Kids can present with noisy respiration for many reasons, so pediatric pulmonologist Ruth Siew, MD, offers a useful review of breathing mechanics and testing tips to help providers distinguish between asthma and similar-sounding conditions. She explains when to suspect exercise-induced bronchoconstriction, foreign body inhalation and aspergillosis; appropriate treatment for various disorders; and when urgent evaluation is warranted.
Good afternoon everybody. Thank you for joining us today. I am Tabitha Constantino. I am one of the physician liaisons and thank you for joining us for our first C M E or actually our second C M E of the year. Um I'm just gonna go through a few housekeeping rules before we get started. You were all muted and if you have a chance to, if you have any questions throughout the top, please feel free to put them in the Q and A function. Um All the questions will be in there and then we will have doctor Su answer them at the very end of our lecture. So please feel free to put them in at any time. Um We have a pediatric musculoskeletal and sports medicine conference coming up in a few weeks and we would love for you to join us. It's in person on site at the hotel in Berkeley. Um This, you can scan the QR code right there and it'll take you to the form um or you can contact one of your physician liaisons and we will be more than happy to send you some information on that. Here's our schedule for the next few weeks. We have no webinar next week. But the uh child and adolescent psychiatric portal is doing their uh continuing their webinar series and they are doing one on Bipolar Disorder. I think that's supposed to be disorder and psychosis. So it's next uh Thursday on the twe uh 12 PM. And then we will continue with um Doctor Diab on the 14th and he's doing a talk on spinal deformity in Children. And on the 21st, we're going to do an abnormal head shaped and infant with Doctor Winston home. And on the 20th, we actually do have a webinar. That's uh we didn't have one originally, but we are actually going to be joined by Emmanuel Waban from our um neurology department and she is the director of U CS F S Regional Pediatric um Mus MS Center and she's going to do a talk on um MS Awareness. So we hope you join us from all of those. And these are your liaisons myself, Maria Bremmer, Amy Johnson and Lauren Robertson. Maria Bremmer is still currently on um maternity leave, but you can contact any one of us and we are more than happy to help you with any questions you have. And if you miss any of our lectures, including this, um any of our C M E lectures, you can catch them all on our med connection site. Feel free to put that QR code or you can reach out to a liaison and we will make sure to get that information to you. Um We have all of our webinars, including our C M E lectures available on there and you can get C M E credits for any one of them that you missed. So let me introduce our speaker. Uh We are so thankful to be joined by Doctor Ruth Hugh. She is a pediatric pulmonologist and she joined us uh not too long ago, she cares for Children with a variety of lung and breathing concerns including asthma, reoccurrence, uh respiratory infections, chronic lung disease, congenital lung abnormalities and conditions that make them dependent on technology for breathing. She collaborates with our aerodigestive clinic and which is a multi multispecialty clinic with Pulmonology E N T and G I as well as speech and nutrition providers. And today she's going to be talking to us about. Not all that uses is asthma. So I'm gonna stop sharing my screen and let doctors go ahead and share her screen. Thank you again for oh, and one more thing because this is AC M E please do not forget to fill out your C M um evaluation forms. They will pop up at the very end of your of the top. And if you don't receive them, please read out, please reach out to us and we will make sure to get that out to you so you can get credit. Ok, doctor, you ready? Yeah, thank you for the introduction to Tabitha. Thank you for um inviting me to speak. Good afternoon everybody. Um I'm excited to talk to you today about this um discussion about not all that at w is asthma and I really wanted to talk about this because I think that there's been a couple of um diagnoses that have come up, especially since the pandemic that I think are really interesting and have been a lot more prevalent. Um And I think that this is just a really interesting topic because while asthma is kind of uh our bread and butter, a lot of our pediatricians, bread and butter, um there's just some things that I think that um are important to talk about and it's just some interesting diagnoses that we can review um that, you know, presents as a but it's not only um I have no relevant financial relationships, I do not intend to discuss anything related to um my uh role as a consultant. So let's go on. So today, the learning