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Hello, everyone. Welcome to Med All Education. My name is Ging and I'm usually on the support desk. It's really great to have you all today here for our talk. We're joined today by Doctor Mala Roman who is a consultant pediatrician at the University Hospital Plymouth. Today, Doctor Roman will be teaching us about pediatric Wes. If you have any questions for her, please leave them in the chat and she'll answer them as we go along. At the end of the event, there will be a feedback form emailed to you and once your attendance, once you've completed your attendance certificate will be on your med all account. Uh That's all for me. Uh I'll let doctor Roland take it away. Thank you very much. Hello, everyone. Um Thank you so much to Metal and to Ging Jing for giving me this opportunity to uh meet you everyone. So I hope that once this is over, I would be able to see um all of you. Um So today I have been given this topic to talk about wheezing Children. Um I'm Mallah Rahman. I work as consultant pediatrician at University Hospital Plymouth, which is northwest of England um I don't have any conflict of interest. So these are the aims and objectives which has been set by me for today's event. It's ambitious. Uh But I'll try my best. At, at the end of today's session, you would have lots of uh thoughts to think about when you pre when you are um presented with a child who has uh been wheezing either acutely or um if you see them in your clinic, um whichever setting you are working. So before we talk about the Children who present on in an un acute manner, those who present unwell, um then you need to think about how you are going to asses this sick child. Um And my understanding initially was that this talk is for the healthcare professionals who are working in Sudan. Um but my apologies if uh there are many from other parts as well. So if you're working in a resource limited setting or any setting, you need to think about what sort of resources you have um way before you set up your clinic or way before you are seeing a child. So for assessing any child, you need to have resources. Um So do you have a nice place to see that sick child? Is it appropriate to see Children? Do you have appropriate equipment? Do you have necessary drugs? How the staff have been trained? Do they get regular training? And can they asses a sick child in a timely manner? And then plan accordingly. It's not just important to have trained, staff, trained resources. They also need to consider what age these Children are and who would be the most appropriate to see the child and what is the urgent problem. So for example, if you're seeing a child who is very wheezy looking unwell, you need to understand that. Is it wheeze, is his main problem or is there some other pressing issue which needs to be addressed first before you start addressing the wheeze. So there is a very good program called eat, which is emergency triage system, um, which is initially and essentially developed by Kenya and Malawi and Royal College of Pediatrics and Child Health has been a partner of that for a long time. Uh, in wh website, you can find some E A information. And, um, if you haven't done the course, I would highly recommend E A plus from Royal College. It's a very good course, gives you a very good structure approach, not only to assess sick Children, but also, um, for teamwork who to, who should be there to identify these sick Children very quickly. And I think in Uganda, they have even trained the personnel who is, for example, cleaner or standing on the door or security guard. Anyone, anyone can recognize a very sick child and quickly take them to emergency room for treatment started very quickly. But that was about very sick Children. How do you assess them if they are coming to emergency care, you assess that airway breathing circulation and then D is in this case, severe dehydration and I base this because I thought this is going to be in a low resource setting. So A and B is your airway breathing? Are they breathing or the breathing is very weak or absent? Is there any obstruction in the breathing? Is there a stridor or these Children are choking? Is there any blueness of the lips or tongue? Are they breathing fast? Is there a head nodding? Chest wall in drawing? Um and then C is for circulation, coma, convulsion and D for your severe dehydration. So, as you can see this uh little picture here, uh so if you start assessing how do they look? So when they have hypo hypoxia and they are wheezing and they are having respiratory dispace, very frightened, look on their face. They have nasal flare, they may look very pale, they may have blue nail, they may have blueness around the lip and they may be head nodding. So there is this little uh nice video done by open pediatrics if I can just show you a very quick a minute video and then you can watch at your own time. But I think it's worth watching because it's not only good for our own training, but also if you are going to be run a simulation session or a teaching session for your own um colleagues or juniors or healthcare professionals and it's really, really very nice. So we don't have to watch the entire session, but it would be a good idea to see a little bit of it. Ok. So um that's what I wanted to show you that that is a very small medicine. It's not very high tech, but you can still see what Children do when they have respiratory distress. Uh And there is a similar one nurse run by a nurse practitioner from open pediatrics. And again, a very good video for teaching or training or for your simulation sessions. Um highly recommended. So because I was under the impression that this is for health care practitioners from Sudan, I wanted to educate myself about what, how big problem is we Children in Sudan or in the resource limit setting. Um So this study was um done by um 15 medical students along with the uh Faculty of Medicine um at Kum Sudan. And this was a questionnaire based study and they recognized school going Children 3352. And what they found was 7% of the study, preschool Children were having diagnosed asthma, which was uh compared to 34% among whoever had wheezing episodes. So, out of all these Children um who had wheezing episode, 7% of preschool Children were diagnosed as asthma. And in this study, they also found that about 20.4% of preschool Children had ever experienced an episode of wheeze and current episode of