1. THE WHEEZY INFANT
ADIL WARIS

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

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

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

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

7. 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

8. 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

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

10. TUBERCULOSIS Enlarged hilar nodes Lateral CXR Failure to thrive
Monophonic wheeze

11. 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).

12. 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

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

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

15. OTHERS Primary ciliary dyskinesia Bacterial tracheitis
Intestitial lung disease

16. 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

17. 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

18. QUESTIONS