Transcript Seretide salmeterol/fluticasone propionate

Respiratory Infections in
Children
Dr Basil Elnazir
PhD, FRCPI, FRCPCH, DCH
Respiratory Tract infections
• Upper
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Pharyngitis
Tonsillitis
Otitis media
Croup
• Lower
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Croup
Bronchitis
Bronchiolitis
Pneumonia
Respiratory Viruses
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Influenza A virus
Adenovirus
Parainfluenza virus
Rhinovirus
RSV
Enterovirus
Coronavirus
Human Herpes 6
Human Metapneumovirus
SARS coronavirus
Bocca Virus
1933
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1955
1956
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1958
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1986
2001
2003
2008
Common Cold
• Infectious viral URTI
• Symptoms
– Nasal discharge/stuffiness
– Throat irritation > cough
– Pyrexia (38o C)
– Feeding & sleeping difficulties
– Myalgia, lethargy & anorexia (older children)
• Usually last up to 7 days
Common Cold
• Investigations
– None
• Management
– Antibiotics (not useful)
– General measures
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Fever relief
Frequent fluid intake
Nasal obstruction/stuffiness relief
Avoidance of Environmental Tobacco smoke
Sore Throat
• Pharyngitis,Tonsillitis, Acute exudative Tons.
& Pharyngotonsillitis.
• Uncommon under 1 yr (peak 4-7 yrs)
– Viruses
– GABHS
• Fever
• Diffuse redness of the tonsils & Pharyngeal exudates
• Tender/enlarged anterior cervical Lymph nodes
Tonsillitis
• Investigations
– Throat swab
– Rapid antigen testing
• Mangement
– Supportive/ Symptomatic
– Antibiotics (not routine)
• Severe clinical condition
• GABHS is suspected (10 day Penicillin course)
• Infectious mononucleosis !!
Otitis Media
• Most common reason for GP/ER visits in
children.
• Causative organisms
– Strept. Pneumonia (40-50%)
– H. Influenza (20-30%)
– Morexalla Catarrhalis (10-15%)
• Amoxicillin ( macrolides if Penicillin allergy)
CROUP
Acute
Laryngotracheobronchitis
Croup
• Acute Respiratory disease of children
• 6 months –5 years (peak 2 years)
• Viral prodrome
• Runny nose, cough & congestion
then
• Barking or seal- like cough, hoarseness, sore throat,
stridor & respiratory distress of varying degree
Pathology
Diagnosis
• History
• Examine Oropharynx ( DON’T)
• Xray (lateral neck)
• Laboratory work (generally unnecessary)
• D/D
Croup: Assessment of Severity
• Mild
– Stridor with excitement or at rest; no RD
• Moderate
– Stridor at rest with I/C & S/C or Sternal recession
• Severe
– Stridor at rest with marked recession, decreased
air entry and altered level of consciousness
Management
• Supportive care in calm environment
• Humidified O2 as blow by
• Steroids
– Nebulised Budesonide
– Oral dexamethasone ( 0.15-0.6mg/Kg)
• Racemic epinephrine
• Potent vasoconstrictor effect which decrease airway oedema
• rapid but short lived
D/D Acute upper Airway obstruction
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Croup (v.common)
Recurrent spasmodic croup
Bacterial tracheitis
Foreign body
• Rare causes
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Epiglottitis
Inhalation of smoke & hot air in fires
Trauma to the throat
Retropharyngeal abscess
Angioedema
Prexisting (congenital) structural abnormality
Clinical Features of LTB (Croup) vs Epiglottitis
Croup
Epiglottitis
Onset
over days
over hours
Preceeding Coryza
Yes
No
Cough
Yes
No
Ability To drink
Yes
No
Drooling saliva
No
Yes
Appearance
unwell
Toxic, very ill
Fever
< 38.5o C
> 38.5o C
Stridor
Harsh, rasping
soft whispering
Voice, cry
Hoarse
Muffled/reluctant
Croup
• Indications for Hospital admission
– Moderate – severe croup
– Toxic looking
– Poor oral intake
– Age < 6 months
– Family circumstances
Croup: Summary
• Clinical syndrome
– Barking cough, inspiratory stridor, hoarse voice
and resp. distress of varying severity
• Routine neck Xray and Oropharynx exam is
not indicated (dangerous!!)
