Recurrent wheeze in preschool children — formative SAQs

SAQ 1 — The frequently-wheezy toddler who is well between colds (20 marks, ~15 minutes)

A 2-year-old boy has had six separate episodes of cough and audible wheeze in the past year, each starting with a runny nose and settling over a few days. Between episodes he is completely well, feeds normally, and is growing along the 50th centile. He has mild eczema and his mother has asthma. [2]

Questions

1. Name the wheeze phenotype and explain what distinguishes it from the multiple-trigger phenotype. (4 marks) [2]
2. Apply the Asthma Predictive Index to this child, listing the criteria and stating whether he is positive. (5 marks) [3]
3. Outline your preventive management, justifying it with the relevant trial evidence. (6 marks) [4] [5]
4. State the non-pharmacological interventions you would prioritise. (3 marks) [2]
5. Counsel the mother on the likely long-term outlook. (2 marks) [1]

Model answer (must-hit)

1. This is episodic (viral) wheeze: discrete attacks of wheeze occurring only with viral respiratory illnesses, with the child completely well between episodes. It is distinguished from multiple-trigger wheeze, in which wheeze or cough also occurs between colds, provoked by exercise, laughter, cold air, or allergen — implying interval symptoms and a more asthma-like, atopic picture. The ERS phenotypes overlap and can switch over time, so the label guides rather than dictates treatment. [2]
2. The stringent Asthma Predictive Index requires frequent wheeze (≥4 episodes in the past year — he has six) plus one major criterion (parental asthma, doctor-diagnosed eczema, or aeroallergen sensitisation) or two of three minor criteria (food sensitisation, blood eosinophilia ≥4%, or wheeze apart from colds). He has frequent wheeze plus two major criteria (maternal asthma and eczema), so he is API-positive, which raises his risk of persistent atopic asthma at school age; the index has high specificity but only modest sensitivity. [3]
3. Because he is API-positive with an atopic phenotype, the key preventive intervention is a monitored trial of daily inhaled corticosteroid for eight to twelve weeks, reviewed formally and continued only if it clearly helps. The PEAK trial (Guilbert) showed that daily inhaled fluticasone in high-risk preschoolers controls symptoms during treatment but confers no lasting disease-modifying benefit once stopped, with a small transient reduction in growth. For a child whose episodes were severe and clearly viral, a pre-emptive high-dose inhaled corticosteroid at the onset of a cold (Ducharme) is an alternative that reduces rescue oral steroid use, again at a small growth cost. Reliever salbutamol via spacer is provided for attacks. [4] [5]
4. The priorities are eliminating tobacco-smoke exposure (the single most important modifiable risk factor) with caregiver cessation support, correcting inhaler and spacer technique, checking adherence, managing the eczema, and providing a written action plan with review. [2]
5. The outlook is good: most preschool wheeze, especially the transient early type, resolves by school age as the airways grow, though his atopy (eczema, maternal asthma, positive API) places him in the minority at higher risk of persistent asthma, so ongoing review is warranted. [1]

SAQ 2 — The acutely severe wheeze attack with an atypical feature (20 marks, ~15 minutes)

A 3-year-old girl presents to the emergency department with two days of coryza and now marked respiratory distress. She has intercostal and subcostal recession, is too breathless to talk, and her SpO2 is 90% in air. Her mother mentions the child "was never right" after choking on a peanut a month ago and has had a persistent noise on one side since. [8]

Questions

1. Grade the severity of this acute attack and outline your immediate management. (6 marks) [2] [8]
2. State the role of systemic corticosteroid here and summarise what the Panickar trial established. (4 marks) [8]
3. Identify the atypical feature and the diagnosis it should prompt, and state why a normal chest radiograph does not exclude it. (5 marks) [2]
4. Outline the investigation and definitive management of that alternative diagnosis. (3 marks) [2]
5. State two features on later review that would prompt you to investigate for a chronic suppurative lung disease. (2 marks) [2]

Model answer (must-hit)

1. This is a severe acute attack (SpO2 below 92%, marked recession, too breathless to talk). Immediate management is ABC assessment, controlled oxygen to keep SpO2 at or above 92%, and nebulised salbutamol driven by oxygen with nebulised ipratropium added, repeated according to response, with a systemic corticosteroid given for the severe attack. For life-threatening features (silent chest, exhaustion, cyanosis) add IV magnesium sulphate and consider IV salbutamol or aminophylline, and involve senior and PICU/retrieval teams early. [2] [8]
2. Systemic corticosteroid is indicated in this severe attack. However, Panickar and colleagues' randomised trial showed that oral prednisolone did not shorten hospital stay in preschool children admitted with mild-to-moderate virus-induced wheeze, so reflex oral steroid is not justified for every wheezy admission; it is reserved for severe attacks, an atopic or asthma phenotype, and children needing intensive care. [8]
3. The atypical feature is the history of choking on a peanut with a persistent unilateral noise since — this is an inhaled foreign body until proven otherwise. A normal chest radiograph does not exclude it, because most aspirated organic objects are radiolucent and the film may show only subtle unilateral air trapping or be normal. [2]
4. The investigation and definitive management is rigid bronchoscopy for both diagnosis and removal of the foreign body, undertaken urgently regardless of a normal radiograph, because a missed foreign body leads to persistent wheeze, recurrent pneumonia, and bronchiectasis. [2]
5. On later review, a chronic wet or productive cough that never fully clears, failure to thrive, finger clubbing, or recurrent pneumonia would prompt investigation (sweat test and CF genetics, and assessment for primary ciliary dyskinesia, bronchiectasis, and immunodeficiency). [2]