Coughing, Wheezy and Stridulous Children

LRTI vs URTI – Key Learning Points

Pneumonia in Children (LRTI)

• Characterized by:
  • Cough
  • Fever
  • Respiratory distress
  • Consistent reduction in activity
• Discharge Criteria:
  • Most children with LRTI can be discharged from the ED with oral antibiotics and careful safety netting.
• Referral Criteria:
  • Age below 1 year
  • Low SaO₂
  • Moderate/severe increased work of breathing
  • Comorbidities (e.g., immunodeficiency)
  • Poor oral intake or urine output (note possibility of AKI or SIADH)
  • Signs of sepsis
• Diagnostics:
  • Chest X-ray is not recommended for diagnosing uncomplicated community-acquired pneumonia.
  • Pneumonia is a clinical diagnosis.
  • Blood tests and chest X-ray are not routinely required even if a child is being admitted.
• URTI in Children
  • Characterized by:
    • Cough
    • Fever
    • Fluctuating level of unwellness
    • Absence of respiratory distress

URTI in Children

• Common Symptoms:
  • Sore throats
  • Sore ears
  • Runny noses
  • Red eyes
• Viral Illness Indicators:
  • Even when tonsils are red or have exudate and eardrums are red and bulging, the likelihood that antibiotics will help is very low.
• Key Management Aspects:
  • Good symptom control
  • Ensure good hydration
  • Rule out sepsis
  • Rule out complications (e.g., peritonsillar abscess, mastoiditis)
  • Provide good safety netting advice
• Antibiotic Use:
  • Evidence suggests antibiotics are not effective in reducing symptoms or complications.
  • Antibiotics should be prescribed mainly for prolonged or otherwise atypical cases of URTI in children.

Wheeze in Children

• The vast majority of pediatric wheeze is caused by one of three conditions:
  • Bronchiolitis
  • Viral wheeze
  • Asthma

Bronchiolitis in Children

• Overview:
  • Think of bronchiolitis as “wet lungs.”
  • Commonly seen in children under the age of 12 months.
  • Gradual progression of symptoms over 3-5 days: cough, wheeze, feeding difficulty, increased work of breathing.
  • Symptoms often plateau for a few days before resolving.
• Management:
  • Many studies have found no effective treatments.
  • Respiratory support and feeding support are crucial.
  • No inhalers, steroids, antibiotics, or nebulisers are effective.
• Assessment in ED:
  • History:
    • Look for red flag symptoms (e.g., blue, pale, or floppy episodes).
  • Feeding:
    • Ensure the infant is taking at least half of their normal feeds and having wet nappies.
  • Comorbidities:
    • Consider if the infant is ex-premature or has known heart problems.
  • Examination:
    • Assess work of breathing, hydration, and signs of alternative diagnoses (e.g., cardiac causes of wheeze).
• Severity and Management:
  • Mild and Moderate Cases:
    • Do not require chest X-rays or blood tests.
    • The decision to admit or discharge is clinical.
    • Chest X-rays can show nonspecific findings, potentially leading to unnecessary antibiotic use.

Case Example: Perplexing Case – A Wheezy 6-week-old

• Presentation:
  • 6-week-old baby with coryza, wheeze, poor feeding, and increased work of breathing.
  • Excessively tachycardic (190 bpm) and a prolonged prodrome (7 days) with worsening symptoms.
• Diagnosis:
  • Although bronchiolitis is a consideration, the symptoms suggest cardiac failure, likely due to a large ventricular septal defect.
  • Clues:
    • Large liver
    • Presence of a murmur (difficult to hear at 190 bpm)
  • Early recognition of heart failure is essential for early treatment.

Viral Wheeze in Children

• Overview:
  • Different from bronchiolitis; characterized by bronchospasm rather than “wet lungs.”
  • Both conditions are caused by viruses but present and respond differently to treatment.
  • The differences are likely due to the development of children’s immune systems over their first few years.
• Clinical Implications:
  • Differentiating between bronchiolitis and viral wheeze is crucial.
  • Bronchiolitis:
    • Should not be treated with bronchodilators.
  • Viral Wheeze:
    • Must be treated with bronchodilators.
• Severity:
  • Viral wheeze is not a benign condition.
  • Children have died from exacerbations of viral wheeze.