objectives will be um like to you to be able to explain the mechanics of breathing that contribute to noisy breathing. So as pulmonologist is something that we always think about, um we want to be able to list some causes of weeping that are not asthma as well as describe some of the diagnostic and treatment modalities for weeping. So the outline for today is very simple. As I just said, we'll talk about some of the mechanics of breathing and then I have three case presentations that I wanted to go over that really highlight um some of the diagnoses that I'd like to discuss. So what the first one, um thing that I want to talk about is what is that sound? And where is it coming from? I think when um a parent comes in and they say my child is wheezing, the first thing that I always want to make sure is that is, are they actually talking about wheezing? Um, because a lot of times, you know, they'll say my child is wheezing, um, or my child, it has noisy breathing and it, it's first of all, not, not even wheezing. So, like you really need to distinguish, um, if it is wheezing, um, or if it isn't because that's really going to change, uh, what you think is the diagnosis. Um, and so, you know, if they say, oh, my child is wheezing and then they start pointing to their nose and they say, oh, they always sound congested. Um, or they, they always have a lot of like a runny nose then, you know, that's probably not wheezing. Sometimes it can be, they'll say, oh, you know, I'm wheezing but they'll point to their throat and say, oh, it feels like something is stuck here. Um, you know, it feels weird in my throat area and then, um, of course, so that would be more upper airway and then you have your lower airway issues where um you have uh your, this is, you know, asthma mucus infection, you maybe things like mass or so, um the first part is really important is just distinguishing what is going on and where is it? The second part is thinking about the mechanics of breathing. So I'll go through this quickly uh but not too quickly. When you think about um the mechanics of reading, there's four parts. The first part inspiration is active. So on inspiration, your diaphragm contracts and it flattens and you use your external intercostal muscles. Um and all of this help to increase the volume of your thoracic cavity. So air is drawn in um you sometimes if you're breathing extra hard, you can use your accessory muscles just your uh um in the case of strider um during inspiration, uh when you breathe, take a breath, soon, the intratracheal pressure goes below atmospheric pressure. Um air follows this gradient and air rushes into the lungs in strider where you have extrathoracic obstruction. Then this causes that striders noise and expiration. When you take an, when you breathe out, this is passive, your diaphragm relaxes returns to its dome shape. Um sometimes if you have force exhalation, this is active. So you use your abdominal wall muscles and your obliques to increase that intra abdominal pressure to push forced air out. And in the case of wheezing, um this is intrathoracic obstruction. And so as you force the air out, the intrapleural pressure is higher, then you're intratracheal pressure, air follows this gradient pushes out and that flow limitation is really intrathoracic and that causes that um that noisy breathing of that wheezing. Um similarly kind of with force expiration, uh cough, cough is very active. You have to it in three steps, you have to coordinate your inspiration, close your clay and then force whatever you want to come out to come out. Um So this requires um you know, coordination of muscle and nerves. Um in order to really be able to have a good strong cough. Um So by combining the location of the sound and the mechanics of breathing can really determine the cause of breathing. And that's your first step. The other two parts of mechanics of breathing is just to think about the ability to protect the airway. So the patient has to have um appropriate and intact swallowing function. You know, being able to swallow really is dependent on intact anatomy and also um well organized sensory and motor function. So that's really important. Um I have a picture here of a child who's bottle propping and that if they're half asleep will not be able to protect the airway and could be a cause of um product. We, the other thing to think about is just making sure that they have appropriate neuromuscular tone and function. If this is the child who has a genetic syndrome they may not be able to protect their airway as well. Ok. So let's go ahead and get started with our first presentation here. We have a 16 year old who presents with noisy breathing during exercise. This is noisy breathing. Um, and she describes it as wheezing dried or she's 16. So she doesn't really have the best history. Um, she says the noisy breathing is so shortness of breath and she says she has trouble