Wheeze, which means that in the last 12 months accounted to 16.6%. And this prevalence of wheeze in preschool Children in Sudan was much more than that I saw in Italy or in Ethiopia. But this, the author feels that these differences could be because uh of the uh other practices, other environmental factors such as smoking, um presence of trees or pollen or animal uh or cooking fumes. And also um it was noted that although the initiation of breastfeeding in Sudan was brilliant, it was 93% for any time breastfeeding or the at birth breastfeeding, but continuation of exclusive breastfeeding at six months was declining. So they think that that might be a cause. So it is a big problem uh wherever you are wheezy Children for various reason. So in our part of the world, we see a lot of wheezy Children during uh October until February March because of respiratory sensitive virus. I live in Devon where it's very damp. So we get lots of dust mite allergies, mold allergies. So we see because of that but other parts of the world see because of fumes and because of cooking because of particulate matter. And that is a very good study from Singapore where they found that the mornings uh smoke and uh fumes of particulate matter related asthma. Admissions were very high. Um in the mornings when Children are going to school So, depending on where you live, the causes may be different. Uh But the problem is that everywhere. So what wheeze is actually um and different people uh define it differently. But essentially the definition is it's a whistling like sound rising from the chest. It's a continuous high pitched sound with musical quality emitting from the chest. It can be inspiratory or expiratory and typically about 400 herz. It's because endre end result of narrowing of the intrathoracic airways and uh sometimes the description which uh is given by, even by healthcare professional, if you haven't heard, many tests may be very variable and accuracy from parents definitely can be very worried. So again, there are very good surveys done where many parents thought that they are describing wheeze, but it was just noisy breathing uh or croup or it was stridor or it was just a bit of a rattly chest and they all recognized that as a wheeze. So if you're going to go with parents say wheeze, then it's better that you show them a video of uh what it should sound like or you mimic the noise of w uh wheeze and then show them how it should be. Uh And then they might be able to recognize what they actually mean by wheeze. Uh This is a picture from uh copied from Wikipedia and you can see what happens. So this is your normal airway and when somebody is having um wheezy episode then the airway gets narrowed. So in asthma, so this is important to recognize that in asthma, your bronchi are getting narrower and the smooth muscle there is a smooth muscle spasm. That's why when you give bronchodilator, it works and you get smooth muscle expansion or relaxation. So the airway is like that, when you give bronchodilator, it becomes like that. Whereas in bronchiolitis, the pathology is in the bronchiole and the problem happening is not so much smooth muscle um constriction, it's more that uh the edema and debris formation is because of infection. So that's why when you give bronchodilator for very small babies with bronchiolitis, they don't respond um to that treatment. Ok. So we are going to go through a series of cases. Um And I just want to ask, changing is the face OK? Or can everybody hear me properly? I think everything is working perfectly. Thank you. Bye. OK. So we will go through about six cases and um we will uh you all, I expect that everyone would start thinking about what this could be and then in the end, we can discuss what, what this case was. So the first case is a 10 month old little girl. Uh These are, these are all real cases from my own practice, 10 month old little girl. Um This is about 67 years back um when I was in the world, um she was admitted to the assessment unit. Uh and this was her sixth presentation of wheeze in the last two months and mom was getting very fed up. She said she's still feeding. Well, she has normal neurodevelopment, but she was very upset that we keep treating her and we keep sending her home that this is bronchiolitis, but she's not getting better. And why is she still wheezing? Uh, she had a bit of increased work of breathing, uh, but she was still active playing around. So, um, how would you approach this case? What questions would you ask? And what investigations to consider? Um, so if it is ok, and if somebody wants to, um, say things, then please feel free to, um, say very quickly so we can move on to second one and then we can come back to the cases again. So in the chat, we've got allergy test, uh, and we've got another comment which says, could it be wheezing associated with GERD? Um, someone else has said I will ask if other symptoms are there. Um, and also allergy test again. Brilliant. Ok, very good suggestions. So, um, allergy test is a good thought. But, um, we need to think about what sort of LSG you are going to, uh, check for and she, she this child for more information. She did not have eczema. Um, she doesn't have any known allergies but doesn't mean we can't explore any environmental type of allergies. So it's a good thought. Um, so yes, so we can do allergy test. Um And then there was another comment about, uh, something else. Uh, um So how would we approach this case? We'll come back to that and the questions you asked was about allergies, uh, a couple of times. So yes, we did ask about allergies. There was nothing no known allergies, no allergies in parents either. Um, and this child's skin was fine. Ok. Um, and then we will come back to this case to see what it was and what we are going to do about it. So our case number two is, this is a four year old Luke who went to a birthday party. He was completely well on that day and soon after the birthday lunch, she reported feeling sick, he had a large forceful vomit. He was in his friend's house, a friend's mom gave some water and then she noticed that Luke wasn't looking very well, he was looking pale and then he started to cough and then he had a very noisy breathing. So mom got very worried friend's mother. She called 999. That's what we do uh, in our part of the world and the paramedics came and they found him to be very wheezy. So again, what's, what's going on here and what should we do? Should