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Pulmonary Clinic

The practice offers a full consultative and management service that covers all of the pediatric pulmonary disorders. The objectives of the pulmonary clinic range from decreasing the duration and severity of respiratory illnesses to improving exercise tolerance in children and preventing the onset of a sedentary or inactive lifestyle due to disease. Special focus is placed on decreasing the incidence of nocturnal symptoms which may affect the child’s quality of sleep.

ALLERGIC RHINITIS

Allergic Rhinitis

Definition

Allergic rhinitis (AR) is an inflammatory, IgE-mediated inflammatory response /disease characterized by nasal congestion, rhinorrhea (nasal drainage), sneezing, and/or nasal itching.

Allergic rhinitis is estimated to affect nearly 1 in every 6 Americans and generates $2 to $5 billion in direct health expenditures annually.

Classification

Allergic rhinitis may be classified using:

  • Temporal patterns of exposure
    • Seasonal allergic rhinitis (SAR) – with symptoms in response to seasonal aeroallergens (eg, pollens).
    • Perennial allergic rhinitis (PAR) – with symptoms in response to year-round environmental aeroallergens (eg, dust mites, mold and animal allergens).
    • Episodic allergic rhinitis – with symptoms in response to exposure that is not normally a part of the individual’s environment (ie, a cat at your friend’s house).
  • Frequency of symptoms:
    • Intermittent allergic rhinitis – characterized by frequency of exposure/ symptoms (<4 days/week and >4 weeks/year).
    • Persistent allergic rhinitis – characterized by persistent symptoms (>4 days/week and >4 weeks/year).
  • Severity of symptoms
    • Mild – when symptoms are present but are not interfering with quality of life
    • Moderate-severe – with symptoms interfering with quality of life such as sleep disturbance, impairment of school or work performance, impairment of daily activities or troublesome symptoms

Clinical presentation

Allergic rhinitis presents with paroxysms of sneezing, rhinorrhea, nasal congestion, and nasal itching. Other common symptoms include postnasal drip, cough, itching of the palate and inner ear. Those with concomitant allergic conjunctivitis report bilateral itching, tearing, and/or burning of the eyes.

Co-morbidities

  • Asthma – The presence of allergic rhinitis significantly increases the probability of asthma: up to 40% of people with allergic rhinitis have or will have asthma.
  • Atopic eczema Atopic eczemafrequently precedes allergic rhinitis.
  • Allergic conjunctivitis – Up to 60% patients with allergic rhinitis usually have allergic conjunctivitis as well.
  • Sinusitis – Allergic rhinitis can also cause obstruction of the sinus ostiomeatal complex, thereby predisposing to bacterial infection of the sinuses in as much as 30 to 80 percent of cases of acute and chronic bacterial sinusitis, respectively.
  • Other conditions – Allergic rhinitis is strongly associated and probably causally related to eustachian tube dysfunction, causing concomitant serous and acute otitis media. Nasal obstruction due to severe allergic rhinitis can also cause sleep disordered breathing and anosmia. Nasal polyps occur in association with allergic rhinitis, although whether allergic rhinitis actually causes polyps remains unclear. There may be an increased prevalence of migraine headache in patients with allergic rhinitis.

Risk factors

The following are proposed or identified risk factors for allergic rhinitis:

  • Family history of atopy (ie, the genetic predisposition to develop allergic diseases)
  • Male sex
  • Birth during the pollen season
  • Firstborn status
  • Early use of antibiotics
  • Maternal smoking exposure in the first year of life
  • Exposure to indoor allergens, such as dust mite allergen
  • Serum IgE >100 int.units/mL before age six
  • Presence of allergen-specific immunoglobulin E (IgE)

 Pathophysiology

Sensitization involves allergen uptake by antigen-presenting cells (dendritic cells) at a nasal mucosal site, leading to activation of antigen-specific T cells. Naive helper T cells are known as Th0 cells, because they produce a pattern of cytokines that spans both the Th1 and Th2 phenotypes. If given the proper stimulus, naive helper T cells can differentiate into the biased Th1 or Th2 subset. In the case of allergy, the Th2 subset plays a central role.

Allergen-specific IgE antibodies coat the surface of mast cells that are present in the nasal mucosa. On reexposure, the allergen binds to IgE on the surface of those cells and cross-links IgE receptors, resulting in mast-cell and basophil activation and the release of inflammatory mediators such as histamine and the cysteinyl leukotrienes. These substances produce the typical symptoms of allergic rhinitis.

In addition, local activation of Th2 lymphocytes by dendritic cells results in the release of chemokines and cytokines that orchestrate the influx of inflammatory cells (eosinophils, basophils, neutrophils, T cells, and B cells) to the mucosa, providing more allergen targets and up-regulating the end organs of the nose (nerves, vasculature, and glands).

Diagnosis

The diagnosis of allergic rhinitis can often be made clinically based on the presence of characteristic symptoms, clinical history (including the presence of risk factors), and supportive findings on physical examination as well as response to empirical treatment with antihistamine and nasal glucocorticoid.