• Steroid therapy is effective (routine in
moderate – severe.
• Nebulised adrenaline may be used to provide
rapid relief
Do Not
Bronchiolitis
RSV
• Site of infection
• Characteristic syncitum formation found
in cell culture and infected tissues
• Possible links between severe
bronchiolitis and asthma are still under
investigation.
Bronchiolitis
• Viral Resp. Prodrome ( Runny nose,
congestion, poor feeding)
• Increased work of breathing, diffuse
wheezing, acc. muscles, diffuse
crackles
• Generally mild and self limiting
Bronchiolitis
• acute infectious disease of the lower
respiratory tract that occurs primarily
in young infants, most often in those
aged 2-24 months.
• Edema and inflammatory infiltration
of the bronchial walls
• Infection is spread by direct contact
with respiratory secretions.
Bronchiolitis
• Epidemics last 2-4 months beginning
in November and peaking in January
or February
• Previous infection with the common
etiologic viruses does not confer
immunity.
• Re infection is common.
Bronchiolitis: High Risk
• Prematurity
• Chronic Lung disease
• Very young age (< 6 weeks)
• Congenital heart disease
• Underlying immune deficiency
Signs & Symptoms
Fever
Increased work of breathing
Wheezing
Cyanosis
Grunting
Noisy breathing
Vomiting, especially post-tussive
Irritability
Poor feeding or anorexia
Management
• O2 & fluids
• Steroids (no role)
• Bronchodilators (minimal effects)
• Racemic epinephrine (appears effective)
Management
• Humidified oxygen (<94%).
• Patients should be made as comfortable as possible
(held in a parent's arms or sitting in the position of
comfort).
• Cardiorespiratory monitoring is essential
• Pulse oximetery is helpful
Management
• ?I/V fluids (difficulty taking bottles)
• Isolation
• ?Nebulised therapy
• ?? steroids
• Antibiotics :not indicated unless
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Toxic/ recurrent apnoea & circulatory impairment
WBC > 15,000
Progressive infiltrative changes in CXR
+ve bacterial Cultures/ Acute clinical deterioration
Bronchiolitis (CXR)
• Hyperinflation of the Lungs with flattening
of the diaphragm
• Horizontal ribs
• Hilar bronchial markings
• Occasional Collapse
Morbidity & Mortality
• Significant morbidity is rare.
• 1% of cases (Hospitalisation).
• Mechanical ventilation is required for 3-7% of
admitted patients
• Mortality rate is 1-2% of all hospitalized patients and
3-4% for patients with underlying cardiac or
pulmonary disease.
• The majority of deaths occur in infants younger than
6 months
Bronchiolitis: Summary
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1-6 months (rare > 2 years)
RSV is the commonest cause
Severe RD is likely in high risk infants
Supportive therapy & O2
Trial of nebulised bronchodilator
Chest physio, routine antibiotic & ribavarin
are not recommended
Pneumonia; LRTI
Pneumonia
• Acute respiratory disease accompanied by
fever , tachypnoea, +/- cyanosis
• Definition
– Bronchopneumonia
• febrile illness with cough, respiratory distress with evidence
of localised or generalised patchy infiltrates on chest x-ray
– Lobar pneumonia :
• similar to bronchopneumonia except that the physical findings
and radiographs indicate lobar consolidation
Pneumonia
• Majority are viral in origin
– RSV, Influenza, adenovirus & parainfluenza
• Bacterial causes
– Newborns
• GBS, E. coli, Klebsiella sp., Enterobacteriaceae
– 1-3 months
• Chlamydia trachomatis
– Preschool
• Strept. Pneumoniae, H. influenzae b, Staph. Aureus
• GAS, M. catarrhalis, Pseudomonas!!
– School
• Mycoplasma pneumoniae, Chlamydia, Strept.