we do any test? Uh, should we take him to the emergency department? What sort of treatment should we offer? What other questions should we ask? So we've got some comments. Uh, aspiration pneumonia, uh, asthma, uh, asthma attack, anaphylaxis. Mhm. Excellent. Yeah. Brilliant. So, um, so aspiration pneumonia is a, it's a good thought but this child never is, is a, a fit and, well, uh, neurodevelopment normal. Yeah, he might choke and aspirate and then he might have it but he wasn't choking. Uh, anaphylaxis. Yes. Spot on. So, this child, um, had nut allergy, um, ate, um, they thought that there was n not what we are offering him. He ate that and had sudden onset of wheeze cough. Uh, and, and that's what, that's what happened. He was taken to emergency department. Uh, and what should we do? What should paramedics must have done for him? What, what would be the treatment? Whoever said anaphylaxis, how would you approach that? What would be the first line in the comments? We've got adrenaline. I really excellent. Yeah. Spot on. So, Anaphylaxis first line treatment is adrenaline. So you have to give adrenaline. So if they had, they might have given him, uh, intramuscular adrenaline and take him and then you can assess ABC, they might have given more than one adrenaline. But that is the right answer. So well done for that. Anaphylaxis equals adrenaline always. So our case number three is a little three year old Emma and now she got sixth admission in the last two years to children's assessment unit with wi she does have cow's milk protein allergy and she also has moderate eczema. Her parents have asthma. Her six year old brother is, well, he doesn't have any allergies. The family have two cat and during all admissions, she responded well to salbutamol. She's not on any regular medications. Um, so now again, her mother is very upset that, you know, every time she comes we gave her salbutamol, send her home, nothing is working and she keeps coming to the hospital. What further questions are you going to ask? What further tests are we going to offer? And how should we draw out the management plan for this little wheezy girl in the comments, we've got allergy. Ok. Um Someone would suggest a methylcholine challenge test. Um and regarding the allergy, uh it's specifically to cat hairs, OK. Um The methylcholine challenge test would be to rule out asthma. OK. Fine. OK. Brilliant. OK. So they are really good suggestions. So this um girl um was coming so many times. She has a history of atypic um her um and her parents also have asthma. So likely this child is having uh going to develop asthma or has asthma. Um So those Children who are preschool, it's a little bit becomes difficult to diagnose asthma. So the specific questions which we need to ask is how is she in the interval period when she gets, when she's not having viral infection? When she's well, how is she when she's running around when she's exercise? Is she sleeping well? Has she got a nocturnal cough. Very important to ask about her feeding habits. Is she feeding growing well? Um, cat allergy? Yes, we can rule that out. But in my experience, if you are going to do the test for the cat allergy, you need to ask parents, what are they going to do with the cat? So most of the parents in my experience do not want to get rid of their pets becomes very difficult, but we might consider doing the allergy test and also other environmental allergens. So, has she got hay fever, should we be considering doing the test for uh grass pollen, tree pollen mold, all of that? She's three? So we don't offer any kind of provocation test at that age. We do not do methylcholine provocation test to diagnose her asthma. But because there are other things in the history which makes it more probability scale, it makes it more probable that this child is heading towards asthma. What we would do in this child is put her on a low dose of a steroid inhaler. And then she would be seen very quickly in the clinic again in 4 to 5 weeks with a good education to parents, how to use the inhaler inhaler with a spacer device. Uh and after good education, we need to see her again in few weeks, time to make sure that things are all good. And then we can see whether we need to add on medication. Should she be on the low dose steroid for a longer or if she needs a bit increasement of the steroid. But we wouldn't do any further test for asthma other than asking relevant question, um, to diagnose that this is most likely, uh, going to be an asthma. We've got one little question in the chat, um, regarding the age at which asthma develops, um, the attendees asking that she thinks, um, she thought you couldn't asthma until the child is five years old. Is that correct or false? Yeah. So um it's um it's that's not entirely true because there are predictors. They are not really clear diagnostic tools before the child is sick because they can't perform spirometry once they are six and over, you can perform spirometry. You can also perform peak flow and keep a peak flow diary, but a lot depends on the history. So it's not true that Children who are under five cannot be diagnosed as asthma, but you need to have relevant history. So for example, in this case, this child does have, she has a cow milk protein that she also has moderate eczema. So this is the atopic child. There's a family history of asthma. So altogether and plus she has had recurrent wheeze for a very long time. So this child is most likely to have asthma. So we have to give her medication trial and see what happens. But it's not true that they do not develop asthma, which we will see in our guideline later on. OK. So this one is another interesting one who I met um about five years back in my asthma clinic. So he is now probably in university. Um But this is a 15 year old uh Conner who was uh so he's not called Conal, but I just changed his name. He was referred to asthma clinic. Um and he was diagnosed as asthma at the age of six. Um And then he never had any hospital admissions, he was never seen in outpatient clinic. Um His father reported that his asthma was never fully got better. So he had loads of changes of his um inhalers uh from various one to the other. Um But he was saying that he just feels a bit worried because he's still coughing, um intermittent cough and he doesn't feel that his asthma is under good control. So when he came to my clinic, he was on uh cere inhaler which is a combination of steroid um and a