Viral Induced Wheeze

Reference: 1702 Written by: Judith Gilchrist Peer reviewer: Kelechi Ugonna Approved: November 2017 Review Due: August 2020

Purpose To guide the management of viral induced wheeze in children

Intended Audience Clinicians involved in the management of viral wheeze in children.

Author: Judith Gilchrist Review date: August 2020 © SC(NHS)FT 2017. Not for use outside the Trust. Page 1 of 6 CAEC Registration Identifier: 1702 Sheffield Children’s (NHS) Foundation Trust Viral Induced Wheeze

Table of Contents 1. Introduction 2. Intended Audience 3. Guideline Content A. Acute Episodes i. Diagnosis ii. Assessment iii. Investigations iv. Management B. Recurrent Episodes i. Diagnosis ii. Definitions iii. Assessment iv. Investigations v. Management 4. References

1. Introduction

Episodes of wheezing that are induced by viral infections of the upper respiratory tract are distinct from persistent atopic asthma. These episodes are common in children under the age of six years. One in three children has at least one episode of wheeze before their third birthday. The majority of these children have few or no interval symptoms between viral illnesses and their propensity to wheeze often resolves by school age.

2. Intended Audience

Clinicians involved in the management of viral wheeze in children.

3. Guideline Content

A. Acute Episodes

i. Diagnosis The history should assess the pattern and severity of symptoms, the presence of interval symptoms, personal or family history of atopy, trigger factors particularly smoking and exclude any other diagnosis. Differential diagnoses include bronchiolitis, atypical lower respiratory tract infections, inhaled foreign body, asthma, Cystic Fibrosis, gastro-oesophageal reflux and structural airway problems.

Author: Judith Gilchrist Review date: August 2020 © SC(NHS)FT 2017. Not for use outside the Trust. Page 2 of 6 CAEC Registration Identifier: 1702 Sheffield Children’s (NHS) Foundation Trust Viral Induced Wheeze

Care should be taken to ensure the airway noise is a true wheeze ie. a continuous high-pitched sound with a musical quality on expiration. ii. Assessment The severity of the attack should be assessed including the level of activity, speech, colour, work of breathing, respiratory rate, chest movement, air entry, degree of wheeze and oxygen saturations. Ominous signs include cyanosis, agitation, reduced GCS, inability to talk, exhaustion or silent chest. The clinical markers of severity are the same as for asthma (See Guideline 342 Asthma) iii. Investigations In the majority of cases no investigations are required as this diagnosis is made by history and examination alone. A chest X-ray is only required if there is obvious and persistent asymmetry on auscultation or if the patient is unresponsive to treatment. Coarse crepitations may be due to retained secretions and do not indicate infection. Other investigations will only be needed if the symptoms are present from birth or if the history or examination points towards an alternative diagnosis. iv. Management OXYGEN: Use as per the acute asthma protocol, (See Guideline 342 Asthma)

BRONCHODILATOR: Salbutamol: Use as per the acute asthma protocol, (See Guideline 342 Asthma)

Ipatroprium Bromide: If the episode is severe or life threatening, use as per the acute asthma protocol, (See Guideline 342 Asthma)

In children below 18 months, if not responding to salbutamol, 1-2 puffs of Ipratropium Bromide (Atrovent) may be more effective. However many children in this age group don’t respond at all to bronchodilators and therefore an assessment of response should be made and bronchodilator treatment discontinued if there is no evidence of response. Under 6 months bronchodilator should not be used.

ORAL STEROIDS: Oral steroids are NOT required for mild-moderate wheezing episodes. Recent evidence has shown no benefit from this. Prednisolone at a dose of 1mg/kg (maximum 40mg) for 3 days should be commenced if the episode is severe or if the child is not improving within 8-12 hours of their admission.

Author: Judith Gilchrist Review date: August 2020 © SC(NHS)FT 2017. Not for use outside the Trust. Page 3 of 6 CAEC Registration Identifier: 1702 Sheffield Children’s (NHS) Foundation Trust Viral Induced Wheeze

INTRAVENOUS AGENTS: If the episode is severe or life threatening use treatment as per the acute asthma protocol. (See Guideline 342 Asthma)

ADMISSION: Not all children with viral induced wheeze require admission. If the child only has a mild or a moderate exacerbation and is able to tolerate 4 hourly inhalers then they can safely be discharged. The family should be advised to continue 2-4 puffs of salbutamol 4 hourly for the next 1-2 days and then to use as required. They should be made aware of how to recognise signs of deterioration and when to bring their child back to hospital. Please complete the ‘Plan for treating my wheeze leaflet’ (no 674) for children / carers available in ED / AAU if the patient is being discharged.

