Read PRN Issue 9 Jan 03 _Wheezy infant_ text version

Paediatric Respiratory News

Volume 1 Issue 9 January 2003

be covered in future issues. The First Volume has now been bound and there are copies on all the wards and one in the Library for reference. The full findings from the audit will be presented at the Paediatric Audit meeting.

Asthma Resource File

An Asthma Resource File has been developed to assist staff when educating and managing children with asthma. It will be available on the wards from February. The file consists of information and guidance on how to complete a Self-Management-Plan, as well as information on how to use all the various Inhaler devices, Peak flow meters, In-check dial and an Epipen. The National Asthma Campaign is no longer producing management plans suitable for children. As a direct result, the respiratory team has developed three new age specific selfmanagement plans for our children as follows: Wheezy infant for age 0 ­ 5 years Junior Plan for age 5 ­ 11 years Senior Plan for age 11 ­ 18 years The resource file should be used in conjunction with the Asthma Link Nurse Box (kept on the fridge in the treatment room) which contains all the required placebo devices, along with other relevant NAC information booklets. Appeal: Required; at least three new Respiratory Link Nurses. Is anyone interested? You need to have been qualified for at least one year, have a keen interest in respiratory illnesses and be willing to spend some time with the PRNS and study for the Asthma Course. Please contact Michele Harrop

Focus on Wheezing in Infancy

Evaluation of the Paediatric Respiratory News

The Paediatric Respiratory News has been in circulation since June 2000. An audit of the newsletter's effectiveness has recently been undertaken. A 72% response rate was obtained from the questionnaires sent out; thanks to all staff who took time to fill in the questionnaire. The audit has shown very favourable results; all respondents who participated in the audit found the newsletter informative, enjoyable and most importantly they said it had had an impact on their clinical practice. The newsletter has encouraged multidisciplinary teamwork and improved communication amongst both the primary and secondary health care workers. Views and suggestions from all respondents have been taken into consideration and suggested topics will


extension 1938 for further information as soon as possible.

(15%, 3%, 2% respectively). There was no difference between those with viral wheeze and controls in airway responsiveness, but those with asthma showed the characteristic hyperresponsiveness to an inhaled challenge. The third and most renowned study to date is that conducted by Martinez et al (1995). Here Martinez and his colleagues followed a cohort of more than 1000 infants from birth in Tucson Arizona. When the children were 6 years of age, the researchers could identify at least two prognostic categories of pre-school wheeze, each with distinctive risk factors. In `Persistent wheezers', wheeze first occurred during viral infection but persisted into school age, and was associated with risk factors characteristic of classical atopic asthma (raised concentrations of immunoglobulin E (IgE) in cord blood, and maternal history of asthma). `Transient early wheezers' who also wheezed during viral infections but had no early markers of atopy. They did, however, have reduced lung function measured in the first year of life, whereas the persistent wheezer's did not. This suggests that airway size is a major factor in early childhood wheeze, and may at least in part explain why many infants who wheeze tend to improve with age. Characteristics of viral wheeze Affects mainly pre-school children Becomes less severe with time Is associated with reduced lung function in infancy Lacks the bronchial hyperresponsiveness characteristic of asthma.

Episodic Viral Wheeze

Episodic Viral Wheeze is a disorder distinct from classical Atopic Asthma and it affects mainly pre-school children. Over the past 15 years the assertion that "all that wheezes is not asthma" has increasingly been called into question. Here we will review the current evidence. Three major epidemiological studies have been identified; the first is a study by Sporik et al 1990, 1991. In this study the authors investigated the effect of early exposure to housedust mite in the development of atopic asthma in a high-risk population. The risk of atopic asthma was shown to be no greater in children who had wheezed in the first 2 years of life than those with no such history. Nether were those children shown to be atopic at age 11 years more likely than atopic children to have wheezed in the first 2 years of life. The second study by Godden et al 1994 looked at groups of children in Aberdeen, selected from a cohort of 2511 primary school children. The three groups- those with clinical diagnosis of asthma (n=121), those who wheezed only in the presence of a viral infection (n=167) and controls (n=167) were followed up 25 years later. Individuals who had had asthma or viral wheeze in childhood were more likely to have current wheeze than controls, but of the three groups those who had had asthma were most likely at follow up to be taking bronchodilators, (42%, 12% and 6% respectively) and inhaled steroids


What is a wheeze? McKenzie (1995) gave the definition of a wheeze as `A non-specific physical sign associated with airflow through narrowed airways which has many causes'. Here are just a few other causes of recurrent wheezing in pre-school children: Asthma Bronchiolitis Recurrent aspiration Maternal smoking Prematurity Cows milk intolerance Congenital heart & lung abnormalities Immune disease When making a diagnosis of either Viral Associated Wheeze or Asthma the history obtained from the parents is the most important piece of evidence needed. Thus the history should be obtained very carefully.

Management of Wheezing in Infancy

Mild Simple reassurance. Bronchodilators may or may not be of benefit. Response is variable with studies showing conflicting results. However infants seem to respond better if they are over 2 years of age. If required a trial of Beta 2 agonist such as (Salbutamol) is usually advocated inhaled via a suitable spacer device and mask.

There is no evidence that oral steroids improve outcomes in acute wheezing, in infancy. They have never been shown to work in infants under 18 months. Moderate/Severe

Symptoms suggestive of diagnosis of asthma in Infancy: Recurrent episodes of cough and, or wheeze Personal or family history of Asthma, Eczema or allergic Rhinitis. (First degree relative!) Exclusion of other causes of wheezing Asthma may co-exist with an alternative condition.

