No 23 - Teaching a systematic approach to the "Wheezy Child"
tldr
Below is the summary of a small group teaching session that used 32 questions to explore a systematic approach to assessing a patient and managing a child with wheeze.
Wheezy Children Medical Student teaching
I am currently working in General Paediatrics as a GP trainee. One of the best parts of being a doctor is being able to teach medical students, because it forces you to concentrate on your subject. No one likes to look incompetent in front on young keen medical students.
My knowledge of actual medical facts is not that great and therefore, I thought I would avoid teaching facts in the normal way and instead I would try to teach a few “systematic approaches” to the wheezy child. Essentially, jargon for how to cheat and use rules of thumb rather than have to know everything.
I am a big fan of practicing using systems, so that it becomes a habit that you can fall back on when you are tired, stressed, overwhelmed and confused.
The following section is a list of questions that should follow in a logical sequence on how to manage these patients and prompts for how to think at different stages during the process. I have included facts from guidelines, https://dontforgetthebubbles.com/search/?q=wheeze, Lissauer’s, PILS and ALS.
My first tip on the systematic approach is that almost everything in medicine can be made into a dichotomy or trichotomy: a yes, no or maybe. This approach can be applied to almost everything and can you help you simplify your way out of seemingly complex situations.
Your scenario: You are asked to clerk a wheezy child in ED/ CDU or GP….
1. Why is learning about Difficulty in Breathing (DIB), or increased work of breathing (WOB) or SOB or wheeze important?
a. Wheezing children who are short of breath are very common!
b. Armon K, Stephenson T, Gabriel V, et al. Determining the common medical presenting problems to an accident and emergency department. Archives of Disease in Childhood 2001;84:390-392.
c. Table 1: Presenting problems of medical patients (3802 in 3434 children) Presenting problem Number (percentage)
d. Breathing difficulty 1164 (31%) > Febrile illness 764 (20%) > Diarrhoea +/− vomiting 617 (16%) > Abdominal pain 239 (6%) > Seizure 178 (5%) > Rash 190 (5%) > Other 650 (17%)
2. What is the first most important question to ask yourself when you see the patient?
a. What does your “end of the bed-o-gram” tell you?
b. Is the patient well, unwell or life-threateningly unwell? (Trichotomy)
3. Why is this important?
a. Because there are two broad approaches (dichotomy) to medical assessments:
b. The ABCDE ALS approach
c. The traditional history and assessment approach
4. How can you tell if a child is sick, without speaking to them?
a. Unusual behaviour
b. Unusual noises
c. Observations
d. The behaviour of other healthcare professionals
e. The environment – resus v GP waiting room – can catch you out
5. What is the point of the ALS approach?
a. To see and treat the most life threatening conditions in priority order
b. To stabilise the patient in order to thing the underlying problem
6. What is the point of the traditional medical assessment?
a. To establish the symptoms and signs in order to produce a list of differentials, which you can then exclude with investigations.
b. If you are lucky then you will find the diagnosis, mostly you wont
7. What is the point of investigations?
a. To rule in or rule out a particular differential?
8. Do you have a system for working out differentials? And why is this important?
a. Like a maths exam, you get points for showing your working out.
b. Show that you have a logical method
c. Show that you have a method that can be applied in any situation, to get you out of trouble
d. Practice using a method, so that you memorise it and it happens automatically
e. Don’t try to look clever by pointing out the obvious answer
f. If you hear hoofbeats, think horses not zebras … but remember that zebras exist
9. What is a good differential system? – VITAMIN D
a. https://radiopaedia.org/articles/surgical-sieve-mnemonic?lang=gb
b. V: vascular
c. I: infective
d. T: traumatic
e. A: autoimmune
f. M: metabolic
g. I: iatrogenic
h. N: neoplastic
i. C: congenital
j. D: degenerative/ Drugs
k. E: endocrine
l. F: functional
10. So, how many ways are there for patients to present?
a. The “classical” MedEd answer is:
b. There are 11 Organ systems – Skin, Skeletal, Muscular, Nervous, Cardiovascular, Endocrine, Respiratory, Lymphatic, Digestive, Urinary, Reproductive,
c. Roughly 30 different medical and surgical specialities
d. ? >100,000 different human illnesses
e. 68,000 ICD-10 Codes (International Classification of Disease, WHO)
f. 13,000 ICD-9 Codes (1979-2015)
g. 157 disorders DSM-V
h.