getting air in. She points to her throat. She says, you know, it's just hard for me to get air in. She says it's in her throat and then sometimes in her chest. So the question is, is this asthma, how do we distinguish these symptoms from exercise symptoms from something else? Is this asthma? Is this asthma plus, what are we looking at? So I wanted to use this case to really highlight um something that we've been seeing a lot more since the pandemic. Um and it, it's become not only more prevalent, but um we've been seeing it in a more wider variety of presentations. So I wanted to talk about inducible laryngeal obstruction I 00 as is normally referred to as vocal cord dysfunction or B CD. Um So usually this has been a onset, uh usually a female predominant. Um, average age has been around 15 or 16 years old. Your typical patient is this high achieving, they get their super high GPA S, they're competitive Varsity athlete. Um And one of the things that really distinguishes this um I L O is that this strider, noisy breathing occurs during these I O I L O episodes. So, um you know, it's, do you have noisy breathing when this is happening when you're feeling that pain? Um And another thing that distinguishes this, this is, this occurs early on in exercise in the first few minutes. Um As I mentioned, since the pandemic, this presentation of I O is not always what you see above. Um Sometimes we see earlier age of onset, um sometimes you see it combined with or as a differential to anxiety or mood disorders. So I think we're, we're starting to see um some more papers come out about this and the um impact the pandemic has had on I L O. So I L O, how is this diagnosed? Um First thing is just a trial of uteral, does it help? Is this exercise induced bronchospasm or is it a lot of time your patient comes in with his history and you can just have them try trial it course of ALBI and they will tell you yes or no. And it's usually pretty clear. Um They'll say absolutely or like no way and they and the teenagers are pretty good about this. Another thing to look at is fero Mery. This is helpful. Um It gives us a sense of is their airway obstruction such as asthma. Um The, the only thing in terms of using it to diagnose I 00 though is that it's not always the best. Um it actually has low sensitivity and um repeatability. Barometry is really dependent on effort. And so the patient has to be able to do good expiration um and good inhalation in order to have a good test. Um These, a lot of times these are these like teenagers, especially these teenage girls and they're not always able to have a good effort. And so if you have suboptimal effort or if you have poor instruction from the person that's administering the test and they aren't able to do a good um breath out and in, then you might not have good results. And so spirometry will not always show it it can be normal. Another thing that we can do, which I have a picture of here is exercise barometry, which we, I'll talk a little bit about later, but essentially um doing sperm tree as they're exercising and then uh dima breathing, nasal breathing and panting. Um Other techniques that are used are biofeedback. Um Hypnosis has also um been used with uh moderate evidence. Um And then it's also really important to treat the comorbidities. So, asthma can be a comorbidity in uh in studies that show it's either, you know, 6 to 25% of cases. Um So it's really important to treat the asthma as well. These are some of the alternative diagnoses. Um that can occur with I O. And I wanted to just to take some time to look at exercise and do the broncho construction with or without asthma. So oftentimes I O is easily confused um with exercise and do broncos constriction and you look very similar. So I want to just take a little bit of time to talk about it. There is a high prevalence of eib exercise induced bronchoconstriction in swimmers. So that in the chlorine water, um, in skiers with, uh, um, the cold air from, um, the snow ice rink athlete, um, because of the fossil fuel from the ice resurfacing machines. Um, and then also in runners because they're often running outdoors in high allergen and ozone areas. Um, testing is done um, on an exercise P F T challenge. And so what this, um, looks like is kind of a setup like this where we'll do pre exercise barometry. And then, um, we'll have the patient do a rapid increase in exercise intensity over a couple of minutes, 2 to 4 minutes where they achieve a high level of ventilation, they'll use some nose clips to help with that. So they raise their heart rate to 80 to 90% of maximum and then they'll continue the exercise for another about five minutes and then we'll have them stop and do post, um, spirometry at 5, 10, 15 and 30 minutes. Um, and then usually recovery is spontaneous and occurs, um, within 30 minutes to 90 minutes. The diagnosis of E ID is confirmed if the F E V one is decreased by at