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Childhood wheeze

Module summary

One in three children will have a wheezing episode by the age of three years, and one in two by the age of six. Most will be viral associated (episodic), and will require no treatment.

BTS/SIGN asthma guidelines present management for adults, for children aged between five and twelve years of age, and for children under five. While the principles of diagnosis and management for children aged five to twelve are similar to those for adults, most wheezing illness in the under 5s is not asthma, and diagnosis and management are more difficult.

Learning objectives

This module will update your knowledge on managing asthma, wheeze and cough in children, including issues such as:

  • Finding out the causes of persistent cough and wheeze in children
  • Prescribing and monitoring over time
  • Presentations that may point to a more serious diagnosis
  • Self-management to prevent exacerbations

Author details 

Dr Duncan Keeley, GP in Oxfordshire and member of the Primary Care Respiratory Society UK executive

Miss AB, aged eight months, is brought in by her mother, with a history of three days’ runny nose and cough which has got worse in the last 24 hours, with difficulty in breathing and difficulty in feeding. She had an unremarkable perinatal history and has been well until this illness.

Acute bronchiolitis occurs in children under two years, most commonly between the ages of 3-6 months1. A coryzal prodrome is followed with worsening cough and difficulty in breathing within 3–5 days1. The most common infective agents are respiratory syncytial virus and adenoviruses. Reduced intake of food and fluids is common and the extent of this is one important guide to severity of illness1.

It is important to ask about the birth and perinatal history, and about preceding respiratory and other illnesses, to get as accurate an idea as possible of the extent to which fluid intake has been reduced. Any history of apnoeic spells should prompt urgent admission.

Important points in examination are the temperature, pulse and respiratory rates, and the degree of intercostal and subcostal recession. Any of a heart murmur, marked liver enlargement or a reduced femoral pulse raise the possibility of heart failure as a cause of breathlessness. A liver edge may be palpable due to hyperinflation of the lungs. Fever occurs in 30% and a fever of over 39 °C suggests the possibility of bacterial pneumonia1. It may be helpful to watch the child take a feed.

The history and examination are compatible with a diagnosis of acute bronchiolitis. Oxygen saturation measurement is available in the practice: AB’s oxygen saturation in air is 90%.

A recent NICE guideline suggests admission according to clinical discretion if the fluid intake is reduced to 50-75% of usual volume. Intercostal recession is common and not in itself an indication for admission, though its extent gives a guide to the severity of airways obstruction. Oxygen saturation of 92% or below is a criterion for admission. Although a small investment is required, it is highly desirable for all medical facilities to have an oxygen saturation monitor suitable for use with infants and small children. Any child with reduced oxygen saturation should have oxygen administered as soon as possible and should be transported to hospital by ambulance and not in the parents’ car. Prematurity, especially less than 32 weeks’ gestation, is a risk factor for more severe illness, but a child born at 36 weeks with no postnatal complications would not necessarily need admission. Normal respiratory rates vary with age but a respiratory rate of 80 breaths per minute is markedly abnormal at any age and should prompt admission1.

Learn how to count and record heart and respiratory rates in children (best done by listening with a stethoscope) since these are cardinal indicators of disease severity in childhood.

Normal ranges for heart and respiratory rate in childhood2

Age Heart rate (beats per minute) Respiratory rate (breaths per minute)
Newborn 90-180 40-60
1 month 110-180 30-50
3 months 110-180 30-45
6 months 110-180 25-35
1 year 80-160 20-30
2 years 80-140 20-28
4 years 80-120 20-26
6 years 75-115 18-24
8 years 70-110 18-22
10 years 70-110 16-20
12 years 60-110 16-20
14 years 60-100 16-20

AB is admitted to hospital by ambulance and makes a good recovery after a three-day hospital admission.

There is no evidence for clinical efficacy for any drug treatment in acute bronchiolitis. Oxygen supplementation if saturations are reduced, and safe feeding, are the cornerstones of management in hospital. Severely ill children may require continuous positive airway pressure (CPAP) or ventilation1.

  1. Bronchiolitis in children: diagnosis and management. NICE guideline 9, 2015. Available at: www.nice.org.uk/guidance/ng9. Last accessed 15th March 2016.
  2. Advanced Life Support Group. Advanced Paediatric Life Support: a practical approach to emergencies. 6th Edn, 2016. Wiley-Blackwell, New York.

Master WB, aged four years, is brought in by his father, with a five-day history of cough and a two-day history of difficulty in breathing with a wheezing sound when he breathes out. He has had this problem several times before.