long acting beta two agonist. Um So he was on that and he was uh we checked his inhaler technique. It was very good. So that, that was the story. So what further questions you think I should ask in the history? What further test if any I should offer and how should we manage this case? Any comments? Uh some questions uh is he using his inhaler properly? I'm checking compliance with medication and checking, he knows how to use the inhaler. Brilliant. That was excellent um suggestion. So, yes. So he, we checked his inhaler technique, which is a paramount, isn't it? Because he had so many changes. Um And we should not just assume when parents come and tell it's not working, we can't assume it's not working. We always need to go back and check for ourselves. What is he doing? So that's what we did. We checked his inhaler technique, uh which was very good. Um And so his compliance with medication was good. We also checked with GP that they are picking up the prescription, which yes, they were picking up the prescriptions very regularly. Um So in further questioning, um what I did was I looked through his old notes, which was very thin because he never had admission, but he had one attendance to the hospital when he was four year old. Uh And before that, it was just, he was born in the hospital. So what I noticed was that at birth, his birth weight was um 75th percentile, his weight and his height was also 75th percentile. His head circumference was 75th percentile. Um And then we have no record until he was four but dad said, yeah, it's well and I, they don't, they were not concerned about anything. Um particularly until I started digging a bit more deeper and started asking very probing questions four years of age when he was seen once for the same, um, asthma diagnosis. His weight, uh, was then, uh, 25th percentile and his height was also at 25th percentile. So those, that was the only clue I had. Um, and then what further test we did his spirometry and, um, which was suboptimal and also his weight. Now, in this clinic, when I see him at 15, his weight was at second percentile. His height was between 2nd and 9th percentile. Ok. So now has somebody got any more suggestions, what should I do or what other investigations if anything I have to do and how should I manage this case? So in the comments, we've got ask about exposure to triggers and PF TFD. Ok. Brilliant. Yeah. So, um, I asked about the triggers. Um, and I, I assume you mean triggers means is there any allergies? He doesn't have any allergies? He doesn't have hay fever, he doesn't have eczema. Um, and, um, that no one, no one smokes in his family. There are no pets in the family and he has a sister who is perfectly fit and well, mom and dad have no health issues at all. Uh, they are also completely well. Um, and then when I asked about, asked dad, dad said that dad was, his father was 5 11 and height. Uh, mom was also 5 10 and his younger sister was fine. She was growing at about like between 50th and 75th percentile. Um And dad's family were all not very short. They were average mom's family were all nice and average. No one has any health issues. So that's where I was. Um And then maybe we come back and I'll tell you what happened to this boy, but just make a note of this 15 year old boy. I was really surprised what I found. So our next case is um case number five is a three month old little leua. He had runny nose for three days. Now he came to assessment unit as urgent um as a review, my 15 year old came to my clinic, but this one came to assessment unit. Um I had fever of about 38 5 for the last 23 days. Um uh And then this morning, he had temperature as well the day he presented. Uh and mom said that previous night he did not feel very well. Mom also reported that, you know, he has this wet sounding cough. She described him as having wheezing. Um He was very unsettled and then she said last five hours, she feels that he's struggling to breathe. And that's the reason she called her GP and GP sent her to the assessment unit. He came with parents, he GP didn't think he needs an ambulance to drive him to the hospital. Um So he mom said that yes, he was born at town. So it's not a preterm baby. Um So again, the same things, what further questions should we ask in the history? Which would tell us probably what is going on? What further tests would you do if any and how should we manage this case? So in the chat, we've got um ask if there's any heart disease, um cardiac asthma and uh one investigation is chloride sweat test. Ok. Good, lovely. So this little one is for on further questioning in the history. He was born at term normal delivery. This baby is feeding beautifully. He is bottle fed. So he takes a good 68 ounce bottle every 34 hourly. He has normal stool consistency. He's not vomiting. Uh he's growing well. Uh there's no family history of any allergies. This baby doesn't have eczema um and um there's no congenital heart disease. His femoral pulse was normal. He did not have any murmurs. Uh but that's a good thought, really good thought. Um but we we would also uh check for that but we, when we clinical examination, there was no heart murmur, his heart sounds were normal. His femoral pulse was normal BP was normal. His oxygen saturation was about 92% on air. Yeah. So what further test? Uh you said sweat test? Um So it's not completely a wrong thought. Um It's a good thought to think about sweat test. Um I would like to know what you are thinking about offering the sweat test. Um and also this is a very short history three days before that he was fine. And so, um, when I said sweat test, you could just comment on that. Sorry, that was my mistake. So, um they were mentioning the chloride sweat test for case four, not case five and I read the wrong one, apologies. Oh, ok. Ok. But in the chat, we've also got um, check for nasal flaring, grunting, um, maybe questioning if it's pneumonia, questioning if it's CF um um checking the throat. And uh one person is asking if the patient presented in winter. Excellent. Very, very good thoughts. Really lovely. Yes. So he did present in not winter but it was um autumn. So it was around mid October. Um And um he was feeling well and I think the other question was um uh so we work test. We did was we did do uh nasal secretions for him and pa um and we sent that to the lab. Um And because this was a 23 day presentation. Um otherwise the child was fine. His um oxygen saturation was ok. He