Treatment of recurrent virus-induced wheezing in young children
- Sujani Kakumanu, MD
Sujani Kakumanu, MD
- Clinical Assistant Professor, Division of Allergy, Pulmonary, and Critical Care Medicine
- University of Wisconsin Medical School and Public Health
- Middleton Memorial Veterans Hospital
- Section Editors
- Gregory Redding, MD
Gregory Redding, MD
- Section Editor — Pediatric Pulmonology
- Professor of Pediatrics
- University of Washington School of Medicine
- Robert A Wood, MD
Robert A Wood, MD
- Editor-in-Chief — Allergy and Immunology
- Section Editor — Pediatric Allergy
- Professor of Pediatrics
- Johns Hopkins University School of Medicine
Wheezing episodes in early childhood are common heterogeneous disorders with significant morbidity. Viruses are widely recognized as common triggers of early childhood wheezing both in children with recurrent wheezing with multiple triggers as well as those with episodic exacerbations whose predominant trigger of wheezing is viral infections. In fact, a viral cause was detected in 90 percent of wheezing illnesses in a birth cohort of children at increased risk of developing asthma . Early childhood wheezing encompasses many clinical phenotypes, and responses to treatment are variable. Instituting or escalating asthma therapies is effective in controlling viral-induced wheezing symptoms in some patients. However, the evidence for this approach is not definitive in controlled studies, particularly in patients with intermittent symptoms.
The optimal management for acute episodes of virus-induced wheezing in infants and preschool children has yet to be determined . Therapeutic trials in this young population are hampered by the inability to predict clinical phenotypes, such as children who will outgrow their symptoms, children who will later develop asthma, and children who have bronchiolitis, a condition for which glucocorticoids generally are not recommended. (See "Bronchiolitis in infants and children: Treatment, outcome, and prevention".)
This topic reviews the treatment of young children with recurrent virus-induced wheezing, defined as a minimum of three to four wheezing exacerbations a year . Treatment of bronchiolitis in infants and virus-induced asthma exacerbations in children and adults are discussed separately. The mechanisms by which viral respiratory infections cause wheezing and asthma exacerbations and the influence of viral infection on both the development and perpetuation of asthma are also discussed separately. (See "Bronchiolitis in infants and children: Treatment, outcome, and prevention" and "An overview of asthma management" and "Virus-induced wheezing and asthma: An overview".)
Virus-induced wheezing is a heterogeneous disorder, and response to treatment may differ among individuals. Inhaled short-acting beta2-agonists are commonly used for symptomatic relief. Combination therapy with hypertonic saline (HS) and a bronchodilator is under investigation for treatment of acute symptoms. Inhaled and systemic glucocorticoids and leukotriene-receptor antagonists (LTRAs) have been studied for the treatment and prevention of acute episodes of virus-induced wheezing in young children who require additional therapy. Treatment of asthma, both for acute exacerbations and prevention of symptoms, is discussed in detail separately. (See "Asthma in children younger than 12 years: Rescue treatment for acute symptoms" and "Asthma in children younger than 12 years: Treatment of persistent asthma with controller medications" and "Acute asthma exacerbations in children: Emergency department management" and "Acute asthma exacerbations in children: Inpatient management" and "Acute severe asthma exacerbations in children: Intensive care unit management".)
Inhaled short-acting beta2-agonists — Inhaled bronchodilators are often first-line therapy for treatment of virus-induced wheezing and are an effective rescue treatment in symptomatic patients, especially in children with established asthma (table 1). However, inhaled short-acting bronchodilators have not been shown to improve clinical outcomes, decrease the rate of hospital admission, or decrease the duration of hospitalization in children with bronchiolitis . In addition, a systematic review and meta-analysis did not show benefit with the use of beta-agonists in children with acute cough or bronchitis, although the analysis was limited to two pediatric trials . (See "Asthma in children younger than 12 years: Rescue treatment for acute symptoms" and "Acute asthma exacerbations in children: Emergency department management", section on 'Dosing and administration' and "Acute asthma exacerbations in children: Emergency department management", section on 'Overview of treatment' and "Bronchiolitis in infants and children: Treatment, outcome, and prevention", section on 'Bronchodilators'.)
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- EPISODIC THERAPY
- Inhaled short-acting beta2-agonists
- - Inhaled hypertonic saline
- Intermittent inhaled glucocorticoids
- Systemic glucocorticoids
- Intermittent leukotriene-receptor antagonists
- Other intermittent interventions
- DAILY THERAPY
- Daily inhaled glucocorticoids
- Daily leukotriene-receptor antagonists
- SUMMARY AND RECOMMENDATIONS