11. Use a system …
12. Do you want to start with the big picture and focus in or the specifics and build out?
13. What is a sensible way to group children?
a. <1 years old = infants – different physiology and anatomy
b. ALS Observations cut offs, weight based cut offs correlate with size
c. <1 = 40 RR HR <205 in 3 month old
d. <2 = 34 HR <180
e. <5 = 30
f. <12 = 24 HR <140 in a 10 year old
g. >12 = 20 HR >100 in >10 year olds
14. What kinds of noises do children make?
a. Talking
b. Snoring
c. Crying
d. Screaming
e. Snuffling
f. Wheeze
g. Cough
h. Stridor
15. What is the difference between stridor and wheeze?
a. Stridor = Upper airway + inspiration
b. Wheeze = lower airway and expiration
16. What are the two options for causing stridor?
a. Complete obstruction = quiet
b. Partial obstruction = stridor
17. Causes of airway obstruction? - Stridor?
a. V: vascular = Blood
b. I: infective = Mucous, secretions, oedema (pharyngeal swelling), URTI, Epiglottitis, Croup (laryngotracheobronchitis), tonsillitis, quinsy, whooping cough (Bordetella Pertussis)
c. T: traumatic = Foreign bodies (toys, food, orthodontics),
d. A: autoimmune = Anaphylaxis
e. M: metabolic
f. I: iatrogenic = nasal cannulae, nasal feeding tubes
g. N: neoplastic
h. N – Neurological = CNS depression
i. C: congenital = Choanal atresia, Pierre-Robin Syndrome etc
j. D: degenerative/ Drugs = Alcohol, sedatives, Z-drugs, opioids legal and illegal
k. E: endocrine
l. F: functional
18. Why is kids anatomy different to adults?
a. Airway is narrower – easier to block
b. Larger head – protuberant occiput – flex neck
c. Weak larynx – easily compressed
d. Smaller face proportionally – difficult to get effective mask seals
e. Tongue is relatively large
f. Preferential nasal breathers – easily blocked, especially while feeding
g. Nasal breathing – anything in their nostril – secretions or tubes can increase their WOB
h. Epiglottis = larger and floppier than adults = easier to damage with airway devices
i. Manipulation of the epiglottis leads to vagal stimulation and bradycardia
j. Infants – small resting lung volume = low oxygen reserve
k. High oxygen consumption = high metabolic rate = rapid decreases in reserve
l. Ribs are cartilaginous = pliable + weaker intercostal muscles = difficult to expand against resistance = gets sucked in – can see sub-costal and intecostal recessions
m. Main muscle of respiration = diaphragm
n. Proportionally large abdominal contents = splints the diaphragm = reduces inspiration
o. Children >5 should have ossified ribs and therefore = recessions = ominous sign!
p. Resp rate increases with agitation, fever, pain,
19. Physiologically, why is there a difference between <1 and >1 years old?
a. We know from our daily practice, and from the literature, that infants <12 months of age with wheeze predominantly have bronchiolitis, and do not respond clinically to salbutamol.
b. salbutamol adrenaline, dexamethasone combination treatment is ineffective in bronchiolitis
c. https://breathe.ersjournals.com/content/15/4/273
d. We argue that infants <1 year of age have functional β2-adrenoceptors within the lung.
e. The reason for the lack of improvement with β-agonists in wheeze associated with acute bronchiolitis, is that bronchiolitic wheeze is caused by mucous obstruction and airway oedema at the level of the bronchioles, rather than due to muscular constriction (bronchospasm) at the level of the bronchi.
f. It is therefore unsurprising that wheeze in bronchiolitis does not resolve with β-agonists such as salbutamol, as the mechanism of wheeze is different.
g. It is for this reason, rather than a mythical lack of receptors, that salbutamol has no role in the treatment of bronchiolitis.
20. What causes wheeze in Infants/bronchiolitis?
a. different pathophysiological processes can lead to acute episodic wheeze in infancy: inflammation and mucus plugging obstructing airways,
b. mucosal wall oedema
c. bronchospasm
21. What do you need to know about B-adrenoreceptors?
a. The β-adrenoceptor is a cell membrane-spanning receptor,
b. with at least three subtypes.
c. β1-adrenoceptors are largely cardiac,
d. β2 receptors are found in the lungs, liver, vascular tissue and uterine muscles.
e. Within the lung, β2-adrenoceptors are largely located on airway smooth muscle, type II pneumocytes, epithelial and endothelial cells, and mast cells
f. G protein-coupled adenylate cyclase activation, increased cAMP and the inhibition of calcium release from intracellular stores, ultimately leading to smooth muscle relaxation and bronchodilation
22. What is one of the side effects of salbutamol?
a. Salbutamol, acts on cardiac β1-adrenoceptors, and therefore also induces tachycardia.
