Recurrent wheeze in preschool children — structured clinical encounter

Station brief (candidate)

You are the paediatric registrar in the general clinic. A 3-year-old girl has been referred after her fifth episode of cough and wheeze this year, each starting with a cold and settling in a few days, with the child completely well between episodes. She has mild eczema, is growing normally, and her mother smokes. The team asks you to establish the phenotype, apply the Asthma Predictive Index, exclude the important mimics, decide on preventive treatment, and counsel the family. You have 12 minutes with the family and 5 minutes for examiner discussion. [2] [3]

Information available on request

• 3-year-old; five episodes of cough and audible wheeze in the past year, each with coryza, settling over a few days; completely well between episodes; no interval cough or exertional symptoms. [2]
• Mild eczema; no known food allergy; mother has hay fever, no parental asthma; mother smokes ten cigarettes a day, sometimes indoors. [3]
• Growth on the 50th centile and tracking; no failure to thrive; no chronic wet cough, no clubbing, no choking history, no neonatal respiratory problems. [2]
• Examination between episodes (on request): well child, normal chest, mild flexural eczema, no added sounds, no clubbing or chest-wall deformity. [2]
• Previous acute episode (on request): responded well to salbutamol via spacer at home; never admitted; never needed oxygen. [8]
• Full blood count (on request, not routinely needed): eosinophils 3%. [3]

Tasks

1. State the wheeze phenotype and the features that define it. [2]
2. Apply the Asthma Predictive Index and state whether she is positive. [3]
3. Exclude the important mimics and state what, if anything, you would investigate. [2]
4. Decide on preventive management and justify it with the trial evidence. [4]
5. Counsel the family on natural history and on the highest-value intervention. [1]

Marking anchors

Must-hit

• Classifies episodic (viral) wheeze: discrete attacks only with viral illnesses, completely well between, no interval or exertional symptoms — and notes the ERS phenotypes overlap and can switch over time. [2]
• Applies the stringent Asthma Predictive Index: she has frequent wheeze (≥4 episodes/year) and one major criterion (doctor-diagnosed eczema), so she meets the major-criterion arm and is API-positive, though her non-atopic pattern (no parental asthma, eosinophils 3%, no wheeze apart from colds) is otherwise reassuring; recognises the index has high specificity and modest sensitivity. [3]
• Excludes the mimics: confirms the noise is true wheeze, and finds no red flags (no birth-onset or fixed noise, no choking, no chronic wet cough, no failure to thrive, no clubbing), so no chest radiograph, sweat test, or bronchoscopy is indicated in this typical, thriving child. [2]
• Chooses management: reliever salbutamol via spacer for attacks; because episodes are mild, viral, and self-limiting with a broadly non-atopic pattern, a daily controller is not mandatory, but given the positive API a monitored trial of daily inhaled corticosteroid for eight to twelve weeks with a defined review is a reasonable option to discuss — cites PEAK (Guilbert) that daily ICS controls but does not modify the disease and has a small transient growth effect, so it is a trial that is reviewed and stopped if it does not help. [4]
• Counsels the family: most preschool wheeze, especially this episodic viral type, resolves by school age as the airways grow (Tucson); the single highest-value intervention is maternal smoking cessation and a smoke-free home and car; checks and demonstrates spacer technique and provides a written action plan with review. [1]

Bonus / distinction

• Explains why systemic steroid was not needed for her mild home-managed attacks, citing Panickar's finding that oral prednisolone does not shorten admission for mild-to-moderate viral wheeze. [8]
• Frames the daily ICS decision explicitly as a shared, time-limited trial with pre-agreed review and stop criteria rather than an open-ended prescription. [4]

Automatic fail

• Labels the child 'asthmatic' and commits her to indefinite daily inhaled steroid without a review plan, or misses the maternal smoking as the key modifiable factor. [2]

Examiner discussion points

• How the phenotype can switch to multiple-trigger wheeze over time and what would change the plan (interval symptoms, exertional wheeze, rising atopy). [2]
• Why atopy and the Asthma Predictive Index, not the number or severity of viral attacks, best predict persistence into school-age asthma. [1] [3]
• How to demonstrate and verify spacer technique and adherence before ever attributing a controller 'failure' to the drug. [4]