Kids can present with noisy respiration for many reasons, so pediatric pulmonologist Ruth Siew, MD, offers a useful review of breathing mechanics and testing tips to help providers distinguish between asthma and similar-sounding conditions. She explains when to suspect exercise-induced bronchoconstriction, foreign body inhalation and aspergillosis; appropriate treatment for various disorders; and when urgent evaluation is warranted.
Good afternoon, everybody. Thank you for joining us today. I am Tabitha Constantino. I am one of the physician liaisons. And thank you for joining us for our first CME or actually our 2nd CME of the year. Um, I'm just gonna go through a few housekeeping rules before we get started. You were all muted and if you have a chance to, if you have any questions throughout the top, please feel free to put them in the Q&A function. Um, all the questions will be in there and then we will have Doctor Sue answer them at the very end of our lecture. So please feel free to put them in at any time. Um, we have a pediatric musculoskeletal and sports medicine conference coming up in a few weeks, and we would love for you to join us. It's in person on site at the Hotel Shattuck in Berkeley. Um, this, you can scan the QR code right there and it'll take you to the form, um, or you can contact one of your physician liaisons and we will be more than happy to send you some information on that. Here's our schedule for the next few weeks. We have no webinar next week, but the, uh, child and adolescent psychiatric portal is doing their, uh, continuing their webinar series, and they are doing one on bipolar disorder. I think that's supposed to be disorder and psychosis. So it's next, uh, Thursday on the 12 p.m. And then we will continue with um Doctor Diab on the 14th and he's doing a talk on spinal deformity in children and on the 21st, we're going to do an abnormal head shaped in infant with Doctor Winston Ho. And on the 20th, we actually do have a webinar that's, uh, we didn't have one originally, but we're actually going to be joined by Emmanuel Wabunt from our um neurology department and she is the director of UCSF's Regional Pediatric uh muscular MS Center and she's going to do a talk on, um, MS awareness. So we hope you join us for all of those. And these are your liaisons, myself, Maria Bremmer, Amy Johnson, and Lauren Robertson. Maria Bremmer is still currently on, um, maternity leave, but you can contact any one of us and we are more than happy to help you with any questions you have. And if you miss any of our lectures, including this, um, any of our CME lectures, you can catch them all on our Med Connection site. Feel free to click that QR code or you can reach out to a liaison and we will make sure to get that information to you. Um, we have all of our webinars, including our CME lectures available on there, and you can get CME credits for any one of them that you missed. So let me introduce our speaker. Uh, we are so thankful to be joined by Doctor Ruth Sue. She is a pediatric pulmonologist, and she joined us, uh, not too long ago. She cares for children with a variety of lung and breathing concerns including asthma, reoccurrent, uh, respiratory infections, chronic lung disease, congenital lung abnormalities, and conditions that make them dependent on technology for breathing. She collaborates with our aerodigestive clinic, and which is a multi Multi-specialty clinic with pulmonology, ENT and GI as well as speech and nutrition providers. And today she's going to be talking to us about not all that wheezes is asthma. So I'm gonna stop sharing my screen and let Doctor Suu go ahead and share her screen. Thank you again for, oh, and one more thing, because this is a CME please do not forget to fill out your CM um Evaluation forms, they will pop up at the very end of your, of the talk and if you don't receive them, please read out, please reach out to us and we will make sure to get that out to you so you can get credit. OK, Doctor C, are you ready? Yeah. Thank you for the introduction, Tabitha. Thank you for um inviting me to speak. Good afternoon, everybody. Um, Uh, I'm excited to talk to you today about this, um, discussion about not all that wheezes is asthma. And I really wanted to talk about this because I think that there's been a couple of, um, diagnoses that have come up, especially since the pandemic that I think are really interesting and have been a lot more prevalent. Um, and I think that this is just a really interesting topic because while asthma is kind of uh Our bread and butter, a lot of our pediatricians' bread and butter. Um, there's just some things that I think that, um, are important to talk about and it's just some interesting diagnosis that we can review, um, That You know, presents as asthma, but it's not always. Um I have no relevant financial relationships. I do not intend to discuss anything related to um my uh role as a consultant. So let's go on. So today, the learning objectives will be um I'd like