least 10%. So how do we treat exercise and do Broncos with constriction? Um These are some of uh environmental options so you can do a pre exercise warm up. So at least 30 minutes before, so you can elicit this refractory period, um that can last up to two hours. So this is having the patient do a warm up 10 to 15 minutes, about 50 to 60% of their maximal heart rate. And they've looked at what type of exercise is best um at helping elicit this refractory period. And they, and they, the studies have shown that it's this variable um high intensity exercise. So um high intensity rest, high intensity rest um for 10 to 15 minutes. Um as we talked about sometimes cold and dry environments can promote bronchoconstriction. And so using a face mask while um during exercise or in the warm up period can help promote humidification um to prevent that bronchoconstriction. And if this patient ha it has known allergies, um if there's a way to minimize exposure to air pollution, environmental allergen, that would be helpful, what about some medication um options. So as we know short acting beta ago, albuterol, this is going to be helpful. You give 2 to 4 puffs with a spacer at least 15 minutes before exercise and this should last you 2 to 4 hours. The only thing is that regular use can induce tolerance. Um where the um where you uh have tolerance to your uh beta Agnes receptors. So this is the athlete who you know, maybe is has practice every single day and they have pe and they need this every single day. So you want to think about some other option, something else to think about could be looking at Mono Leu cast where you give it at least two hours before exercise. Mono Luca has not been shown to induce tolerance. Um It has a longer effect so it can last up to 24 hours. So you give it once a day and it can last them through all of their physical activity for the day. The only thing that has not been studied, head to head with albuterol. I mean, the other thing to be careful about is the black box morning with Mono Leu where um patients can have psychiatric side effects, mood changes including suicide. So if they have at a baseline had known psychiatric side effects, I would be more cautious with starting this. Um And I always cancel patients about this. Um If they do end up starting it and having um mood changes, you stop the medicine and the side effects go away almost immediately. Another uh good option is using a daily inhaled corticosteroid. And so um this is a nice option um in as an alternative to mono Leu cast um similar to what you would use for asthma. Second line options would be E Petro um which does not have good evidence. Um and chrome, which is not as easily accessible in the US. So I think it's very confusing and I wanted to just go through um the differences between eib exercise induced bronchos, constriction and exercise induced obstruction, E I L O. So on this side, we have eib this is really a lower airway issue. So this is going to be respiratory symptoms such as that we, the symptoms really peak after exercise. So, um you know, around 3 to 15 minutes after the patient is done exercising, they might have symptoms during, but it's really after that, um the symptoms occur, Chris E I L O is really the um upper airway issue. So, symptoms are more inspiratory that inspiratory strider, that noisy breathing that you hear and the peak of the symptoms are really at peak exercise. So it's during activity um and then it stops pretty soon after exercise. So hopefully this um will help kind of help you distinguish between one and the other. I wanted to look at a couple of the other differential diagnoses. Um So in addition to EIB, um sometimes it's just decreased fitness deconditioning. This is we are seeing a lot of this early on um when people are coming back from the pandemic, um post COVID. Um this is very common also on the on the other end of the spectrum, you have overtraining syndrome. Um where you have these athletes who are strong go getters, they um you know, are pushing themselves, just kind of over um over pushing themselves. Um Other alternative diagnoses would be psychological or respiratory disease, which will talk about cardio pulmonary disease. Um arrhythmias, hypertrophic cardiomyopathy, you know, more rare ones, pulmonary hypertension, um thrombolic disease, it's cardio pulmonary disease and kind of differentiating between these. You wanna ask what exertions thing could be and a family history of sudden death. Um uh example of other diseases includes reflux that can also cause leine and then rarely exercise, induce Anaplex. So we've gone through our first um case presentation looking at I L O eib and I wanted to go through two additional um presentations. So this one is a 21 month old with recurrent wheezing. Um The parents say the symptoms started about six months ago on exam, you hear right sided wheezing and crackles. Um you know, you, she's