Pneumoniae,
Pneumonia
• Tachypnoea
– <2 months
>60/min
– 2-12 months
>50/min
– 12mo- 5 yrs
>40/min
Pneumonia
• Hospital admission
– Community acquired pneumonia can be treated at home.
– Criteria for admission
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Children < 3 months
Fever ( > 38.5o C)
Refusal to feed / vomiting
Rapid breathing +/- cyanosis
Systemic manifestation
Failure of previous antibiotic therapy
Recurrent peumonia
Severe underlying disorders (immunodef, CLD)
Pneumonia: Invest.
• Investigations
– CXR
– WBC & diff
– CRP
– Blood Cx ( +ve 10-30 %)
– Resp. secretions C/S
– BAL (P.carini in immune compromised)
– Serological studies (M. pneumoniae)
Pneumonia
• Management
– Supportive
– Antibiotic therapy
– Chest Physiotherapy
Pneumonia: Summary
• Tachypnoea is the best single predictor of
pneumonia in children of all ages.
• Bacterial pneumonia cannot be reliably
distinguished from viral pneumonia
• The age of the child, local epidemiology of
respiratory pathogens determine the choice of
antibiotic therapy.
• 4. Anti-tussive remedies and chest physiotherapy
should NOT be routinely prescribed for children
with pneumonia
Pearls
• Lobar consolidation is a feature of
pneumoccocal pneumonia.
• Multiple cavities containing fluid/air in
staphyloccocal pneumonia.
• Common for children to start with viral
pneumonia and get bacterial superinfection.
• Pertussis (whooping cough)… Leucocytosis
with absolute Lymphocytes
Asthma
Asthma
• Chronic inflammatory pulmonary disorder,
characterised by
REVERSIBLE OBSTRUCTION
of the airways .
Asthma Burden
• ISAAC
– Ireland 4th
– 15% children
• Asthma Society of Ireland
– 5-11 yrs
– 12-18 yrs
– 79%
3.5 school days/ yr
2 school days/ yr
suboptimal control
Prevalence of asthma in children
• estimated 1.4 million children
receiving treatment for asthma in the
UK
• 29% of consultations for asthma in
primary care are for children (aged 0–14
years)
Pathophysiology
• Chronic inflammation
• Bronchial Hyperresponsiveness
• Reversible bronchospasm
• Intermittent exacerbations
Causes of Asthma Exacerbations
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VRI
Allergic exposure
Air pollution/ tobacco smoke
Bacterial infections
Stress/ Emotional factors
Excerise
Cold Air
Diagnosis of asthma in children
Presenting features
• wheeze
• dry cough
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breathlessness
noisy breathing
Chronic Cough
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Recurrent RTI
Asthma
Allergic Rhinitis/ Sinusitis/ PND
Infections (Pertussis, RSV, Mycoplasma)
Inhaled foreign body
Suppurative lung disease (CF, PCD)
GOR
TB
Cigarette smoking (Active /passive)
Habit cough / Psychogenic cough)
Recurrent Wheeze
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Asthma
Post RSV bronchiolitis
Recurrent aspiration of feeds
CLD
CF
Pulmonary/ cardiac Congenital anomalies
Maternal smoking
Cow milk allergy/intolerance ( infants)
ASTHMA:
• A clinical diagnosis
– symptoms / history
– Signs
– objective evidence
DIAGNOSIS
Asthma History
• Nature of symptoms
• Pattern of Symptoms
– (severity/frequency/seasonal & diurnal variation)
• Precipitating/aggravating factors
• Profile of AAA (ER visit/ ICU)
• Previous and current drug therapy
– Response, dosage, delivery, S/E
• Impact of disease on child and family
– Exercise tolerance,sleep disturbance
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Atopic History
School performance & attendance
Environmental history (active/passive smoking)
General medical History of child
ASTHMA:
DIAGNOSIS
SYMPTOMS: none are specific for asthma:
wheeze, SOB, cough (esp: at night, exercise)
F.H. (+)ve
SIGNS wheeze, Harrison’s sulcus, AP diameter
OBJECTIVE :
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reduced FEV1 ( / FVC )
PEFR variability >20%
exercise-induced bronchospasm
sputum eosinophils (research)
Asthma diagnosis:
children
Suspect asthma in any wheezing child:
ideally heard on auscultation
Δ Similar to adults - but can’t measure lung function
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presence of KEY FEATURES
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no alternative diagnosis
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RESPONSE to Mx plan
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RE-ASESSMENTS
HISTORY: ‘chesty’ with viral URTIs
: cough (esp. at night, on exercise )
: wheeze
Classification of Asthma Severity: Clinical Features Before
Treatment
Days With
Symptoms
Nights With
Symptoms
PEF or
FEV 1 *
PEF
Variability
Step 4
Severe
Persistent
Continual
Frequent
60%
>30%
Step 3
Moderate
Persistent
Daily
-5/month
>60%-<80%
>30%
Step 2
Mild
Persistent
3-6/week
3-4/month
80%
20-30%
Step 1
Mild
Intermittent
 2/week
2/month
80%
<20%
What is Asthma Control?