to, uh, you to be able to explain the mechanics of breathing that contribute to noisy breathing. So as pulmonologists, it's something that we always think about. Um, we want to be able to list some causes of wheezing that are not asthma, as well as describe some of the diagnostic and treatment modalities for wheezing. So the outline for today is very simple. As I just said, we'll talk about some of the mechanics of breathing. And then I have 3 case presentations that I wanted to go over that really highlight um some of the diagnoses that I'd like to discuss. So that's the first one, thing that I wanna talk about is what is that sound and where is it coming from? I think when, um, a parent comes in and they say, my child is wheezing, the first thing that I always wanna make sure is that, is, are they actually talking about wheezing? Um, because a lot of times, you know, they'll say, my child is wheezing, um, or my child has noisy breathing, and it, it's, first of all, not, not even wheezing. So, like, you really need to distinguish, um, If it is wheezing, um, or if it isn't. Cause that's really gonna change, uh, what you think. is the diagnosis. Um, and so, you know, if They say, oh, my child is wheezing, and then they start pointing to their nose and they say, oh, they always sound congested, um, or they, they always have a lot of, like a runny nose, then, you know, that's probably not wheezing. Sometimes it can be, they'll say, oh, you know, I'm wheezing, but they'll point to their throat and say, oh, it feels like something's stuck here. Um, you know, it feels weird in my throat area. And then, um, of course, so that would be more upper airway, and then you have your lower airway issues where, um, you have, um, your This is, you know, asthma, mucus, infection, maybe things like mass or cysts, so, um, The first part is really important, is just distinguishing what is going on and where is it. The second part is thinking about the mechanics of breathing. So, I'll go through this quickly, uh, but not too quickly. When you think about um the mechanics of breathing, there's 4 parts. So first part, inspiration is active. So on inspiration, your diaphragm contracts. And it flattens and you use your external intercostal muscles. Um, and all of this helps to increase the volume of your thoracic cavity, so air is drawn in. Um You, sometimes if you're breathing extra hard, you can use your accessory muscles, your salines, your uh sternocleidomastoids. Um In the case of Strider, um, During inspiration. Uh, when you breathe, take a breath in. The intratracheal pressure goes below atmospheric pressure, um, air follows this gradient and air rushes into the lungs. In stridor, where you have extrathoracic obstruction, then this causes that stridorous noise. And expiration, when you take an, when you breathe out, this is passive. Your diaphragm relaxes, returns to its dome shape. Um, sometimes if you have forced exhalation, this is active, so you use your abdominal wall muscles and your obliques to increase that intra-abdominal pressure to push forced air out. And in the case of wheezing, um, this is intrathoracic obstruction. And so as you force the air out, the intrapleural pressure is higher. Then your intratracheal pressure, air follows this gradient. Pushes out and that flow limitation is really intrathoracic and that causes that um that noisy breathing of that wheezing. Um, similarly, kind of with forced expiration, uh, cough, cough is very active. You have to, it's in three steps, you have to coordinate your inspiration, close your glottis, and then force whatever you want to come out. To come out. Um, so this requires, um, you know, coordination of muscle and nerves, um, in order to really be able to have a good strong cough. Um, so by combining the location of the sound and the mechanics of breathing can really determine the cause of breathing, and that's your first step. The other two parts of mechanics of breathing is just to think about the ability to protect the airway. So the patient has to have um appropriate and intact swallowing function. You know, being able to swallow really is dependent on intact anatomy and also um well-organized sensory and motor function. So that's really important. Um, I have a picture here of a child who's bottle propping and that if they're half asleep, will not be able to protect the airway and could be a cause of um chronic wheeze. The other thing to think about is just making sure that they have appropriate neuromuscular tone and function. If this is a child who has a genetic syndrome, they may not be able to protect their airway as well. OK. So, let's go ahead and get started with our first presentation. Here, we have a 16-year-old who presents with noisy breathing during exercise. This is noisy breathing, um, and she describes it as wheezing, strider, she's 16, so she doesn't really have the best history. Um, She says the Noisy breathing is associated with shortness of breath. And she says she has trouble getting