An 18-month-old child presents with his first episode of wheeze. He is pyrexial and has shortness of breath with some subcostal recession. Wheeze is heard all over his chest.
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(a) Which of the following diagnoses are most likely?
(1) Asthma; (2) Inhaled foreign body; (3) Bronchiolitis (4) Croup (5) Whooping cough
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Asthma and bronchiolitis are both possible. A child this age is at risk of inhaling a foreign body as they are inquisitive and put small objects in their mouth. A foreign body will either cause airway obstruction leading to choking, stridor and cyanosis, or if inhaled into one main bronchus may cause unilateral wheeze. Fever is less likely. Croup causes a characteristic cough and stridor but no wheeze. Whooping cough presents with coughing and sometimes vomiting but not wheeze.
Bronchiolitis due to respiratory syncytial virus (RSV) infection is very common in the first 2 years of life. There may be a fever. Asthma does not cause fever, but may be triggered by a viral upper respiratory tract infection.
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(b) If you were considering asthma as a likely diagnosis, what family history may be relevant?
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You should establish if there is a family history of atopy—asthma, hay fever or eczema in siblings or parents suggest this. Does anybody smoke in the house? Are there any pets in the home?
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(c) If you were considering bronchiolitis as a likely diagnosis, what diagnostic test would you perform?
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A nasopharyngeal aspirate or swab for RSV immunofluorescence, which can identify the presence of RSV or other respiratory viruses. A chest radiograph may be helpful if there is diagnostic uncertainty or if the child is very ill.
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(d) What treatment is likely to have been given?
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The response to treatment followed by recurrence suggests reactive airways disease (asthma) which is responding to bronchodilators such as short-acting beta-agonists (e.g. salbutamol). These may be administered by inhaler (using a spacer device) or by nebulizer.
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(e) What would you prescribe and what would you tell his parents about administering it?
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The child probably needs an inhaled beta-agonist such as salbutamol. It is important that this is given via a spacer device as this child is too young to use a metered dose inhaler directly. As he is coughing most nights the bronchodilator should be given regularly at bedtime.
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(f) What further treatment would you consider?
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He responds to the short-acting bronchodilators but is having regular symptoms despite these. Low-dose inhaled corticosteroids should be given regularly for a trial period to reduce airway inflammation and gain symptom control.