was still feeding, usually feeds very well, but on this occasion, feeds are a little bit less. So he takes about 34 ounces every four hourly. Um and last 34 hours he's taken even less. So this child um test came back as RSV so respiratory syn virus from his penas secretions. Um and um he uh we did not do chest x-ray because the baby otherwise looked fine. Uh, we diagnosed this as bronchiolitis, which is the most common presentation between, uh, now September, September and until February, typical presentation of little babies, mostly under six months, but maybe up to nine months, 10 months, sometime even a year, typically present with a runny nose, some temperature, lots of cough, very typical wet sounding bronchioli cough. We call it as and once you hear, you never forget that. And then they are very, very noisy chest. So when you put your stethoscope on their chest, there is a wheeze and a crackle everywhere, very busy, very noisy chest and they may have varying degree of respiratory distress. So some of you asked whether they are grunting, he wasn't grunting, but it's a good thought. We need to see whether they are grunting. Is there a head bobbing is a nasal flaring test in drawing tachypnea, how fast they are breathing. So once you check all of that, then we can make a management plan and I'll show you that later. Ok. So the next case is case number six, this might be the last one. So this is a 14 month old child who again um came to clinic and his parents reported that he has cough all the time. He has runny nose all the time and he gets lots of ear infections. Um When I asked him, what do you mean by all the time they said actually his runny nose from the day he was born, uh he was born at 36 weeks gestation. He was admitted to the neonatal intensive care for about uh 3 to 4 days uh with some mild respiratory distress. Uh and they felt that it might be just transient tachypnea of newborn. Uh He did not have pneumonia, they did a chest x-ray, there was some collapse, I think of the middle lobe but no major pneumonia changes. Uh They kept him, they did give him antibiotic for 48 hours. But as everything was fine, that was stopped and then he went home, never required home oxygen. Um He is slowly putting on weight. He's not completely failure to thrive, but he's not growing fast either. So on clinic, his weight was at 25th percentile. His height was also at 25th percentile. He was a very lively, active, lovely little boy. So what further questions we should ask for this baby in the history? I already told you about the growth. But that is by far the very important question you ask everyone who comes in your clinic at least for pediatrics. Um And then what further tests would you offer? And how should we manage this case? Because this is also again, a cough and the wheeze and the runny nose or I don't see wheeze in the later in in my uh presentation, but parents said is, you know, runny nose cough, wheeze all the time and they describe this from birth. So, what should we do for this one? Any ideas for me too? What should I check this baby for? So, in the chat, um, that could be an immunodeficiency. Ok. A cystic fibrosis. Mhm. And nothing in the chart yet. Ok. Very good. I think that that's um, brilliant suggestion. Excellent. So, yes, we need to think about immunodeficiency. We need to think about cystic fibrosis. So, can this child have bronchiolitis as simple as bronchiolitis? Probably not, isn't it? Because they are coming to clinic, always coughing. He always has a runny nose, he has lots of otitis media. Um So when we think about immunodeficiency, the important question to ask would be number one, are they growing? Are they eating well? Uh and are they putting on weight? Second, is, is there a chronic diarrhea? So if the child is eating very well and doesn't have diarrhea, they should grow. But in immune deficiency Children, even if they're eating, they don't grow. So growth is very important factor for immune deficiency. So that was a very good suggestion. The other thing to ask in immune deficiency would be, did this child have any invasive infections? So he had recurrent otitis media, um but he didn't have any other unusual infections. Um So that would mean that at this age, they may have a group, a strep infection. Uh But if this child has, for example, has pseudomonas infection I would be very surprised. Um That's why this unusual infection in otherwise. Well, child. So, or has he got lots of pneumonias? That would be an invasive infection requiring intravenous antibiotic? So, if they got more than two infection in the ear, needing intravenous antibiotic, that would be very abnormal. Or if this child has chest infection and uh also has bone infection like osteomyelitis, uh or he has chest infection and meningitis. So more than one part of your body is involved, that would be unusual. And again, that would point to immune deficiency. The other thing important in immune deficiency, if there is a family history of primary immune deficiency, and that is a very one most important single marker for us to think. Could there be immune deficiency? So that's a very good thought. And yes, we did consider immune deficiency in this baby. CF is again a very good thought as well. He's 14 months, he's coughing, runny nose all the time. Otitis media all the time. So, yes, we have to think about cystic fibrosis in this baby. But because he's 14 month old, he in UK, we do do a newborn blood spot screening on day five and they all get checked for cystic fibrosis. Um So there are other conditions which they get screened for. So, one of them is cystic fibrosis. Um And if that is normal, by far, we can be reassured that it's ok. But yes, we still have to go ahead and confirm that. So the questions we asked was family history. Um Has he had any hospital admission? He didn't, he was always treated as outpatient. Um Is he growing? Yes, slowly, but he's still growing and he did not have any unusual infection. Um And um he did not have any other infection other than otitis media and his hair nail was all ok. He did not have hepatosplenomegaly on examination. He did have a thick green nasal discharge uh and he did have very wet sounding chest. So the further test I offered was chest x-ray and I did do his baseline immunology along with the bloods to check for his vaccine responses. So when we are given vaccine, we should make good response by making antibody. If they are immune deficient