air in. She points to her throat. She says, you know, it's just hard for me to get air in. She says it's in her throat and then sometimes in her chest. So, the question is, is this asthma? How do we distinguish these symptoms from exercise symptoms, from something else? Is this asthma? Is this asthma plus? What are we looking at? So I wanted to use this case to really highlight um something that we've been seeing a lot before since the pandemic, um, and it, it's become not only more prevalent but um we've been seeing it in a more wider variety of presentations. So I wanted to talk about inducible laryngeal obstruction, ILO. This is formally referred to as vocal cord dysfunction or BCD, um, so usually this has been a teenage onset. Uh, usually a female predominant, um, Average age has been around 15 or 16 years old. Your typical patient is this high achieving, they get their super high GPAs, they're competitive varsity athlete, um. One of the things that really distinguishes this um ILO is that the stridor and noisy breathing. Occurs during these ILO ILO episodes. So, um, you know, it's Do you have noisy breathing when this is happening, when you're feeling that pain? Um, and another thing that distinguishes this is this occurs early on in exercise, in the first few minutes. Um, as I mentioned, Since the pandemic. This presentation of ILO is not always what you see above. Um, sometimes we see earlier age of onset. Um, sometimes we see it combined with or as a differential to anxiety or mood disorders. So, I think we're, we're starting to see um some more papers come out about this and the um impact the pandemic has had on ILO. So, ILO how is this diagnosed? Um, first thing is just a trial of albuterol. Does it help? Is this exercise-induced bronchospasm? Um Or is it Tylenol. A lot of times, your patient comes in with this history and you can just have them try, trial a course of albuterol and they will tell you yes or no. And it's usually pretty clear. Um, they'll say absolutely or like, no way. And they're, and the teenagers are pretty good about this. Another thing to look at is spirometry. This is helpful. Um, it gives us a sense of is there airway obstruction, such as asthma, um, The, the only thing in terms of using it to diagnose ILL though is that it's not always the best. Um, it actually has low sensitivity and um repeatability. Spirometry is really dependent on effort. And so the patient has to be able to do good expiration, um, and good inhalation in order to have a good breath. Um, a lot of times these are these like teenagers, especially these teenage girls, and they're not always able to have a good effort. And so if you have suboptimal effort or if you have poor instruction from the person that's administering the test and they aren't able to do a good um breath out and in, then you might not have good results. And so spirometry will not always show it. It can be normal. Another thing that we can do, which I have a picture of here is exercise spirometry, which we'll, I'll talk a little bit about later. But essentially, um, doing spirometry as they're exercising. And then, uh, diaphragmatic breathing, nasal breathing, and panting. Um, Other techniques that are used are biofeedback, um, hypnosis has also, um, been used with, uh, Moderate evidence. Um, and then it's also really important to treat the comorbidities, so Asthma can be a comorbidity in an In studies that show it's either, you know, 6 to 25% of cases. Um, so it's really important to treat the asthma as well. These are some of the alternative diagnoses um that can occur with ILO and I wanted you just to take some time to look at exercise-induced bronchial constriction with or without asthma. So oftentimes, ILO is easily confused um with exercise-induced bronchi constriction and they look very similar, so I wanna just take a little bit of time to talk about it. There is a high prevalence of EIB exercise-induced bronchoconstriction in swimmers, so in that, in the chlorine water, um, in skiers with uh Um, the cold air from, um, the snow, ice rink athlete, um, because of the fossil fuel from the ice resurfacing machine. Um, and then also in runners because they're often running outdoors in high allergen and ozone areas. Um, testing is done, um, on an exercise PFT challenge. And so what this, um, looks like is kind of a setup like this where we'll do pre-exercise spirometry. And then, um, we'll have the patient do a rapid increase in exercise intensity over a couple of minutes, 2 to 4 minutes, where they achieve a high level of ventilation. They'll use some nose clips to help with that. So they raised their heart rate to 80 to 90% of maximum. And then they'll continue the exercise for another about 5 minutes. And then we'll have them stop and do post um spirometry at 5, 1015, and 30 minutes. Um, and then usually recovery is spontaneous and occurs, um. Within 30 minutes to 90 minutes. The diagnosis of EIB is confirmed if the FEV1 is decreased by at least 10%. So how do we