What features in the further history that you take would support a diagnosis of asthma as the cause for his recurrent respiratory symptoms?

Careful and repeated history-taking is vital in a child with recurrent respiratory illnesses. Onset of symptoms at or soon after birth, or a history of choking or cough after feeds or of recurrent loose cough, raise the possibility of alternative and more serious diagnoses (such as congenital heart or lung abnormalities, foreign body inhalation, reflux with aspiration, bronchiectasis, or cystic fibrosis). A family history of asthma or other atopic conditions increases the likelihood of asthma, as does a personal history of allergy or other atopic conditions such as eczema or hay fever1.

Correct diagnosis depends on integrating information from history-taking, examination, physiological testing (where possible) and response to trials of introducing (and withdrawing) treatments. Errors in diagnosis are common in both primary and secondary care. Do not assume, when you take over the care of a child with an earlier asthma diagnosis, that the diagnosis is correct – seize the opportunity to review the evidence on which the diagnosis was based.

After taking the history you remain uncertain about whether WB has asthma.

What features in the physical examination would make the diagnosis of asthma less likely?

Though a child who was wheezy in the night may have a normal chest examination when seen in the morning, it is unusual for wheezing never to be heard if the child is seen during symptomatic episodes. This makes careful recording of examination of physical findings important.  Finger clubbing or failure to thrive suggest more serious diagnoses such as cystic fibrosis – failure to thrive due to severe asthma is now exceedingly uncommon.

The challenge is to differentiate children with asthma from the many children with recurrent minor upper respiratory tract infections, children with episodic viral induced wheezing, and a small number of children with more serious respiratory conditions1.

The British Thoracic Society/Scottish Intercollegiate Guideline Network (BTS/SIGN) asthma guideline contains useful tables of features in the history and examination which increase or reduce the likelihood of an asthma diagnosis.

Clinical features that increase the probability of asthma1

  • More than one of the following symptoms: wheeze, cough, difficulty breathing, chest tightness, particularly if these symptoms:
    • are frequent and recurrent
    • are worse at night and in the early morning
    • occur in response to, or are worse after, exercise or other triggers, such as exposure to pets, cold or damp air, or with emotions or laughter
    • occur apart from colds
  • Personal history of atopic disorder
  • Family history of atopic disorder and/or asthma
  • Widespread wheeze heard on auscultation
  • History of improvement in symptoms or lung function in response to adequate therapy

 

Clinical features that lower the possibility of asthma1

  • Symptoms with colds only, with no interval symptoms
  • Isolated cough in the absence of wheeze or difficulty breathing
  • History of moist cough
  • Prominent dizziness, light-headedness, peripheral tingling
  • Repeatedly normal physical examination of chest when symptomatic
  • Normal peak expiratory flow (PEF) or spirometry when symptomatic
  • No response to a trial of asthma therapy
  • Clinical features pointing to alternative diagnosis

Where there is continuing diagnostic uncertainty or failure to respond to asthma treatment, specialist referral to a paediatrician is necessary for diagnostic assessment and management advice. If there are good grounds to suggest more serious pathology then a chest X-ray should be arranged in advance of the child being seen by a paediatrician1.

 

Criteria for specialist referral1

  1. Diagnosis unclear or in doubt
  2. Symptoms present from birth or perinatal lung problem
  3. Excessive vomiting or posseting
  4. Severe upper respiratory tract infection
  5. Persistent wet or productive cough
  6. Family history of unusual chest disease
  7. Failure to thrive
  8. Nasal polyps
  9. Unexpected clinical findings e.g. focal signs, abnormal voice or cry, dysphagia, inspiratory stridor
  10. Failure to respond to conventional treatment (particularly inhaled corticosteroids above 400 micrograms per day or frequent use of steroid tablets)
  11. Parental anxiety or need for reassurance

WB has a strong family history of asthma and has had some trouble with eczema. There are no worrying features in the history or on examination to raise the possibility of alternative diagnoses. He responds well to salbutamol by spacer in the surgery, with improvement in his wheezing.  You measure his height and weight and start him on beclometasone 100 micrograms (mcg) twice daily by spacer, ensuring good inhaler technique, and this results in continued improvement. After three months you discontinue the beclometasone but his symptoms recur two weeks later. You make a diagnosis of asthma and continue the beclometasone, with a plan to review him in another three months, and to keep the presumptive diagnosis under review.

  1. British Thoracic Society/Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. 2014. Available at: www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/. Last accessed: 15th March 2016.

