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Preschool wheeze affects at least one-third of all children younger than 5 years old, and a disproportionate number of preschool children use healthcare resources for wheezing episodes compared to school-aged children with asthma. However, despite this high prevalence, it remains a significant management challenge. Establishing a diagnosis is difficult, with almost complete reliance on accurate parental symptom reporting, and there are no objective tests to assess lung function or airway inflammation. These patients have a relatively poor response to traditional asthma medications, and we cannot predict or prevent who will progress to asthma.
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CONFIRMING THE DIAGNOSIS
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The presence of wheeze must be confirmed before any treatment is initiated. Unfortunately, establishing its presence can be a challenge, especially if the child is seen when he or she is well. The history relies on accurate parental reporting, but parents’ and physicians’ understandings of wheeze may be very different. Another factor is the influence of language and culture; there is not an equivalent word for “wheeze” in all languages, and many parents may not understand what is implied by the term and may respond incorrectly. The most important aspect of the history is, therefore, to ask open-ended questions and to allow the parents to describe the symptoms. Asking “Does your child have noisy breathing or difficulty in breathing?” may be a good start, followed by asking the parents to describe any noises that they hear. The use of terms such as “whistling” have been adopted especially for epidemiologic questionnaires; however, they may also be too directive and significantly influence the way parents respond. It is, therefore, best to minimize the use of any specific or leading words. It is important to remember that difficulty in breathing or breathlessness may be more apparent to parents than are overt noises. In the current era of smartphones, the best way to determine whether a child has true wheezing may be to ask the parents to record and/or take a video of their child during an episode. Numerous algorithms using smartphone technology to allow objective recognition of wheeze in the clinic are being generated; however, none is in routine clinical use. A good alternative is to use a video questionnaire containing clips of videos of varying noises including wheeze, upper airway noises, and stridor that can be shown to parents to try to objectively confirm wheeze. It is important to ensure that upper airway and rattily chest noises are not misinterpreted as wheeze. The presence of a cough often is equally as apparent as the presence of wheeze, and enquiry about the nature of the cough, specifically whether it is moist- or wet-sounding, rather than dry or tight, is essential to direct appropriate management.
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Given the difficulties inherent in the objective confirmation of wheeze (or bronchospasm, which is not the same thing) when a child is well, the primary care physician ...