in the office and you try um albuterol treatments and you give them an albuterol inhaler for home. Uh You even try, since you hear um abnormal breast down, you try the amoxicillin for pneumonia and the treat seemed to help, but then the cough comes back. This patient goes to daycare and has an older sibling in preschool. So, is this asthma? Um there are definitely um characteristics of this case that make it seem like she has asthma, she has recurrent wheezing, um Albuteral help. Um and also she seems she goes to daycare and has an older, pre, older sibling. And so she is going to constantly be exposed to different um viral pathogens. And so common things being common. Yes, this is possibly asthma, but there are a couple of things that are seem off. So, um this is a kind of, this has been going on for a long time while the treatments help, the cough seems to come back. Um I wanted to go through a couple of other things that might make it seem weird. So, of course, we always take a great history and we're really ca uh careful in thinking about timing. So when this first start, how long has it been going on for? I think a really important thing to think about is, is this episodic or continuous? And has this been worsening? So, when the patient is well, do they still have symptoms of cough if that is the case that makes you a little bit more concerned about a systemic issue or um kind of a chronic issue that's not related to um recurrent viral infection if the patient is worsening, um, or if they have any of these couldn't um uh severity concerns, retractions. I notice they're not growing well, they're not gaining weight, they're always tired, fatigued, they're lethargic and they don't want to play. Those are things that make you concerned and make you want to think that this is not just asthma. Oh, sorry. Um Additional associated symptom, you wanna ask is the cough and wheeze related to wheezing, to feeding um to activity is a reflux. Are there, are there always fevers associated with this continuous or episodically? Um is there lymphadenopathy, different things like that? And then in their medical history, you know, has there been a history of intubation that's gonna increase your suspicion for things like subotic STIs. Are there any neurologic conditions or genetic syndromes? Was there prematurity? So, again, um you wanna locate the weed, is this more um inspiratory bi physic or expiratory? And that's gonna give you clues as to where the level of obstruction is and then give you clues as to is it a diagnosis where it is what it is? So, here you have um some inspiratory upper airway um causes of wheezing, noisy breathing, Lario, laryngomalacia, uh vascular malformation. If it's right at the subglottic area, you think about glottic webs, um subotic stenosis, um lao class. And then if it's respiratory wheezing, you really think about thoractic extrathoracic tracheal, um uh tracheal ideologies and below. So, including the lungs. Um and this will be things that are lower form bodies, tracheal maia, that sort of thing. And then I wanted to look at a couple of other nonpulmonary differential diagnoses. So, um infectious ideologies, is this acute or chronic um could this just be acute tracheitis is this a retro access? You know, you would know if this is acute epiglottitis or c um And then, has there been any concern for trauma or mechanical burn inhalation, caustic injection ingestion I have form body here again or other tracheal injuries. And then rarely, you would know if this is an acute issue, Anaplex or angioedema. So what's next? You have this patient who has a chronic, um, wheeze, they have abnormal breast sounds. Um you've tried a few treatments and they don't seem to work um or they work and then they, and then the symptoms come back. Um So far she's had no um testing or imaging. So your first thing to do would just be to get an x-ray. I always like to get a baseline x-ray either when they are sick and then if that sick, one is abnormal to get to get a uh when, when they are not sick um or when they're in their healthiest state um to make sure that there isn't anything that we're missing. So it's really a screening xray. And so for this patient, you immediately notice there is this left sided unilateral hyperinflation much there's and there's this asymmetry as hyperinflation is causing this right word meal shift with this resulting volume loss on the right. See this, what is your next step is an urgent E N T consult. When you see something like this. You think about foreign body aspiration, you consult E N T. Um uh this is an interesting case because I'm pulmonary, but we always talk to E N T because they are the ones that have the tools to take foreign bodies out. And we, as pulmonologists are not able to usually look, we're only able to look and not able to extract. So we um call E M T E and T is able to take them into the O R and on a rigid