patient, they don't make antibody response. So they still remain exposed to having these infections. So we did cystic fibrosis test as well. We offered him a strep test which was normal. All his immunology bloods were normal. Uh His full blood count was normal and all the tests which I did was normal. So I was like, OK, I need to think about something else. So I'm going to move forward leaving you to think about what something else this could be. OK. Uh And then we will come back to this again. So how do we approach a case of wheeze in Children? You saw six cases and you will see 1/7 1 as well. So, we need to ask, is it really a wheeze. There are various studies where they did the questionnaire survey to parents and they all recognized wheeze when it was not wheeze, uh, even doctors recognize wheeze when it's not wheeze. So we need to see, is it really a wheeze or is it just a rattly chest or is it just a loose cough which needs a bit of physiotherapy and it would go away? So, is it a wheeze, then we need to think, is it a sudden onset wheeze or is it gradual onset? So if it is a sudden onset of wheeze, you would think differently, like you thought about foreign body, you thought about um anaphylaxis in the other child. Uh So is it sudden onset or is it gradual as we saw in other Children who were having wheeze slowly? Not suddenly, didn't come suddenly? Is it recurrent or is it just there? So recurrent, meaning that that would be a trigger factor and then each time they're exposed to the trigger, it would happen, it could be viral infection as a trigger or it may be allergy as a trigger, but it's not there all the time it just comes and goes and what makes it better? So has the GP or pediatrician given them uh salbutamol inhaler? Is that, is what making it better or it just goes away on its own? And then we need to think about interval symptoms from that. I mean, if they are having this wheeze, only when they are having a viral infection and in between, they are absolutely fine. They're running around, they don't have nocturnal cough, they're eating, drinking well, and they get symptoms back again when they have viral infection. So those Children probably have viral induced wheeze, not asthma. So, interval symptoms are important. Is it exerciseinduced? So parents typically tell each time they go for pe lesson, they are coughing or they go on trampoline that they end up coughing and they have to stop doing what they are doing again. About nocturnal symptoms. Is, are they ok at night? Are they having cough? And I think someone did mention if they have gastroesophageal reflux and I think yes, that's a very good thought. Uh So if your child is having lots of cough at night, nothing in the morning, uh and they, as soon as they go and uh go supine, they have symptoms, you should think about gastroesophageal reflux. It's a good thought. Is the symptoms worsening or is it persistent? So each as the time is passing, they are getting more and more wheezy, more and more cough along with that or losing weight or not putting on weight or the symptoms are just there just wheeze there. Uh Are they thriving? And I think in pediatrics, it's one of the most important question which gives you a great deal of reassurance or it should make you worried is about the growth. So, if Children are putting on weight, well, then it's less of a worry if they're faltering growth, then you should be worried about. Even if it was asthma or it was any other diagnosis, faltering growth should raise alarms about something. Not right. Um, are they term infant or they were preterm infant? So, lots of preterm infant, if they had chronic lung disease, they spent long time in the IQ, they had ventilation for a long time. They may have chronic lung disease and those Children have longterm wheeze. And in my experience, they don't respond to what you do. Sometimes they respond sometimes they don't. So are they term or preterm infant? And then with your wheeze, what other symptoms they have, do they have cough? Do they have any atopy like eczema? Do they have any allergies or they have anatomical problems like tracheoesophageal fistula or they have um uh bronchomalacia tracheomalacia which can all present like a rattly breathing and it may be wheeze or do they have any chromosomal syndromes which may make their airway floppy uh or any other anatomical problems? So, these are the things which you have to think when you are approaching a case of wheeze. But by far the commonest one would be common things happen commonly. So think about bronchiolitis or something more common, but you have to think about other causes as well if you want to actually make proper diagnosis and get these Children better. Ok. So differentials of wheezy Children. So our case number five where this baby had a three day of cough temperature, not feeding, she had bronchiolitis RSV positive. And then we'll see how we manage her other case number one, which if I may go back. Uh So our case number one was a 10 month old girl who presented with sixth presentation of wheeze in two months, everything was fine. We did do NPA for her bronchiolitis which was negative. We did a chest x-ray and there was a very tiny, I wish I could have shown you the chest x-ray, a very, very small area of collapse on the chest x-ray. So I asked mom does, she put things in her mouth and mom says, definitely not because I'm always watching her, but because it was so many times this has happened, it just wasn't fitting in. So I asked ent to see her and they actually took her to do a bronchoscopy and pulled out a fluff of carpet uh carpet fluff um on bronchoscopy. Um And then that was the cause of giving her so many times uh bronchiolitis type of symptoms. Um So if things do happen, we just have to be very vigilant and think about weird and wonderful presentations. Um Case two of uh this boy who went on the birthday party and uh had some food and suddenly started to have cough and a Wheeze. Yes, he did have anaphylaxis and he has no nut allergy. Uh, but the food he was given, they said there was no nut, but surely there was some contamination and the management would be first line would be adrenaline, always adrenaline. And then you can give blue inhaler or salbutamol and then in the hospital there will be definite management for that. Ok. So the another 15 year old boy, um, who came with symptoms of um un un um not uncontrolled but poorly managed asthma where number of inhalers were