Physical findings may include

  • Iinfraorbital edema and darkening due to subcutaneous venodilation (“allergic shiners”)
  • Accentuated lines or folds below the lower lids (Dennie-Morgan lines)
  • A transverse nasal crease caused by repeated rubbing and pushing the tip of the nose up with the hand (the “allergic salute”)
  • Pale bluish hue along with turbinate edema/swelling
  • Clear rhinorrhea (anterior and posterior)
  • Hyperplastic lymphoid tissue lining the posterior pharynx( “cobblestoning”).

Tests/evaluations

Allergy testing confirms that the patient is sensitized to aeroallergens, although it is not necessary for the initial diagnosis. Allergy testing should be performed for patients with a clinical diagnosis of allergic rhinitis who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy.

  • Allergy skin testing vs blood testing
    • Allergy skin testing
      • A quick, cost effective, and safe way to identify the presence of allergen-specific IgE
      • Prick skin tests correlate more closely with symptoms than intradermal tests
      • Skin testing a very symptomatic pollen-allergic patient during peak pollen season should be avoided
    • Allergy blood testing
      • IgE antibodies in the serum have limited utility in the diagnosis of allergic rhinitis
      • More expensive and less sensitive for the diagnosis of allergy to inhalant allergens compared with skin tests although some studies similar sensitivity
      • Advantages of blood testing are that the patient does not need to stop taking antihistamines several days in advance and technical skills are not required to perform the test.

Treatment options

Pharmacotherapy

  • Intranasal steroids
    • Most effective single maintenance therapy for allergic rhinitis with only few side effects at the recommended doses
    • Particularly effective in the treatment of nasal congestion.
  • Antihistamines
    • Oral antihistamines
      • Oral second and third generation/less sedating antihistamines are recommended for patients with primary complaints of sneezing and itching.
    • Intranasal antihistamines
      • Have the benefit of rapid onset and increased effectiveness over oral antihistamines for nasal congestion
    • Oral leukotriene receptor antagonists
      • Should not be used as primary therapy for allergic rhinitis.
      • Some randomized trials have shown a benefit of adding the leukotriene-receptor antagonist montelukast to an antihistamine

Combining a nasal antihistamine with an intranasal steroid could offer additive effects, over either therapy alone, especially for breakthrough symptoms

 Allergen Immunotherapy

  • Allergen injection immunotherapy
    • Involves injection of gradually increasing doses of allergens to which a patient has demonstrated sensitivity. Over time, a dose is attained that effectively alters the patient’s immune response to that allergen, resulting in fewer symptoms with natural exposure
    • Unique among treatment modalities in its ability to alter the pathologic process that underlies allergic rhinitis in a semi-permanent manner.
  • Sublingual and oral immunotherapy
    • Involves the application of allergen to the oral mucosa or sublingual tissues either in the form of solutions or dissolvable tablets. The solution/tablet is typically held in the mouth for a few minutes and then swallowed.
    • Subligual tablets are FDA approved but limited number of allergens available for treatment where as sublingual solution are currently used “off-label” .
  • Anti-IgE Therapy
    • Allergic inflammation appears similar in the upper and lower airway, and new antiinflammatory therapies explored in allergic asthma are potential therapies for allergic rhinitis and vice versa.
    • Recombinant human monoclonal antibody to immunoglobulin E (IgE), omalizumab (Xolair), binds circulating IgE and prevents the interaction of IgE with surface receptors on mast cells.
    • Not approved by the US Food and Drug Administration (FDA) for allergic rhinitis.

References:

  1. Seidman M. et al. Clinical Practice Guideline: Allergic Rhinitis. Otolaryngol Head Neck Surg February 2015 vol. 152 no. 1 suppl S1-S43
  2. Wheatley L.Met al. Allergic Rhinitis. N Engl J Med 2015; 372:456-46
  3. Allergic rhinitis: Clinical manifestations, epidemiology, and diagnosis: UpToDate
  4. Overview of immunologic treatments for allergic rhinitis: UpToDate

This topic last updated by Seifu M. Demissie, MD: June 03, 2015.

BRONCHIOLITIS

Bronchiolitis

Definition

Bronchiolitis is a disorder commonly caused by viral lower respiratory tract infection in infants. Bronchiolitis is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, and increased mucus production. Signs and symptoms typically begin with rhinitis and cough, which may progress to tachypnea, wheezing, rales, use of accessory muscles, and/or nasal flaring.

Epidemiology

The most common etiology of bronchiolitis is respiratory syncytial virus, followed by rhinovirus. Less common causes include influenza virus, human metapneumovirus, parainfluenza virus, adenovirus, coronavirus, and human bocavirus. The highest incidence of respiratory syncytial virus (RSV) infection occurring between December and March in North America; however, regional variations occur.

By the first 2 years of life, about 90% of children are infected with RSV and up to 40% will experience lower respiratory tract infection during the initial infection.

Bronchiolitis is the most common cause of hospitalization among infants during the first 12 months of life, according to a 2013 Pediatrics study, costing an estimated $1.73 billion/year.

Clinical presentation and clinical course

Bronciolitis generally presents with generally presents with fever, cough, and respiratory distress (eg, increased respiratory rate, retractions, wheezing, crackles). Typical illness with bronchiolitis begins with upper respiratory tract symptoms, followed by lower respiratory tract signs and symptoms on days two to three, which peak on days five to seven and then gradually resolve.

