Optimising the management of wheeze in preschool children.

One third of all preschool children will have an episode of wheeze and many of these present to primary care. Most will fall within a spectrum of diagnosis ranging from episodic viral wheeze to multiple trigger wheeze or early onset asthma. A small proportion will have other rare, but important, diagnoses such as foreign body aspiration, anaphylaxis, gastro-oesophageal reflux, congenital anatomical abnormalities or other chronic lung diseases. Clinical assessment should try to classify children into either episodic viral wheeze or multiple trigger wheeze phenotypes. In clinical practice children rarely fit neatly into either category and the phenotype may change overtime. Clinical examination may well be normal in a child presenting with chronic symptoms. Urgent outpatient review should be considered for symptoms present from early infancy, chronic wet cough, failure to thrive or systemic involvement. The child should be referred to hospital immediately if you suspect an inhaled foreign body or anaphylaxis (after administering IM adrenaline). NICE recommends immediate referral for children with wheeze and high-risk features and also those with intermediate-risk features failing to respond to bronchodilator therapy. Children with high-risk features on assessment should be treated immediately with inhaled bronchodilator therapy. Those with intermediate risk should be treated immediately with bronchodilator therapy and reassessed 15-30 minutes later. Intermediate-risk children who respond and low-risk children can be managed at home with bronchodilator therapy via a spacer device.