Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Okay. Good evening. Welcome back. Thank you for coming back again on today for our rearrange session. All about wheeze in Children. Um, I'm joined this evening by Doctor Cheryl Abraham, who is an s h o. Who's currently working in pediatrics and also hope to pursue a career in pediatrics. Uh, she'll be taking us all the way through wheezes in Children, something that anyone that's, uh, seeing Children at the moment, we'll hopefully have a fair bit of experience with, uh, as always, uh, please do get involved. If you have any questions, do stick them in the chat. I'll be here for the whole web and ask. I'll be able to rely, uh, real a rather any questions on to Doctor Abraham. And also, if we have some questions for you guys, please do just shout out the answers, stick them in the chat, um, and get involved. So over to you, Doctor Abraham. Thank you. Thanks, James. Um, so as James is very assist inked, Lee and I don't think I need any more of an introduction, so we'll go straight into it. I think reason Children at this time of year is probably the most common pediatric presentation that you will see either if you have a pediatrics job or if you're working in A and E. This is, I think, the main things that you will see, um, during the winter months and it's actually happening a lot earlier as well. So I think early September, October time, we were seeing a lot of the wheezy presentations where previously it was kind of December, November time. And there's also been a massive surge in RSV, which is one of the main causes of respiratory, um, distress in Children. So, um, in terms of what I wanted to go through today, um, and as James has mentioned, feel free to ask questions as we're going on. I don't mind being interrupted if anything doesn't make sense, Um, you can just use the chat function. Um, but I think the main learning objectives from today is just to, um understand why exactly Children are more likely to present with a wheeze. Um, how we would assess the severity of these presentations. So a lot of these Children, um, can just go home after a pair of observations, but some of them will need to stay in hospital. So how do you assess the severity? And that also will dictate what treatment you give, um, understanding kind of common differential diagnosis for childhood wheeze, which also varies a lot with age. Um, and just how we manage various we we've presentations so and why exactly, is we is more common in Children. Obviously, adults are also prone to print to having a ways in adults, most commonly as asthma. Um, but in Children, because their airways are essentially smaller, they're more likely to have increased resistance in their airways. Um, and that can increase the pressure essentially in your intro Thoracic Airways. So I've put this equation at the top, but it's not something that you might need to learn. But essentially the your peripheral airways is equals your resistance. Um, so your peripheral, where your small, the smaller peripheral airways is due to resistance, which is essentially one divided by your radius to the power for so Children will have a smaller radius. And because of that, the resistance is greater because that's what the equation essentially explains. Um, in newborns, especially their chest walls, are very compliant, so they expand and collapse very easily. Um and that increased intrathoracic airway collapse is due to kind of inward pressure. Produce an expiration. And that's why newborns actually have quite high risk of presenting with wheezing. Um, there's also things like difference in truck like tricky or cartilage composition, which is not as strong as adults, um, and just the general like airway muscle tone. And there's also immune factors. So they have more, um, lymphocytes and neutrophils in there, B a l, which is, like from the fluid and your bronchioles. Um, so essentially, a wheeze is more duty, your intrathoracic airways narrowing. So that's, um, in contrast to, like, a strider which is more your extra thoracic airways narrowing and because if you think about Oh, sorry, could you go back a slide? Thank you. Um, if you think about your actual in inspiratory and Xperia Torrey phase of breathing, Um, when you're intrathoracic airways narrow, that is predominantly your expiry torrey phrase. And that is why we use is an expiry torrey sound. Um, so an acute reason essentially due to partial obstruction of your intrathoracic airways. And there are various reason why you can get obstruction in your intro. Thoracic Airways. So it could just be to you to inflammation of the mucosa, which we see in things like bronchiolitis. It can be Broncho constriction, which I'm sure you will know is the path of main pathophysiology for asthma. Or it could be a mechanical obstruction. So something like a foreign body is something that you need to rule out in a child presenting with Louise. Uh, okay. So how do we assess a child with a week wheeze? So the first thing you would want to do is take a history. Obviously, if a child comes in very unwell, we would go straight to the examination first and then take a history. Um, but if if a child is able to, um obviously we're actually gonna get most of the history from the parents, so things we'd want to know are there age. Um, the reason why age is so important is because different, um, different. Um, age is present with different causes for wheeze. Um, so essentially, your bronchiolitis type babies, more common in the kind of first one year of life between 1 to 5, is very common to have a viral wheeze. And then after five, you see more asthmatic Children. So after five, your viral wheezers tend to kind of fade out and you get more of an acute exacerbation of asthma. Um, there's also something called multiple trigger wheeze, which I will talk about a bit later. Um, so in a history you'd want to ask about onset. So things like an acute exacerbation of an asthma will have a very quick onset of a wheeze like a maybe a few. Our history of always, um A to B is also really common. Um, so with with asthma. So if you have an atopic asthma, um, you're likely to have conditions like hay fever and eczema. You also want to ask about a family history of ATP as well, because, um, and a family history of asthma, because those Children are more prone to having a viral wheeze and also developing asthma. Um, coryza symptoms are really important, especially in bronchiolitis, which is essentially a viral infection, which causes the wheeze, Um, these Children present with, like, a 2 to 3 day history of like, a runny nose, a cough, and then they will have their wheeze. So these kind of give you ideas as to what your diagnosis is going to be similarly with a fever. So a fever is more likely to be a viral wheeze or a bronchiolitis rather than an asthma, unless it's an effective exacerbation of an asthma. Um, feeding as an all pediatric history is is really important. So if a child's having reduced feeds, you know that's going to indicate severity and in a reason for admission as well. Um, and that goes as well with growth and failure to thrive. Um, birth history is also really important. So, for example, preterm babies, um, because their airways are smaller than more likely to develop a viral wheeze. Um, and also, if you have respiratory conditions in your neonatal period like meconium aspiration or bronchopulmonary dysplasia, those type of things, you're more likely to be at risk of severe bronculitis. So it's really important to get aspects of the birth history. Um, when you're speaking to the parents as well, pets and smoking, these are all triggers. So even, um, if babies are not necessarily a lot of the time, parents will say that they do go outside to smoke. That that's it's not really good enough because their smoke particles stick on their clothes and things like that, and babies will inhale them, Which increases the risk of bay, Basically essentially all respiratory conditions. Um, and previous HD you and I t u Admission's is really important for your