bronchoscopy, bronchoscopy, they see a sunflower seed and they take it out from the left names and bronchus. So how do you know where the obstruction is based on that? Um So this is looking at the ball valve effect where if the obstruction is say on this side, in this case, in this diagram, it is on the right side, on the left side, I'm sorry. Well, we'll just say it's on the left side. Um Even though we think about patient better and an x-ray, this would be on the right side anyways. Um So on this side, on the left, if, if the um foreign body is here on inspiration, air is able to enter into the lungs. And so, um both and it's able to enter equally on both sides. But on expiration, as we just talked about when um the uh abdominal muscles contract and um air is forced out, this is the site of the flow limitation. And so air is not able to um exit and So this gets bigger and bigger and bigger causing that hyperinflation. And so the side of the obstruction um is where the hyper inflation is. So, foreign body aspiration um can present acutely orth chronic symptoms. Common findings are Cody and wheeze or even decreased breast sounds on that side. It's very common in kids under three years old. Um there can be no clinical findings. Um in one study, they, at least 16% of Children had no clinical findings and 6% were completely asymptomatic. Um And it's not always reliable even if there was no reported or witnessed event. So oftentimes these kids, um you know, sometimes they're the youngest one and, and um there's all these other kids running around. Um And so they, they might not have witnessed uh the kid putting something in their, in their mouth. Um This is the age where they're always putting things in their mouth. So it's very common. Again, a chest x-ray can be normal in 20% of cases and they found that nuts and seeds are the most common. Um, when you look at the x-ray, a lot of times you think about the right, right main stem with its um angle. Um it and the anatomy of the right main stem being more kind of, more of a straight shot. That's usually the area that we think about that is more common for aspiration, but they're actually equally distributed between the left and the right um around 30 to 40% are on either side. So it's really important to have a high in index of suspicion for form body aspiration in these kids with chronic aspiration. Ok. So um here we've talked about two of the different presentations and then I wanted to um go over one more uh case presentation of a more rare uh disease. So this is a 10 year old with persistent asthma and recurrent episodes of wheezing. Um This patient takes them to court the higher dose 1 62 plus twice daily with the space there, they say that they use the space there every time and they're pretty good about taking it twice a day. Um But for some reason, they still have these frequent urgent care er, visits and um TCP visits for wheezing happens at baseline at home when he goes outdoors and with exercise, it's still happening a lot. When you do the exam, you find this frequent dry cough, nasal congestion and allergic shiners. There is also diffuse sweetening. So, of course, the question is, is this asthma there are he has known asthma. So is this just uncontrolled asthma? Is he taking his face there? Is he taking his medication if he is? As he says, why are all these visits still happening? Why does he still have these significant symptoms? He also complains of having a cough, intermittent dynia and fatigue and lately he's had a low appetite. So as we noticed he had, he had allergies, he takes singular days daily and Zyrtec, um he's never been tested for allergies before. And so you send him for allergy testing and it comes back positive to grass dust and Aspergillus. So what is in your differential? So I wanted to use this case to highlight just a few of um a few other rare diseases, um especially in a 10 year old. So severe asthma, definitely high on the differential, severe uncontrolled suboptimally controlled asthma is definitely still high in the differential. You wanna make sure that that is not the case. We have certainly ruled out or we have certainly diagnosed patients with cystic fibrosis at age 10 or beyond. Um These are the patients that have uh less disease causing mutation, not your common Delta F five oh eight. Um or they just have a more rare mutation. So they potentially have gotten missed um on newborn screening. Um But certainly they'll have in their medical history have, you know, a lot more um issues, they might have sinus issues. Again, if you think about cystic fibrosis, you always want to think about primary Hillary dyskinesia, which is even more rare. Um And then tuberculosis has there been exposures. Um How long has this cough been going on for? You get a chest x-ray, you can get it um a free on um in our history when we take, uh when we see an initial patient, we always ask about pets in the family. Um