23. What is Bronchiolitis?
a. Acute respiratory viral infection in infants leads to bronchiolitis of the medium and small bronchioles – secretions, oedema, closing of bronchioles, = airway obstruction and lymphoid hyperplasia (extrinsic compression)
b. Tube is blocked and crushed – reduces air flow
c. respiratory syncytial virus bronchiolitis
24. What viruses cause Bronchiolitis?
a. Respiratory syncytial virus (RSV) accounts for the majority of cases,
b. rhinovirus, human metapneumovirus, bocavirus, influenza, parainfluenza, and adenovirus
c. COVID-19
25. What is Viral Induced Wheeze?
a. Bronchiolitis is Kids <1
b. VIW is kids 1 to 5 years old
c. Asthma is kids over 5 or with infrequent symptoms
26. What treatments can be used for children with wheeze?
a. OSHIT
b. Position
c. Physiotherapy
d. Nebulised Saline or drops
e. Oxygen – Prongs, masks, Airvo,
f. Humidified oxygen
g. Salbutamol Nebs or inhalers or IV
h. Atrovent, Ipratropium Nebs or inhalers
i. Dexomethasone, Prednisolone, Hydrocortisone,
j. Inhaled steroids
k. MgSo4
l. Aminophylline, Theophylline
m. Adrenaline IM or nebulised
n. Antibiotics – Amoxicillin, clarithromycin, Co-Amoxiclav,
o. Tamiflu
p. ITU
q. NG feeding or IV fluids
r. Chronic management – LABA, Montelukast, inhaled steroids, diet https://dontforgetthebubbles.com/wheeze-treatment-simple-isnt-meredith-borland-dftb19/
27. What investigations can we do for kids with VIW?
a. Bedside – Obs, Peak Flow, viral swabs, sputum culture, symptom diary
b. Biochemical – routine bloods, serology, culture, reverse transcriptase polymerase chain reaction (RT-PCR), enzyme-linked immunosorbent assay (ELISA) rapid antigen detection
c. Radiology – CXR, CT
d. Allergy testing – for atopy, allergies, triggers,
e. infant pulmonary function tests
28. Causes of wheeze in children?
a. V: vascular =
b. I: infective = Mucous, secretions, oedema, Respiratory syncytial virus (RSV), rhinovirus, human metapneumovirus, bocavirus, influenza, parainfluenza, and adenovirus, COVID-19
c. Bacteria = Typical, Atypical, Mycobacterium
d. Fungi
e. T: traumatic = Foreign bodies (toys, food),
f. A: autoimmune = Anaphylaxis
g. M: metabolic =
h. I: iatrogenic =
i. N: neoplastic
j. N – Neurological =
k. C: congenital =
l. D: degenerative/ Drugs =
m. E: endocrine = Diabetes/DKA,
n. F: functional = Anxiety, panic attack,
29. What is the simple way to break down wheeze?
a. Bronchospasm
b. Inflammation
c. https://dontforgetthebubbles.com/steroids_in_wheeze_meredith_borland_at_dftb18/
d. there are different cohorts of children between the age of 1-5 who present with similar symptomatology but for different pathophysiological reasons.
e. https://dontforgetthebubbles.com/steroids-for-pre-school-wheeze/
30. What criteria are part of the DIB triage?
a. https://dontforgetthebubbles.com/covid-and-rsv/
b. Change in behaviour (Green – Amber – Red)
c. Change in Skin
d. Respiratory rate
e. O2 sats
f. Chest recessions
g. Nasal flaring
h. Grunting
i. Hydration
j. Apnoeas
k. Risk Factors
31. Symptoms and Signs
a. https://bestpractice.bmj.com/topics/en-gb/28
b. cough
c. tachypnoea
d. wheezing
e. rhinitis
f. apnoeas
g. Lethargy
h. fluctuating clinical findings
i. irritability, malaise, and poor feeding
j. fever <40°C (<104°F)
k. winter months
l. passive tobacco smoke exposure and air pollution
m. Prematurity (<32/40) or bronchopulmonary dysplasia
n. Babies <3 months or infants <3 years
o. Chronic lung disease
p. Neuromuscular disorders
q. Immunodeficiencies
r. Congenital heart disease
s. Feeding? 100 and 150 ml/kg/day
t. Wet nappies <50% of normal?
32. What are the important Sats to know?
a. The exact cut-off for sats will depend on your local guide, but it’s likely to be somewhere between 90% and 92%.
b. The recent NICE guidelines said that in under six-week-old babies, we should maintain sats >92%,
c. but in over six week old babies we could tolerate >89%
d. https://dontforgetthebubbles.com/5-top-tips-in-bronchiolitis/
33. Discharge criteria for Bronchiolitis?
a. Nap in air
b. Feed in air
c. Sats >89%
d. Mild WOB
Thank you for reading. I hope it has been useful. Please let me know in the comments if you have any thoughts on how to improve this session or approach.