treat exercise-induced bronchial constriction? Um, these are some of, uh, environmental options. So you can do a pre-exercise warm-up, so at least 30 minutes before, so you can elicit this refractory period, um, that can last up to 2 hours. So this is having the patient do a warm-up, 10 to 15 minutes, about 50 to 60% of their maximal heart rate. And they've looked at what type of exercise is best um at helping elicit this the refractory period, and they, and they, the studies have shown that it's this variable um high-intensity exercise, so, um, high-intensity rest, high-intensity rest, um, for 10 to 15 minutes. Um, as we talked about, sometimes cold and dry environments can promote bronchial constriction and so using a face mask, um, during exercise or in the warm-up period can help promote humidification. Um, to prevent that bronchial constriction. And if this patient has known allergies, Um, if there's a way to minimize exposure to air pollution and environmental allergens, that would be helpful. What about some medication um options? So as we know, short-acting beta agonist albuterol, this is going to be helpful. You give 2 to 4 puffs with a spacer at least 15 minutes before exercise and this should last you 2 to 4 hours. The only thing is that regular use can induce tolerance, um, where the, um, Where you uh have tolerance to your uh beta agonist receptors. So this is the athlete who, you know, maybe is, has practiced every single day, and they have PE and they need this every single day. So you wanna think about some other options. Something else to think about could be looking at montelukast, where you give it at least 2 hours before exercise. Montelukast has not been shown to induce tolerance. Um, it has a longer effect so it can last up to 24 hours. So you give it once a day and it can last them through all of their physical activity for the day. The only thing is that has not been studied head to head with albuterol. Um, and the other thing to be um careful about is the black box warning with montelukast where, um, patients can have psychiatric side effects. mood changes including suicide. So if they have a, at a baseline have known psychiatric side effects, I would be more cautious with starting this. Um and I've always counsel patients about this. Um, if they do end up starting it and having, um, mood changes, you stop the medicine and the side effects go away almost immediately. Another uh good option is using a daily inhaled corticosteroid. And so, um, this is uh a nice option, um, in, as an alternative to montelukast, um, similar to what you would use for asthma. Second-line options would be ipratropium, um, which does not have good evidence, um, and chromolyn, which is not as easily accessible in the US. So, I think it's very confusing and I wanted to just go through um the differences between EIV exercise-induced bronchos constriction, and exercise-induced laryngeal obstruction, EILO. So on this side, we have EIV. This is really a lower airway issue. So this is going to be expiratory symptoms such as that wheeze. The symptoms really peak after exercise, so, um, You know, around 3 to 15 minutes after the patient is done exercising. They might have symptoms during, but it's really after that, um, the symptoms occur. Chris is EILO really this. Um, upper airway issue, so symptoms are more inspiratory, that inspiratory stridor, that noisy breathing that you hear. And the peak of the symptoms are really at peak exercise. So it's during activity, um, and then it stops pretty soon after exercise. So hopefully, this, um, will help kind of help you distinguish. Between one and the other. I wanted to look at a couple of the other differential diagnoses. Um, so in addition to EIB, um, sometimes it's just decreased fitness, deconditioning. This is, we are seeing a lot of this early on, um, when people are coming back from the pandemic, um, post-COVID, um, this is very common. Also, on the, on the other end of the spectrum, you have overtraining syndrome, um, where you have these athletes who are strong go-getters. They, um, you know, are pushing themselves just kind of over, um, over pushing themselves. Um, other alternative diagnoses would be psychological or respiratory disease, which we'll talk about, cardiopulmonary disease, um, arrhythmias, hypertrophic cardiomyopathy, you know, more rare ones, pulmonary hypertension, uh, thrombolic disease. With cardiopulmonary disease and kind of differentiating between these, you wanna ask about exertional syncope and a family history of sudden death. Um, uh, example of other diseases includes reflux that can also cause wheezing, and then rarely exercise-induced anaphylaxis. So we've gone through our first um case presentation looking at ILO EIB and I wanted to go through two additional um presentations. So this one is a 21 month old with recurrent wheezing. Um, the parents say the symptoms started about 6 months ago. On exam, you hear right-sided wheezing and crackles. Um You know, you, she's in