bronchiolitis and asthma. We, um Children. So you just know that they present with us more severe form of the illness, um, and drug history. So you want to know if they're on any inhalers? Are they compliant with their inhalers? Do they, you know, just take them once a month or should do they take them, you know, every few weeks. So that's also really important. Um, peak flow, essentially a peak flow is only really accurate after the age of about five. So it's useful if if I mean, I haven't known many people that actually do regular peak flows as a child, but it's worth asking if they are known asthmatic. If they do do peak flows and you know what are their values? Etcetera, Um, in an assessment, you would do a peak flow, um, probably towards. It depends on, like how unwell the child is, but we do use peak flow to assess the severity of asthma, Um, heart rate and respiratory. Also really important criterias that we use to assess severity, um, confusion. So that's like G c s agitation. So if they're getting drowsy and tired of, they're getting agitated also really important. Um, respiratory distress. So, um, this is really important and probably the most important way to to know if a child is really unwell. So it's looking for your signs of respiratory distress, and I've got a few videos that you guys can watch later. Well, we can show at the end if we have time. Um, so your moderate signs would just be if your heart rate and your respiratory rate are raised, um, you might see nasal flaring where the nostrils get a bit wider use of accessory muscles. Um, your intercostal and subcostal recessions head bobbing. So they're more moderate signs, definitely signs that they're unwell, but moderate rather than severe. Your severe signs will be things like cyanosis tiring because you just got increased work of breathing. Reduced, conscious level in asthmatics, we sometimes see something called a silent trust where you cannot hear breath sounds at all on auscultation in, um and your oxygen level was being less than 92% despite oxygen therapy. So that indicates a very severe, um, asthma or bronchiolitis. So I'm going to talk about these three conditions because these are gonna be your most common causes of weeds in Children. Um, there are rare causes that I think you should always exclude in a differential diagnosis. But these are your main three that you need to know about their exams and just for treatment. Okay, so case study one. So this is a seven week old infant, so she presents to A and e. She's born at 35 weeks. She's breastfed. Um, she presents with rhinorrhea, which is essentially a runny nose. Uh, lethargy, poor feeding on assessment, You see mildly increased work of breathing. She has one brief ethnic episode. Um, her oxygen SATs in 93 to 96%. So essentially, that's fine. Um, a fire brow, and otherwise it's a normal physical exam examination. So she's got two siblings at home with upper respiratory tract infection symptoms. Mhm. There we go. So, uh, I think because of the age range, you can probably guess what this is. Um, so this is a presentation of bronchiolitis. So what is bronchiolitis? It's an acute viral inflammatory illness of your smaller airways that occurs in the winter epidemics. Um, and it affects Children aged under two years, thick incidences around six months. You're most common bugs. I think this is a very common exam. Question is, um, RSV, which is about 80% of, um, bronchiolitis cases. But you also about other causes such as rhinovirus, adenovirus. Um, if you have co infection. So like an RSV and another virus that that is meant to cause a more severe form of bronchiolitis. The course of illness is about two weeks, Um and most of the time, that actually just quite well and they self resolve. But sometimes they do need hospital admission. Very rarely. It can cause permanent damage to the airways. And this is called bronchiolitis obliterans. Um, I think it's quite common when you've got RSV and human meta numerous when those two are together, or it might be Adina virus section might be wrong. Um, in terms of how these present, Um So, as I mentioned before, they have these Kerasal symptoms for about 2 to 5 days before the presentation. They might also have a cough, which is sometimes paroxysmal. Um, they'll have this intermittent wheeze, irritability and poor feeding. I might have a mild pyrexia. Um, but it's very rarely very high. So very rarely, it will be higher than 38.5 Respiratory distress for the progressive tappin tachypnea um, flaring, nasal flaring intercostal recessions. They might have these periods of apnea or hyperventilation, which are quite common. Um which is just due to tire tiring, um, hyperinflated chest on examination. And when you listen on auscultation, the classical findings are widespread. Fine crackles under wheeze, which is over both lung fields. Um, as bronchiolitis is going to be your most common differential in in Children kind of less than two that present with these kind of symptoms. But you should always have in your back of mind that there are other causes. Um, especially if babies are not responding to conservative management, which is essentially how we treat bronchiolitis, so differentials that always important to bear a mild mind, A recurrent viral induced. We've which can happen at this age early asthma. So babies can have asthma from a really young age, cystic fibrosis, which is, um, can happen with, like, a recurrent chest infections. You need to rule out a statistic. Fibrosis. Um, Pegasys, Um and you're like whooping cough. Um, recurrent aspiration, um, foreign body in your trachea or a congenital lung up anomaly. So those are all important things to to bear in mind if a child is not responding well to treatment and they're getting repeated episodes of bronchiolitis. So this is a video. I think maybe we can watch it if we have time, or I don't mind if we watch it now. Um, what do you think? James should watch it now. Complain. Uh, let me just see if I can get it working. Minor work. Uh oh. It's all right. I mhm. Uh uh, Yeah. Mhm. Mhm. Thanks. Means, uh so, yeah, I thought that was just a really nice video that was made, um, during an RSV awareness week. Um, just to show exactly what these babies look like when they come into hospital. Um, so this picture, um, I got this from the sunflower textbook. I don't know if there's any medical students listening, but there's some flour. Textbook is what I used during med school, and it's got nice really nice. Um, images and pictures to for for learning and things. So, yeah, they'll have this, like, noisy breathing, Um, or a dry kind of wheezy cough. The cyanosis and pollock is in the kind of severe stages hyperinflation of the chest, which just looks expanded. Um, your sternum might be quite prominent or your liver displaced downwards. Obviously, you get these subcostal and intercostal recessions when you get these fine end in spiritual crackles and a prolonged xperia torrey, we've which are your classic findings in bronchiolitis? Um, yeah, I think that's Oh, so we've just got to talk about investigations and, of course, how we manage it. So say if a child comes in, you're suspecting a bronchiolitis. The key investigations that you want to do is a pulse oximetry. So you want to see how their oxygen SATs are doing, and I'll talk a bit about target oxygen. SATs for bronchiolitis A bit later. Um, an M p. A. Is a nasopharyngeal aspirate, and what we can do with them is essentially test for a whole host of viruses. So one of them will be RSV but would also test for things like influenza, adenovirus, those kind of things, essentially, like an extended viral swab. Um, you also might want to do a chest X array. Um, uh, not routinely needed unless there are signs. Um, so a severe respiratory failure suspected, or you've got to say, focal pathology. So you here just crackles in one part of the lung, or essentially, you might see chest asymmetry. So those kind of things might point you towards your chest. X ray, um, similar with blood gasses only really needed if