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]