Data suggest about 2% of infants with RSV bronchiolitis require hospitalization. The most common risk factor for hospitalization is age.

Although clinical practice varies widely hospitalization for supportive care and monitoring usually is indicated for infants and young children with:

  • Toxic appearance, poor feeding, lethargy, and dehydration.
  • Moderate to severe respiratory distress.
  • Hypoxemia with or without hypercapnia.
  • Parents who are unable to care for them at home.

Severely affected patients with risk factors (see Risk factors below), are at increased risk for complications, the most serious of which are apnea (present in 18% to 25% of hospitalized infants) and respiratory failure. Infants who require mechanical ventilation for apnea or respiratory failure may develop air leak, such as pneumothorax or pneumomediastinum. Other complications include dehydration and secondary bacterial infection.

Risk factors

Risk factors for severe or complicated bronchiolitis include:

  • Prematurity (gestational age <37 weeks)
  • Age less than 12 weeks
  • Chronic pulmonary disease, particularly bronchopulmonary dysplasia
  • Congenital and anatomic defects of the airways
  • Congenital heart disease
  • Immunodeficiency
  • Neurologic disease

Pathophysiology

RSV is an enveloped, nonsegmented, negative-stranded RNA virus and a member of the paramyxoviridae family. Two subtypes, A and B, are present in most outbreaks. Subtype A usually causes more severe disease. Re-infection can occur with a different subtype in the same infant during a single season. The incubation period ranges from two to eight days; viral shedding ranges from three to eight days, although it may continue for up to four weeks in young infants.

An RSV infection begins with replication of the virus in the nasopharynx. The virus spreads to the small bronchiolar epithelium lining the small airways within the lungs, and a lower respiratory tract infection can begin in one to three days. If a lower respiratory tract infection occurs, it causes edema, increased mucus production, and eventual necrosis and regeneration of these epithelial cells. This leads to small airway obstruction, air trapping, and increased airway resistance.

Diagnosis / Tests/ Evaluations

Bronchiolitis should be diagnosed on the basis of history and physical examination. Characteristic features include a viral upper respiratory prodrome followed by increased respiratory effort (eg, tachypnea, nasal flaring, chest retractions) and wheezing and/or rales in children younger than two years of age. Respiratory symptoms can range from mild tachypnea to impending respiratory failure. Thus, it is crucial that the clinicians assess risk factors for severe disease as listed above. Serial observations over time may be required to fully assess the respiratory status. Upper airway obstruction contributes to work of breathing. Suctioning and positioning may decrease the work of breathing and improve the quality of the examination.

Tachypnea, defined as a respiratory rate ≥70 per minute and oxygen saturation <90 percent by pulse oximetry while breathing room air, have been associated with increased risk of severe disease in some studies but not others.

Routine laboratory or radiologic studies are not recommended to support the diagnosis. Infants with bronchiolitis often have abnormal-appearing radiographs including hyperinflation, areas of atelectasis, and infiltrates.

Chest x-ray they may be necessary to evaluate the possibility of secondary or comorbid bacterial infection, complications or other conditions in the differential diagnosis, particularly in children who have pre-existing cardiopulmonary disease.

xray

Chest radiograph of infant who has RSV bronchiolitis, demonstrating hyperinflation and small areas of patchy, bilateral atelectasis.   Tamara Wagner Pediatrics in Review 2009;30:386-395

Routine testing for specific viral agents in children with bronchiolitis is not necessary, unless the results of such testing will alter management of the patient or patient’s contacts (eg, discontinuation of palivizumab prophylaxis, initiation or continuation/discontinuation of antibiotic therapy, anti-influenza therapy, or cohorting of hospitalized patients or caregivers).

Treatment options

Supportive care

The primary mode of therapy for infants with bronchiolitis includes maintenance of adequate hydration, provision of respiratory support as necessary, and monitoring for disease progression.

  • Hydration
    • Patients may require intravenous fluid rehydration and continued intravenous fluid or nasogastric feedings until feeding improves.
    • Those with severebronchiolitis may benefit from nasogastric feeding for nutrition support until feeding improves.
  • Respiratory support
    • Supplemental oxygen should be provided to maintain SpO2above 90 percent
    • Chest physiotherapy should not be used to treat bronchiolitis
    • Repeated clinical assessment of the respiratory system is necessary to identify deteriorating respiratory status in both the outpatient and inpatient settings

 Pharmacotherapy

  • Inhaled bronchodilators
    • Albuterol (or salbutamol) should not be administered to infants and children with a diagnosis of bronchiolitis.
    • The previous guideline included a trial of β-agonists as an option. However, given the greater strength of the evidence demonstrating no benefit, and that there is no well-established way to determine an “objective method of response” to bronchodilators in bronchiolitis, this option has been removed.
  • Epinephrine
    • Epinephrine should not be administered to infants and children with a diagnosis of bronchiolitis, except potentially as a rescue agent in severe disease, although formal study is needed before a recommendation for the use of epinephrine in this setting.
  • Nebulized hypertonic saline
    • Nebulized hypertonic saline should not be administered to infants and children with a diagnosis of bronchiolitis in emergency department.
    • Nebulized hypertonic saline may be administered to infants and children hospitalized with bronchiolitis. This weak recommendation was based on length of stay.
  • Inhaled glucocorticoids
    • Inhaled glucocorticoids should not be administered to infants and children with a diagnosis of bronchiolitis.