Miss TH, aged eight years, has had asthma since the age of four. She has had two admissions to hospital and has needed occasional courses of oral prednisolone for out-patient treatment of exacerbations. Her regular prescribed treatment is beclometasone (as Clenil Modulite) 200mcg twice daily, by metered dose inhaler (MDI) using a spacer device, and salbutamol as needed, also by MDI with a spacer device.

She comes in with a four-day history of worsening cough and wheeze. She had little sleep last night, but is able to talk in full sentences when you talk with her.

Which of these clinical features on examination (among others not listed here) are necessary to include in the clinical assessment of severity in a child with acute asthma?

Assessment of severity in a child with acute severe asthma is important in deciding how to treat the child and whether to admit to hospital.

In this history it is important to ask about the frequency and severity of previous attacks and how they were treated, the story of this episode, and the key features of ability to sleep, undertake normal physical activity and speak in full sentences. It is good to ask how severe this attack is compared with previous attacks. You need to know in detail what treatment has already been given for this attack. It is also very important to understand what degree of symptoms the child was experiencing and exactly what treatment was being given before the attack started, to inform the provision or modification of a personal asthma action plan after the attack has resolved.

On examination of a child with acute asthma, the capillary return is not relevant and blood pressure measurement is unlikely to be contributory to decision making. Heart and respiratory rates are key variables1. You need to be aware that if the child has had a lot of salbutamol already then this may contribute to a tachycardia, and that low pulse or respiratory rates can be a sign of impending cardiorespiratory arrest in a severely ill child1. The degree of subcostal and intercostal recession is an important guide to the severity of airways obstruction – although these may also apparently “improve” in a seriously ill child prior to respiratory arrest.  On auscultation the usual finding is of scattered wheezes in all lung fields; breath sounds are important because marked symmetrical reduction can be an indicator of severe obstruction (the so-called “silent chest”) while marked asymmetry of breath sounds should prompt suspicion of a pneumothorax. Pulse oximeters are now inexpensive and any healthcare facility assessing sick children should have one. The BTS/SIGN guideline states that ‘Accurate measurements of oxygen saturation are essential in the assessment of all children with acute wheezing. Oxygen saturation monitors should be available for use by all health professionals assessing acute asthma in both primary and secondary care settings1.

Normal ranges for heart and respiratory rate in childhood2

Age Heart rate (beats per minute) Respiratory rate (breaths per minute)
Newborn 90-180 40-60
1 month 110-180 30-50
3 months 110-180 30-45
6 months 110-180 25-35
1 year 80-160 20-30
2 years 80-140 20-28
4 years 80-120 20-26
6 years 75-115 18-24
8 years 70-110 18-22
10 years 70-110 16-20
12 years 60-110 16-20
14 years 60-100 16-20

 

In the surgery TH is given eight puffs of salbutamol by spacer and 30mg of soluble prednisolone.

Poor response to initial treatment in primary care should prompt hospital assessment for admission. However, particularly after high-dose salbutamol, a pulse rate of 120 bpm in an eight-year-old would be unremarkable, as would a respiratory rate of 24 breaths per minute (BTS/SIGN criteria for acute severe asthma in children over 5 are pulse >125 bpm and respiratory rate >30 breaths per minute)1. A brief period of fine tremor of outstretched hands is also common after high-dose salbutamol. Significant hypoxia is a sign of a very severe asthma attack and a child with saturations of 92% in air after treatment should receive oxygen as soon as possible and be admitted to hospital urgently by ambulance1.

Initial management in primary care should include high-dose salbutamol (10 puffs of salbutamol by MDI and spacer) and the administration in the surgery of the first dose of a 3–5-day course of oral prednisolone (20mg daily age 2-5, 30-40mg daily over 5). Any child who is seriously unwell or shown to be hypoxic should receive oxygen as soon as possible1. It can be given alongside high dose salbutamol by spacer, taking the mask off long enough to give the salbutamol and then replacing it. If a nebuliser (2.5mg of salbutamol) is used it should be oxygen-driven, since air-driven nebulisers can exacerbate hypoxia in severely ill children.

High-dose salbutamol – whether given by spacer or nebuliser – can be repeated at short intervals if there is a delay in the ambulance arriving.

If the child has responded well to the initial treatment with high-dose bronchodilator and there are no absolute indications for admission then, provided the parents are confident and there are no substantial adverse social circumstances, the child may be allowed home. There should be a clear written management plan including features suggesting deterioration and contact details for emergency services in the event of serious concern. Detailed instructions should be given for continued use of high-dose salbutamol with advice on stepwise reduction as the child improves, and for a further 2–4 days of oral prednisolone. Ensure that there are adequate supplies of medication, including regular inhaled corticosteroids, which should be continued after the attack at least until the child has been reviewed – and probably longer – and should be started now if the child was not on them before. A follow-up appointment in primary care should be made in 2–7 days’ time to ensure improvement and reinforce continuing management advice.

