Wheezy bronchitis


Wheezy coughs, with or without shortness of breath,  are common in babies and  young children and don't respond to usual cough syrups or suppressants.  A bronchodilator  is required and  usually given by inhalations.  Occasionnally  no wheeze is heard, breath sounds may be decreased, and the cough responds to this treatment, evidence that  an unsuspected  bronchial spasm was present.

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Machine nebulizers are  often prescribed unnecessarily since  metered aerosols  have been shown more effective in most cases, and are much simpler and easier to administer provided a spacer is used.  A  puff is sent  inside  the spacer and the child should breathe at least  five times after each puff  to absorb the medication. 

The bronchodilator is given to open bronchial tubes and  help mobilize secretions within them. The first puff opens the large bronchial tubes first,  at the center of the lung.  When a  second puff is needed it  reaches further to open smaller bronchial tubes. More puffs are occasionnaly  needed to  break  a  tight  bronchial spasm associated with shortness of breath (asthma attack). 

A rule is never to exceed  one puff for each  3 kg of body weight, with a maximum of 10 puffs, treatment which can be repeated twice, 30 minutes apart, but  these guidelines for severe asthma are  upper limits,  which should be approached only in a safe and  appropriate setting such as a hospital   emergency room. On the other hand, it may be important to stress that  official dosage recommendations are often too low and the  age under which these  treatments are not recommended (often 12 years !) is too high. These notions are obsolete and don't  reflect   current  professional opinion. 

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This is  called the attack treatment. To keep bronchial tubes open, one (sometimes more) maintenance puff(s) is/are advised within 4-5 hours. If a previous treatment was given   more than 6-7 hours  before,  a second puff may be needed, seldom more,  i.e. a new attack treatment, with a  risk of noticeable side effects (excitement, poor sleep).  If this treatment remains useful for more than 4 weeks, or fails to break the bronchial spasm,  the addition of  a local (inhaled)  steroid should be discussed.
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Expectorants before the age of 12-18 months tend to increase secretions and should be avoided or given at a very low dosage. Maintaining a high fluid intake is safer and  probably more effective to make secretions more liquid and easier to bring up. On the other  hand,  cold or hot mist  humidifiers are  not recommended.

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Physical therapy for this indication (wheezing)  is  controversial. The purpose is to mobilize secretions within bronchial tubes and help the child  expectorate, but whenever significant bronchial tubes narrowing  is present, this treatment is ineffective and may be poorly tolerated, if not counterproductive. 

However a trained physical therapist's frequent (daily) visits  may provide a precious supervision  and may  alert the parents to a potentially dangerous situation requiring  more intensive care, including hospital admission.

On the other hand,  parents can  learn to perform effectively  this task themselves, by using the chest clapping  technique :  one hand applied flat over the child's  chest, hit this hand with four fingertips of the other hand, perpendicular to the chest. This needs  not last more than 1-2 minutes but  should entirely cover both lung fields, in front,  in back and on both sides. If successful, this treatment will trigger an effective productive cough effort. It can be repeated several times a day and may be particularly useful against night coughing spells.









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