You always want to make sure that, you know, you're not missing some random bird that they have and they have some hypersensitive pneumonitis also very rare. Um But important then even more rare things, eosinophilic granulomatosis with polyangiitis, E GPA or formerly known as Turk Strauss or they have asthma, eosinophilia and vasculitis. Um Another thing to think about that is also rare is chronic opic pneumonia, um where this is where they have. This is very confusing. It could present with dyspnea, systemic symptoms. Um your typical asthma symptoms as well as elevated E S R C R P. Um I elevated I G E but one thing that distinguishes it is um these peripheral round opacities and changes on uh C T S. So I wanted to um just take a minute to talk about a goddess as you remember, he was positive on his skin testing for this um mold. And oftentimes we hear there's mold in my home and um it's very concerning a lot of patients and their families and parents are very concerned about this. So, Aspergillus is a fungus. It's found in the environment in soil, plant matter, vegetation health beds, even in uh marijuana, healthy individuals can clear these fungal school or they're everywhere in the environment. And usually healthy individuals are able to clear this immunocompromised patients or atop patients that are exposed to these fungal spores, they are unable to clear them and So they form a hypersensitivity reaction that leads to I G production, mast cell degranulation and neophilia or acute patients or healthy individuals that can cause an acute aspergillosis infection. But again, in the immunocompromised patients or atop patients, it can, it can lead to an allergic response leading to allergic bronchopulmonary aspergillosis or A B P. So A B P A presents in patients with asthma or cystic fibrosis. The diagnosis is based on a constellation of findings. So a positive Aspergillus skin prick test or intradermal skin test. Usually the serum total I G E is very elevated and so it's over 1000 is very typical and common. Um Other lab tests that can be positive would be elevated serum I G E to the Asper Goddess, elevated I G G to Asper Goddess. You can also have peripheral blood eosinophilia, abnormal chest x-ray with patchy infiltrates and long term. They can have um a long prank injury with bronchia tree and findings for central nodules. So, the treatment of A B P A is to control their symptoms, prevent further exacerbation and to minimize lung injury. So, unfortunately, treatment is a very long course. Um it involves oral corticosteroids for weeks, followed by taper and some patients are on um a very low maintenance dosing. They can be on intraconazole to um actually treat the a the aspergillosis um and then also good airway clearance if they've had this long term and they have um evidence of bronchia, you want to make sure that they're able to um clear out the mucus that is present um in their lungs. Ok. So today we've talked about three um different uh uh cases that highlight three different um diagnoses that I think are interesting um and can mimic asthma and can present with leaves. These are some of the signs and symptoms that require urgent attention. We kind of touched about some of these, but if the patient is, has apnea and or has we and apnea, persistent apnea diagnosis, failure to describe aspiration or core pulmonology. These are all um reasons to either um request an urgent referral, send them to the er um depending on how severe the symptoms are. So, a couple of takeaway points um is to recognize when wheezing or noisy breathing is abnormal. So, while asthma is very, very common in our practices, um pointing out and finding those little things that make the presentation seem abnormal and make you scratch your head, um that is when you need to have a high um index of suspicion for certain things such as um I L O or body aspiration if you have persistent symptoms. Um It's always a good idea to get a screening chest x-ray, even if you've got, even if you had one when symptoms first started six months ago, it's good to get another one just to see where things are at. Um we talked about A B P A and this can present as uncontrolled asthma while this is rare. And when in doubt, it's always good to refer early on to pediatric pulmonology. I thought this is interesting because this is your patient at home and then when they come to see the doctor, they're fine and then they go home and they're that again. And with that, um this is how you can refer our patient. And uh if you have questions, I'm happy to read them now. And also here's my email. So I'm gonna go ahead and um start with our Q and A. Yeah. So if anybody else has um there are already some questions in the Q and A function, but if you have any, please feel free to put them in right now and Dr Sue is gonna go over them right now. Perfect. OK. So we have a couple of ones. So I'll start with the first