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I think it's well, the final thing is that we prepared a short quest to enable you to test and consult that you're learning. So please stick around to the end. Enough said, I think, Doctor, uh, Donahue over to you. Okay. Thank you. Thank you very much. Turn, um chuffed. Honored it to be the first person to to speak to the society. And so hopefully hopefully I think it's topical, so I stopped at the moment. Respiratory pages. Obviously very busy. So what? What I hope to do is go through, try and fly through your number off big areas just in the next 40 45 minutes, and then happy happy to take any questions after that. So what I'd like to do these on. We want to go. We'll go through bronculitis because it's obviously very and we're very busy. The hospitals, very busy bronchitis it in minute this. But you see on the news most nights that a day is is full of croup will go through that and just about a croup from the primary care perspective. Asthma. A zoo. Well, obviously, on the effects may be that the pandemic is hard upon asthma. chronic productive cough a little bit about cystic fibrosis on developments in CF and then we're finished with obstructive sleep apnea. But that's not acute. Teo, go to sleep. But I think it is important as well and something we don't always talk about. So just like 23 go through a few two or three slides on obstructive sleep apnea. So I want to say bronculitis is really back with a bang this year. If we look at this graph, which is on the public health website, this looks at this is the graph of RSV from 2019 up to 2021 we can see that was the usual curve from about, um, mid October to February March Every year we have the bronchiolitis spike. We didn't have it last year because, uh, the in possession of social distancing Onda uh, worry is and Southern Hemisphere it really came back with a bang in their winter. And that's really what we're seeing now and that RSV is really all over short. Stay E d. Awards of followed babies with RSV importantly is well because normally, as you know, we see babies from got one team one year old they get RSV But these babies missed out last year. So we've got to court so potential RSV babies. So Children, one tumor seen three year olds with RSV type rhonchi litis. So that's really concerned. And it's pressing are really pushing a lot of pressure upon the hospital in a minute. So as you know, bronchial Linus, Typical presentation, runny nose cough. And then after 24 hours or so, it goes into the lower airways and we get a shortness of breath ways and in drawing. So what, uh, what we'd if we look at the nice guidance for management of bronchiolitis This gives us some kind of same posting about how to manage these on assess these babies. So they they break up the, uh, assessment into amber and red. We get worried if we wait. If we see a baby is tucking me, it was significant. Enjoying, we say above 60 breaths per minute is really of consume also, obviously, if they reduced all intake so picky to 75% of usual because we were worried about getting dehydrated on If we see the mini d or you see the room primary care. You put a SATs monitor on them and they're the Sanctura a ting. Then that's obviously a concern as well, because the two big things we can offer in the hospital our oxygen on also, well, suction as well fluids we can give. And there's a gastric feeds or intravenous the fluids just to ensure rehydration. So the really red flags for bronchiolitis or apnea office space off the baby stop screaming, profuse seconds or just in this recurrently they look seriously. Well, if they're very Tuckett, we accept the respiratory rate. There's about 70 breasts per minute on there against significant subcostal and drawing or intercostal, and in drawing on also. Obviously, if we see central cyanosis, babies must commit to a hospital. Generally, as we say in hospital, we try minimize suction because that can actually cause more secretions. We give oxygen would give. That would be a little bit of high flow, a swell over. There's no great evidence for that. So, as you know, generally the treatment. It's supporter, but he's a really the big things to look for in primary care. If you see babies here, tuck it, Li, you are decent actuated and especially if there are also they're not getting fluids and they need to. They need to come in if we Beavon to group or acute laryngotracheal bronchitis. As you know, typically it presents with a barking type cough in a strider. So I really tight in drawing inspiratory sound and generally caused by para influenza virus in the emergency department and maybe in primary care, our big priorities to get steroids on board the hospital are be HSC. Guidance suggests dexamethasone, no 0.15 mg per kilogram or they generally, um, if babies or Children are still very strange. A lisp. With that, we'll give nebulized steroids, specifically budesonide nebulizers, usually 1 mg, and that usually works for 95% of Children. However, it was still have Children who are symptomatic despite that will give adrenaline nebulizers. But the big, big problem with the Drennen said it can help very, very well, but we can get rebound effect. So if someone's getting adrenaline nebulizer, they're going to be staying in hospital. The big differential diagnoses for Children with croup are. Could it be a foreign body? Could could a baby or could get a toddler, put a toy in their mouth and aspirated to be on a full axis. Bacterial Truckee, I This is always something we think about. If a baby or child appears to be on responsive to the traditional treatments, so nebulized or or all steroids and they're still working very hard on with thinking know something's not right here and not responsive to steroids, which the vast majority of babies are. Could it be a bacterial or per espera opera infection such as Truckee itis? In which case we're thinking about intensive care and intravenous antibiotics? Could it be a big glass tile is? Thankfully, we don't see that really with the, uh with the standard childhood vaccination program. So that's something thankfully, we've haven't seen for a number of years. If you look at the algorithm for croup on this is only and the NHS website what a 0 to 18 and it's really, really good, I think breaks down and arrhythmias