• Standards for assessment of Control
– Minimal symptoms day and night
– Minimal need for reliever
– No exacerbations
– No limitation of physical activity
– Normal Lung functions (FEV1and /or PEF
>80%
Asthma : Management
• Avoidance of triggers
• Prompt treatment of acute attacks
• Prevention of Asthma attacks and
symptoms
Severe Acute Asthma
• Severe AAA
– Increased Resp rate
– Too breathless to talk or feed
– Accessory muscle use
– Pulsus paradoxus (older children)
• Potentially life –threatening features
– Silent chest or feeble respiratory effort
– Cyanosis
– Reduced level of consciousness or fatigue
– Pneumothorax / pneumomediatinum/ SC air
Severe Acute Asthma: Treatment
• Recognition
• Close observation
• Relieve Hypoxemia
– O2 via face mask
– Aggressive use of bronchodilators
• Salbutamol 5mg/kg (2.5 mg/kg <5 yrs)
• +/_ ipratropium bromide (125-250 micro grams)
– Systemic steroids
• Oral prednisolone (1-2 mg/kg)
• I/v Hydrocortisone (100 mg qid)
• Reassessment (monitor PEFR & O2 sats
Severe Acute Asthma: Treatment 2
• Aminophylline
– 20 mg/kg over 20 min (omit if theophylline)
– Continuous infusion 1 mg/kg
• CLOSE OBSERVATION & Reassessment
PROGNOSIS OF CHILDHOOD ASTHMA
‘Not all who wheeze will always do so’
FH asthma, rhinitis (esp. in mother )
- predict persistence to late childhood
not adulthood
Co-existent eczema / rhinitis
- predict persistence to late childhood
and adulthood
Markers e.g. (+)ve skin prick tests
- reflect current severity
- do not predict long-term outcome
PROGNOSIS OF CHILDHOOD ASTHMA
Gender
boys: early childhood asthma
: more likely to ‘outgrow’ asthma
girls :
persistence to adulthood
PROGNOSIS OF CHILDHOOD ASTHMA
SMOKING
maternal smoking: infants wheeze
(no evidence of persistence to adulthood)
PREMATURE / LBW infants
more likely to wheeze in early childhood
(but not adulthood)
PROGNOSIS OF CHILDHOOD ASTHMA
SEVERITY
the more severe the asthma in childhood,
the more likely to persist into adulthood
LUNG FUNCTION
poor function in childhood predicts
persistence of asthma into adulthood
Asthma Drugs
• Short acting Bronchodilator
 b2 bronchodilator
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(Reliever, Blue)
• Salbutamol (Ventolin / Salamol etc.)
• Terbutaline (Bricanyl)
– Anticholinergic Bronchodilator
• Ipratropium Bromide (Atrovent )
• Preventative/ Prophylactic Treatment
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Cromoglycates (DSCG…..Intal)
Methylxanthines (Theophylline)
Leukotriene Inhibitor (Montelukast (singulair),Zafirlukast)
Oral Prednisolone
Asthma Drugs
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• Inhaled Corticosteroids
– Budesonide
(Pulmicort …Brown)
– Beclomethasone (Becotide)
– Fluticasone
(Flixotide…..Orange)
• Long acting Bronchodilator (LABA)
– Salmetrol
– Formetrol
• Combination (ICS + LABA)
– Seretide (Fluticasone + Salmetrol) (Purple)
– Symbicort ( Budesonide + Formetrol) (Red)
Asthma Hx
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Pregnancy (smoking)
Birth Hx (prem?), hx of RSV etc
When did symptoms start?