Prevention

Administration of palivizumab, a monoclonal antibody (immunoglobulin G) directed against RSV, to select groups of infants might prevent hospitalization for bronchiolitis.

General Indications for palivizumab includes:

  • Gestational age < 29 weeks and <1 year of age
  • Gestational age <32 weeks, 0 days’ gestation and a requirement for >21% oxygen for at least 28 days after birth and <1 year of age
  • Infants with hemodynamically significant heart disease < 1 year of age
  • Children with pulmonary abnormality or neuromuscular disease that impairs the ability to clear secretions from the upper airways may be considered for prophylaxis in the first year of life.
  • Children younger than 24 months who will be profoundly immunocompromised during the RSV season may be considered for prophylaxis.

Strict hand hygiene and isolation policies remain the cornerstone of preventing nosocomial RSV infections. Additional preventive strategies include avoidance of tobacco smoke and encouragement of breastfeeding throughout the bronchiolitis season.

 References:

  1. Ralston S. et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics 2014;134:e1474–e1502
  2. Wagner T. Bronchiolitis. Pediatric in Review Vol. 30 No. 10 October 1, 2009 pp. 386 -395
  3. Committee on Infectious Diseases and Bronchiolitis Guidelines Committee, “Updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection,” Pediatrics, vol. 134, p. e620, 2014
  4. Bronchiolitis in infants and children: Clinical features and diagnosis: UpToDate
  5. Bronchiolitis in infants and children: Treatment; outcome; and prevention: UpToDate

This topic last updated by Seifu M. Demissie, MD: June 04, 2015.

COUGH

Cough in children

Cough can be a stressful event for children and their parents/guardians. It can lead to sleepless nights, disruption of school and family life, limitation of physical activity, and missed school and workdays. Thankfully most of the time the cough will resolve on its own.

Sometimes families try to suppress the cough with over the counter medication, when, in truth, the underlying cause needs to be identified. It must be understood that cough is an important defense mechanism to keep the lungs clear and aerated in children and usually should not be suppressed with medication.

Although cough can be a nonspecific symptom, it usually indicates that there is something causing irritation, inflammation or mucus production in the lungs or upper airway. Receptors in the airway send signals to the cough center in the brain about the presence of this irritant that is then forcefully expelled from the airway through the cough reflex mechanism.

Most of the time a cough is triggered by a respiratory viral infection, which will naturally resolve once the virus is cleared by the body. But, at times, cough may need medical attention to find out the underlying cause and to manage it appropriately.

Physicians normally approach the diagnosis to cough by taking a relevant history, performing a physical examination and requesting pertinent investigations (i.e. chest x-ray, CT-scan, blood tests, sputum tests, lung function tests, endoscopic evaluation of the airway). Sometimes these investigations are not conclusive, or not needed, and a trial of treatment is conducted (i.e. oral steroids and bronchodilators for presumed cough variant asthma) to assess response.

An improving nonspecific cough in a healthy child usually does not need treatment, just observation. A chronic wet cough, though, indicates excessive mucus in the airways and may point to a serious lung disease. Fortunately, protracted bacterial bronchitis appears to be the most common reason for a chronic wet cough and responds to an appropriate regimen of antibiotic(s).

Causes of cough can be divided by duration of symptoms but there is overlap. Acute cough usually lasts less than 2 weeks. A chronic cough lasts more than 4 weeks.

Common causes of acute cough (lasting less than 2 weeks)

Infectious Causes

Upper Respiratory Tract Infections, such as the common cold, can occur up to 8 times a year in healthy preschool children who attend daycare. The common cold usually presents with a runny nose, mild to moderate hacking cough and possible low-grade fever. For the common cold, no medications are usually needed.

Sometimes, the common cold, if recurrent or prolonged, can be associated with pain from ear, throat or acute sinus infection that may result in lingering cough. If there is suggestion of an associated ear or throat pain or headache, one can see their doctor to assess for a bacterial infection that may need antibiotics. In all cases when children are sick, they may not want to eat or drink so one must ensure they are adequately hydrated.

Bronchiolitis. Also, in infants and preschool children, the virus from a common cold can travel from the upper airway to the small lower airways (bronchioles) deep in the lungs leading to moderate to severe coughing, wheezing (musical sound, usually on breathing out) and difficulty breathing. These children need medical attention and, sometimes, admission to the hospital for observation and supportive care.

Viral Croup. Viral croup also usually begins with common cold symptoms that lead to a “seal barking” cough, stridor (harsh musical noise on breathing in) and difficulty breathing. Theses symptoms are due to viral infection and inflammation of the voice box, windpipe and large airways and severity is due to the size of the child’s airways and the amount of inflammation. The severity of croup can range from mild to severe breathing difficulty. Although humidified air has been used for decades to help treat these children, many may need steroids and aerosolized adrenaline to decrease the swelling of the inflamed walls of the upper airway (including voice box). If the child has difficulty breathing, he or she needs immediate medical attention.