the office and you trial um albuterol treatments and you give them an albuterol inhaler for home. Uh, you even try since you hear um Abnormal breath sounds, you tried the amoxicillin for pneumonia, and the treatment seemed to help, but then the cough comes back. This patient goes to daycare and has an older sibling in preschool. So, is this asthma? Um, there are definitely Um, characteristics of this case that make it seem like she has asthma, she has recurrent wheezing, um, albuterol helps. Um, and also, she seems, she goes to daycare and has an older priest, older sibling, and so she is going to constantly be exposed to different, um, viral pathogens. And so, common things being common, yes, this is possibly asthma. But there are a couple of things that are seen off, so Um, this is kind of, this has been going on for a long time. While the treatments help, the cough seems to come back. Um, I wanted to go through a couple of other things that might make it seem weird. So, of course, we always take a great history and we're really um careful in thinking about timing, so when this first start, how long has it been going on for? I think a really important thing to think about is, is this episodic or continuous, and has this been worsening? So when the patient is well, do they still have symptoms of cough? If that is the case, that makes you a little bit more concerned about a systemic issue or um kind of a chronic issue that's not related to um recurrent viral infection. If the patient is worsening. Um, or if they have any of these, um, Uh, severity concerns, retraction cyanosis. They're not growing well, they're not gaining weight, they're always tired, fatigued, they're lethargic and they don't wanna play. Those are things that make you concerned and make you want to think that this is not just asthma. Oh, sorry. Um, additional associated symptoms, you wanna ask, is the cough and wheeze related to wheezing, to feeding, um, to activity, is there reflux? Are there Are there always fevers associated with this, continuous or episodically? Um, is there lymphadenopathy, different things like that. And then in their medical history, you know, has there been a history of intubation that's gonna increase your suspicion for things like symbotic stenosis? Are there any neurologic conditions or genetic syndromes? Was there prematurity? So again, um, we wanna locate the wheeze. Is this more Um, inspiratory, biphasic, or expiratory, and that's gonna give you clues as to where the level of obstruction is and then give you clues as to, is it, uh, the diagnosis, where it is, what it is. So here you have um some inspiratory upper airway um causes of wheezing, noisy breathing, laryngo laryngomalacia, uh, vascular malformation. If it's right at the subglottic area, you think about glottic webs, um, subglottic stenosis, uh, laryngeal clefts, and then if it's expiratory wheezing, you really think about thoracic, extrathoracic. tracheal, um, Uh, tracheal etiologies and below, so including the lungs. Um, and this will be things that are lower hemangioma cyst foreign bodies. Tracheal malacia. That sort of thing. And then I wanted to look at a couple of other non-pulmonary differential diagnosis. So, um, infectious etiologies, is this acute or chronic? Um, could this just be acute tracheitis? Is this a retropharyngeal abscess? You know, you would know if this is acute epiglottitis or croup, um, And then, has there been any concern for trauma or mechanical burn, inhalation, caustic ingestion, I form body hair again, or other tracheal injuries? And then rarely, you would know if this is an acute issue, anaphylaxis or angioedema. So what's next? You have this patient who has a chronic um wheeze, they have abnormal breath sounds. Um, you've tried a few treatments and they don't seem to work, um, or they work and then they, and then the symptoms come back. Um, so far, she's had no, um, testing or imaging. So the first thing to do would just be to get an X-ray. I always like to get a baseline X-ray. Either when they are sick, and then if that sick one is abnormal, to, to get a, uh, one when they are not sick, um, or when they're in their healthiest state, um, to make sure that there isn't anything that we're missing. So it's really a screening X-ray. And so for this patient, you immediately notice there is this left-sided unilateral hyperinflation, much there's, and there's this asymmetry. As hyperinflation is causing this right word mediastinal shift. With this resulting volume loss on the right. And See this What is your next step is an urgent ENT consult. When you see something like this, you think about foreign body aspiration, you consult ENT, um, Uh This is an interesting case because I'm pulmonary, but we always talk to ENT because they are the ones that have the tools to take foreign bodies out. And we, as pulmonologists are not able to usually look. We're only able to look and not able to extract. So we um call ENT. ENT is able to take them into the OR and on a