Spacer devices (such as Volumatic or Aerochamber) have many advantages in improving the effectiveness of asthma treatment with MDIs.

TH makes a good response to the initial treatment in the surgery and you decide it is appropriate to let her go home with a written self-management plan, a clear set of safety net instructions and a follow-up appointment in a week’s time. You encourage her and her parents to make consistent use of the spacer device for her regular asthma treatment.

Children of any age can be treated with an MDI and spacer (with suitable mask attachments for younger children), and indeed an MDI with spacer is the only inhalation technique recommended for young children in NICE guidelines for inhaled therapies.

Drug deposition in the lung is increased from around 10% (MDI with good technique) to around 20% of the metered dose, increasing the effectiveness of treatment. Technique errors leading to even greater reduction in drug deposition in the lung are common when MDIs are used without spacers, but far harder to make when MDIs are used with spacers.

Oral drug deposition is greatly reduced, since any drug not reaching the lung is mainly deposited in the spacer. This reduces the incidence of side effects, such as oral candidiasis when using inhaled corticosteroids.

Numerous randomised controlled trials, summarised in a Cochrane Review, have shown MDIs with spacers to be as effective as nebulisers in the treatment of acute severe asthma.4 Patients with life-threatening attacks were generally excluded from these trials so the comparative efficacy in such patients is unknown.

It should be noted that the advantages of having and using spacers to improve the effectiveness of treatment with MDIs apply as much to adults as they do to children.

General recommendations for cleaning are that spacers should be washed with a gentle detergent and allowed to air dry once every 4 weeks, and replaced every 6-12 months.5

  1. British Thoracic Society/Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. 2014. Available at: www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/. Last accessed: 15th March 2016.
  2. Advanced Life Support Group. Advanced Paediatric Life Support: a practical approach to emergencies. 6th Edn, 2016. Wiley-Blackwell, New York.
  3. National Institute for Health and Care Excellence. Guidance on the use of inhaler systems (devices) in children under the age of 5 years with chronic asthma. NICE technology appraisal guidance 10. 2000. Available at: www.nice.org.uk/guidance/TA10. Last accessed: 16th March 2016.
  4. Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for delivery of beta-agonist relievers in the treatment of an asthma attack. Cochrane Database of Systematic Reviews, 2013, Issue 9.
  5. UK Medicines Information. What practical issues need to be considered for the use and care of spacer devices? 2012. Available at: www.medicinesresources.nhs.uk/GetDocument.aspx?pageId=775868. Last accessed: 23rd March 2016.

Miss RD, aged 13 years, is brought in to see you by her Mum. Last week she complained of breathlessness and chest pains during a PE session at school and the teachers called Mum in to take her home. She had been tending to complain of breathlessness during exercise for the last year or so and wants to be given a letter saying she can’t do games. She has not previously been thought to have asthma and there is no family history of this. You take a careful history and examine her and remain uncertain whether or not she has asthma.

Chest radiography is unhelpful in this situation and is not indicated unless more serious pathology is suspected. Chest X-rays may show hyperinflation during acute severe episodes of asthma.

Because variable airway obstruction is the hallmark of asthma examination, physiological measurements of airflow obstruction such as spirometry and peak expiratory flow may be normal if performed when the person is asymptomatic.  During an episode of symptoms (in asthma) you would expect to find wheezing on auscultation of the chest, reduced peak expiratory flow rate and an obstructive picture on spirometry (FEV1/FVC <0.70), with improvement in all of these findings after the administration of salbutamol1.

If child and parent understand and can demonstrate how to make peak flow measurements and how to plot them on a peak flow chart, then a peak flow diary can be very helpful, and the child and parent can be asked to make measurements before and after exercise. It would be unusual for there to be no significant peak flow variability over a period which included episodes of symptoms.

Making a diagnosis of asthma can be difficult and diagnostic errors are common. Children under the age of five with occasional episodic viral-induced wheezing may be misdiagnosed as having asthma – especially if they are given inhaled corticosteroids and the natural resolution of the symptoms is misattributed by parent and doctor to this treatment. In older children a diagnosis of asthma is sometimes wrongly given when the problem is one of hyperventilation/anxiety or simple physical unfitness. The key to minimising diagnostic errors is careful follow-up over time, with repeated history-taking, examination and physiological measurements at appropriate intervals. Apparently-successful trials of treatment should be followed by gradual supervised withdrawal of treatment to see whether symptoms recur.