In admitted children, as the clinical picture improves inhaler treatment can be spaced. Most children, when clinically ready, can be spaced from 10 puffs two hourly to 6 puffs 4 hourly and then discharged ( remember to write up inhalers PRN in case they don’t tolerate the spacing). Those children who have had a more severe episode may require more cautious spacing of treatment. Before discharge ensure the parent/ carer has a written management plan ‘Plan for treating my wheeze leaflet’ (no 674) and that inhaler technique has been checked. Check understanding of current medication. Don’t forget a smoking history and cessation advice. Encourage to attend GP for review 48hrs after discharge

B. Recurrent Episodes

i. Diagnosis Pre-school children can have recurrent episodes (4 or more per year) of wheeze and these are mostly related to viral respiratory infections. However, it can be difficult to distinguish recurrent viral induced wheezing from early asthma which makes diagnosis and management of these patients difficult. There have been some controversies in the management of viral induced wheeze making it difficult to have a consensus on the best treatment. ii. Definitions To aid management decisions, these patients should, if possible, be classified into having either episodic viral wheeze or multi-trigger wheeze.

EPISODIC VIRAL WHEEZE: The wheezing occurs during discrete time periods, often in association with clinical evidence of a viral upper respiratory tract infection, with absence of wheeze between episodes.

MULTI-TRIGGER WHEEZE: This is discrete exacerbations of wheezing but there are also symptoms between episodes eg in response to allergens, emotions, activity.

Author: Judith Gilchrist Review date: August 2020 © SC(NHS)FT 2017. Not for use outside the Trust. Page 4 of 6 CAEC Registration Identifier: 1702 Sheffield Children’s (NHS) Foundation Trust Viral Induced Wheeze

iii. Assessment A full history and examination are required to exclude any other conditions causing the symptoms.

ASTHMA PREDICTIVE INDEX (API): Use of the API should be used to help predict which patients will develop asthma and which will out-grow their wheezing.

Children younger than 3 years who have had 4 or more significant wheezing episodes in the past year are much more likely to have persistent asthma after 5 years if they have either of the following:

One Major Decisive Factor Or Two Minor Decisive Factors Parents with asthma Food allergies Physician diagnosis of eczema More than 4% blood eosinophils Sensitivities to air allergens (positive Wheezing apart from colds RASTS or Skin-prick tests) iv. Investigations No specific investigations are indicated in viral induced wheeze. v. Management EPISODIC VIRAL WHEEZE: 1) Management of exacerbations using Salbutamol as required. The maximum dose before seeking medical attention is 6 puffs 4 hourly.

2) Inhaled corticosteroids appear to have minimal benefit but could be tried if there is a family history of atopy or if episodes are very frequent or severe.

MULTI-TRIGGER WHEEZE:

1) Management of exacerbations using Salbutamol as required. The maximum dose before seeking medical attention is 6 puffs 4 hourly.

2) If > 4 significant episodes per year consider a 3 month trial of inhaled corticosteroids. Some studies have shown this to reduce symptoms and exacerbations and improve lung function and airway hyper-responsiveness. However, since a Cochrane review concluded that there is no definite evidence for this treatment, it should be stopped if no improvement is seen.

3) If there is a poor response to inhaled corticosteroids then consider a trial of Monteleukast although Cochrane also concluded that there was poor evidence of its efficacy. Consider referral to respiratory services for further assessment and

Author: Judith Gilchrist Review date: August 2020 © SC(NHS)FT 2017. Not for use outside the Trust. Page 5 of 6 CAEC Registration Identifier: 1702 Sheffield Children’s (NHS) Foundation Trust Viral Induced Wheeze

management.

4. References

Ducharme FM, Chalut D, Plotnick L, et al., The pediatric respiratory assessment measure: a valid clinical score for assessing acute asthma severity from toddlers to teenagers. The Journal of Pediatrics 2008; 152: 476-80.

Panickar J, Lakhanpaul M, Lambert PC, et al. Oral prednisolone for preschool children with acute virus-induced wheezing. New England Journal of Medicine 2009; 360:329- 338.

Brand P, Caudri D, Eber E, et al. Classification and pharmacological treatment of preschool wheezing: changes since 2008. European Respiratory Journal 2014; 43:1172-1177.

Cochrane review Brodlie et al Oct 2015