into primary care settings and acute care settings. And I think this gives good guidance about how to assess and treat babies with group, as we say the vast majority will respond to, or else steroids, dexamethasone or prednisolone or nebulized steroids as well and very filmed. Thankfully, we don't weigh. Admit very few Children with with croup know days. We have a few Children in the community. You have recurrent croup, in which case we give them access to all steroids. Some parents will, by the rule, nebulizers as well. But usually it's not necessary if we move on to asthma, which, as you know, is the most is chronic was calm, chronic disease have chanted, and we're obviously doing really well and in a small way, because we're we're different country with plenty of money compared to a lot of other countries on. If we look for evidence of this, the know feel Trust published a guideline February 2019, looking at the international comparisons health and well, well being in adolescents An early adulthood, and it was shocking, really, in terms of where the UK falls in terms of asthma mortality rates compared to the rest of the countries, we can see Portugal and sorry, The top graph is for Children between 10 and 14 years of age. Portugal, on top in terms of very low asthma mortality rate in the UK, is next to the worst Onley behind New Zealand in terms of aspirin mortality rate. And it can if we look on the bottom graph. Children, adolescents, adults between 15 and 19 were way down the bottom of the chart, which is really embarrassing, shocking and really startling figures here. So we're obviously not doing things well in terms of our asthma management. The European Risperidone Regional published a paper at the end of April just looking at practice guidelines to clarify and streamline the diagnosis of asthma and Children between five and 16 years of age. And it gave the definition of asthma. But I think is good just to revise for a couple of seconds. So it says, asthma is a disease that includes symptoms of ways. Call breathing difficulty together with reversible airway obstruction, airway inflammation and bronchial hyperspasticity. This so the really big things here always. So if we don't see a waste, it's very rare to have asked me. Very unlikely. We've got asthma in the adult world. People do talk about cough variant asthma, but we see it next to never in pediatrics. So we're almost always seem weeks in the last month. Cough breathing difficulty, fine, reversible Airways obstruction. This is really important as well, because it means that if we give, say, so beautiful and somebody seems to get better, they're suggests reversibility. And it suggests asthma, airway inflammation really, really important because this is the crux of the problem and also the treatment bronchial, hypersensitive nous in response to triggers again, we know that such as house dust mites such as exercise such as upper respiratory tract infections. What the European Respiratory Journal says, though, is that we may not have all of these things. So we move almost always have ways, but we may not have evidence of inflammation or evidence of hyper sponsored this of or reversible airways obstruction. But these are the cornerstones of asthma that feeds into are approached, actually treating us. Miller. If we want to treat asthma, we need to get inhalers to the right place. So how are we going to do that? And what inhalers are we going to try and get into the lungs, where it should be straightforward Because we know his airway hyper responsiveness, it would give subunit more. We'll see evidence of a transient improvement in with the shortness of breath, transient improvement isn't what we're looking for. We're looking to give a better standard life, so minimize airway symptoms. So we know inflammation is the basis of the problem. We want to give antinflammatory. So we need to get inhaled steroids into the lower airways. So we keep on we. We have to get inhaled steroids to dump in this information. How are we going to do it when it's really important that we use a Japonese devices? So if they have a say, a two year old, we're going to use a meter dose inhaler on an aero chamber? Yellow Where Or chamber. So we generally use MDI is in the l aware of chambers up until about five years of age. And, as you know, the L Aware Chamber has a mask from five years of age of words. We'll use an MDI on Blue Errol Chamber that has a mouthpiece to turn up to my stroke delivery into the lower airways from 56 upwards. We can think about trying a powder device is really, really importantly. We want to demonstrate in here attending because if we don't demonstrate that we can't expect patient patients will parents to be able to use it on. We want to. We usually employed teach back, so we show them how to use it unless there ask them to show back or teach back tours. We wanted Sampo system about what to do in the event of a problem. So we give a personalized ask him a plant, and that's modeled around green, green lumber and red so green of the medications as you know, the inhalers when everything's hunky door in where everything's good number is what to do in the event of somebody getting a, well, more wheezy, more short of breath. And so we want to. Same coast about giving more s are beautiful and then reread is what we do in an emergency and generally about involves 10 parts of sub you tomorrow and then go into the emergency department. But we want to Hummer home about using inhaled steroids regularly. You'll be aware of the National Review last Modesto, published in 2000 14, that looked at the numbers that reviewed the cases of Children and adults who died with asthma in the one year period from February to January from 2012 to 2013, As you can see there, there are 195 deaths, and 14% of those were in Children or people under the age of 19 years of age. More with the big messages that came out in the national Review of Ass MCATs. There were two glaring messages. The under use of inhaled steroids. As we've said already on the over the use of short activity to organists. Ventolin substitute Beautiful. It's just natural if we have. If we have a headache, I'll take the sub UTI we'll take. We'll take a proximal. If we have a ways, we'll we'll take Subunit because it gives us instant relief. Transient. Really. That