you're seeing signs of respiratory failure. Um, um, a blood gas is important because sometimes that does dictate oxygen therapy and bronculitis so routinely, Actually, if you've got a child with moderate to severe respiratory distress, we do tend to do blood gasses. Um, so the hospital admission, um, I pulled these from national guidelines, So hospital admission is generally if you've got periods of apnea observed or reported. So even if the parents say, um, there was an apneic that episode, but also we like to keep a child in to see if we we see those things. Um, oxygen SATs of less than 92% in the early phase of the illness, and that's quite important because essentially the trajectory of bronchiolitis is that it gets worse around day, four day, five, day six, and then it gets a bit better. So if your oxygen sats are less than 92% in the very early phase of an illness, that's not a good sign, because the first kind of few days is when, uh, the the child is the most. Well, so you'd expect your oxygen SATs to be above 94 95. Um, and then you expect kind of it might dip to below 92 day five day six. So, essentially, it depends. We don't really tend to put a target SATs until we know what day of bronchiolitis they are. Um, inadequate oral fluid intake is really important. So we sent tend to say less than kind of 50 to 75% of normal is inadequate. Um, and then we need to keep them in to observe feeds. Um, and they might also need supplementary feeding, um, severe respiratory distress or a respiratory rate over 70 underlying cardiac defects, or if you're just not sure so diagnosed diagnostic uncertainty. So how do we manage a bronchiolitis essentially um most of it is conservative management, so they might want to clear some of the airway by suction, either through the nares or the mouth. Um, saline drops are essentially a lifesaver. What they do is if you essentially put a drop in each nostril before feeds. Um, it just kind of clears the airways. So babies are very much, um, breathe through their nose, essentially because of the anatomy. Their mouths are really small, so they breathe a lot through their nose. And that's why they're breathing. Gets really affected because their nose is just get really blocked and stuffy, and they really struggle with their breathing. So the saline drops essentially help open up the nose and just help with their breathing. So we tend to give them just before their feeds, because that's when their most, um, they're kind of respiratory distress and oxygen. SATs tend to dip while they're feeding, um, so in terms of oxygen therapy, we can give oxygen via a face mask for the reservoir bag or nasal prongs, 1 to 2 liters per minute. If they are less than three months or have comorbidities, we tend to prescribe oxygen. If the saturations are less than lunch. 2%. So essentially, you have a lower criteria. Um, when we actually give humidified oxygen. So this is the main reason why we might admit a child is to put them on humidified oxygen. So that depends on respiratory distress, Um, or essentially a blood gas. So say if you take a blood gas and the CO2 levels are very high and you see a respiratory acidosis, that child needs help to, um, essentially get rid of the excess carbon dioxide. So s essentially how humidified oxygen works. Is it some something that we call Peep, which is, um, positive expiry? Torrey Um, airway pressure. Actually, the I've forgotten what the second B stands for, um, but it is very similar to CPAP, but essentially, what peep does is it keeps your airways open, whereas CPAP is actually, um, slightly different. But I don't want to go into the the kind of physics, and I don't think that's needed. But, um, ever just essentially humidified oxygen essentially keeps the baby's airways open so that they essentially helping with the expiry torrey phase, um, in terms of when we give them fluids that would be if the fluid intake is just in terms of fluid, intake is not enough. So if from bottle feeds and N g feeds, the trial is still not getting enough, then we can supplement with IV fluids or N G fluids, where we tend to restrict this to 80% of maintenance. Because so many of the babies during bronchiolitis they don't need 100% of their feeds, so they tend to only need about two thirds of their feeds. Um, so that works out about 100 mils per kg. A normal is 100 and 50 mils per kg, so two thirds is 100 mils per kg. And this can be either through bottle feeds, breast feeds sort of solids if they're weaning or n g feeds. But that's a really important thing is we don't discharge until they actually met two thirds of their feeds. Um, cpap and mechanical ventilation. That would be if a child is not responding to humidified oxygen and then just got persistent respiratory distress, um, persistent hyper cup like ratio to respiratory acidosis. They may need CPAP or ventilation, which can happen in bronchiolitis. I've seen, I think two or three cases that have been, um, intubated and ventilated because of severe bronchiolitis. So it does happen. Um, sometimes, actually, if these babies have a temperature so above 39 we do start them on antibiotics. So especially if they're less than six weeks, Um or even actually, for us, if they're less than three months and have a fever, we tend to start a Sep Sepsis protocol, which involves antibiotics. Um, just because we're assuming there's bronchiolitis, but they may have a bad pneumonias, which is called sepsis. So, um, obviously, before you do that, you want to discuss things with a consultant? Um, I've put a stand with their in brackets because I think they only tend to a stand where there is an antiviral. So say if, um from your viral swab, someone is flu positive. We can give an anti flu medication, which is a stomach here, but I think they only tend to use that Actually, an immunocompromised babies. Um, so it's not routinely used, Um, and then very importantly, is prevention. So things like good hand hygiene is really important to educate parents on, um, cohort nursing. So we tend to keep Children who are well away from bronchiolitis babies to prevent spread, um, gowns and gloves. A VP and palace can't say it now. Palace even mob is essentially, um, a vaccine against RSV, and it's incredibly expensive. And, uh, I think again, I've only known one baby who's been actually has a fit the criteria to receive it. Uh, essentially, if if a child is very immunocompromised and prone to having a repeated episodes of bronchiolitis, sometimes they will meet the criteria for receiving that. So I think that's it for bronchiolitis. Um, if anyone has any questions, feel free to put them in the trap. So our next case study is a five year old girl who presents to A and E with dysphania wheezing and chest tightness. And she had a recent upper respiratory tract infection function with cough congestion and a runny nose with a low grade fever and the mother state, she seems to get relief from a blue inhaler that was prescribed previously, and she has a background history of eczema, and her mother also has asthma. Her father was a smoker. That mother states that he smokes outside. So when you come to assess Anne. She has the following. She has intermittent coughing Xperia, Tory Louise Subcostal recessions. Um, she has a temperature of 70. 