changed. Um We did his um so I did his immune deficiency test as well. Um And his sweat chloride was 110 which was the highest I have seen. I don't do CF clinics, but I, this is the highest sweat chloride I have seen. So he had CF cystic fibrosis undiagnosed for 15 years. Uh So there are lots of implications for this boy. Um I had to send him to endocrine clinic, referred him to my respiratory colleague who do uh cystic fibrosis clinic. Um And his CT chest showed that he had bronchi disease. Um but he is so well, he started treatment straight away physiotherapy and uh antibiotics and he was absolutely suddenly started growing, put on weight and he's doing very, very well. Um So again, if you are faced with somebody who has a wheeze and need to think, is it fitting in, you know, is it, is it asthma or something else. And even in your asthma clinic, you can see something else. So that, that was a lesson for me as well. But, but at least he got a diagnosis which was not ideal, but he is doing much better. And then our, um, little girl who was a three year old Emma six technician, uh, we did diagnose her as asthma and, um, and then I put her on, um, Budesonide. Um She went on cle moly 52 puff twice daily. Uh And then I saw her, she is much better. She hasn't had any more admissions, but we do keep an eye on her regularly. Uh And uh and then she gets a community review once every now and then to make sure there is compliance and the technique of inhaler is good. Um So she's eating well growing well. Um So the other things which you should consider when you see Children wheezy is um something called persistent bacterial bronchitis. Uh which again, parents come and say that they are always have noisy breathing, rattly chest. But these Children look very well. They just have noisy breathing. They look well, they are growing well, they're feeding well. Uh and what happens is sometimes they may have had bronchiolitis type of illness. Uh And then since then, they never stop coughing and never stop having rattly chest. So if they have that kind of persistent symptoms, then, um you can do a chest x-ray but often chest x-ray doesn't show much. Um So these Children are the one where you may have to give extended course of antibiotics from anywhere from two weeks to 45 weeks of co amox. And uh usually that does the trick and they get better. The other conditions could be tracheomalacia, bronchomalacia. And that also sometimes reported as having very wheezy, but usually they may just have a bit of a noisy breathing most of the time, it just resolves on its own as the child is getting better. But if it's not getting better, then it's good to get um review by the ent uh department to make sure that there is nothing else anatomical going on. So I would like all of you to think about what clinical signs for bronchitis, foreign body anaphylaxis, uh cystic fibrosis. What are the questions you are going to ask? So please think about it. Um What investigations we should do and it's just not able to cover every single management. Um But it would be a good idea to think in these lines to see what else we should do if we are faced with a child who is wheezy. So for bronchiolitis, uh which is the most common cause for um, cough and the wheeze. Um and especially now that we are in hot autumn. Um So we admit these Children if their oxygen saturation is less than 92% and if they are feeding less than 75%. So if Children come. Um and because babies, especially if they are less than three months, their chest wall is very, very smooth. So even if they got a bit of a blocked nose, they chest made it trapped and it looks like they're working hard. But if they're agitated, not feeling very well and their oxygen saturation is less than 92%. We should admit them. And high risk infant as somebody very correctly suggested for our bronchiolitis baby to rule out congenital heart disease. So those who have congenital heart disease or those who are preterm and have chronic lung disease or immune deficiency, they are high risk. So if they develop viral infection, their bronchiolitis may be much, much more severe than babies who are otherwise. Well, so we need to make, be mindful of the fact if these Children come with bronchiolitis and we should probably keep them in and have a low threshold for admission. Generally how we, what we do, we do minimum handling. So once we know that this is bronchiolitis, you ruled out any other problems, then you, you leave them alone, you put a na nasogastric tube. If they are not feeding at least 75% you put a tube and you give them their own feeds, 100 mils per kilo also do an NP A to see if you can identify viruses. And um of course, you would think about PPE uh isolation how they should be looked after, uh, by nurses. Sometimes we have so many bronchiolitis that we have to make a bronchioli bay. So all the RSP babies are nursed together in one bay. So something like that you need to think about if they are having severe, moderate to severe distress, which is not getting better, although you stop them from orally feeding and put a tube. But if that's not doing the trick and their oxygen requirement is going up, then you may have to stop their feeds initially and give them IV fluids at 75 mils per kilo uh 0.9 C line. And you can give 5% extras or if they're very tiny, 10% extras and make sure you measure their blood sugar. Um and also always be aware of inappropriate secretion of antidiuretic hormone. So anything to do with lungs like pneumonia, bronchiolitis, um you may have si A DH and your sodium may drop. So always be aware of that. So when you're giving fluids, at least after 24 hours, you should measure electrolytes if they are less than three months. And if these little babies because of bronchiolitis start to have apneas, not breathing, you need to think about uh either putting them on something called opti flow, which is a high flow oxygen or are they needing CPAP. But you can also consider caffeine for these babies from oxygen point of view, you can give nasal candela oxygen. But if it's not doing the trick. Think about high flow, humidified nasal oxygen, uh which works very well for the babies. And in our unit, we do that all the time and we hardly use CPAP anymore. But if you have to use CPAP and very large babies are going to fight, so it becomes a bit of a struggle. But if there are little ones, less than six kg, then it works well. If the symptoms are so bad that they are not