problem is, if we're just these people that died, almost all of them became reliant on short acting. Beta two agonist on. We're just using prn Bensel. It's a beautiful apartment symptom, really, But it wasn't addressing the in the airway inflammation that was talked about already. So we really push home about regular use of enhanced steroids, and we try and scare parents, actually, and tell them about if you don't take in him steroids, your your risk of dying your chance at risk of dying and we know this significant increased risk of harm and Children. You take more and 12 canisters of sub you to more per year so you can see the shocking figures there that in Children and adults who died, 14% of not being prescribed inhaled cortical steroid on 4% of patients were getting more than 50 inhaled some beautiful canisters per year. So they're the two big messages under use of inhaled steroids on overuse of sub you tomorrow on the problem. One of the many problems with overuse of salbutamol Resilient. Get down regulation of the receptors so the actual receptors, salbutamol receptors don't work so well anymore. So you're harboring than that hard that they're no longer respond to the usual stimulus off salbutamol, which is bronchodilation so way really push, push, push about using inhaled cortico steroids on tell patient's parents that the Children could die if we don't take those regularly. And this is also homered home in there. The most recent version off the asthma guidelines, and this is the BTS saying guns. But it's the same in the gene. A guideline as well. We can see it used to be Step one used to be commencing inhale sub you tomorrow Step two low dose inhaled cortico steroids But we can see on the most recent literation off the beach. Yes, guidance. This is for adults and adolescents here that step one is actually low dose inhaled steroid. So it's pushing, getting inhaled steroid on board from the get go from a nerve, the stage then go into putting in parts of a long acting beta two agonist in combination There appeal Lucas actually try and receptor antagonist and then going up the step wise algorithm There short acting beta two agonist. So obviously important for for deterioration or for acute acute deterioration, we can see that along the bottom line off the guidance. So we know the particularly vulnerable group for asthma deaths are teenagers 14, 15 years of age. For those we push a smart regime. So Symbicort used for maintenance and reliever therapy. So it's Symbicort. So is Budesonide with formoterol eso. The formoterol is long acting beta two agonist, but it can work quickly, So the beauty of that is that we can use this combination therapy Symbicort as a reliever as well as maintenance therapy. So we ask patients to take one, inhaled one or two, inhale inhalations off Symbicort in the morning and then contained to eight through the day. So that can use this is a xyralid. But as we said so that gets the inhaled steroid on board whenever there, whenever they're symptomatic, is where. So it's really just trying to be, say, a shift away from some beautiful to get to giving regular inhaled steroids to dump in this information. As you said already, we know for many years now that adherence is a massive problems on. As we said of the Iran, we want to get inhaled medication to where it's working. But if we're not taking the inhalers, it's obviously not gonna work. And we know now for 25 years, and many studies have shown that common in levels of adherence are between about 30 and 50% which is ridiculous, really So obviously we're not taking the inhaled steroid as we found it already were at a greater risk of death. So how can we address that? Well, there's a big, big way we conduct in primary care on that's reviewing repeat prescriptions because we know that the usual dose Ingwer Asia for inhaled steroids is one canister permanent. Know whether that's, Ah, combination therapy serotype or whether it's better matters. Own Clennell. It's usually 11 canister problem, so we can see and the repeat prescription on the right hand side of the slide here so we can see budesonide on the March 2000 and nine, and then we can see really no more. Inhale steroid, plenty of oral steroids. We can see budesonide again in March 2000 and 10 on December 2000 and nine, so there's no evidence of regular inhaled steroid. So that should alert us that they patient apparent isn't giving regular inhaled cortico steroids to the child. So then were thinking that they're risk off of acute deterioration so we can monitor that primary care by reviewing repeat prescriptions. Warm, more secondary care. We're using smart inhalers that tells us by blue too attached to Bluetooth. They're bad Bible it to to, uh, to come to our computers that can tells if a patient is using their small inhaler and a, if you're using it, be if they're using it properly. Direct observed therapy has been used in a number of large scale studies in America. But increasingly and in Belfast, we're using remote direct observed therapy, which was direct by which was, which was conceived by Professor Shields here in the Children's Hospital and Professor Michael name the professional pharmacy. So we ask for two weeks in Children we should spend time taking their inhalers. We ask the parents today to show a of the but the Children taking and there and here is and B are they taking it correctly. So in summary, looking at the Children who have been felt how difficult asthma in this study from a few years ago and done in in Holland of 142 Children felt a have difficult Asmat, 97% of them actually didn't have difficult asthma when they common problems were addressed. The common problems are, as we've said, already looking at adherence to to their inhalers, looking at common triggers and trying on avoidance of those and also looking at inhaler technique on trying to optimize in here the technique and giving a personalized aspirin a plan to direct that. So if we do the simple things well in Asmara, we can avoid deaths, and we can avoid deterioration so we don't have to be reliant on monoclonal antibodies or some high tech solution. If we do the simple things generally, our patients will be safe if we now move on to acute asthma. So in the emergency department or a child with acute flare up and asked me