ManagementofPreschoolWheezeAsheretalLancet2006;368(9537):733-43.

ProblemsrelatedtowheezingdisordersinpreschoolchildrenWhendowecallitasthma?Whataretheprecipitatesofattacks?Whatistherelationshipwithatopicasthmalateroninlife?Whatcanbeusedtopreventattacks?Anydrugstoalterthenaturalhistory?Preschoolwheeze:Whatdiseaseisit?PreschoolwheezingisaverycommonsymptomUpto50%ofCaucasianchildrenhavehadatleastonewheezingepidsodebyage6yrsPrevalenceisabitlowerforAsianchildrenWheezeisjustasymptomsRecurrentrespiratorytractinfectionsCongenitalproblems:CongenitalheartdiseaseCysticfibrosisPrimaryciliarydyskinesiaTracheomalaciaImmunedeficiencyTBForeignbodyaspirationBPDVascularringERSTaskForceAvoidtheterm“asthma”Episodicwheezeormulti-triggerwheezeWeatherExposuretoallergensExerciseIrritantsURIActaPediatrica,2009Phenotypeschangeovertime!N=71outof13254%ofthesubjectschangedafterjustoneyr.Themany“faces”ofpediatricasthmaProblemswithwheezingphenotypesLackofagreeddiagnosticcriteriaPhenotypes:overlapsandchangesovertimeMostclinicaltrialsdonotselecttheirsubjectsbasedonclearlydefinedphenotypesWhendowecallitasthma?Frequencyofattacks?AsthmaINCO:3ormorewheezingepisodes Papadopoulosetal.Allergy2012;67:976-97.Responsetotreatment?GoodresponsetocontrollersPersonalorfamilyhistory?MakesitmorelikelytobepersistentatopicasthmaModifiedAsthmaPredictionIndexThefirstepisodeofwheezing:

Thestartofasthma?BronchiolitisEtiology:RSV,MPV,HumanRhinovirusCoronaVirus,parainfluenzaTreatment:Oxygen,fluid,andpatienceAchildwithwheezingLittleJaysonFirstepisodeofwheezing18monthsWheezewith‘URI’3timesfrom18monthsto3yrsNosymptomsbetweencoldsFamilyhistory:negativeBornterm,noeczemaIsthisasthma?Treatmentforwheezingillness?BronchodilatorsSystemicsteroidsICSLTRAPathophysiologyofbronchiolitisMeissnerHCNEJMJan7th2016ManyRCTs,meta-analysis,reviewperformed:GadomskiCochraneReview2010GlenFloresPediatrics1997Bronchodilatorsforbronchiolitis:Durationofhospitalization:

Gadomski&Bhasale.CochraneReview2010BronchodilatorsforbronchiolitisNoeffectsonoxygenationNoeffectsondurationofhospitalizationNoreductionofadmissionifusedinoutpatientsTransientandminorimprovementofclinicalsymptomsscoresWhatifthechildcomesfromhighriskfamilywithrecurrentepisodesofwheezing?Doessystemicsteroidreducetheseverityoftheacuteepisode?Doesearlyuseofsteroidhavelonglastingeffect?Whatshouldbethemostappropriatetreatment?SystemicsteroidforhospitalizedpreschoolerwithviralinducedasthmaStudydesignRCT687Subjects:10-60months(meanage26months)Viralinducedwheezeadmittedto3hospitalsinUKTreatment:5daycourseoforalprednisolonePrimaryoutcome:durationofhospitalizationResults:OralprednisoloneofnobenefitsOutpatientuseoforalsteroidforintermittentviralwheezeAIMStrialn=215,798LRTIsMISTstudyn=278,133severeLRTIsNoeffectonsymptomseverityBeigelmanetalJACI2013EpubMarchSteroidforacutewheezingForhospitalizedpatients,oralsteroidwillnotreducetheseverityorshortenthelengthofhospitalization.Foroutpatients,oralsteroidwillnotreducetheseverityofwheezingattackedassociatedwithrespiratoryinfections.Whataboutlongterm/intermittentuseofICSforrecurrentwheezing?Long-TermICSinPreschoolChildrenatHighRiskforAsthma:thePEAKstudy285highrisk(“API”)2-3yrolds

Treatmentperiod2yearsFluticasone88μgbidvsplacebo

Observationperiod1yearNostudymedicationCAREnetworkGuilbertetalNEJM2006Long-TermICSinPreschoolChildren:thePEAKstudyGuilbertetalNEJM2006Long-TermICSinPreschoolChildrenatHighRiskforAsthma:thePEAKstudyPreventionofasthmabyuseofInhaledFluticasoneinWheezyInfants:theIFWINstudy200childrenwithoneatopicparentfollowedfrombirth(MAAS)RandomizedafteroneprolongedortwoconfirmedwheezyepisodesMedianage1-2yearsFluticasone100μgbidvsplaceboFollowedto5yearsMurrayetal.Lancet2006TheIFWINstudy:OUTCOMES

PlaceboTreatment

(n=88)(n=85)Currentwheeze47%52%MDDxasthma64%61%AsthmaRxcurrent66%66%Murrayetal.Lancet2006SystemicSteroidtreatmentforwheezingdisordersSystemicsteroidforacuteepisode:LittlebenefitsifanyICSthebesttreamentforthoserecurrentwheezing(AsthmaPredictionIndexpositive)BenefitsinreducingsymptomsWouldnotaffectnaturalhistoryThedifficultiesoftreatingwheezingillnessinpre-schoolchildrenVariabletonoresponseGoodresponsetoRxGoodresponsetoRxGoodresponsetoRxAcutewheezing Mild-severe,few >3/yr >3/yr episodesSymptoms/URI Shortlasting,<7dayssymptomsoftenlast >7days >7daysIntervalsymptomsLittle/none someinterval intervalsymptoms&FamilyHxAtopy symptoms exercise FamilyhistoryThechallenges:WheezingdisordersinpreschoolchildrenDifferentsubtypes:phenotypes