getting better, then you should consider doing a chest x-ray to see. Is there a pneumothorax? Is there pneumonia? Why they are not getting better? And so consider but not every bronchiolitis baby. We do a chest xray. So mostly it's a conservative management. Um just leaving them alone looking after their oxygenation and feeding and once their oxygen is about 92% they're feeding more than 75% work of breathing is mild, but then they can go home. Ok. So this is from the GNA guideline and you can have a look of clinical clues to alternative diagnosis and visit Children. It's a really good one. And uh and then these are very quickly the factors which may uh which may direct you towards that. Oh, this may be developing into asthma is age at presentation if they are having wheezing at very early age, probably is a better prognosis. It's probably bronchiolitis, uh severity and frequency of previous wheezing. So, if the Children are coming lots of wheezing episodes very frequently. And they also need an HTU admission or the IC U admission because of their wheezing. Then that is probably going to persist into their late childhood. And they may develop asthma if they have atopic disease. Uh like rhinitis, then you should treat that rhinitis very well because it's a one airway from nose to lung. It's a one airway and it's a one disease. If they have rhinitis, in all probability, they might develop asthma. So you have to treat their nose very well to get their lungs better. Uh And if they have eczema, they have probably bit more chances of developing that into asthma if they're wheezing. If there are family history of atopy, that's also indicator that they may go towards asthma if they're wheezing and other risk factors. For example, environmental particulate matter, family history of smoking, cooking practices, all of these contribute. But in every opportunity ask about smoking in mom or dad or brother, sister, whoever. Um and you should always not worry to counsel them and explain to them the um ill effect of smoking on the child's lung health or their own lung health as well. How do we diagnose asthma in Children? Um Getting a really good history examination. Um in my clinic, I always do a spirometry and if the FV one by FVC ratio is less than 70% we also do bronchodilator reversibility. So we give them 10 puffs of salbutamol. And uh if the FV one was less and now it improves more than 12% after we have given the bronchodilator and do a spirometry. Again, that indicates that probably there is an airway um uh airway disease present, we also measure their nitric oxide and for Children, it should be 35 parts per billion or less. And we see the peak flow variability. So we send them home with a peak flow diary. So these are good uh diagnosis for asthma. But by far, I do not do any other provocation test in my clinic or I don't think anyone regularly does that. This is again a very good uh decision making tree um from the Gina and I'll show you that in a minute. Um This is our step voice management of asthma in Children. Sorry, I have to rush. Um but this um if I get a chance to talk about asthma, we can definitely go much in detail. But please have a look, get this, this is from BT S and sign guideline, really good. Um stepwise approach for asthma. And again, World Health Organization has also developed good resources for noncommunicable disease. And this one is actually a guideline which has developed in Sudan um for noncommunicable disease and asthma is one of them. So this is a pocket guide, which is free you can download from Gina or there is a British uh guideline and sign guideline as well for asthma, which are excellent resources, so highly recommended for all of you who look after Children with asthma. Uh And then this is a nice tabulation about Children who have asthma more than two years, less than two years. Um And then I think we don't have time to talk about her. Um So in summary, which is not uncommon, uh parental description is variable. So you need to ask in depth question. Uh You need to give parents and care education what to watch for. Think about why differential is this child growing? Well, it's a very important question. You also check compliance with medication and please use the guideline and you can, based on that, you can make a local guideline which may be readily available wherever you all are practicing. Ok. So thank you very much. Um and this is a beautiful picture from global asthma network uh giving every child a chance to live their full potential. And in the right, that is a very nice film, please watch if you get a chance. This is from 1967 a short film made in New Zealand about asthma and it's beautiful animation and it's very, very nice to watch. So if you get a chance, please watch and it's astonishing to see we have come quite far, but many things have still not changed. So at that time, the treatment was only physiotherapy. Um So that's a wonderful thing to watch. Thank you so much for listening to me. Happy to take questions again. Thank you very much, Doctor Rahman. If anyone has any questions, please pop them in the chat. Um I will just pop a little message. Um, a feedback form will be emailed to you and once completed your attendance certificate will be on your meow account. We do have another event uh tomorrow. Uh This one will be on pancreatitis. So do join us if you're available. Lots of thank you in the chat. Oh. Someone's asked, could you please explain again why bronchodilators do not work for bronchiolitis, please? Um Yeah. So where can I see everyone? If you just close that pole, you'll be able to see the chat. You might have to scroll up a wee bit. Um They won't be able to turn on their cameras and mics, but they're all messaging in the chat. Ok. Yeah. So they can still hear me. Is it? Yes. Yeah. So in um in bronchiolitis, the pathology is at the level of bronchioles. And second thing is that the pathology is different in bronchiolitis, you are getting a viral infection related swelling um and lots of uh immune mediated debris and inflammation. So it's not essentially your smooth muscle contraction. Whereas in bro, in asthma, you are having smooth muscle, bronchospasm and that's why you are giving beta two agonist like salbutamol which leads to bronchodilation. Uh and the pathology is different in bronchiolitis. So that's why even if you give it doesn't work. We chat. Ok. Thank you JJ. Thanks a lot. I hope it was useful. Thank you. Thanks.