37.3. Her heart rate is 100 respiratory rate 40 her oxygen saturations and 92%. And she's got purulent mucus from her from her nose. And she's catching her breath often. Well speaking. Oh, watch Why the slides not changing. There we go. Um, so this is a case of a childhood asthma, so an exacerbation of asthma. So asthma is actually the most common long term condition among Children and young people. Um has about 1.1 million Children currently receiving asthma treatment. So it's something that's really important to know about because it's it's the most chronic pediatric chronic condition. Um, and actually, the UK is not very good with managing severe acute exacerbations that come into hospital. Um, I'm not quite sure why, but it's got a statistic that it's not very good at doing that. Um, I'm just going to talk about key features of asthma. Um, this applies to adults and Children. So it's good. Good revision. Um, so this is really important for establishing the difference between asthma and a viral wheeze because a viral wheeze will not have these features. Not all of these features. So, um, with asthma, you'll get interval symptoms with a positive response to asthma therapy. Uh, so what What are interval symptoms? So there'll be, um, things like exercise induced shortness of breath or wheeze, Um, things like a night term cough or an early morning cough. Essentially, it's not the wheezes not just triggered by a virus. It's It's triggered by triggers like pets, dust, allergies, those kind of things exercise, um, etcetera. And then you get those asthma symptoms. Um, more frequently essentially, um, diurnal variability. I've already mentioned so things like, um, a nighttime couple early morning cough. So essentially, the symptoms vary throughout the day. But very common is that the symptoms are worse early in the morning or late in the night. Um, a polyphonic wheeze, um, is a key feature that you'll find on listening on auscultation. Obviously, we'll also hear a polyphonic wheeze with with a viral and juice wheeze, um, and then a personal family history of ATP. So things like hay fever, eczema or a family history of asthma um, almost I think most Children who have asthma have at least the family history or or kind of atopic history. Um, so those are the I think the key for things for, um, as a like a diagnostic feature of asthma. Um, so this slide, um, I think nicely summarizes, uh, kind of the path of physiology of asthma. So essentially, there are the three things at the beginning. I think of what contribute to this bronchial information that you get in asthma. So, um, and you get this genetic predisposition. So, like this family history of asthma or family history of ATP or actual HP, the child has ATP themselves. So, like hay fever, extra etcetera, um, or environmental triggers like, um, respiratory tract infections, halogen smoking, exercise, even things like stress and anxiety, um, or chemical irritants. And that essentially causes your bronchioles to inflame, which causes edema, um, excessive mucus production. And then what happens is your bronchioles become hyper responsive. And then you get this exaggerated twitchiness, um, to an inhaled stimuli. And that's what causes your airways too narrow and you But you get this reversible airway air flow obstruction with asthma, which means that it will respond to Broncho Dilators Um you will have this peak flow variability with Bronco Dolly to Broncho Dilators, um symptoms, which which then lead to your symptoms of, like, your wheeze and cough, breathlessness and trust tightness. So I think that's quite a nice diagram to to summarize asthma. Really? So how would we investigate if we're suspecting a child comes in with with asthma? Um, our child, I think I mentioned right at the beginning that that we see the kind of asthma Children. The kind of how it works with age is the asthma tends to appear in Children kind of at the age of five. So, um, how we would routinely investigate this if if we were suspecting it is actually just a history and examination. So that is kind of a key diagnostic thing for for asthma. There's no investigation, which we say is used to diagnose asthma. Um, I know that's quite different to adults, because obviously in adults, we routinely use spirometry to diagnose asthma and COPD etcetera. But that's not the case for Children. Um, because actually, most of them cannot do spirometry. They won't sit still. Or, um, they won't be able to understand for the test. Um, So, um, essentially, history and examination, Um, and those those key features that I've mentioned before So chest X ray is not routinely performed, but again, like in bronchiolitis. If you see signs of, like, severe respiratory distress or chest asymmetry Focal pathology, then you will, of course, do a chest X ray. Um, you can do skin prick testing. So, um, for those of you don't know what skin prick prick testing is is that essentially it tests for allergies, so they actually put a little bit of, um whatever. They think the allergy is on the skin, and they see the reaction on the skin to see to see if they're actually allergic. Um, so if if someone has, you can see if they've got a a topic history. If that makes sense, um, peak flow. We only tend to do this if the child is over five years. But obviously, if they come in with an acute asthma attack, we do use peak flow to assess severity. Um, blood gas. Again, we don't attend to routinely do a blood gas. Only if you see signs of severe or life threatening asthma, which which can happen. And it's very important to dictate whether they again might need CPAP or ventilation. So these tests that I've mentioned at the end, they're not they're not required. They can be done, but they're not required. So the spirometry, um this is exhaled nitric oxide. Um, and peak flow variability can also be used, but none of them are required. So, um, they're just useful things to know. So, um, in in terms of differential diagnosis again, as I mentioned in Bronculitis, I think it is important to consider these things if a child is not responding well to asthmatic treatment. So in Children age less than two years, you have an initial poor response to beat it to agonists, um, administered with a good technique, you should continue treatment if it's severe. But you should always consider an alternative diagnosis and other treatment options. So some of these are very similar to bronchiolitis. So the things like cystic fibrosis aspiration, but obviously things like an inhaled foreign body and pneumothorax, um, track you Bronco Malaysia or decay you to kind of maybe consider these diagnosis is at the back of the back of your mind. Um, I think someone, someone in the chat has mentioned that the talk has frozen. I don't know her thoughts. I hope everyone can still hand. Yeah. No, it's not frozen for myself. Okay, Okay. We'll continue. So, yeah, it's really important that you consider those differentials. If you're still not sure. Um, so this is from your B T s guidelines, Um, that you can find this pdf online. It's really easy to access. Um, and I definitely, um, mention I would definitely. Um, Also, they recommend looking up through them. But I've put the key things in this slide that I think from that I got from the BTS guidelines on asthma. So the main things is, um, actually diagnosing severity. So this again is different to adults. So I think in adults, it's moderate to acute, severe to life threatening. Whereas, uh, Children, there isn't a mild to moderate. An acute, severe and life threatening is just acute, severe and life threatening. Um, so your key things that are going to differentiate between a an acute event and a life threatening is, um, your peak flow. So your oxygen saturations of the same. So if they're less than 92%. You know, you've got an asthma which is severe, which is, you know, or not really responding well to oxygen therapy. Um, if your peak flow is 33 to 50% of best or predicted, then we say that's an acute severe, whereas if it's less than 33% of best or predictively, so that's a life threatening. Um, if they're struggling to complete sentences in one breath or they're too breathless to talk or feed, we'd say that's an acute severe Um, and then your tachycardia and tacky paneer is different for various ages. Um, which I won't. I won't read them all out. Um, but essentially, if they're tacky, cardia Kentucky panic. That's you know that's on the side of the severe. Um, your life threatening signs are really important to know and identify, um, so things like exhaustion and lethargy and drowsiness, um, hypertension cyanosis. A silent chest, which I think I mentioned before, is essentially when you you won't be able to hear any breath sounds on auscultation. And that's essentially because the child is so tired. Um, then again, like poor spiritual effort