Understanding the distinctions between bronchiolitis and viral wheeze is essential for appropriate management and treatment to ensure the best outcomes for pediatric patients.

Bronchiolitis vs. Viral Wheeze

Key Differences:

• Age:
  • Bronchiolitis:
    • Typically affects children under 12 months.
  • Viral Wheeze:
    • Commonly affects children aged 1 to 5 years.
• Symptom Onset:
  • Bronchiolitis:
    • Gradual onset over days.
  • Viral Wheeze:
    • Rapid onset over hours.

Diagnostic Approach:

• Bronchiolitis:
  • Avoid using bronchodilators as they can tire out the infant.
  • Focus on supportive care: respiratory and feeding support.
• Viral Wheeze:
  • Treat with β-agonists (e.g., salbutamol).
  • Prefer inhalers via spacers over nebulisers, except in hypoxic children.
  • Steroids are reserved for severe episodes, not routinely used.
  • Chest X-rays are generally not helpful unless in severe cases or with specific indications.

Case Example: Perplexing Case – A Wheezy 3-Year-Old

• Presentation:
  • 3-year-old with increased work of breathing and a coryzal illness.
  • History of viral wheeze but no wheeze heard on auscultation, with good air entry.
• Considerations:
  • Despite the absence of wheeze, it is likely still viral wheeze.
  • Try administering 10 puffs of salbutamol.
  • Improvement might manifest as a wheeze appears due to slight relief in bronchospasm, allowing for a different musical note in the lungs.

Summary:

• Age as a Diagnostic Tool:
  • Under 12 months: Likely bronchiolitis.
  • 1 to 5 years: Likely viral wheeze.
• Symptom Duration:
  • Bronchiolitis: Symptoms develop over days.
  • Viral Wheeze: Symptoms develop over hours.
• Treatment Considerations:
  • Bronchiolitis: Supportive care only.
  • Viral Wheeze: Use β-agonists, monitor response to treatment.

Understanding these differences ensures appropriate and effective treatment, minimizing unnecessary interventions and optimizing patient outcomes.

Viral Wheeze vs. Asthma in Children

Key Differences:

• Viral Wheeze:
  • Multiple episodes are common in young children.
  • Often triggered by viral illnesses.
  • Asthma misdiagnosis risk due to recurrent episodes.
  • Rare in children under 5 years old.
  • Episodes typically related to viral infections.
• Asthma:
  • Rare in children under 5 years old.
  • Suspected in under-5s with repeated wheeze episodes not linked to viral illnesses.
  • Prolonged cough without wheeze is unlikely to be asthma.
  • Requires careful differential diagnosis, especially when treatment response is poor.

Treating Asthma:

• Critical Points:
  • Failure to respond to treatment is a serious concern.
  • Consider alternative diagnoses or comorbidities if there is no response:
    • Anaphylaxis
    • Pneumothorax
    • Cardiac causes (e.g., myocarditis)
  • In many cases, more aggressive treatment may be necessary.

Case Example: A 2-Year-Old with a Cough for 2 Months

• Presentation:
  • 2-year-old with a persistent cough for two months following a severe URTI.
  • Initial cough severity led to vomiting.
  • Parents suspect asthma due to the prolonged cough.
• Evaluation:
  • Prolonged cough without wheeze is rarely asthma in young children.
  • Post-infective coughs, such as from pertussis, can last for months.
  • Referral Criteria:
    • Daily cough for 8 weeks warrants outpatient assessment.
    • Urgent referral is needed if red flags are present:
      • Weight loss
      • Haemoptysis
      • Contact with TB

Summary:

• Viral Wheeze vs. Asthma:
  • Viral wheeze is common and often linked to viral infections.
  • Asthma is rare in children under 5 and typically presents with non-viral triggers.
  • Persistent cough without wheeze is unlikely to be asthma.
• Management:
  • Failure to respond to asthma treatment requires consideration of other diagnoses.
  • Persistent, daily coughs for 8 weeks need further evaluation.
  • Recognize red flags for more urgent referrals.