Pertussis (Whooping Cough). Pertussis is a very contagious respiratory infection, known as “the 100 days cough” in China because it can last weeks to months.   Importantly, it is most infectious in the first couple of weeks and therapy for the child and close contacts may help decrease its severity and spread. The first week is usually looks like the common cold with a nonspecific cough. Then “coughing fits” occur where the child’s face may turn red or blue from frequent, successive coughing. Coughing fits lead to vomiting and a younger child may make a “whooping” sound when breathing in. Smaller children/infants may even stop breathing temporarily or develop severe complications. Vaccination for pertussis prevents or minimizes the severity of the disease. Diagnosis is made by testing nasal swab specimens or washings. Blood specimens may show a certain pattern of white blood cell elevation (atypical lymphocytosis).

Pneumonia. Pneumonia involves infection and inflammation of the air sacs of the lung. It can be caused by a variety of infections; most commonly viral and bacterial and usually follow an upper respiratory infection. Children with underlying lung disease or immunodeficiency may also develop fungal pneumonias. Children most commonly present with fever and rapid breathing. They may also have increased work of breathing, cough, chest pain, sleepiness, and may look unwell. Children may not have particular findings on chest examination; and chest x-rays can be helpful in showing lung involvement. Depending on their presentation to a medical provider they may or may not need antibiotics.

Environmental Causes

Irritant exposure:  Infants with parents who smoke have a higher risk of developing inflammation of the small and large airways and pneumonia. Children of smokers have higher rates of coughing, phlegm production and wheezing and reduced lung function. There is evidence that those with allergic predisposition who live in smoking environments also develop asthma. Children of smokers tend to also become active smokers leading to further injury to their lungs.

Children can also develop cough if they are breathing around pollution, burning wood, other debris or chemicals in the air.

Other Causes of Acute Cough

Foreign Body Aspiration: A child inhaling a foreign body (i.e. peanut, hot dog) into the airway is a rare but potentially fatal reason for an acute and sometimes chronic cough. The cough usually begins suddenly and parents can report that the child was running with food in the mouth or playing with small objects such as seeds, coin or toys. A history of choking before the cough began can be noted by parents but not always. If there is a concern of foreign body aspiration, the child should be brought for medical evaluation to assess if an urgent procedure (rigid bronchoscopy) is needed to remove the foreign body.

Acute asthma exacerbation The first symptom of uncontrolled asthma can be a dry cough at night or with exercise. Symptoms may be persistent or wax and wane through out the year depending on what triggers are present in the child’s environment (tobacco smoke, pollen, URI, environmental allergies etc.). As airway inflammation from asthma progresses, twitchy muscles surrounding the airways constrict leading to narrower airways. The child can develop wheezing and difficulty breathing leading to an asthma exacerbation and significant breathing difficulty. The mainstay of treatment is usually frequent bronchodilator treatment (to open the airways) and oral or intravenous steroids (to decrease the inflammation of the airways). There also is usually a personal or family history of asthma or allergies.

In allergic rhinitis (allergies leading to a runny nose) and upper airway cough syndrome (throat clearing type cough), a steroid nasal spray or antihistamine medication may be effective in treating the cough.

Nonpulmonary conditions Sometimes pulmonologists diagnose non-lung-related causes of acute cough such as leukemia or heart failure.

Common causes of chronic cough (>3-4 weeks duration)

Mycoplasma pneumonia is also known as “walking pneumonia” and is most common in children older than 5 years, although can be seen in younger children. Children may have a low-grade fever and chronic cough. Sore throat and ear infections may also occur. Chest examination, blood testing and chest x-ray can help with the diagnosis. Investigations are not always needed. It is treated with an antibiotic to shorten the length of the illness.

Pertussis, as mentioned above, can also present as a chronic cough lasting weeks to months. In adolescents and young adults, especially those who have been previously immunized, one may not have the typical coughing fits with whooping as noted above in younger children.

Post-infectious cough can occur after a significant airway infection due to irritation of the airways that need time to heal. These coughs usually resolve with specific medications. Some children with a “post-infectious cough” (prolonged acute coughing after an obvious upper respiratory infection) cough for much longer and this is especially true for those with pertussis. Provided the child is otherwise well, waiting for a period of time allows natural resolution of post-infectious coughing and pertussis to occur.

Habit cough is typically a “honking” cough that is absent at night and found in up to 32% of older children and adolescents with a chronic cough. Once other causes of chronic cough are excluded, the treatment is primarily behavioral through suggestion techniques to empower child to take control f his/her cough (i.e. drinking hot lemon tea to suppress the cough).

As opposed to a dry cough, which is usually associated with asthma, a wet cough can indicate excessive mucus and a bacterial infection of the airways.

Protracted bacterial bronchitis is an infection of the airways that can be found in an otherwise well young child with a moist or wet cough lasting more than 3-4 weeks. Other causes need to be considered but these children generally respond well to a 2-week course of antibiotics. Lung washings can be performed to help confirm diagnosis, if needed.

Chronic wet cough can also be a marker for more serious diseases associated with chronic airway infection such as bronchiectasis (abnormally widened segments of the airway which are prone to infection and excessive mucus production). Regular aspiration (inhalation of oral or gastric contents) can leading to progressive bronchiectasis, usually in children with neurological difficulty resulting in swallowing dysfunction and/or significant regurgitation of food contents from the stomach into the lungs (gastroesophageal reflux disease). Some other conditions, which involve progressively worsening bronchiectasis, include cystic fibrosis, immune deficiency and primary ciliary dyskinesia. Pulmonologists usually help diagnose and manage these conditions.