A four to eight week trial of regular inhaled corticosteroids along with beta 2 agonist on a PRN basis via a suitable spacer and soft facemask. Parents will be encouraged to monitor symptoms and the response to treatment.

Treatment should be stopped if there is poor response and other investigations initiated looking for other possible causes for the symptoms.


Therapeutic Evidence

Clinicians have long recognised that some wheezy infants respond to brochodilators but others do not. A review of the past 20 years data on inhaled and nebulised bronchodilators in wheezy infants have drawn the following conclusions: A single nebulised dose of salbutamol may lead to transient worsening of hypoxaemia. Giving the same drug via pMDI and spacer seems to be less troublesome and more effective. The likelihood of a clinical response to bronchodilator treatment increases with age. Limited evidence from one trial suggests that the anticholinergic agent ipratropium bromide (Atrovent) is more effective in wheezing infants than a beta 2 agonist such as salbutamol, but these findings have not been replicated. Most of the evidence relating to improved symptoms using Ipratropium bromide has been anecdotal. Godden 1994 & McKean 1999. A systematic review of the use of inhaled corticosteroids in viral wheeze (McKean 1999) identified five recent papers on the subject. Two studies looked at prophylactic/maintenance therapy with inhaled corticosteroids, in pre-school and school aged children (Wilson 1995 & Doull 1997), and three at episodic high-dose inhaled corticosteroids in pre-school children (Wilson 1990, Connett 1993 & Svedmyr 1999).

All studies were double blind, randomised placebo controlled trials. The Cochrane reviewers examined in detail the outcomes of the five studies. The two studies of maintenance corticosteroids did not demonstrate any clear benefit. The three studies of episodic high-dose inhaled corticosteroids showed that the active treatment reduced the need for oral corticosteroids and parents expressed a clear preference for inhaled corticosteroids over placebo. All five studies recorded symptom scores. Neither study of maintenance therapy showed a difference in severity, frequency or duration of symptoms, whereas all the three studies of episodic high-dose inhaled corticosteroids found less severe symptoms scores of shorter duration with corticosteroid than with placebo. There are no randomised-controlled trials of the efficacy of oral corticosteroids given specifically for viral wheeze. Debate still surrounds the issue of administering oral corticosteroids in the very young. However as the evidence of efficacy is more substantial when given to children with acute pre-school atopic asthma (Brunette 1988 & Gleeson 1990), the weight of evidence has been translated into national guidelines (BTS 1997) that recommend a short course of oral prednisolone for acute asthma at all ages. Because of the difficulty in discriminating between viral induced wheeze and asthma in an acutely ill pre-school child, most physicians will treat all episodes similarly, with oral steroids.


Spacer Devices

The National Institute for Clinical Excellence (NICE) guidelines (2000) recommend that spacer devices plus or minus a soft face mask are used for all children under the age of 5 years because this: reduces the problem of co-ordination, increases drug deposition, reduces and eliminates oral absorption of the inhaled corticosteroids and it is as effective as a Nebuliser.

importance of spacer use. It also depends on the co-operation of the child. A positive attitude and some patient participation in using the device is often helpful. Active involvement from as early an age as possible is encouraged. The spacer and mask should be allowed to be an every day item that the child observes around the home, making the spacer look nice with stickers individually chosen by the child may help make the spacer more appealing and personalised. To make medication times fun using play therapy will also enhance acceptance of the spacer and medication by the child. Electrostatic charge within the spacer may reduce the amount of medication that the patient receives. To minimise this spacers should be washed in detergent at least once a month, sooner if obviously dirty and then allowed to air-dry without rinsing. They should not be kept in plastic bags as this may induce electrostatic charge. The practice of keeping the pMDI's inside the spacer should also be discouraged as this scratches the inside thus reducing the antistatic effect of the detergent. All children should be encouraged to clean their teeth, or rinse and spit out after they take their inhaled corticosteroids. If a facemask is used gentle cleaning of the face will be required to remove any steroid deposits on the face.

Practical implications

The dose that spacer devices deliver depends on factors such as static charge, facemask design, spacer volume, the drug used and the breathing pattern of the child (O'Callaghan 1997). It is important that there is minimal delay between actuation of the inhaler and inhalation from the spacer. Large volume spacers such as the Volumatic (Allen & Hanbury) or Nebuhaler (AstraZeneca) are the commonest on the market. They have been found to provide the most costeffective way of achieving good drug deposition. However this depends on consistent education on the technique and parental understanding of the


Nebuhaler (made by AstraZeneca for use with Bricanyl and Pulmicort)

Nebuchamber (The new anti-static spacer from AstraZeneca for use with Bricanyl and Pulmicort.


(Made by Allen & Hanbury used for Ventolin, Becotide, Flixotide, Seretide, Serevent, & Atrovent)

Spacer Techniques

From approximately 4 years of age children may be able to perform tidal breathing when using their spacer. However not all will be able to do this. It is advised that you try the child using this technique and assess effectiveness. If the technique is poor advise the parents to administer the inhalers using a spacer with a soft face-mask, with a view to trying tidal breathing again when the child is a little older. Remember each child is an individual.


Never force the child down using a spacer and mask as they will become very frightened and it will be difficult to gain their trust again for future attempts. Use as much play therapy as possible, perhaps singing nursery rhymes, rocking too and frow and perhaps counting with the child to make the procedure more fun! Inform the parents that it is not an easy task, but if approached with a positive attitude from an early stage acceptance is usually achieved quite readily. If the infant wants to hold the spacer or the mask allow them to do so to enable some control and participation in treatment.

Produced by M. Harrop PRNS Edited by Dr. L. Amegavie Next Issue: Respiratory Function Tests



PRN Issue 9 Jan 03 _Wheezy infant_

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