presenting to you in primary care I just want to mention briefly about the use of oral steroids, because the husband a change over the last three years in the emergency department here, in here in the Children's Hospital move away from prednisolone towards dexamethasone. Um so the Children's hospital uses a dose off dexamethasone, no 0.3 mg a kilogram. Sorry, that should be stopped for acute asthma attacks. And and there was a review of this in the August publication off our kinds of disease in childhood, with a pro con debate on Do They top on the top of this slide of just put the pro. But it was also a compromise. Another another center in London. Looking at this importantly, there's no evidence that Dexa met his own has superior efficacy. Let's see to prednisolone um, and however it is better tolerated in a number of studies have shown that there is less vomiting. The dexa matter is, um, but I think crucially on importantly for you in primary care that it's really quite difficult to store. Um in improvement is quite difficult to get holdovers well, so I don't see that there is any definite overwhelming benefit to trying to get dexamethasone and primary care. Person is Lem works well. We've used it for tens of years on, and it's worked very well. So I don't think there needs to be a big move towards steps, um, episode. And in this Procardia bait that I mentioned in the August diversion in the August publication of our kinds of diseases in childhood, the con, the people that were advocating or send it there's no, you know, definitely, Benefit said that really, why people have been talking about this. It said it's comparative Ultram to playing the Brahms Violin Concerto while Rome is going up in smoke. I I we shouldn't be wasting time thinking about tomatoes, tomatoes peninsulem dexamethasone when the big thing is about inhaler adherence on trying to get inhaled steroids on board on a regular basis. So I just wanted to mention that because you may have heard, or you may have witnessed that the move away from prednisone towards dexamethasone. But I just wanted to reassure you that there isn't any big problem to continue using prednisone. Um, if we move now onto chronic productive cough and this is a big problem, Children or perceived is a big problem for parents. I do very fair do occasional private clinic one every couple of weeks on the vast majority of Children that are a sense that private clinic are with chronic productive cough rather than asthma. So it's not asked me, and the big thing that's gonna court could kill Children. It's the chronic productive cough, the big thing that causes a really be rate for parents because they hear this really irritant cough in It is that's what's bribe is them to take them for, for their assistance or for their help. So if we look at what is a chronic cough, well, it's to find is a cough lasting more than four weeks? The big thing, Is it dry, or is it productive? And if we look at the British Thoracic Society guidance, core assessment and treatment of course if we looked on the right hand side of this slide. Um, people always think about asked him a with a cough, certainly a dry cough that has a wheeze and shortness of breath. Certainly asthma. But has it said before? If we have no ways, Bassman is going to be on like late post nasal drip of the jet rhinitis does cause a lot of true wrote clearing an irritant kind of wet upper upper airway car. If we look at the wet, productive cough and this is what we're going to focus on for two or three minutes here in the next slides were thinking about could it be a cystic fibrosis? Unlikely because it's tested for in the neonatal screening program could be primary ciliary dyskinesia, which is a very rare condition characterized by wet, productive type cough, along with frequent ear infections or a tightness media on in 50% of cases with dextrocardia. But it's quite rare. Could it be persistent bacterial bronchitis? I'm going to part that for two seconds because we're gonna come. We're going to come back to it. But could it be immunodeficiency? So when somebody comes into the hospital with a chronic, productive cough. We're thinking, Well, could it be immunodeficiency? We'll check the A immunoglobulins. Well, maybe checking an X ray as well. Um, if we move onto the next box and the algorithm choking with feet so we see a lot of aspiration and coughing, especially in Children with your disability. So Children with cystic sorry with cerebral palsy or some syndromes that have difficulty swallowing and have unsafe swallow way. Try and address that with the speech and language therapist. Um, look at Safeway's of feeding, brassy or barking cough. We can see which is usually a dry cough with trecumulatia or bronchial manship on. Increasingly, we see habit cough a psychogenic off, and you may be aware of the increased through the pandemic corporate pandemic or off ticks on do. Aligned. With that, we're seeing more habit car as well. So the big big thing about having coffee is that it's dry and it disappears completely when asleep. And we need to treat how big cough we try and reassure the patient's rule out. There are the things that is that it is dry, that it's irritant that it's not getting any better. Um, that there isn't any ways. We try and work on suggestion therapy just to try and get him to sue their their airways, their their throat, taking regular drinks. So we're seeing quite a lot of that recently. Interstitial lung disease. Thankfully, we don't see that very much TB. Occasionally we see. But then play. Not not really very much. Got a briefcase here for and a half year old girl. Problematic cough for a year. It's a wet cough. It's loose on down on the parents that describe it. It's like being like a smoker's car. There's no ways know. Strider and treatments have been tried, inhaled steroids and montelukast for a month. No improvement that was stopped. No change with the steroids were given again. No improvement. Antibiotics were tried to courses of Mark Sizzler. They did appear to help for the duration off the course of antibiotics. But then the cough. Rickard. So what are the possible diagnoses? As it said already know UPN always ask me, is unlikely. Also, we tried aspirin treatments, and there's no response to treatment. Also, it's an affordable, loose, productive