and confusion or an altered G C s, um so when would we actually admit a child? Um, so essentially, if you, um a lot of Children, a lot of parents know to actually increase the salbutamol dose. So giving one puff every 30 to 60 60 seconds and then they can increase the number of puffs to a maximum of 10 puffs. A lot of adults do know that, but we tend to say that if a child has had their maximal 10 puffs via salbutamol or if they as in via inhaler or a spacer, then they should bring 999. So your maximum is 10 puffs, and then they need to call an ambulance. Um, if symptoms are severe after after you've given your bronco dilator, they still need to to see kind of go to hospital. Um, paramedics often do give administered nebulized salbutamol. Um, um, often they actually can give nebulizers and oxygen together. Um, and they'll tend to do that while they're transferring the child to a any, um so if if a child is not responding to an inhaler, they need a nebulizer, Um, and yeah, if they've got severe or life threatening asthma, they need to be transferred to hospital urgently, and we tend to again consider inpatient treatment if the oxygen So that's less than 92% in the air after an initial bronchodilator treatment. So this slide is very busy, but it's a really good summary. Um, I don't know if you'll get a copy of these slides or if any of you want to take a picture of it. Um, so it essentially tells you what exactly I'll break this down very quickly. Um, it tells you how we treat a mild, moderate and severe or life threatening asthma. So your mild to moderate is going to be your most common, um, presentations that you get to a hospital so they'll have very mild symptoms like a mild wheeze. Um, the oxygen SATs, we find the p global be above 50. Um, we What we tend to do is we'll give them salbutamol 2 to 10 puffs via a spacer. Um, we might give them oxygen if they need it. Um, and we tend to give prednisolone. So, um, for all, actually, um, exacerbations of an asthma or a viral wheeze we routinely give or prednisolone. And that's because we know that and the path of physiology is that the the airways are going to be slightly inflamed. And prednisolone, as you know, is steroid. It will help with that anti inflammation. Um, so we tend to give a three day dose, and the doses vary between age, but you don't need to know those off by heart. So, um, very importantly, as in with all of these, these mild, moderate, severe life threatening is that you assess every 15 to 30 minutes. Um, so if they've met discharge criteria, they can go home. So discharged criteria will be if they're maintaining their oxygen SATs. Um, And if we know that their respiratory rate and heart rate come down depending on their age and their peak flow is fine, very importantly on that last point is that they're stable. They have to be stable on four hourly inhaled treatment. So we cannot send a child home until they've been free from nebulizers or inhalers. Um, for four hours. Once they've met that four hour criteria, we can send them home. Um, and what we actually tend to do is they'll have 10 puffs and then we wean them down to six puffs and we can send home on six puffs and they'll be sent home on a wheeze plan, which I'll talk about a bit later. Um, so I think I think I've mentioned those things. They should always probably have a just just in general patient education. So how to use inhalers? Um, and check the inhaler technique. Some will have follow up with consultants, but they tend to be the more severe side. Or they might have, like, community nurses that come in on checking these Children, um, moving on to the severe and life threatening. So this this is going to be your important side and to what management we give. So we've already talked about what? How we'd say something is severe and life threatening. So in terms of severe, um, we would initially still treat that with high flow oxygen, um, and salbutamol 10 paths via a spacer or face mask. So if after giving 10 puffs, we know we can still see the child is working very hard, they're still very wheezy. Then we can try nebulizer, albuterol, or and we know that nebulizers actually just open up the airways better than, um, temper than actual inhalers. So, um, sometimes they do tend to work a lot better. Um, so the actual dose of salbutamol will vary between age. We give a smaller dose if you're less than five and a slightly bigger dose if you're older than 12. Um, if you get a poor response from Nebulizer's albuterol, you can then give ipratropium bromide. Um, and actually, it tends to work quite well when we give a combination. So we give salbutamol and ipratropium bromide. So we call that mixed NEBs. Um and what tends to happen? Um, I don't know if you've seen this in A and A is that they refer to it as back to back NEBs. Um, essentially what? That what that means is the child gets nebulizers every, um basically every kind of 10 minutes. They'll get back to back NEBs Um, and it's common that they might have three or four NEBs until they go on to, um, just the inhaler. What quite what is quite common practices that will give maybe three NEBs they might have once a beautiful neb one EPA Tropea um neb another sub beautiful neb. Um, but quite importantly, before you give each Neb. You need to assess the child. You give one nebulizer, then a doctor will need to assess the child, then decide if they need a further back to back neb. Uh, so between each neb, there should be an assessment. Um, but it tends to after the nebulizer, they tend to go down to 10 paths. Um uh, two hourly is quite common. Um, and then we can essentially stretch the inhalers. So two hourly four hourly. Then we know that once they run four hour leave, they can actually go home. Um, and then I've already spoken about prednisolone, so it should be for three days. Ideally, if oral steroids are not tolerated, we can give IV hydrocortisone. Um, I think steroids are really strongly encouraged. Um, so essentially, if by that time you've given all those treatments, if they have met the discharge criteria, they can go home. But if they haven't, you need to admit them. Um, and essentially, some of these Children might don't have life threatening asthma. So, with a life threatening asthma, essentially the treatment the initial treatment will be the same. So your nebulizers of sub eater or ipratropium to see if they have a response? Um, it might be that actually, they have signs of shock, so they might need a fluid bolus or just IV maintenance fluids. Um, and then we can also can, um now continue, um, consider additional drugs. So if they're not responding, went to nebulizers and you still see the signs of life threatening asthma. Um, we tend to consider, um, IV salbutamol or IV magnesium sulfate. Um, I don't think AMINOPHYLLIN has mentioned on this particular guideline, but that's also one that's, um, used in common practice. Obviously, you would refer to your trust guidelines to see what exactly they give. Um, these are just generic national guidelines. Um, So, um, if in terms of a cell, beautiful bolus, um, the kind of details of drawing it up and everything I hear. But I wouldn't say that's too important. Um, unless when you come to prescribing it, obviously, it's important to know the dose. But, um, I wouldn't worry about how to draw it up and everything. Um, but very importantly, with monitoring is that these Children need to be on continuous monitoring. So continuous heart rate and respiratory monitoring, um, continuous oxygen and carbon dioxide monitoring and E c. G. Monitoring. Um, and you will also need a baseline user knees, which is really important for IV salbutamol because it can cause a hypochelemia. So, um, after say, if, after you've given a cyber beautiful infusion, it's still not working, then you can consider your additional things like IV magnesium sulfate, um, or or aminophyllin. So, um, with all these Children, So with life threatening, you would do a blood gas and a chest X ray. Um, you need to rule out that there's nothing else going on. And also, you