A 4 year old boy with recurrent wheeze and chest infections

doi:10.1136/bmj.b1255

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Atul Gupta, specialist registrar in paediatric respiratory medicine,
Donald S Urquhart, specialist registrar in paediatric respiratory medicine,
Sarah Donovan, paediatric respiratory technician ,
Andrew Bush, consultant and professor

¹Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London SW3 6NP

Correspondence to: Atul Gupta atulgupta{at}doctors.org.uk

A 4 year old boy presented with a history of recurrent wheeze and chest infections over the previous two years, which had caused him to be admitted to hospital many times. Previous chest radiographs had shown right middle and lower lobe changes. The episodes had been treated with antibiotics with limited effect. Treatment for asthma (a bronchodilator and steroid inhalers) also failed to improve the situation. He was admitted for a 24 hour investigation, a 20 hour epoch of which is displayed below (figure)⇓.

Twenty hour trace

Questions

1 What is the name of the investigation shown?
2 What is the abnormality shown?
3 What are the limitations of the test?
4 How should it be treated?

Answers

Short answers

1 Oesophageal pH monitoring, which is used widely as an index of oesophageal acid exposure—it measures the frequency and duration of episodes of acid reflux.1 2
2 Multiple episodes of gastro-oesophageal reflux—113 reflux episodes in 20 hours and 52 minutes (5.3 per hour) (table⇓). Some of the reflux episodes were prolonged, and the longest reflux event lasted for 31 minutes. Overall, pH was <4 for 9.7% of the study, which is indicative of severe gastro-oesophageal reflux.

View this table:

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Details of episodes of reflux

3 The limitations of the pH study are that it does not detect non-acidic reflux episodes, it cannot diagnose pulmonary aspiration, it gives no indication of the volume of refluxate, the location of the probe must be confirmed radiographically, it cannot detect anatomical abnormalities (such as hiatus hernia or stricture), and it does not provide an objective measure of inflammation.
4 Medical treatment should be the first option. Infants respond favourably to changes in positioning, and some small infants respond well to thickening of feeds.3 Gastric acidity can be reduced by a histamine (H₂) antagonist (such as …