a sign of
  increasing respiratory failure

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Bronchiolitis

• Affects approximately 50 children lt 2 years of
  age
• Peak incidence 6-8 months, winter, spring
• RSV accounts for gt50 of cases
• Parainfluenza type 3, influenza, adenovirus,
  ?rhinovirus can also be causes
• Usually viral prodrome with cough, URTI symptoms
• Most often mild disease
• Can affect those with underlying cardiac, lung
  disease more severely

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Bronchiolitis contd

• Wheezing, tachypnea, tachycardia, respiratory
  distress lasting 5-7 days
• CXray may show hyperinflation, increased
  peribronchial markings, areas of atelectasis,
  linear densities
• NP swab to detect viral etiology
  (immunofluorescence)
• Oximetry - keep O2 sat gt 92 with humidified O2
• Trial of salbutamol or racemic epinephrine
• Admit if persistent tachypnea, respiratory
  distress, very young infants, persistent hypoxia
• Antibiotics have no role unless also suspect
  complicating bacterial disease
• Consider prophylaxis of those high risk patients
  (BPD, cardiac disease etc.) with Palivizumab
  (monoclonal antibody against RSV) monthly during
  RSV season

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Management of Pneumonia- Investigations

• CBC, differential count
• Blood culture
• Sputum for culture (if child is old enough)
• Arterial blood gas if respiratory distress
• Tuberculin skin test with Candida control
• Cold agglutinin titer
• Chest X-ray PA and Lat
• Diagnostic thoracentesis if significant amount of
  pleural fluid

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Management of Pneumonia- Treatment

• General supportive care including PO or IV fluids
• O2 as needed
• IV or PO antibiotics appropriate for most likely
  etiologic organism or organism cultured
• Admission based on clinical status
• Empyema requires chest tube drainage
• Consider anaerobic coverage if aspiration a
  possibility

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Pneumonia- Treatment
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Pertussis

• Pertussis is an important cause of chronic cough
• The Chinese named Pertussis the 100 Day Cough
• Immunization does not guarantee protection from
  Pertussis
• Cough may have classic inspiratory whoop in
  chronic phase

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Chlamydia Pneumonia
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Chlamydia Pneumonia
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TB remains an important infection!
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Measure the induration when performing a 5-TU
tuberculin skin test
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RDS- Early Changes
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BPD- late changes
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Case Presentation- Patient L.M.

• 40 day old infant admitted to CHEO January 15
  2003, with 4 day Hx of wheezy illness RSV ve
• Hx intermittent cough since 2 weeks of age
• Slow weight gain since birth B.W. 3640g weight
  on admission 4080g
• Hx of greasy stools
• Meconium took about 2 weeks to pass
• Hx of hypo echoic bowel on prenatal ultrasound
• O/E scrawny infant with crackles over left
  anterior and lateral chest wheezes bilaterally
• Sweat Chloride Tests x 2 82 and 91 mEq/L

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Psychosocial Issues

• Both Parents and Patients can present with a wide
  array of psychosocial issues
• Coping with a chronic condition
• Compliance Issues
• Adolescence Issues
• Death and Dying Issues
• Issues regarding drug plans and financial support

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Agents Aimed at Altering Properties of CF Mucus

• N-acetylcysteine- no longer used due to bronchial
  irritability
• Recombinant Human DNase (dornase alpha)- breaks
  down DNA from dead neutrophils administered as
  2.5 mg once daily by aerosol. Studies of
  sustained improvement or decreased decline in
  PFTs have yielded mixed results (Ramsey et al,
  Am Rev Respir Dis, 1993) (Fuchs et al, NEJM
  1994)
• Not an inexpensive therapy

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