need to see if they are in respiratory failure. So type two respiratory failure would be your most common. That you would see that they're just retaining their common dioxide. And if it is persistently might, then go on. Might need to go on to see Papa Ventilation. Um, so, yeah, I think that diagram is a really good summary. Uh, but of course, referred to US guidelines. Sure. Have you seen there's a couple of questions in the chat? Oh, yeah. I have, um, So inhaler question if in primary care needing escalation control already on Monte Lucas and high Dose, I see s needing better control. What does your area start answered? Um, I will actually have got. I think it may be my next slide. I've got the step way led ladder that also exists for Children. Um, so we'll go. We'll go through that. Um, there it is. Yes. So, essentially, I think most it's not really area dependent. I would say most people would follow this, which is again the B T s guidelines. So this does exist for adults as well. So, uh, you questions if they're already on Montego Lucas and high dose I see s what does your heiress start? So I mean, that's quite severe. If they're on Monte Lucas and high dose, I see, uh, yeah, I would think that that would be managed by a respiratory doctor like a specialist that they would They would need a consultant, but rather than that, that would be my primary care. Uh, to be honest, if most Children who are on an eye CS and an inhaler, um, and Monte Monte Lucas, I think tends to be started by pediatricians not routinely by GPS, um has quite bad side effects and Children like nightmares and things, and also not all Children respond to Monte Lucas is kind of like some Children respond to it, and some don't. Um, so this this is this diagram is for a chronic asthma. Um, so essentially, I'll briefly talk about it and focus more on the slide. Um, everyone that's suspected asthma will be started on low dose. I see s service are beautiful or an Atrovent. And then they should be on a regular preventer if they have this, um, kind of if they have frequent wheezy episodes, um, or if they're less than five, they can be started on a leukotriene receptor agonist, which is your montelukast. Um, And then your initial add on therapies are an eye CSF. They're not already on it. Um, if they're over five, you can then add your lab er which is like your same to roll those type ones. Or Monty Lucas. If they're under five, then you can add an l T. Um, agile Monte Lucas. If that makes sense, um, and then your additional therapies. I think we've essentially the kind of ceiling of care is an eye CS or lab or an L R T A. We don't tend to do anything else. If at that point you would refer to a consultant to consider other things. Um, but, yeah, that that diagram is quite a good summary. Um, and then what was the other question or sorry, Do you ever used X mason? Just always. So, my where I, um we use prednisolone. Um, I don't I I don't know about other areas, to be honest, but where where am I? We use prednisolone. I don't know if genes. Yeah, we use prednisolone as well. I know that there are a few pediatricians that do advocate for the use of decks instead, and there are some quite good papers out there on it as it being the same level of effectiveness. Um, most trust guidelines. Um, but I've seen, say, to use prednisolone at the moment. And yeah, I think for us they actually the the only thing that, like the guide language for dexamethasone, is croup, that we use dexamethasone. But but for viral wheeze and asthma, we tend to use prednisolone. But I think they are equally as effective. So it would just it tend to be wherever you work. What? What? Your trust guidelines would say. And then what is your opinion on magnesium Self? It in a nebulizer. Oh, okay. I'll be honest. I've only seen it been given IV. So I don't know about you, James. I've I've only seen our protocols. I've never seen it. Nebulized. But yeah, I'll have a little left. You're going through the next slide and see if I can find anything about it. The the NFC has it in, like a nebulized form. Uh, yeah, I've only seen it given IV. So sorry. Always. Also should nibble is is always, always be delivered via oxygen. Um, I mean, I think him what I've seen it depends on the oxygen saturations. So if they're needing it to be driven by the child needs oxygen. They combine the nebulizers with oxygen, but if not, they can just have it without oxygen. Do you agree with that dreams? Yeah, absolutely. So we only put the never on via oxygen if the child's saturations are below what you'd expect them to be? Yeah, on that topic if if if a child's oxygen sats are low, um which, like we tend to say, is 92% in these. These kind of cases. Um, we do not give inhalers. We would always give nebulizers if they're on your kind of one hourly, um, 10 puffs or two early 10 puffs, but their oxygen SATs so low you would give nebulizers, not inhalers, if that makes sense, Um, someone's put mega NEBs get used in Glasgow from what I've encountered, if that helps, I'm not sure. I don't know what Mega NEBs are, actually, um, but yes, we will. I think James, we missed a slide off week. Come back. No, no, there we go. So, um, I briefly talked about discussed about discharge criteria, but it's really important just to reiterate it, because so many of these asthmatic Children go home as a failed discharge and then come to any the same like the next day. Um, so really important things is that you educate the patient on compliance and inhaler technique. So especially when we start a low dose I see s, which is a twice a day inhaler. Um, the parents need to be told this is a twice a day inhaler. Not just not to just use it when you get short of breath. Um, And what a nice way that we tend to do is that we say do with when you brush your teeth. So, um, use your brown inhaler when you brush your teeth in the morning and when you go to bed before when you brush your teeth because that tends to be quite a nice way. Um, and a good think it's quite different. Difficult too often. Ask about compliance as well. Um, so when you're asking about inhaler, inhalers and compliance, a consultant told me quite a nice way of asking. It is in the seven days of the week. What? How many days a week do you use your inhaler? And some of them might say, two days a week, three days a week. So then you can establish how compliant they are. Um, inhaler technique is something that should always be done before a child leave. So check they know how to use a spacer. Um, and the nurses should be able to do that, especially pediatric nurses. They're really good at that. That kind of stuff, um, a wheeze plan or a personal asthma plan will vary between trusts. Um, where I work, essentially, they can go home if they've been free from. I think this is nationwide. But if they've been free from nebulizers or written inhaler for four hours, they can go home and we tend to discharge on a six puffs, four hour leave regime, and then they can be weaned down. So it goes from 10 puffs in hospital, six puffs on discharge, um, and then essentially weans down. But I won't go into the details because I think it varies between trust. So just know that a wheeze plan exists. Um, and it's just a regime that weens you down on your salbutamol puffs. Um, and all all severe and life threatening Children would need a special specialist referral. Um, and these are also other reasons why you would need to do a specialist referral. So any child that has failure to thrive so they're not growing well, um, you would want to do a specialist referral. A persistent wet cough is a sign of something we call bronchi Actis iss, which can present in these kind of asthma asthmatic Children, Um, and also a severe upper respiratory tract infection. Um, but those Children who don't need a consultant referral, they can have like a community nurse or a GP follow up. And that's really important. You talk to parents about things like smoking and stopping smoking. Um, weight loss for the older Children. Um, an early prevention. So things like