A new and potentially promising diagnostic aid is measurement of fractional exhaled nitric oxide (FeNO) in expired air: raised levels are indicative of active airway inflammation and hence of asthma. This measurement is not currently widely available even in hospital departments, but its use was advocated in a draft and as yet unreleased NICE guideline on asthma diagnosis, and it may come to have a more established place in clinical practice as more evidence is gathered.

RD returns after four weeks – her exercise-induced symptoms have become more noticeable, and her peak flow chart shows substantial variability – several times her peak flow dropped by 25% after exercise. She has also noticed that cats and her Dad’s cigarette smoke make her chest feel tight.

You think that asthma is likely and decide to try asthma treatment for her.

Which of the following treatments might be appropriate in the first instance for a 13-year-old child with moderate and frequent, mainly exercise-induced wheezing? Good training in the use of any inhalers is assumed.

Most clinicians would recommend initial treatment with regular low-dose inhaled corticosteroid as well as a salbutamol inhaler to use if needed. The aim is to minimise or abolish this girl’s regular exercise-induced symptoms and enable her active participation in sport and games. Starting her directly on a combination inhaler would represent overtreatment at this stage. Theophylline is an older therapeutic agent with significant side effects which, though it still has a place in the management of problematic or severe asthma, is not suitable for first-line treatment. Montelukast, though more expensive and generally less effective than low-dose inhaler steroids, may be of benefit and may have a place particularly in the management of children whose parents are very reluctant to used inhaled corticosteroids for their child.

  1. British Thoracic Society/Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. 2014. Available at: www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014/. Last accessed: 15th March 2016.

Miss RG, aged two years and two months, is brought in with a three-day history of upper respiratory symptoms and a one-day history of worsening cough and wheezing. She has not been feverish and is feeding normally. She has had two previous similar illnesses lasting a week or so; the first occurred when she was eight months old and led to an overnight hospital admission. She has been entirely well between these episodes. She was given a blue inhaler (i.e. a short-active reliever inhaler) for both of her previous wheezy illnesses but it did not seem to help. There is no history of allergic or atopic illness in her or her family. Examination is unremarkable except for diffuse wheezing on auscultation and a slightly raised respiratory rate with mild intercostal and subcostal recession. She is afebrile. Her heart rate is within the normal range for her age and her oxygen saturation is normal.

Recurrent wheezing under the age of five years is common and many of these children do not have asthma but rather a condition currently labelled as episodic viral wheezing. These children tend to have symptoms and signs only with colds, with no history of precipitation by other triggers, and no family or personal history of atopy.  They are less likely to respond to any asthma treatments, and no treatment of any kind may be needed for mild episodes. Inhaled salbutamol can be tried but generous doses are needed if this is to be effective. Two puffs are unlikely to have any effect since even with correct spacer use infants and young children need larger doses to achieve effective lung deposition.

Short-course montelukast may be tried – there is some (relatively weak) evidence for effectiveness in this context. These children gain no benefit from treatment with oral or inhaled corticosteroid at any dosage. There is no place for antibiotics in the management of this condition. Avoiding exposure to tobacco smoke is very important here – always ask about parental smoking and offer support to quit for parents who do smoke.

Symptoms do not usually continue beyond the age of five years. For a full account of this complex topic see Brand et al1. The important thing is to be aware of this possibility.

You decided that RG has episodic viral wheezing and not asthma. You prescribe no treatment on this occasion and the symptoms settle in a few days without causing the child or the parents undue distress. You arrange to review her two weeks later and the parents come to you then with a number of questions.

Occasionally children who present with episodic viral wheezing under the age of five do later develop asthma and it is therefore better to avoid categorical reassurances. These children are unlikely to go on wheezing after age five. Salbutamol by spacer and intermittent montelukast are sometimes helpful and may be tried for troublesome symptoms. Evidence for the value of cat avoidance is weak even in definite asthma and would certainly be overcautious for a child with episodic viral wheezing, as would be advice to avoid day nursery. There is good evidence, cited by Brand et al., that early treatment with inhaled corticosteroids does not improve the long-term prognosis in recurrent wheezing in early childhood1.

You review LG twice in the following year and are pleased to find that she experiences no further recurrence of her symptoms.

  1. Brand PL, Baraldi E, Bisgaard H, et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach. Eur Respir J 2008; 32(4): 1096–1110.

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