one, do daily inhaled corticosteroids taken daily for many years, decrease max adult height. How do you counsel patients and families? So that's a great question. I always talk about this because parents always want to know, you know, my child, my 16 month old is on an inhaled steroid. You, you know what are the side effects? And so um the studies have shown that it's um higher doses. So if they're just on flo flo 44 that hasn't been studied and, and that has, that's not the case. So it's the higher doses for longer periods of time. Um that can decrease your max adult height by um two centimeters or one inch. Um And so most of the time parents are fine with this and they, you know, it's not a big deal because it's not a for sure either. This is just a risk. Um Sometimes we have patients who, you know, they're on a high dose and you can always track their height velocity. And if for whatever reason you, you start to see more systemic symptoms um that maybe have mood changes with the higher dose of inhaled corticosteroids, you can track the hype loss. So you see that maybe it's starting to slow, you can, I would just switch them and they can go on um uh an IC of lava instead or, or something else. Um But usually patients are OK. And if they're not, then then we just pick something else. I hope that answers your question. Um OK. Next question. So for our teens with exercise induced asthma or EIB, if they are exercising daily, do they need an additional med like IC F or singular? How many times a week can a patient use albuterol before developing palais? Does this mean that every kid with eib will need more than just albuterol if they are exercising daily? So that's a great question. That does come up a lot because as we talked about um these patients that have eib A lot of them are exercising daily. They have practice every day. So I am cautious about having our patient take albuterol on a daily basis. Um When they, when they do get to that, the recommendations are to start, um usually it's to start the inhaled corticosteroids, so to start um like your flow event. Um and that's usually the first line recommendation. Um So let me just make sure I answer it exactly. So, um I, so yeah, so if they are exercising daily, I would start an I CS. Um I usually, usually, if it's daily, then I would recommend starting it. If it's, you know, three times a week, then they can keep using their albuterol. Um And then just kind of seeing in between if it's like four times a week and you can, you can kind of figure um talk to the patient to see um how they feel. But uh does that mean that every kid with eib will need more than just Albuterol? So yes, I think that that is smart because I am worried that um about down regulation of their um beta Agnes receptors. Um and that they can develop tolerance to uh daily albuterol. OK. So can you repeat what kind of x-rays to order for patients with suspected foreign body? Yeah, so I um showed a photo of just um uh A P. So usually for all of my patients that, that get any sort of x-ray, if they can, I'll do a two view. So, a P and lateral um for these younger patients, if you can do um uh a cross table uh where they're laying on their side, um That's helpful too. Um because sometimes patients, you know, when they're small, they're not able to control their inspiration and their expiration, they're not able to hold that. And so if um so in these younger kids, if you put them on their side, uh the affected side is going to stay hyperinflated. Um If they're, you know, laying on the side, the gravity, they should be able to pull down and that side should be smaller. But if that um side is affected with a foreign body, it will stay hyperinflated. So you can do um cross tables on uh both sides. OK. So this is our current last question for exercise induced asthma. What is the dose of inhale period? And what dose? Um So I would you start the patient on whatever dose um would be appropriate for their age and their weight? So, um usually in a kid probably just the 44. If they're bigger, then I would do the um 1 60. There isn't as much data and the recommendations are not as strong for starting um uh combined is lava at this point. Um So right now, um we recommend just the inhaled cor coo. OK. Thank you, Doctor Sue. Um If anybody else has any questions I'll give you one last chance. And if not, um, I'm gonna say thank you and uh, please do not forget to fill out your evaluations. That way you can receive credit for attending. And if you don't get that pop up with the evaluation, please let your physician liaison know. We will make sure to send that out to you. And, um, that's Doctor Sue's email, you can contact her there and she sees patients both in Mission Bay and in Oakland. So we hope that you join us at our next lecture. And thank you again, doctor so, so much for giving this great talk and everybody else have a great afternoon. Thank you. Thank you.