breast feeding of so shown to reduce the amount of respiratory, lung conditions and Children. So those kind of things are really important as well as immunizations, et cetera. Um, so, yeah, there was another question. What is your What is your opinion on bronkaid lighters and under ones who are present, Louise have a constant battle with my practice. Is my doctor. OK, I've mentioned this, Um, when I go on to talk about viral wheeze. So essentially, there is a lot of debate as to whether broncho dilators actually work in Children under 18 months, 18 to 20 months. Um, they actually do work in a select amount of Children. Um, so some Children do respond to Broncho dilators if they're under 18 months. Um, but some don't. So there is no harm in doing a trial of a Bronco dilator to see if they if a child responds to it. Um, but quite often they don't. So there's there's actually no guideline to say not to use it. Well, don't don't use it. I've been told that you can use it as a trial, but in quite importantly, um, bronchiolitis, uh, bronchodilators are not use. Um, but if you've got a viral wheeze in a child under 18 months, there is no harm in trialling s salbutamol neb. And see if they improve. If they don't, then you know that they have probably haven't developed the receptors for Broncho dilators. So yeah, trial and error. Um, but when James has filed an article, which is good, Thank you. Um, so this slide just, um, talks about the different devices that we use, Um, for broncho dilators. So the first one is Looks like a space, uh, so that's suitable for all Children. Kind of this says under the two years of age, but actually older than that, a spacer is probably the best delivery for a young child. Um, and parents can use it, uh, to educating on how to use a spacer is really important. Um, that there are Second one is a dry powder inhaler, which we tend to give in Children over four years. Um, and then nebulizers we can give in all Children. Essentially, Um and I've already gone over that very complicated slide. Um, so the final case, Sorry we're running a bit over time is, um, a viral wheeze case. So this is a two year old boy who presents the easy with a history of wheeze and shortness of breath. Um, prior to this, he had a cough and a runny nose for three days, but no fever. Um, he's drinking fluids, but has a reduced appetite. Um, has he had previous admission sinks six months ago due to a similar episode? Um, but no interval interval symptoms. And no family or personal history of ATP. He was born at 35 weeks by a normal vaginal delivery, and he has no pets at home. But father resist smoker. So on assessment, His oxygen saturation at 94% on room A, um, heart rate is 1 35 and respiratory rates 30. Um, he's a fair Briles. Um, on auscultation. He's got a scattered wheeze, transmitted airway sounds and sub cost of recessions as well as the trachea tug. He's got coughing and rhinorrhea, but it's responding well to back to back nebulizers So viral induced wheeze. Um, this is gonna pre probably, I would say, the most common presentation that you will see in Children after the age of kind of to, um but obviously we do see it in young babies as well. Um, so, uh, viral wise can be lit up into two different categories. So you get your viral episodic wheeze or your multiple trigger wheeze. So your viral episodic wheezes essentially wheezes that are triggered by a virus and your multiple trigger wheeze. Um, as in the name has multiple triggers. So it can be things like allergens, dust, hay fever. Um, smoking pets, those kind of things and the multiple trigger wheezes are more likely to develop into an atopic asthma, which is quite important. Um, the viral induced wheezes tend to resolve by about five years. Um, so the pattern is that your ryland juice Weezer's, um, they are born with kind of not great airways. Um, and then after the age of five, their airways open up and get a lot better in a really simplistic form, a way of saying it. Whereas your asthmatics, they are actually often born with really normal Airways. And then after the age of five, um, they're always just get worse. Um, so, uh, they kind of mirror each other in opposite ways in the in the kind of trajectory. If that makes sense, um, in terms of risk factors for viral induced, we's, um, things like being small for gestational age, being preterm or less than 2.5 kg or maternal smoking. Um, those are really important things to to ask in your history. Um, then we'll go onto signs and symptoms. So if there's an evidence of a viral illness proceeding, um, onset of your respiratory symptoms, that is very typical. The viral induced squeeze. So, um, like a cough and runny nose, etcetera. And then you get your shortness of breath and expiry. Tubize, Um, in your history, it's really important to ask about interval symptoms. Um, that we mentioned before, which, in a violent juice well, you shouldn't have interval symptoms. Um, and things like a two p more likely in asthmatics. A proceeding illness, um triggers if the child growing and thriving. Um, previous treatment from the G p, which that's really important. So have they had steroids from the G p Have they had nebulizers from GP? Um, so that's really important, um, and compliance with inhalers. So, um, which I've already mentioned and then your actual like clinical assessment and initial management is exactly the same as for an acute asthma, so you don't have to learn to different treatments and management's. It's exactly the same in Children who are less than three years who've had four or more significant wheezy episodes in the past year. They are Children who are much more likely to have a persistent asthma after the age of five. And it's if they have these following factors. So actually got these from not my hospitals teaching guidelines but, uh, teaching Children Teaching Hospital and Sheffield, which is quite a large pediatric hospital. So they they say, there's a if. If you have these frequent wheezing episodes and you're under three, you're more likely to develop assistant asthma after the age of five. If you have one of the following parents with asthma, a physician's diagnosis of asthma, um, sensitivities to air allergens or positive breasts or skin protests, or you have to minor decisive factors. So like things like food allergies, more than 4% blood, ears, NFL's or wheezing apart from Kohl's. So essentially, there are various factors which can influence you, then going on to have a persistent asthma. But these are the kind of things that you want to be looking out for. Um, so with a viral wheeze, there are further investigations that you can do. Um, there again, there is no routine investigation that we would do for a viral wheeze. You would just want to make sure that their SATs are okay. Um and that that is the only the only kind of investigation that you would need to do. Um, further investigation that you can do. Um, you can do something called a video fluoroscopy. And what this is really good for is picking up things like silent aspiration. So a lot of Children, um, they actually with adults, it's a lot easier to pick up signs of aspiration. Um, things like aspiration. Pneumonia. But with with Children, often the silent aspiration can present as a wheeze. Um, and the main way that we actually diagnose that, um is doing like a video test, um, looking at the esophagus and the and the kind of hours to see if they are aspirating at all. Um, and this this can happen in, like Children who have, um, kind of defective, defective airways or defective, like the kind of a Sophocles and things is not working as it should be. So this doesn't happen for all Children that they get a video fluoroscopy because this happens at tertiary hospitals. But if a child is having recurrent wheezy episodes, it's an investigation to consider, um, and the other things that you can consider things like a bronchoscopy or a CT chest. Um, and those things pick up things like bronchiectasis, which chest X tary Wouldn't, um, other things that you can do a blood test. So, like