cough when it's least we're thinking about infection. We did some investigations the usual ones, maybe for asthma and secondary care. Spirometry was very good, 100% predicted normal flow volume loop and no evidence of airway inflammation. So excelled. Nitric oxide is less than 27 past billion, so it's normal. So what is the diagnosis? Will diagnosis is one of exclusion, so persistent Work off the response to antibiotics. But then Rikers, so typical of persistent bacterial bronchitis, the child was given a four week course of antibiotics. Clock or marks the club is on. It's recommended on those an excellent response. They, um So what is so PBB, as we say, is a wet cough in the absence of other diagnoses that response to antibiotic. And but then Rikers, often treated with uh, Smith therapy with no response, usually will try and get some sputum. And if we can, this will often or usually grow haemophilus or Moraxella. A chest X ray is usually done. A swell metal generally show some patchy changes or bronchial world faking it. The guidance from the ER s or a European respiratory sites society is online, but PBB and you can see one of the authors there is our own professor might Shield's Who has recently returned. So the treatment for PB be a Zyrtec amended by the European respiratory societies to the four week course of antibiotics usually recommend calm. Oxy class and studies have shown that in half the cases will be complete resolution. However, the one in eight or 15% will require six or more courses of antibiotics. Reassuringly, I think there's a strong association with large airway Malaysia. Why, that's reassuring is that as a Children grow older, their airways are will become bigger than more reserve on their outgrow. This so that be not. The phlegm will not tend to block the airways so much so it can coexist with asthma and if it Rikers way need to refer. Importantly, recent studies have shown that this likely is a pre bronchiectasis condition so that if we don't treat it, it can result in bronchi active cysts generally, as we say in the hospital and we'll check your immune profile, make sure there isn't any evidence of immunodeficiency we may do. A sweat test is well because although the vast majority of Children with assisted by process of picked up in the neonatal all right program that will be one every year that slips through the nets. So we do. We often do. You sweat test. We may do bronchoscopy, but after know, we'll see are maybe a degree of malicious years. We've said already on phlegm so we can get Bronco. We can do bronchial washings and get and get phlegm maybe. Sure, but Moraxella just said already this condition primary ciliary dyskinesia is current rise by. They're very low levels of nasal mattress box side. We don't do it very much. Occasionally we will do CT of the chest Philip of Bronchiectasis. But we want to reduce exposure to to radiation as much as possible. Assistant, if we move on to cystic fibrosis now, also just meant to say with a smart asses Well, thankfully called. It didn't seem to affect asthma, so it didn't seem to exacerbate Children who suffer with asthma. They're having problems at the moment, with all the other virus is such a rhinovirus and RSP to some extent as well. But Kobe really hasn't had an effect on Children with aspirin, and a lot of parents have found that reassuring. But many studies have shown that corporate hasn't hasn't been a problem for Children and indeed adults We last met so cystic fibrosis and I won't dwell on this. You know a lot about it already, but something that I do want to bring Teo your attention is Aziz. You know, cystic fibrosis is an orifice, um, a recessive condition on the PSA genetic condition current to rise by problems with this CF transmembrane conductance regulators. So the barrier and sells a bit on the on the cell surface has a problem with it with chloride transport. So we can't get chloride across cells on. That means that if we can't, if there's a problem moving chloride we have problems with water as well on we can get water into the airways off Children assisted by a process which results in like mucoid secretions. That plug of the airways and cause recurrent infections and the bronchi active cysts over the last few years has been a development in the personalized medicine and cystic fibrosis, which has really been a massive change. So consequently, as the results of this, we hardly see any impatience or her hardly have any impression assisted pro process. So these CIA modulators the two big ones that have been released on the market in last few years are I work after, or the trade name is carried a koh which which address is which is modulates the GI by 51 D mutation on is used for Children with this mutation greater than six years old on the big one that's really made a massive difference is that it focuses on the most common gene mutation. Doubt at five a weight. So patients that have two copies of a Delta five away mutation have been happen Agreement to be given, uh, or come be, which is a combination off CIA modulators lumacaftor. And I've recapped er on this has been licensed for Children greater than two years old. I won't say any more about this other than these. See, uh, modulators have made a massive difference in terms of the care of Children. Maciste equipment on adults with cystic fibrosis over the over the last few years. So if you move on to obstructive sleep apnea, Onda uh, as you know, they seize these Children who snore on, then pauses in the breathing on then and then snortin awake through the night. So they have recurrent waken ings on have very fractured poor quality sleep on as a result, there absorbs Sted in the morning and have daytime somnolence So o s a first and a recorded or noted a snoring and restlessness at night on as a cause of backwardness on stupidity in Children and the BMJ in 18 89 in the first case, serious was only published in 1982 on why it's important that it was recognized. Core as a course of backwardness and stupidity is that there's a clear association with cognitive and you're a cognitive impairment on do attention deficit disorder in Children with it with obstructive sleep apnea. So it's really important that we think about it that we recognize it on that were possible. We treat it so who is at risk? So in