In addition to the chronic cough, if children have other significant symptoms like weight loss, night sweats, bloody sputum, persistently worsening cough, the child likely needs to see a pulmonologist.

Asthma and foreign body aspiration (discussed above) can also manifest as chronic cough and should be kept in mind.

Treatment of chronic cough begins with making the appropriate diagnosis and minimizing exposure to irritants/triggers such as tobacco smoke and pollution.

Because asthma is a common cause of chronic cough, a trial of therapy maybe the less stressful and less expensive way to proceed with diagnosis of the chronic cough. Usually response to asthma therapy at least twice is needed to confirm a diagnosis of asthma.

References:

ERS Handbook of Paediatric Respiratory Medicine. 2013.

Pediatric Pulmonology. American Academy of Pediatrics. 2011.

ASTHMA

WHAT IS ASTHMA

What is Asthma?

Asthma is a chronic disease consisting of reoccurring episodes of difficulty breathing, shortness of breath, wheezing, chest tightness, and/or coughing.

Asthma occurs mainly in the small breathing tubes known as the bronchioles. In Asthma, these small breathing tubes are hyper-responsive or over reactive to a number of triggers. These triggers can consist of weather changes, pollution, irritants, allergies, illness/colds, cigarette smoke, heartburn/acid reflux, ozone, exercise, and/or emotions (i.e. laughing).

asthma-causes

When these over reactive breathing tubes are stimulated by one or more triggers, changes in these airways can occur in a short duration of time.

changes areThis results in significant narrowing of the small breathing tubes where individuals experience common symptoms of difficulty breathing, shortness of breath, wheezing, chest tightness, and/or coughing.  People may experience one or more of these symptoms which may vary with every episode.

Videos for Kids and family about Asthma.   Please click on the link below.

http://iggyandtheinhalers.com/videos-for-kids-with-asthma/

WHAT ARE ASTHMA WARNING SIGNS

People have experienced warning signs of asthma, yet many never recognize them.  These signs present early in an asthma flare up or exacerbation, and consist of:

  • childSneezing
  • Runny nose
  • Itchy eyes
  • Coughing
  • Wheezing
  • Shortness of breath
  • Chest pain
  • Chest tightness
  • Feeling “funny”
  • Feeling tired
  • Decrease activity
  • Behavioral changes
  • Become quiet
  • Grumpy
  • Trouble sleeping

These warning signs can progress slowly to a more rapid fashion.  It is important to monitor how frequent you experience these warning signs.  It allows you and your health care provider to determine if your Asthma is interfering with your quality of life or if you are at greater risk for more severe symptoms, even fatality.  Please click on the link below to help you assess your Asthma and provide it to your health care provider.

  • ACT for 4 to 11 years old
  • ACT for 12 years and older

When these warning signs arise, they provide an opportunity for the individual to act based on their plan of action recommended by their health care provider.  The plan of action may vary from person to person.  However a few key parts are the same.

Videos for Kids and family about Asthma. Please click on the link below.

http://iggyandtheinhalers.com/videos-for-kids-with-asthma/

WHAT DO YOU DO IF YOU HAVE ASTHMA

With the help of your health care provider, form a plan of action which will allow you to minimize or prevent asthma symptoms.  This plan of action will also guide you when you experience asthma symptoms.  The plan of action is broken up into key components:

  1. One component of the plan of action consist of identifying your triggers.  When triggers are identified, steps can be taken to modify your life style and minimizing environmental exposures.
  2. Another component is to have a better understanding of your asthma and learning to monitor your symptoms.  This information will allow you and your health care provider to better manage your asthma.
  3. The use of medication is another component in the plan of action. The health care provider will determine appropriate medications based on above mentioned components along with other determinants.  It is important to use medications as directed by a health care provider in order to obtain their full benefits.

There are two main types of medications used in Asthma:

  1. Controller medications are required to be taken consistently in order to minimize reoccurrences of asthma symptoms.
  2. Rescue/Quick Relief medication (i.e. Albuterol) are used to relieve symptoms when they occur and last for four to six hours. (please click here to view the medications)

The plan of action is reviewed and adjusted at your visit with your health care provider. A written form of the plan known as an Asthma Action Plan can be used as a reference.  There are many different looking Asthma Action Plans.  There are times when multiple Action Plans are given by different facilities creating confusion.  Despite the many different looking Asthma Action Plans, they all have the same common approach.  However always review your plan of action (including Asthma Action Plans) with the health care provider treating your asthma at every visit

Asthma Action PlanAAP

 

Videos for Kids and family about Asthma.   Please click on the link below.

http://iggyandtheinhalers.com/videos-for-kids-with-asthma/

ASTHMA ACTION PLAN

Asthma Action Plan

AAP

 

INHALERS

inhalers

ASTHMA CAUSES

asthma-causes

ACT TEST FOR CHILDREN 4 TO 11 YEARS

Childhood Asthma Control Test for children 4 to 11 years.