I said, if you see like an ears and Ophelia, that could indicate someone is more likely to develop, uh, asthma like and it also kind of dictates the severity of the the viral. Louise, Um, see if they're sensitive to at least one error allergy. And so these two fact is an affiliate and being sensitive at least one error allergen. These Children are at greatest risk of developing asthma, and that actually most beneficial to to a daily I see s um and that's a study that showed that. So, um, if you do spot that definitely start a child with viral, we've on inhaled corticosteroid. Um, however, you should be cautious in starting steroids in mild presentations and in Children less than 12 months because they are found not to be entirely effective, Um, and have more harmful side effects. Um, we can also consider azithromycin prophylaxis. So azithromycin is the kind of choice for prophylaxis in for those that get recurrent chest infections. Um, and it covers a very wide kind of atypical spectrum of bugs, which is why it's a choice. Um, and there are a lot of Children that are on this is a thermite prophylaxis. Um, so, uh, like I said, a chest X ray is not is only kind of required if there are kind of obvious or persistent asymmetry on auscultation or kind of unresponsive to treatment. Very importantly, if you hear crepitations on auscultation in, uh, that's not a reason to start antibiotics or Jewish chest X ray, which I think is a mistake quite confident. Commonly done by GPS is that they hear reputations and start antibiotics. But quite often these sounds are just essentially retained secretions that the child cannot cough up. Um, and they don't indicate an infection. Um, they just don't have a very good cough reflex. So, um, that's also really important. Um, if, uh So this goes on to the question that someone was asking about response to salbutamol. So if a child is less than 18 months and not responding to salbutamol, which can happen because often we find that the actual beta two receptor agonists four salbutamol are not fully developed until after 18 to 20 months. Um, Atrovent, which is essentially ipratropium bromide, may be more effective. So actually, we we tend to give a trial of ipratropium more commonly than a trial of salbutamol. Um, and many Children in this age just don't they just don't respond to bronchodilators. Um, and, uh, this this is actually what someone told me that, actually, if someone is less than six months, you shouldn't routinely use bronchodilators. Um, so that that answers the question. Um, if we've got time, if and if people are interactive on the chat, um just want to do a quick quiz. Um, hopefully everything that I've that is on the question should have been covered. Um, but yeah. If you if you just use the chat function to put your answers down, I think that's probably the best way to do it. Okay, um, does if anyone has any questions before we do the quiz, uh, feel free to put them in the chart as well. Um, Okay, So first question is, um, a wheeze is largely to you to narrowing. Of what airways? Are they your extra cirrhotic or intrathoracic? Yeah. Quite a few people have put the Yep. So it's your intrathoracic airways. Yeah. Which gives you an expiry, Torrey. We's so the most common pathogen associated with bronchiolitis is a RSB. Be rhinovirus. See adenovirus or deep Our influenza. Yeah, quite a few people up Putting a So that's really good. RSV. It's a very common exam question. Uh, this one's a bit harder. Which of these is not an absolute criteria for admission of bronchiolitis so inadequate oral intake less than 50 to 75% be severe respiratory distress. See oxygen saturations of 90% in the early phase of the illness or a pre existing lung disease? Yeah. D is correct. A pre existing lung disease is a relative criteria that you might, you know. It's not an absolute criteria, but it's a relative criteria that you might consider admission, not an absolute criteria. Which of these is not a key feature of asthma? So a polyphonic we's the interval symptoms. See positive response to asthma therapy, deep personal and or family history of a two p or e a wet cough? Yep, is correct. Most commonly will actually be a dry cough. Um, that happens in the morning or late night. Um, and a wet cough, like a persistent wet cough, is is can be a worrying sign, and you might need to rule out something for brachial bronchiectasis. But yes, someone has put quite correctly in the chat. Asthma is a dry cough. In what age and above is peak flow accurate? Yeah, see, it's five years and above. Routinely, we don't tend to do peak flows if they're less than five years, and when assessing severity of asthma in Children younger than five, we don't use that peak flow less than 33% or 33 55% as well. Which of these is not a feature of life threatening asthma. So a P E F R 33 to 55 50 33 to 50% of predicted or best be hypertension see silent chest or D oxygen such reasons of less than 92%. This one's a little bit harder. We're getting a mixture of answers. So he people said D and a few people have said a so yeah, it is, in fact, a So in a life threatening asthma, it's P P E f R peak experience the flow rate of less than 33% whereas this 1 33 to 50% is for your acute severe, not your life threatening. But B, C and D are all features of life threatening asthma. Yeah. Um, so this is in my trust. Um, but I've have routinely seen this, Uh, I've asked consultants about it, and they've said this is the kind of common practice among those trusts in the country. So, on what regime can an asthmatic or a viral and juice visa be safely discharged? So 10 puffs. Three hourly, eight puffs, three hourly, six puffs, four hour leak or six puffs. Six hourly. Yep, six past four. Hourly. Um is correct. Um, think then potentially might be the last question. Um, in what age group can bronchodilators be ineffective? So a less than 12 months be less than 24 months. See, less than 18 months or d less than 20 months. Yeah. Yeah, again, Getting quite a mixture of answers. Yeah, the A N C. I think is the majority. Um, so, yeah, the answer is C less than 18 months. Um, that is just what studies and papers have shown is that less than 18 months, your receptors against bronchodilators are probably you'll be to do receptor. Um, Agnes have not actually fully developed if you're less than 18 months. Um, but like I said, it's not a kind of thing that we cannot travel a sub you to one of less than 18 months, But routinely, if they're less than six months, we tend not to use them. Um, but, uh, I mean, in that kind of age, we would tend we tend to trial, um, ipratropium bromide more than something to more they not the kind of take home message. Um, I think that might be the last question. So, um, thank you, everyone for listening. If you've got any questions, please put them in the chat. And I would really appreciate if you could fill out a feedback form. Um, just for us to know things to improve on. Um, And you also needed to claim your certificate for attending. So, um, thank you. And I think me and James will stick around for a bit If anyone has any questions, and I think the slides will be available. Yes, that's right. I'll stick them on the event page on medal. Uh, will be uploaded there. Uh, and, yeah, please do fill out the feedback form so you generate your certificate. But it's also useful for, uh, presenters portfolios. And it's useful for us to improve future sessions. Uh, thank you all very much for coming. And thank you, Doctor Abraham, for your session. I particularly enjoyed the quiz. I was upset. I got there was one just before the end. I got wrong. I was quite disappointed with myself. Uh, I think it was the life threatening a small one. Yeah, I think that's quite a bit because it's also different to the adult one. Um, there's like to to learn which which can be. Yeah. And to Hafsa. Hussain? Yes. The session is recorded. Um, it normally goes up on YouTube. Maybe a day or so after the session. Um, so if you go on the mind the bleep YouTube page, you can find it there. Okay? Mm.