rigid bronchoscopy, uh, bronchoscopy, they see a sunflower seed and they take it out from the left main sun bronchus. So how do you know where the obstruction is based on that X-ray? Um, so this is looking at the ball valve effect where if the obstruction is, say, on this side, in this case, in this diagram, it is on the right side, on the left side, I'm sorry, well, We'll say it's on the left side, um, even though we think about patients that are on an X-ray, this would be on the right side. Anyways. Um, so on this side, on the left, if, if the, um, foreign body is here, On inspiration, air is able to enter into the lungs. And so, um, both, and then it's able to enter equally on both sides. But on expiration, as we just talked about, when, um, the, uh, abdominal muscles contract and, um, air is forced out, this is the site of the flow limitation and so air is not able to, um, exit. And so this gets bigger and bigger and bigger causing the hyperinflation. And so the side of the obstruction, um, is where the hyperinflation is. So foreign body aspiration um can present acutely or chronic symptoms. Common findings are cough, dizziness. And wheeze or even decreased breath sounds on that side. It's very common in kids under 3 years old. Um, there can be no clinical findings. Um, in one study, they, at least 16% of children had no clinical findings and 6% were completely asymptomatic. Um, And it's not always reliable even if there was no reported or witnessed event. So oftentimes these kids, um, you know, sometimes they're the youngest one and, and, um, there's all these other kids running around, um, and so they, they might not have witnessed, um, the kid putting something in their, in their mouth. Um. This is the age where they're always putting things in their mouth, so it's very common. Again, a chest X-ray can be normal in 20% of cases, and they found that nuts and seeds are the most common. Um, when you look at the X-ray, a lot of times we think about the right main stem with its, um, angle, um, it, and the anatomy of the right main stem being more, kind of more of a straight shot. That's usually the area that we think about that is more common for aspiration, but they're actually equally distributed between the left and the right. Um, Around 30 to 40% are on either side. So it's really important to have a high index of suspicion for foreign body aspiration in these kids with chronic aspiration. OK. So, um, here, we've talked about two of the different presentations and then I wanted to um go over one more, uh, case presentation of a more rare, uh, disease. So this is a 10 year old with persistent asthma and recurrent episodes of wheezing. Um, this patient takes Symbicort, the higher dose, 160, 2 puffs twice daily with a spacer, they say that they use a spacer every time and they're pretty good about taking it twice a day. Um, but for some reason, they still have these frequent urgent care, ER visits, and, um, PCP visits for wheezing. Happens at baseline, at home, when he goes outdoors, and with exercise. It's still happening a lot. When you do the exam You find this frequent dry cough, nasal congestion, and allergic shiners. There is also diffuse wheezing. So of course, the question is, is this asthma? There are He has known asthma. So is this just uncontrolled asthma? Is he taking his spacer? Is he taking his medication? If he is, as he says, why are all these visits still happening? Why does he still have these significant symptoms? He also complains of having a cough, intermittent dyspnea, and fatigue, and lately he's had a low appetite. So as we noticed, he had, he had allergies. He takes Singulair Day, daily, and Zyrtec. Um, he's never been tested for allergies before and so you send him for allergy testing and it comes back positive to grass, dust mites, and Aspergillus fumigatus. So what is in your differential? So I wanted to use this case to highlight just a few of, um, a few other rare diseases, um, especially in a 10 year old. So severe asthma, definitely high on the differential, severe uncontrolled, suboptimally controlled asthma is definitely still high on the differential. We wanna make sure that that is not the case. We have certainly ruled out or we have certainly diagnosed patients with cystic fibrosis at age 10 or beyond. Um, these are the patients that have, uh, Less disease-causing mutations, not your common delta 508, um, or they just have a more rare mutation, so they potentially have gotten missed, um, on newborn screening. Um, But certainly they'll have In their medical history have, you know, a lot more um issues. They might have sinus issues. Again, if you think about cystic fibrosis, you always wanna think about primary ciliary dyskinesia, which is even more rare. Um, and then tuberculosis, has there been exposures? Um, how long has this cough been going on for? You get a chest X-ray, you can get a um quantiferon. Um, in our history, when we take, uh, when we see an initial patient, we always ask about pets in the