This test will provide a score that may help the doctor determine if your child’s asthma treatment plan is working or if it might be time for a change.

How to take the Childhood Asthma Control Test

Step 1 Let your child respond to the first four questions (1 to 4). If your child needs help reading or understanding the question, you may help, but let your child select the response. Complete the remaining three questions (5 to 7) on your own and without letting your child’s response influence your answers. There are no right or wrong answers.

Step 2 Write the number of each answer in the score box provided. 19or less If your child’s score is 19 or less, it
may be a sign that your child’s

Step 3 Add up each score box for the total. asthma is not controlled as well

Step 4 Take the test to the doctor to talk about your child’s total score, as it could be. Bring this test to the doctor to talk about the results.

Have your child complete these questions.

test1Please Click Here to download and print the form

ASTHMA CONTROL TEST 12 Yrs. AND OLDER

FOR PATIENTS:
Take the Asthma Control TestTM (ACT) for people 12 yrs and older. Know your score. Share your results with your doctor.

Step 1 Write the number of each answer in the score box provided.
Step 2 Add the score boxes for your total.
Step 3 Take the test to the doctor to talk about your score.

test2

Please Click Here to download and print the form

PNEUMONIA

Overview

Pneumonia is defined as an infection of the lungs. Some of these are spread by coughing or by direct contact with the infected person’s saliva or mucus. It may originate in the lung or a complication of a generalized inflammatory process.

Pneumonia is more common in children younger than five years of age than in older children and adolescents. Risk factors for pneumonia include environmental crowding, having school-aged siblings, and underlying cardiac, pulmonary, and other medical disorders. Abnormalities of airway and abnormalities predispose to increased complications. The air sacs may fill with fluid or pus, causing cough with phlegm or pus, fever, chills, and difficulty breathing.

It is important to recognize, prevent and treat the underlying pathology in order to care for children with pneumonia.

EPIDEMIOLOGY

Childhood pneumonia is an important cause of morbidity and mortality in the world, especially in the developing countries. The World Health Organization estimates that one in three newborn infant deaths worldwide is due to pneumonia. Although the overall rate of pneumonia has decreased in the United States with the use of the vaccine, the rate of complicated pneumonia has increased.

Pneumonia can occur at any age, although it is more common in younger children. Pneumonia accounts for 13% of all infectious illnesses in infants younger than 2 years. One of the highest rates of influenza-associated hospitalizations in the United States was in children younger than 5 years.

Etiology

A variety of organisms, including bacteria, viruses and fungi, can cause pneumonia.

There are several types of pneumonia. Most common type is Community Acquired pneumonia. It occurs outside of hospitals or other health care facilities. It may be caused by bacteria, especially Streptococcus pneumoniae. This type of pneumonia can occur on its own or after you’ve had a cold or the flu. It may affect one part or lobe of the lung, called lobar pneumonia.  Mycoplasma pneumoniae also can cause pneumonia, commonly causes walking pneumonia. It typically produces milder symptoms than do other types of pneumonia. Viruses are the most common cause of pneumonia in children younger than 5 years. Viral pneumonia is usually mild. But in some cases it can become very serious. Fungal etiologies are the most common in people with chronic health problems or weakened immune systems, and in people who have inhaled large doses of the organisms. The fungi that cause it can be found in soil or bird droppings.

Other types of pneumonia are Hospital acquired pneumonias that people may catch during a hospital stay for another illness. This type of pneumonia can be serious because the bacteria causing it may be more resistant to antibiotics. People who are on breathing machines (ventilators), often used in intensive care units, are at higher risk of this type of pneumonia.

There is also Aspiration pneumonia with inhalation of food, drink, vomit or saliva into your lungs. Aspiration is more likely if something disturbs your normal gag reflex, such as a brain injury or swallowing problem, or excessive use of alcohol or drugs.

In the immunocompromised children, virtually any bacteria, virus, fungus, or even parasite can invade and infect the lungs if the immune system is sufficiently impaired.

Pathophysiology

An inhaled infectious organism must bypass the host’s normal immune and non immune defense mechanisms in order to cause pneumonia. Some mechanisms are nonspecific and are directed against any invasive agent, whereas others are targeted against only microbes or substances with specific antigenic determinants. Anatomic structures of the upper airway and associated reflexes discourage particulate material from entering, whereas coordinated movement of the microscopic cilia on the tracheal and bronchial surfaces tends to sweep particles and mucus up the airway and away from the alveoli and distal respiratory structures.

Mucoid airway secretions provide a physical barrier that minimizes epithelial adhesion and subsequent invasion by microorganisms. Indirect injury is mediated by structural or secreted molecules and generally interfere with the delivery of oxygen and nutrients and removal of waste products from local tissues

There are several pathologic types of pneumonia: Bronchopneumonia, a patchy consolidation involving one or more lobes, usually involves the dependent lung zones, a pattern secondary to aspiration of oropharyngeal contents. The exudate is prominently neutrophilic, found mostly in bronchi and bronchioles, with centrifugal spread to the adjacent alveoli.

In interstitial pneumonia, patchy or diffuse inflammation involving the interstitium is characterized by infiltration of lymphocytes and macrophages. Bacterial superinfection of viral pneumonia can also produce a mixed pattern of interstitial and alveolar airspace inflammation.