Have you ever heard your child wheezing
Hx of infantile eczema, allergies
Problems with swallowing/GOR
Environment (smokers/pets/wooden floors, overcrowded
accommodation)
F Hx of atopy (asthma, eczema,hay fever, food allergy).
Nocturnal symptoms (cough, night time awakenings)
Exertional symptoms
GP/ER visits, Steroids
School absenteeism
Severe Acute Asthma
• Physiological features:
– SaO2 < 91 % (R/A , before treatment)
– PEF
< 50 % predicted or personal best
– PaCO2
> 5.3 Kpa (40mmhg) if measured
Summary BTS/SIGN Asthma Guideline for
patients under 5 years
STEP 4
Refer to respiratory paediatrician
STEP 3
In children aged 2-5 years, consider trial of leukotriene
receptor antagonist.
Patients should be
regularly reviewed to
ensure that the level
of treatment they
receive remains
optimal.
STEP 2
Add inhaled corticosteroid*: 200-400 μg/day or leukotriene receptor
antagonist if inhaled coticosteroid cannot be used.
STEP 1
Inhaled short-acting β2-agonist as required
Adapted from BTS /SIGN Asthma Guideline
Thorax 2003; 58 (suppl I): i1 - i94
(*beclometasone or equivalent)
Stepwise management of
asthma in children aged 5-12 years
Step 1: Mild intermittent asthma
Inhaled short acting ß2 agonist as required
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Stepwise management of
asthma in children aged 5-12 years
Step 2: Regular preventer therapy
Add inhaled steroid 200-400mcg/day *
(other preventer drug if inhaled steroid cannot be used)
200mcg is an appropriate starting dose for many patients
Start at dose of inhaled
steroid appropriate to
severity of disease.
* BDP or equivalent
Step 1: Mild intermittent asthma
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Stepwise management of
asthma in children aged 5-12 years
Step 2: Regular preventer therapy
Add inhaled steroid 200-400mcg/day *
(other preventer drug if inhaled steroid cannot be used)
200mcg is an appropriate starting dose for many patients
Start at dose of inhaled
steroid appropriate to
severity of disease.
* BDP or equivalent
Step 1: Mild intermittent asthma
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Stepwise management of
asthma in children aged 5-12 years
Step 3: Add-on therapy
1. Add inhaled long-acting ß2 agonist (LABA)
2. Assess control of asthma:
• good response to LABA – continue LABA.
• benefit from LABA but control still inadequate – continue LABA and
increase inhaled steroid dose to 400mcg/day * (if not already on this dose).
• no response to LABA – stop LABA and increase inhaled steroid to
400mcg/day *. If control still inadequate, institute trial of other therapies
(e.g. leukotriene receptor antagonist or SR theophylline).
Step 2: Regular preventer therapy
Step 1: Mild intermittent asthma
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Start at dose of inhaled
steroid appropriate to
severity of disease.
* BDP or equivalent
Stepwise management of
asthma in children aged 5-12 years
Step 4: Persistent poor control
Increase inhaled steroid up to 800mcg/day *
Step 3: Add-on therapy
Step 2: Regular preventer therapy
Step 1: Mild intermittent asthma
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Start at dose of inhaled
steroid appropriate to
severity of disease.
* BDP or equivalent
Stepwise management of
asthma in children aged 5-12 years
Step 5: Continuous or frequent use of oral steroids
Use daily steroid tablet in lowest dose providing adequate control
Maintain high dose inhaled steroid at 800mcg/day *
Refer patient to respiratory paediatrician
Step 4: Persistent poor control
Step 3: Add-on therapy
Step 2: Regular preventer therapy
Step 1: Mild intermittent asthma
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Start at dose of inhaled
steroid appropriate to
severity of disease.
* BDP or equivalent