family. Um, you always wanna make sure that You know, you're not missing some random bird that they have and they have some hypersensitive pneumonitis, also very rare, um, but important. Then even more rare things, eosinophilic granulomatosis with polyangiitis, EGPA or formerly known as Turk-Strauss, or they have asthma, eosinophilia, and vasculitis. Um Another thing to think about that is also rare is chronic eosinophilic. Pneumonia, um, where this is, where they have, this is very confusing. It could present with dyspnea, systemic symptoms, um, Your typical asthma symptoms as well as elevated ESR CRP, um, elevated IgE. One thing that distinguishes it is, um, these peripheral round opacities and changes on, uh, CT scan. So I wanted to um just take a minute to talk about Aspergillus pneumatus, as you remember, he was positive on his skin prick testing for this um Mold and oftentimes we hear there's mold in my home and um it's very concerning. A lot of patients and their families and parents are very concerned about this. So aspergillus is a fungus. It's found in the environment and soil, plant matter, vegetation, household dust, even in uh marijuana. Healthy individuals can clear these fungal spores, they're everywhere in the environment. And usually healthy individuals are able to clear this. Immunocompromised patients or atopic patients that are exposed to these fungal spores, they are unable to clear them, and so they form a hypersensitivity reaction that leads to Ig production, mast cell degranulation, and eosinophilia. For acute patients or healthy individuals, this can cause an acute aspergillosis infection. But again, in the immunocompromised patients or atopic patients, it can, it can lead to an allergic response leading to allergic bronchopulmonary aspergillosis or ABPA. So ABPA presents in patients with asthma or cystic fibrosis. The diagnosis is based on a constellation of findings, so a positive aspergillus skin prick test or intradermal skin test. Usually the serum total IgE is very elevated and so it's over 1000, um, it's very typical and common. Um, other lab tests that can be positive would be elevated serum IgE to the Aspergillus pseumagattis, elevated IgG to Aspergillus pseumagattis. You can also have peripheral blood eosinophilia, abnormal chest X-ray with patchy infiltrates. And long term, they can have um a long parenchymal injury with bronchiectasis, tree and bud findings for central lobular nodules. So the treatment of ABPA is to control their symptoms. Prevent further exacerbation and to minimize lung injury. So unfortunately, treatment is a very long course. Um, it involves oral corticosteroids for weeks followed by taper and sometimes patients are on um a very low maintenance dosing. They can be on itraconazole to, um, Actually treat the the aspergillosis. Um, and then also good airway clearance if they've had this long term and they have um evidence of bronchiectasis, you wanna make sure that they're able to um clear out the mucus that is present, um, in their lungs. OK. So, today we've talked about 3 different uh Uh, cases that highlight three different, um, diagnoses that I think are interesting, um, and can mimic asthma and can present with wheeze. These are some of the signs and symptoms that require urgent attention. We kinda touched about some of these, but if the patient is, has apnea and, or has wheeze and apnea, persistent tachypnea, cyanosis, failure to thrive, aspiration, or chlor pulmonality, these are all Um, reasons to either, uh, request an urgent referral, send them to the ER, um, Depending on how severe the symptoms are. So a couple of takeaway points um is to recognize when wheezing or noisy breathing is abnormal. So while asthma is very, very common in our practices, um, Pointing out and finding those little things that make the presentation seem. Abnormal and make you scratch your head. Um, That is when you need to have a high um index of suspicion for certain things such as um ILO foreign body aspiration. If you have persistent symptoms, um, it's always a good idea to get a screening chest X-ray, even if you've got, even if you had one when symptoms first started 6 months ago, it's good to get another one just to see where things are at. Um, we talked about ABPA and this can present as uncontrolled asthma, while this is rare. And when in doubt, it's always good to refer early on to pediatric pulmonology. I thought this is interesting because this is your patient at home and then when they come to see the doctor, they're fine, and then they go home in there. Bad again. And With that Um This is how you can refer our patients and uh if you have questions, I'm happy to read them now and also here's my email. So I'm gonna go ahead and um Start with our Q&A. Yeah, so if anybody else has, um, there are already some questions in the Q&A function, but if you have any, please feel free to put them in right now, and Doctor Sue is gonna go over them right now. Perfect. OK. So we have a couple of ones. So