this diagram we can see the normal airway or the normal operate away in a child and normal size pharynx, normal sized tonsils and adenoids. So people that have a problem, as you know, when Children, the most common cause of obstructive sleep apnea, is under no tonsils or hypertrophy, so it can see a normal size airway in the center with big chunky tonsils that are blocking the airway and causing the snoring and causing the apnea. So we also increasingly, we're seeing Children with normal sized airways, a normal sized tonsils, but are overweight. So the classic call I don't type of obstructive sleep apnea because off impinge in a soft tissues on the operator away. We also see a lot in pediatric practice of Children with and normal tonsils and adenoids but small airways. So Children with syndrome such as classically in Down syndrome or trisomy 21 where we see Children, little boys and girls with small airways and normal sized tonsils. But the normal size tonsils are sufficiently big to cause obstruction to the air ones in Children and with down Syndrome, and we see it with a lot of other syndromes. A swell. We see a lot of problems, say, with achondroplasia, Children and adults with constipation because of the small airways and the normal tonsils that obstruct the airways. So how do we screen for it? Well, usually will do overnight oximetry. I'm sorry this tracing is quite small, but the upper graph shows the oximetry tracing, which should be a straight line with a saturation overnight of between say, 96 97%. But we can see this child has recurrent cyclical d saturations through the night. The lower graph is heart rate, and we can see spikes in the heart rate and that coincide with the D saturation. We know that the problems that people that have obstructive sleep apnea have problems in our EMR ram sleep when when we become Hypo Tonic. And that's really when the airways become hypotonic on we on on day saturate for the period of ram sleep. That's why we can see this cyclical sat saturation episodes. We've got a serious off oximetry recordings here from normal at the top two mild obstructive sleep apnea moderate on, then severe where we can see the saturations into the seventies. And I think from that you could appreciate that a child who's de saturating recurrently every night to this 70% is obviously going to have new record knitted difficulties. That's really important that we pick this up. So So how can we once we pick it up, how come retreat it? Well, the main treatments, as you're aware for somebody big tonsils or obstructed tonsils, will be it will be tonsillectomy, plus or minus adenoidectomy and a swell Um sometimes, as we say, increasingly were seen. Overweight Children, Children with obesity or you have obstructive sleep apnea. We recommend weight loss. It's obviously easier to say. Then, then then do. It can also sometimes will try and nasal steroids as well, because if we're worried about that, no swollen aren't noise in particular. And nasal steroids can help shrink these and increase away at flowing in the nose. But sometimes tried decongestants, antihistamines. There is some evidence for the use of montelukast as well. But I would mention just in passing about Montelukast that we know from a number of studies from Smith that 15% of Children will develop side of back to montelukast within the first two weeks of starting therapy. And this can be really quite marked in terms of behavioral difficulties on night terrors. So we tend not to use montelukast so much as you know it's a leukotriene receptor antagonist. It can be used for a sleep apnea but is more commonly used for asthma. But we're moving away from it because of the poor side of that profile, especially the severe sleep Terrorist nasal CPAP We use quite a locked in Children who are overweight on that in whom had know tonsillectomy is not going to work on again. Children, we with syndromes, down syndrome we will often try CPAP for for them to to address the O S. A. It's a little bit, uh, very a book called The Children of Tolerated Younger Children. That's so but we have really quite amazing. Respiratory nurse is you don't take no for an answer. I have tried different different interfaces, different soft masks just to try and help patients help Children tolerate CPAP often will try it. It'll be used part of a game turn cpap on the teddy bear or on their dolls that can help with compliance. So the number of ways we can the controlling address that so in summary, we've been through taking a ways through all the common or a lot of the common topics and for spiritual pediatrics, including a bronculitis topical at the moment croup chronic productive cough that we're seeing a lot of at the moment asked me which we always have cystic fibrosis just to highlight there developments with insisting process and they're in a brilliant work done on the development of CIA modulators on then finally, obstructive sleep apnea. Though we have a child who's snoring, maybe having pauses in their breath that we should think about obstructive sleep apnea because there are sick we landing, um to it's such a The neurocognitive consequences it's quite easily screened for in in most Children's quite easily treated. So with that finish off and happily take any any questions you might have. And that's great. Thank you very much, Doctor or Johnny. And then he has any questions. You can just put them in the chat and we have a couple for a year. That's okay, down certain. And so what? I'm making a primary care referral for, um, USA. Would you send to ent or Pediatrics? Respiratory? It's a good question on goes both ways. Um, probably, um, I suppose if you can see a clear cause, so if you can see big tonsils that you think would would damage definitely benefit from not being there, I think straight to to ent thing is we work closely with the anti, so if they have any concerns with with do the sleep studies in a way. So I think if you can see a big, ah, big problem that they can deal with it in ent. If it's somebody say overweight, say, a 12 year old boy who's overweight snoring, Uh, he's got a lot of daytime somnolence, but you can't see big tonsils sent to pediatrics and we'll see. But just we'll do the screening and then maybe think about CPAP. Thank you. And what are the storage difficult days to you mentioned