Imagine that you’re in a training post and working in an acute paediatric
setting. A nurse gets your attention and
says, “Would you have a listen to this child please? They are due their salbutamol but I wonder if
they are ready to space*.”
* Increase the interval between inhalers.
Most of us have heard those words or something very
similar. I suspect that most of us are
never actually taught exactly what we should assess when reviewing a child post
salbutamol. We are making assumptions
and reverting to our safe place of “more is more” when it comes to clinical
information. What is also interesting is
that a large number of clinicians feel that auscultation is not the most
important part of the assessment. Many
feel that the auscultation bit is positively unhelpful when reassessing a
wheezy child.
So, what is the deal?
Does the noisiness of the wheeze matter after the initial assessment?
Let’s consider a case.
Three year old Adam has developed a wheeze after four days of having a
cold. He didn’t have any treatment at
home.
When you clinically assess Adam, he is snotty but looks well
and is hydrated. He is sat on his parent's knee, playing with his
favourite soft toy – a ragged bunny rabbit covered in drool and snot. You can see from where you sit that he has
increased work of breathing and you can hear a quiet wheeze.
On closer physical examination you see moderate intercostal
recession and tracheal tug. On
auscultation there is a loud wheeze throughout his chest. There are no focal signs. Other than signs of an uncomplicated URTI,
examination is normal.
What is the diagnosis?
Adam is too old for bronchiolitis to be a real
possibility. In any case the onset ofthe wheeze very much goes against bronchiolitis as a diagnosis. (1) Asthma is also very unlikely. This is his first episode of wheeze, he is
three years old and there is a clear viral trigger. Viral wheeze is the winner of the “what is
the likely diagnosis?” competition?
How should Adam be treated?
Viral wheeze is the poor cousin of the childhood wheeze
family. Very little guidance exists
compared to Asthma or bronchiolitis.
There are plenty of RCTs but these tend to focus on wheeze in certain
age groups and avoid the issue of viral wheeze vs asthma (or multi-trigger
wheeze).
The only uncontroversial treatment for viral wheeze is
beta-agonist therapy (e.g. salbutamol). Regardless
of you views on steroids and montelukast as rescue therapy for acute viral
wheeze, beta-agonists are the only intervention that will have immediate
effect.
Oral steroids might be used for a child like Adam but the evidence for this is conflicting and confusing. The latest research supports a practice of reserving steroid use for more severe cases and those in which response to salbutamol is poor. (2)
There is no consensus on how many puffs of salbutamol you
should give a child such as Adam. 10
puffs of salbutamol via a spacer is what many would recommend. What happens next is the more uncertain
element. The main aims of the game are
to make Adam feel better and to make sure he is clinically safe. How we assess all of that comes back to the
original question.
How do we assess response and improvement (in viral induced
wheeze) following beta-agonist treatment?
There are actually several ways of doing this. There is no absolute consensus on what
measures should be used and, as usual, in that situation, there is a broad
spectrum of practices involved in what gets assessed and what gets particular
weight put on it.
Let’s look at each option and think about the pros and cons
of each.
The noise
Wheeze is a musical sound like any other. The bronchial tree happens to be the musical
instrument. Anyone who has ever tried to
play a brass or wind musical instrument will tell you that it’s not how hard
you blow that matters the most. Wheeze
is subject to the same musical rules.
The amount of air being moved, the constriction of the airways and the
pattern of breathing will all have an effect on the loudness of the
wheeze. Wheeze can be absent in children
with bronchospasm. It can be louder as
the child improves. Wheeze can persist
even when all other signs and symptoms are resolved.
Wheeze is a hugely valuable clinical finding. It tells you that you are dealing with a
wheezy illness. That limits the
possibilities and it is important to have definite wheeze at some point when
diagnosing an illness (e.g. asthma) that has wheeze as a primary symptom. The significance of what happens to the
wheeze once treatment has begun is less certain.
Auscultation can be misleading in other ways. Focal crackles are very common in viral induced wheeze. This can create anxieties about the presence of secondary infecton. The good news is that wheeze is a strong negative predictor of bacterial LRTI. (3) If the child looks really well, a few crepitations in one zone is a poor indicator of pneumonia.
Auscultation can be misleading in other ways. Focal crackles are very common in viral induced wheeze. This can create anxieties about the presence of secondary infecton. The good news is that wheeze is a strong negative predictor of bacterial LRTI. (3) If the child looks really well, a few crepitations in one zone is a poor indicator of pneumonia.
What is certainly true is that auscultation is essential if
there is any sign of deterioration (worsening recession or child becomes more
tired) as this could indicate a number of things. Even then, the wheeze will probably not tell
you what you need to know i.e. has something else happened such as a
pneumothorax or a collapsed lung.
Another issue with using auscultation findings is that this
only happens when a clinician is present.
When the child is at home, this is not part of the assessment. It could be argued that the implication that
auscultation is important undermines the confidence of a parent or carer who is
required to make ongoing decisions about whether the child can continue to be
treated at home or needs to return for further medical assessment.
The visible signs of abnormal breathing
The visible effort of breathing is a more logical measure of
the severity of bronchospasm. Look at
respiratory rate, recession, tracheal tug and use of accessory muscles. The severity of these signs, regardless of
the degree of wheeze, are more likely to indicate what treatment is needed.
There are three important caveats to this. Firstly, if a child is becoming tired, these
signs might become less apparent.
Improvement should be accompanied by an increase in activity if it is to
be truly considered a sign of resolution of bronchospasm. Secondly, the child with neurological or
muscular abnormality will have less visible signs. These children should be treated in the
knowledge that what we see may not reflect how bad the problem really is. Thirdly, the adolescent is more likely to be
having a more severe episode with minimal visible signs.
The overall appearance and behaviour of the child
The appearance and behaviour of a child are measures of
efficacy of breathing. Essentially, they
tell us about what the problem means for the all-important end organs. If a child has wheeze but is running around,
the end organs are telling you something.
If the child is subdued and inactive, this is important clinical
information.
What next for Adam?
After being given salbutamol, Adam is running around and playing. He has no recession and no use of accessory muscles to breathe. He chatters away with no signs that he is short of breath. Do you need to listen to his chest to decide what to do with him next?
The bottom line is that whether or not you auscultate the
chest when reassessing a child with viral induced wheeze, you probably shouldn’t
put too much emphasis on what you hear if there are visible signs of
improvement. As is so often the case in
paediatrics, the take home message is simple: look at the child.
Edward Snelson
Mill Town Keeny
Mill Town Keeny
@sailordoctor
Disclaimer: If a wheeze falls in the forest and never causes other signs or symptoms, was it ever there?
References
- Snelson E., A simple model for understanding the causes of paediatric wheeze, Paediatrics and Child Health, Volume 29, Issue 8, 365 - 368
- Foster S et al, Oral prednisolone in preschool children with virus-associated wheeze: a prospective, randomised, double-blind, placebo-controlled trial, The Lancet Respiratory, Vol 6, Issue 2, P97-106, Feb 01, 2018
- Shah SN, Bachur RG, Simel DL, Neuman MI. Does This Child Have Pneumonia? The Rational Clinical Examination Systematic Review. JAMA. 2017;318(5):462–471. doi:10.1001/jama.2017.9039