Preschool wheeze is not asthma: a clinical dilemma

Recurrent wheezing is common in preschool children and often gets labelled as asthma. It is important to differentiate preschool wheeze from asthma through focused history, examination and exclusion of other serious conditions that may present as wheeze. Two different pragmatic clinical phenotypes viz. episodic viral wheeze (EVW) and multi-trigger wheeze (MTW) have been described although categories do not remain fixed and cross over is often seen in clinical practice. Episodic use of inhaled bronchodilators such as salbutamol when wheezy, is the mainstay of treatment along with non-pharmacological measures such as avoidance of environmental tobacco smoke and parental education. Inhaled corticosteroids are the first choice for maintenance therapy in MTW whereas montelukast may be useful when maintenance therapy is considered in EVW. Any maintenance therapy should be viewed as a trial and need to be discontinued in cases where no benefit has been demonstrated. Short term systemic steroid therapy should be reserved for excaerbation of wheezy symptoms where hospitalization is necessary. Prognosis is good in recurrent mild EVW although remission in atopic MTW is often not achieved and the children in the latter group go on to develop asthma.