THE WHEEZY INFANT ADIL WARIS

ACUTE BRONCHIOLITIS Usually one off episode Recurrence is rare Mx hypertonic saline .. Mechanism of action?

CHRONIC BRONCHIOLITIS Bronchiolitis obliterans History of a severe insult important Measles and adenovirus Persistent air trapping Mx don’t do antihistamines

COW MILK ALLERGY Clear history on formula milk use Even via breast milk Examine the skin Trial of DAIRY AVOIDANCE indicated

GERD Classic symptoms may be absent Weight associated GERD Investigation tools not accurate, not readily available, expertise needed, expensive Trial of therapy acceptable

CARDIAC History and CVS exam ECHO Cardiac conditions that result in pulmonary artery dilation and/or left atrial enlargement, including large left to right shunts, can compress large airways and cause wheezing. In addition to compression of the mainstem bronchi by markedly enlarged central pulmonary arteries, compression of intrapulmonary bronchi by abnormally branching pulmonary arteries has been reported in patients with absent pulmonic valves Left ventricular failure or pulmonary venous outflow obstruction can result in distension of the pulmonary vascular bed, bronchiolar wall edema, increased airway resistance, and wheezing [10]. Bronchial hyperresponsive was also reported in patients with congenital heart disease [11]. One hypothesis is that pulmonary venous hypertension may cause hypertrophy of pulmonary veins, increase spasm of pulmonary vasculature and, as a final event, release vasoreactive substances that affect both vascular and bronchial smooth muscle reactivity, leading to a "pseudoasthmatic" state [12]. In some infants with obstructed venous return, cardiac findings including cardiomegaly and murmurs may be absent. Therefore, a high index of suspicion is required to make the diagnosis [13]. Wheezing was reported as the only presenting symptom in cases of isolated cor triatriatum

Broncho - pulm dysplasia “chronic lung disease of infancy” h/o IPPV and oxygen use increased airway reactivity Exacerbation of wheezing may occur in viral infection, physical exertion, GER, or fluid overload

BRONCHITIS Protracted bacterial bronchitis(PBB) Chronic cough Relatively well May wheeze but rare Not air trapped on percussion 10 – 14 day antibiotic course

TUBERCULOSIS Enlarged hilar nodes Lateral CXR Failure to thrive Monophonic wheeze

Congenital airway anomalies Tracheal stenosis / web Tracheoesophageal fistula Bronchogenic cysts Vascular rings and slings – usually pulm artery slings give wheeze, at rest a stridor Ct scan indicated The historical approach was to perform barium swallow if a vascular ring was suspected. This has now been replaced in most centers by computed tomography (CT) angiogram or magnetic resonance imaging (MRI) with contrast (magnetic resonance angiography [MRA]) [6]. MRI or CT can also identify foregut anomalies (eg, tracheoesophageal fistula and esophageal atresia).

SWALLOWING INCOORDINATION Neurologically impaired child Wet bibs Oropharyngeal pooling History of cough with fluid diet Modified swallow studies Trial of water and solid diet Trial of NG feeds

FOREIGN BODY Rare in infancy Clear history.. hopefully Monophonic wheeze or unequal breath sounds Flexible bronchoscopy Remember esophageal FB

CYSTIC FIBROSIS Mainly caucasians Failure to thrive Loose stool… fecal elastase/ Fecal steatocrit Air trapped Sweat test not available Sweat iontophoresis Delta F 508

OTHERS Primary ciliary dyskinesia Bacterial tracheitis Intestitial lung disease

ASTHMA Takes time to aerosensitise History of first episode important Two patients in ten years and symptoms began in 11th month Everybody has a family atopic history

Conclusion Very common Easy to mismanage Choose your investigational tool well Trial of therapy where appropriate eg ten day dairy free then PPI trial Cow milk allergy and GERD common Asthma rare

QUESTIONS