I'll start with the first one. Do daily inhaled corticosteroids taken daily for many years decrease max adult height? How do you counsel patients and families of So that's a great question. I always talk about this because parents always wanna know, you know, uh, my child, my 16 month old is on an inhaled steroid, you, you know, what are the side effects? And so, um, The studies have shown that it's um higher doses, so if they're just on Flovent 44. That hasn't been studied and, and that has, that's not the case. So it's the higher doses for longer periods of time um that can decrease your max adult height by um 2 centimeters or 1 inch. Um, and so, Most of the time parents are fine with this, and they, you know, It's not a big deal because it's not a for sure either. This is just a risk. Um, sometimes we have patients who, you know, they're on a high dose and you can always track their height velocity and if for whatever reason you, you start to see more systemic symptoms, um, That maybe have mood changes with the higher dose of inhaled corticosteroids. You can track the height loss, you see that maybe it's starting to slow. You can, I would just switch them and they can go on um uh an ICF lava instead or, or something else. Um, but usually, patients are OK and if they're not, then, then we just pick something else. I hope that answers your question. Um OK. Next question. So for our teens with exercise-induced asthma or EIB, if they are exercising daily, do they need an additional med like ICS or Singulair? How many times a week can a patient use albuterol before developing tachyphylaxis? Does this mean that every kid with EIB will need more than just albuterol if they are exercising daily? That's a great question that does come up a lot because as we talked about, um, These patients that have EIB, a lot of them are exercising daily. They have practice every day. So I am cautious about having our patients take albuterol on a daily basis. Um, when they, when they do get to that, the recommendations are to start, um, usually it's to start the inhaled corticosteroids, so just start, um, like your Flovent, um, And that's usually the first line recommendation. Um, so, let me just make sure I answered exactly. So, um, I, so yes, so if they are exercising daily, I would start an ICS. Um, I usually, usually, if it's daily, then I would recommend starting it. If it's You know, 3 times a week, then they can keep using their albuterol. Um, and then just kind of seeing in between if it's like 4 times a week, and you can, you can kind of figure, um, talk to the patient to see um how they feel. But, um, Does that mean that every kid with EIV will need more than just albuterol? So yes, I think that, that is smart because I am worried that um about down regulation of their um beta agonist receptors. Um And that they can develop tolerance to uh daily albuterol. OK. So, can you repeat what kind of X-rays to order for patients with sus suspected foreign body? Yeah, so I um showed a photo of just um Uh, AP, so usually, for all of my patients that, that get any sort of X-ray, if they can, I'll do a two view, so AP and lateral. Um, for these younger patients, if you can do, um, Um, a cross table, uh, where they're laying on their side, um, that's helpful too, um, cause sometimes patients, you know, when they're small, they're not able to control their inspiration and their expiration, they're not able to hold that. And so if, um, So in these younger kids, if you put them on their side, uh, the affected side is going to stay hyperinflated, um, if they're, you know, laying on their side. The gravity, they should be able to pull down and that side should be smaller, but if that um side is affected with a foreign body, it will stay hyperinflated. So you can do um cross tables on uh both sides. OK. So this is our current last question for exercise-induced asthma, what is the dose of inhaled steroid and what dose? Um, so I would use, start the patient on whatever dose, um, would be appropriate for their age and their weight. So, um, usually in a kid, probably just the 44. If they're bigger, then I would do the um 160. There isn't as much. Data and the recommendations are not as strong for starting um Uh, combined IS lava at this point, um. So right now, um, we recommend just the inhaled corticosteroid. OK. Thank you, Doctor Sue. Um, if anybody else has any questions, I'll give you one last chance. And if not, um, I'm gonna say thank you. And, uh, please do not forget to fill out your evaluations. That way you can receive credit for attending. And if you don't get that pop-up with the evaluation, please let your physician liaison know. We will make sure to send that out to you. And, um, that's Doctor Sue's email. You can contact her there and she sees patients both in Mission Bay and in Oakland. So we hope that you join us at our next lecture and thank you again, Doctor Su so much for giving this great talk and everybody else have a great afternoon. Thank you. Thank you.