Miliary pneumonia is a term applied to multiple, discrete lesions resulting from the spread of the pathogen to the lungs via the bloodstream.

CLINICAL PRESENTATION

Common symptoms include cough, fever, tachypnea, wheezing, trouble breathing or pain when breathing in, bluish tint on the lips and nails caused by decreased oxygen in the restlessness or trouble feeding children.

Newborns more commonly present with poor feeding and irritability, as well as tachypnea, retractions, grunting, and hypoxemia.

Older children and adolescents may also present with fever, cough (productive or nonproductive), congestion, chest pain, dehydration, and lethargy. In addition to the symptoms reported in younger children, adolescents may have other constitutional symptoms, such as headache, sharp chest pain, and vague abdominal pain. Vomiting, diarrhea, pharyngitis, and otalgia/otitis are other common symptoms.

Physical exam examination findings include crackles on inspiration, also called rales and crepitations, decreased breath sounds may be noted in, coarse, low-pitched continuous breath sounds, expiratory wheezes, and high-pitched breath sounds. Alternatively, examination of the chest may be normal, but it may show decreased chest expansion on the affected side.

Findings may sometimes reveal low blood pressure, high heart rate, or low oxygen saturations. Patients may be breathing faster than normal, and this may occur a day or two before other signs.

Travel history is important because it may reveal an exposure risk to a pathogen more common to a specific geographic area (eg, dimorphic fungi). Any exposure to TB should always be determined. In addition, exposure to birds (psittacosis), bird droppings (histoplasmosis), bats (histoplasmosis), or other animals (zoonoses, including Q fever, tularemia, and plague) should be determined.

DIAGNOSIS

Identifying the causative infectious agent is the most valuable step in managing a complicated case of pneumonia. Unfortunately, an etiologic agent can be difficult to identify as various organisms cause pneumonia. Bacterial, viral, and fungal infections are relatively common and have similar presentations, complicating clinical diagnosis.

In patients with complicated pneumonia who have not had a treatment response or who require hospital admission, several diagnostic studies aimed at identifying the infectious culprit are warranted, including sputum or pleural fluid cultures, serology, a CBC count with the differential, and acute-phase reactant levels (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP]).

Some other techniques that may help identify the etiologic agent in difficult cases can be antigen detection, nucleic acid probes, polymerase chain reaction (PCR)-based assays, or serologic tests.

A chest XRay is frequently used in diagnosis. In people with mild disease, imaging is needed only in those with potential complications, those not having improved with treatment, or those in which the cause is uncertain. It is also used to determine the extent of involvement. If a person is sufficiently sick to require hospitalization, a chest radiograph is recommended. Findings do not always match the severity of disease and do not reliably separate between bacterial infection and viral infection.

Radiologic findings may not be present in the early stages of the disease, especially in the presence of dehydration, or may be difficult to be interpreted in the obese or those with a history of lung disease.  A Chest CT scan can give additional information in indeterminate cases.

TREATMENT

Treatment is variable and depends on the child’s age, the severity of the pneumonia, and the etiologic agent, caused by bacteria or a virus. Some children, who are very sick, especially young children or babies, might require hospitalization.

Pneumonia that is caused by bacteria is treated with antibiotics. Antibiotic administration must be targeted to the likely organism, bearing in mind the age of the patient, the history of exposure, the possibility of resistance, and other pertinent history.

When pneumonia is caused by a virus, usually there is no specific treatment other than rest and the usual measures for fever control. Cough suppressants containing codeine or dextromethorphan are not recommended, because coughing is necessary to clear the excessive secretions caused by the infection. Viral pneumonia usually spontaneously improves after a few days, although the cough may linger for several weeks. Ordinarily, no medication is necessary.

With therapy, the most important tasks are resolving the symptoms and clearing the infiltrate. With successful therapy, symptoms resolve much sooner than the imaging, in some studies up to 8 weeks after therapy. If therapy fails to elicit a response, the whole treatment approach must be reconsidered.

SUMMARY

The definition of pneumonia is an infection of the lungs. It is a serious illness, especially in young children. Pneumonia can be caused by bacteria, especially in older children or viruses in younger children. Most infections follow an upper respiratory tract infection.

Some of the predisposing factors are underlying cardiopulmonary disorders, such as asthma, congenital heart disease, bronchopulmonary dysplasia, cystic fibrosis, immune and neuromuscular disorders.

Usually the pathogenesis is pneumonia that follows an upper respiratory tract illness that permits invasion of the lower respiratory tract by bacteria, viruses, or other pathogens that trigger the immune response and produce inflammation, in the airspaces.

They’re most common during the fall, winter, and early spring, when children spend more time indoors in close contact with others.

It typically presents as coughing, fever, and trouble breathing, which varies depending on the etiology and degree of involvement.

It is a preventable disease. The best methods of prevention is hand washing. Also there are several vaccines that help to protect against pneumonia.

The American Academy of Pediatrics recommends that all children starting at 2 months of age receive immunization called pneumococcal conjugate or PCV13.  Another pneumococcal vaccine, PPV23 is also recommended for older children 2 to 6 years of age, especially who have a high risk of developing an invasive pneumococcal infection.