Croup and Other Upper Airway Problems in Children

Key Points:

• Croup:
  • Common cause of upper airway noises in children.
  • Classic presentation: runny nose followed by a barking cough.
  • Diagnosis is straightforward with these symptoms.
• Differential Diagnoses for Stridor:
  • Foreign Body:
    • Presumed if there has been a choking episode.
  • Epiglottitis, Bacterial Tracheitis, or Diphtheria:
    • Suspect if the child appears more unwell than expected for a viral infection.

Management of Croup:

• Severity-Dependent:
  • Mild cases may only require symptomatic care.
  • Moderate to severe cases often require medical intervention, such as corticosteroids and nebulized epinephrine.

Case Example: Perplexing Case – A Squeaky 4-Week-Old

• Presentation:
  • 4-week-old baby with noisy breathing, especially after feeds and when lying down.
  • Well, thriving, and normal examination.
  • Video shows inspiratory noise like a squeaky toy.
• Likely Diagnosis:
  • Laryngomalacia:
    • Floppy larynx, common in infants.
    • Often exacerbated by reflux.
    • Usually resolves on its own as the child grows.
    • ENT specialist assessment recommended to rule out rarer causes (e.g., haemangiomas, tracheal stenosis).

Role of Antibiotics:

• Protracted Bacterial Bronchitis (PBB):
  • Antibiotics are indicated for PBB.
  • PBB is characterized by chronic wet cough and bacterial infection.

https://www.racgp.org.au/afp/2015/june/the-wheezing-child-an-algorithm

Summary of the most common wheezing conditions in young children
Condition	Estimated incidence in children	Clinical signs	Investigation	Expected clinical course	Management
Viral wheezing (these include a spectrum of viral lrtis that are not always clearly separated eg viral lrti/recurrent viral-induced wheeze/bronchiolitis – management of episodes is identical and the distinction is sometimes arbitrary)	Very common, especially in the first 2 years of life50% of children will have at least one wheezing episode	Wheeze associated with respiratory tract infections May be singular or recurrent Bronchiolitis (usually in children <2 years) manifests with fine crackles +/– wheeze on auscultation	No specific investigations Nasal samples sent for virology usually do not change clinical management but isolation of RSV in infants is highly suggestive of bronchiolitis	60% will outgrow wheeze by 6 years A further 15% acquire wheezing after 6 years After 7–8 years, only 1 in 5 will outgrow it	Trial salbutamol if >1 year of age and continue only if effective Supportive care involving monitoring adequate fluid intake (>50% of usual intake) and for signs of increasing respiratory distress
Asthma	15–20 % of the paediatric population	Wheeze on a regular basisSome will have persistent/interval symptoms between episodes of viral wheeze (cough and/or wheeze at night or with exercise)	Spirometry with bronchodilator response may be possible in children ≥5 years of age in experienced laboratories	Usually expected to be lifelong but clinical courses can vary widely between individual	Exacerbations: Regular salbutamol (as per asthma guidelines) and consider oral prednisolone for up to 5 days Regular preventer usually indicated
Airways malacia (airways floppiness): either tracheomalacia or bronchomalacia	1 in 2100	Usually present soon after the neonatal period with wheeze, stridor, cough and rattling; children are usually well and often labelled as ‘happy wheezers’	Bronchoscopy usually diagnostic but not necessary in most cases	Majority outgrow it by age 2 years Secondary PBB can occur, presumably from poor cough clearance	Treatment rarely required If there are worsening symptoms or failure to thrive, specialist referral is indicated
Protracted bacterial bronchitis (PBB)	Probably common, but exact incidence unknown	Chronic wet cough (typically >4 weeks). Concurrent wheeze and/or rattly breathing is common	Bronchoscopy may assist diagnosis, but usually unnecessary Radiological findings usually normal or non-specific	Majority resolve with 1–2 courses of antibiotics	2–6 week course of antibiotics: commonly amoxicillin/clavulanic acid (approximately 20 mg/kg/dose twice daily)