Wheezing From PCO
Wheezing From PCO
Wheezing From PCO
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Essential History
Ask about:
Age at onset
Frequency of wheezing
Fever
Acute onset
Frequent vomiting
Positional wheezing
Difficulty in swallowing
Allergies, anaphylaxis
Haemoptysis
Breathlessness
Panic / anxiety
Previous admissions
Tachypnoea
Recessions
Unilateral wheezing
Viral bronchiolitis, viral lower respiratory tract infections and asthma account for most
wheezing
Asthma
o
Contact with animals
o
Stress or emotional disturbances
o
Weather conditions
Family history
Tracheomalacia
Inspiratory airway collapse
o
Detectable by fluoroscopy
o
Detectable by bronchoscopy
Bronchomalacia
Airway collapse
Detectable by fluoroscopy
Collapsing bronchus
o
Detectable by bronchoscopy
Foreign body
Sudden onset
Many patients with foreign body aspiration do not have an obvious history of
choking
o
Choking should be suspected even in a child whose wheezing has been present
for days or weeks
Heart failure or pulmonary oedema
Poor growth
Hepatomegaly
Responds to diuresis
Bronchiolitis
Infant
o
Upper respiratory tract infection symptoms
o
Expiratory wheeze
o
Inspiratory and expiratory crackles
May have inspiratory as well as expiratory component
Pulmonary function tests may be normal, may have reduced peak expiratory flow
rate (PEFR) and with abnormal inspiratory loop
Cystic fibrosis
Recurrent pneumonia
Recurrent pneumonia
Pulmonary haemosiderosis
Rare disorder causing anaemia and recurrent wheezing from blood irritating the
peripheral airways
No bronchodilator response
No response to therapy
Stridor noted at times
Wheezing that appears at birth or soon afterward should prompt an evaluation for:
o
Tracheomalacia
o
Complete tracheal rings
Investigations
To be undertaken by non-specialist practitioners (eg, General Practitioner (GP) Team):
Nasopharyngeal aspirate in younger children (below 2 years of age) for viral studies
(if available)
Chest X-ray
Thoracic masses
Airway fluoroscopy
Useful if a vascular abnormality is suspected
Diagnostic procedures
o
Obtain objective data on wheezing in patients aged 5 years and older
o
Distinguish reversible airways disease from fixed obstruction
o
Distinguish small airway from large airway obstruction
Flexible bronchoscopy:
o
Gives visualisation of airways
o
Usually involves a general anaesthetic
o
Useful to characterise dynamic lesions (ie, tracheobronchomalacia)
Rigid bronchoscopy
o
Can be useful in diagnosis and treatment of:
Treatment Approach
In general, when evaluating and managing the wheezy child:
For acute management of wheeze in asthma and viral induced wheeze see British
guideline on the management of asthma [ SIGN clinical guideline 141].
Asthma
Oral prednisolone 1-2 mg/kg (max. 40 mg) once daily for three days
Viral bronchiolitis
Hypoxaemia
Poor feeding
Dehydration
To be undertaken by specialist practitioners (eg, Emergency Department / Paediatric /
Paediatric Respiratory Team(s)):
For the acute management of asthma and viral wheeze see British guideline on the
management of asthma [ SIGN clinical guideline 141].
Ipratropium bromide
Oral prednisolone
When to Refer
Refer to specialist practitioners (eg, Emergency Department / Paediatric / Paediatric
Respiratory Team(s)) if:
Acute wheeze
Hypoxaemia
Presence of Harrison's sulcus (horizontal groove along lower end of rib cage):
o
May represent exaggerated suction of diaphragm on inspiration
o
*Please note: whilst these resources have been developed to a high standard
they may not be specific tochildren.
Resources
National Clinical Guidance
British guideline on the management of asthma (pdf), SIGN clinical guideline 141,
Scottish Intercollegiate Guidelines Network.
Bronchiolitis in children (Web page), SIGN clinical guideline 91, Scottish Intercollegiate
Guidelines Network.
Bronchiolitis in children (Web page), NICE clinical guideline NG9, National Institute for
Health and Care Excellence.
Asthma (Web page), NICE quality standard QS25, National Institute for Health and
Care Excellence.
Omalizumab for treating severe persistent allergic asthma (Web page), NICE
technology appraisal TA278, National Institute for Health and Care Excellence.
Inhaled corticosteroids for the treatment of chronic asthma in children under the age of
12 years (Web page), NICE technology appraisal TA131, National Institute for Health
and Care Excellence.
Inhaled corticosteroids for the treatment of chronic asthma in children aged 12 years
and over (Web page), NICE technology appraisal TA138, National Institute for Health
and Care Excellence.
Acknowledgements
Content Editor: Dr Srini Bandi
Clinical Expert Reviewer: Dr Simon Langton Hewer
GP Reviewer: Dr Janice Allister