with dexamethasone? I'm not really sure, but apparently there are some, um, I think it made the difficulty appear on encountered this myself when I tried to get some from my GP is that it's quite hard to get hold off in primary care on that this might be related to storage difficulties and somebody told me that. But I don't know specifically what they are. I think I think this is only to use. It actually is the bottom line, and I think we were reviewing practice in Children's. It's really quite a big. It's a massive hip of steroids as well. For the vast majority that come through E. D. It works very well because again, we're often worried about compliance. And if we say go home with three days of prednisone load, we can't We know that 45% of Children will finish your three day course of prednisone, so at least we know we give him a a single dose of dexamethasone, the vast majority. We can see them taking it, and they'll be okay. They're really, really severe. Children without small with the difficult to treat are smart. Aches were happier with prednisolone, actually, because well, often give maybe a five day course of prednisone, and then it taper it down, and so so that that's that's really practice what we generally do next question is, how do we carry out free no measurement in Asmat diagnosis? I think that's a really good question. And I think has been a big push from nice in particular about doing excelled, nitric oxide and primary care. I don't think that it's I don't think it's really, um, always necessary. I think a history examination hearing a ways will tell you this area obstruction. And if you've got a primary care as meniscus, they'll often do spirometry and excelled nitric oxide. But a big study in Thor ups in May 2020 Done and Primary care looked at a big. It was done in Leicester, Children with asthma. Who? A big cohort you had Fino done and spirometry as well. A lot of them had abnormal finals. A lot of them had abnormal spirometry. A lot of them had abnormal fino and spirometry. But a lot of them had We're we're actually not symptomatic, but had an abnormality on the Converse was a lot of them didn't have an abnormality but were symptomatic. So I think the big thing is getting a good history, good examination and then using investigations that you've got access to try and corroborate. What do you think? But I wouldn't go fishing. I wouldn't go searching for a pheno as they're you know, they're They're called standard investigation because we know what we see it quite a lot that we see normal. Well, in the asthma clinic, we see Children who are well controlled that we know can be high. And conversely, you see Children who are poorly controlled in there, you know, come below. So it's a good marker of inflammation, but it can go up with allergic rhinitis is well there is a cost implications, which obviously has great a consequence in primary care as well. That may be a final cost, maybe 5 lbs a pop. You know, that's not an insignificant cost. So I didn't answer your question. That's a question was how do you carry out of phenol on, uh, you know, small management. So it's it it It's a machine that's a breathing machine on. We use it as a little game with a child that the keeper balloon above the line. And if they can keep the balloon above the line for 10 seconds, that allows a reading of the exhaled nitric oxide level. Normal level is below 35 parts per billion on elevated is is obviously greater than that. We can be helpful. But as you say, it's not the bill on end off on that would. Actually, if you, if you don't mind, would point you to be and paper. And then they're outline that I mentioned in the Diagnosis of Asthma published in the European Respiratory Journal in April of this year, and it's got nine questions knowing clear questions about making a diagnosis of US men in just Iggy a shin or asthma. And I think I would say I think I would be really useful to look at because it does Look at Phenomenon does look a spirometry and its conclusion generally is that it come be useful. But it's really building up a picture based on your history and examination, which by far the most important thing. But then looking for extra information over in a bottle, we'll stop. Stop speaking Any other question and there's one more here, Um, are there any long term, dangerous, off earlier use of cortical steroids, as their understanding was, that story should be avoided for look for a long as possible, particularly increasing the risk of pneumonia and thyroid to try and avoid it all cost. There used to be a move to, uh on D still are in the community, actually, in the community aspect clinics, um, a number of Children with maintenance on maintenance or of steroids, But we've got we've only in the difficult aspect. Clean it with only got two Children at the moment or mental, it's us or steroids, and they're only in 2 mg on alternate days. So all the steroids definitely is your problem So what time? Reduce the doses of, um, stop doses of oral steroids as well. So we don't want that smell is on every week or every two weeks or prednisone. So I think the way we can do that, as it as we can, as he said, is looking at three inhaler technique. Looking at adherence to inhaled corticosteroid on. Looking on, all sort of personalized, asked My parents. Are the dangers with inhaled steroids? Yes, but we'll try and minimize those by using the lowest dose of inhaled steroid that we can get away with. We do need so often with start with 50 micrograms of plan, a lot better matters on two puffs Speedy, Open a Bassett best majority of Children that that may be sufficient. Um, then we go up to maybe combination therapy, serotype dull or Symbicort and sometimes relivora, but always trying to minimize dose of inhaled steroid. So there are dangers with inhaled steroid, but by far, far, far greater danger with frequent or a long maintenance or on steroids. We also ask absolutely Children to ensure parents did sure that you take a drink of water after taking inhaled steroid because there's always a risk off getting kind of inflammation and kill I two hours in ocular inflammation just becomes in a mouth as well. So if you take a little, you take a little drink that insures that we won't get them was thinking and just another one. Is it a kiss off avoiding oral