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Edgel Acebedo Pediatrics August 11, 2014

3 A MEDICINE ONLINE SGD Wheezing Disorders Dra. Andaya



Salient Features:
C/C: Difficulty of breathing associated with wheezing.
15 months old infant
Had recurrent wheezing episodes since 2 months old
(responsive to beta-2 agonist).
Mother is a known asthmatic
Brother has atopic dermatitis
Physical exam: Normal Values:
Weight: 13 Kg. Age appropriate
Pulse rate: 120/min 70-110 beats per min
Respiratory rate: 55/min 20-30 breaths per min
Temperature: 38.6 degrees Celsius
Symmetrical Chest expansion
Presence of moderate chest retractions
Presence of bilateral expiratory wheezes
Presence of irritable Respiratory distress
Refuses to feed
Fair air entry

Questions:
1. Based on the clinical data given, what is the most probable diagnosis?
Non atopic wheezing- wheezing, coughing beginning at early life, often with Respiratory Syncytial Virus; resolves
later in childhood without increased risk of asthma. It is associated with bronchial hyper responsiveness near
birth.
2. How will you assess the severity of the asthma exacerbation?
The patient is classified under severe asthma exacerbation
Criteria Severe Asthma Exacerbation Actual findings in patient
Suprasternal retraction: usually present Presence of chest retraction
Wheeze:

usually loud throughout
inhalation and exhalation
Presence of bilateral expiratory wheeze

Pulse rate: >120 beats per minute 120 beats per minute
Respiratory rate: >30 breaths per minute 55 breaths per minute
Alertness: usually agitated Irritable due to respiratory distress
Refuses to feed
Note: in children no singles assessment tool appears to be the best for assessing the severity and exacerbation
or for monitoring response to treatment and predicting hospital admission.

According to table 138-4 Formal Evaluation of Asthma Exacerbation severity in urgent or emergency care
setting, the patient is classified under Severe Asthma Exacerbation.
Table 138-4
Criteria Actual Severe
Pulse rate 120 /min >120/min
Respiratory rate 55/min often >30/min
Presence of retraction present usually
Alertness Irritable respiratory distress usually agitated
Refuses to feed
Wheeze Presence of bilateral expiratory wheeze Usually loud throughout inhalation and
exhalation

According to table 138-7 Assessing and initiating treatment for patient who are not currently taking long term
control, the patient will be classified under Persistent Moderate Asthma.
Criteria: Persistent Moderate Asthma
SABA use for symptoms. Daily
Interference with normal activity Some limitation

Rationale: The patient was classified under Persistent Moderate Asthma, because according to this guideline, At
the present, there are no inadequate data to correspond frequencies of exacerbations with different levels of
asthma severity. So for treatment purposes, for patient who had >/= 2 exacerbations reqiring oral
corticosteroids in the past 6 months, or >/= 4 wheezing episodes in the past year, who have risk factors for
persistent asthma may be considered the same as patients who have persistent asthma, even in the absence of
impairment levels consistent with persistent asthma which is the reason why patient was classified under
persistent moderate asthma.

3. How will you assess the level of asthma control?
The level of asthma control in the patient is not well controlled
Rationale: Patient since 2 months old had recurrent episodes of wheezing up to the present. But the patients
drug regimen only consist of SABA for acute control of his recurrent wheezes, the patient does not have yet a
drug for long term control of his recurrent wheezes.

4. What test will you request to confirm the diagnosis?
Allergy testing
to assess sensitization to inhalant allergens
Helps with management and prognosis of asthma
Identifies patient with inhalant allergen sensitization thru allergy prick skin test

Bronchodilator response
To assess if there is any symptom relief thru any of the following:
Disappearance of respiratory distress
Disappearance of chest retractions
Disappearance of wheeze bilaterally

5. What are your differential diagnoses?
Lower Respiratory Tract Conditions
a. Bronchopulmonary Dysplasia
b. Viral Bronchiolitis
c. Gastroesophageal Reflux
d. Medication Associated With Chronic Cough
i. Acetylcholinesterase Inhibitors
ii. B-Adrenergic Agonist
iii. ACE Inhibitor
e. Causes Of Bronchiectasis
i. Cystic Tumors
ii. Immune Deficiency
iii. Allergic Bronchopulmonary Mycoses
iv. Chronic Aspiration
v. Immotile Cilia Syndrome, Primary Ciliary Dyskinesia
f. Bronchiolitis Obliterans
g. Interstitial Lung Disease
h. Hypersensitivity Pneumonitis
i. Pulmonary Eosinophilia, Churg-Strauss Vasculitis
j. Pulmonary Hemosiderosis
k. Tuberculosis
l. Pneumonia
m. Pulmonary Edema (Eg. Congestive Heart Failure)
Middle Respiratory Tract Disorders
a. Laryngotracheobronchomalacia
b. Laryngotracheobronchitis (Eg. Pertussis)
c. Laryngeal Web, Cyst Or Stenosis
d. Vocal Cord Dysfunction
e. Vocal Cord Paralysis
f. Tracheoesophageal Fistula
g. Vascular Ring, Sling, Or External Mass Compressing On The Airway (Eg. Tumor)
h. Foreign Body Aspiration
i. Chronic Bronchitis And Environmental Tobacco Smoke Exposure
j. Toxic Inhalations
Upper Respiratory Tract Conditions
a) Allergic Rhinitis
b) Chronic Bronchitis
c) Sinusitis
d) Adenoidal Or Tonsillar Hypertrophy
e) Nasal Foreign Body

6. What initial measures would you like to give at E.R.?
Assessment depends on P.E.
Use of accessory muscles, inspiratory and expiratory wheezes, paradoxical breathing, cyanosis and respiratory
rate> 60 are key signs of serious distress.
Obj. measurements, such as O2 sat. Of 90%, also indicate serious distress.
Response to SABA therapy can be variable and may not be a reliable predictor of satisfactory outcome, because
infants are at greater risk for respiratory failure, a lack of response noted by either P.E. or objective meas.
Should be an indication for hospitalization.
Use of oral corticosteroids early in episode is essential but should not substitute for careful assessment by
physician.
Most acute wheezing episodes result from viral infections and may be accompanied by fever. However,
Antibiotics generally are not used.

7. What are the preventive measures?
Conventional anti inflammatory intervention is the cornerstone of asthma control
Early immunomodulatory intervention might prevent asthma development
Hygiene hypothesis purports that naturally occurring microbial exposures in early life might drive early immune
development away from allergic sensitization, persistent airway inflammation and remodeling, thus it has Anti-
asthma properties.

Non pharmacologic interventions:
Avoidance of environmental tobacco smoke
Prolonged breastfeeding
Healthy diet
Immjunizations
All standard childhood immunizations are recommended for children with asthma including varicella
and annual influenza vaccines.