steroids? If the clinical picture lawyers that and using inhaled instead, um, think in acute situation, probably all steroids of the way to go. So I would say the people that mostly present Teo, um, permit care, maybe in it, you know, with an exacerbation. So I would say at that stage and keep on the oral, steroid is probably the radical rather than giving inhaled steroid inhaled steroid is important for maintenance. We want to ensure that it's every day that taken it every day. And the thing that we can ensure that it's personally significant reduce the chances of needing on steroids. But you're right. The acid depends on the clinical presentation. But if somebody is a cute really, if they're having acute deterioration in their asthma and oral steroids, are are the way to go. Whether that be Dex, um, at his own start dose or a three day course of prednisone. Great. That's great. Thanks. Mm. I think that's all the questions that have come up in the charts. And thank you very much. No problem. Also, if anyone else, if you think of any questions otherwise or anyone has any questions that they're too shy a little bit, I know that's probably exactly and they're free. They certainly email me. It's just the dot well, Donahue a qu be done a c dot UK Be really very happy to have a chap. And if anyone ever wants to come up too difficult to treat aspect Clinic. I know you've got far better, far more interesting lives than toe have to do that. But if anyone was ever interested in doing that, that be very, very welcome. It's great, thank you very much. I don't prince for asking me, really enjoyed it. And so now we're just going to move onto the quiz and so just really quick, just questions. So it's on a hits. I'll just send in the link in the chart here, and and I'm aware that there's idiot off use all my suit for um however, the one we were only able to get was the 50 people. So I apologize. And if you're not able to get onto the quiz, but you'll still be able to see the questions come up, one of them isn't one of the stories. Difficulties with expenses. And we'll see dot Okay. There. Yeah. Okay. And if you just put in the pin up the street to to get to 50 here and then that's all the spaces. We'll just take a go ahead and lie to start. Well, you okay? And so the answer for that was 70. We couldn't. We want to. Next question as to which of the 41 is used as a first line treatment in the monitoring up a key group. Okay, on the answer for that is dexamethasone. Um, and in the house, no monitoring pathway. Which medications is initially prescribed as a regular preventer? Great. On the answer is low dose ICS. Which country in the world has a highest awesome or tell you right in your people age 10 to 16. Okay, on the answer There is New Zealand and hard on should've called be present for before being described was crawling. Think the timers that long for this one? What cancer flies four weeks and a cystic fibrosis is condition characterized by mutation, which cruise in okay on the answer there. Seven. Yeah. What is the most common treatment for Children with obstructive sleep apnea? Good eyes there. Since we're there on the last question using data from awesome UK harmony Children and more than on into your currently receiving treatment for asthma you get on, the answer is to be six employees and and that's the end of the cruise there. And thanks very much. And also just we promote for a child house Saudi own. Wednesday we have our first event and at seven. PM, but more details to follow, um will be on our social media tomorrow on all this home back over to the GP Society very much made it so much car for taking us through that quiz on again. A big thank you too. Doctor Donahue for did, uh, bring such unformed talk on childhood Risperdal. Richard presentations. We've really hope that you've enjoyed tonight's talk on, you know, let something new or consolidated your previous landing just to be mindful that the talk has been recorded on will be available to rewatch within the next 24 hours On out of it the page I would really appreciate if you could complete the feedback form that I will send in to the chart here. Now, Um, just to let us know what you've enjoyed about the event on what we can do to kind of improve for the next time on completion off the feedback form you will receive on automated certificate for your report Rodeo to do get that completed on Finally, from May Next event is on. Pediatric cardiology on will be delivered next Monday at seven PM by Dr Andrew's Sand. Who's going to be talking about structure and function abnormalities? Rhythm problems on funny tight turns. So if you haven't already registered for that event using, you could use the link that I'm going to send into the chat now. But that's all from May and thank you so much again if I can pass on to double for a special announcement from GP society, yes and thank you so much everyone for joining us tonight. It's been really wonderful and have you all with us armed. Hopefully you'll be able to join us for the rest of the Siris as tar and says, and so this Siris will be running for the next six months nights. But we've got some other really exciting events coming up with the GP society on That's particularly and the launch tonight of our GP spotlight in the hot seat event. Don't their first in person events since Kobe it on. It's going to be taking place on Wednesday, the 24th of November at seven PM and Elmwood Hall. We've got lots of different GPS with loads of different special interest. You're going to be coming on sticking to us on the night. You'll have the chance to ride, interact with them, chopped with them about their career there. Hotly anti general practice on. We really, really hope that you might consider joining us So looking is going to go live, especially a 30 pm but you could get a little head start outside the book like into the Chapman eye on hopefully and you're really sort of joining us and the forces free pizza for everyone on the night. So maybe that one producer from along. But don't forget before then. We've got the pediatric Siris continuing. So thank you so much. Everyone for attending, going to forget to fill up the feedback forms and certificates. And of course, But I do two. Don't crude on you and forgiven some time, if this time Right. Thank you, everyone.