Pediatric respiratory emergencies
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Pediatric Respiratory Emergencies. THE LOWER AIRWAYS. Case 1. 2M male 3 day history of URTI associated with fever (38.5) Onset of difficulty feeding, increased WOB today Vitals - HR 160 RR 65 SpO2 90% on R/A T 37.9 TT, indrawing, nasal flaring, diffuse crackles and wheezes.

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Pediatric Respiratory Emergencies

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Pediatric respiratory emergencies

Pediatric Respiratory Emergencies

THE LOWER AIRWAYS


Case 1

Case 1

2M male

3 day history of URTI associated with fever (38.5)

Onset of difficulty feeding, increased WOB today

Vitals - HR 160 RR 65 SpO2 90% on R/A T 37.9

TT, indrawing, nasal flaring, diffuse crackles and wheezes


Differential diagnosis of wheeze

Differential diagnosis of Wheeze

  • Infection (Bronchiolitis, pneumonia)

  • Asthma

  • Cystic Fibrosis

  • CHF

  • Foreign body

  • Anaphylaxis

  • Croup

  • Epiglottis

  • Vocal cord dysfunction

  • GERD

  • Bronchopulmonary dysplasia


You think he has bronchiolitis

You think he has bronchiolitis

  • What do you tell his parents about his illness and its natural history?


Bronchiolitis

Bronchiolitis

  • Viral infection

    • RSV, influenza, parainfluenza, echovirus, rhinovirus, adenovirus

    • Mycoplasm, Chlamydia

  • Children < 2 years, peak at 2 M

  • October to May

  • Contact/Droplet

  • Peak at 3-5 d

  • Resolves 2 weeks


Bronchiolitis1

Bronchiolitis

  • Inflammation of terminal and respiratory bronchioles

    • Mucus plug + edema

    • Airway narrowing

    • Decrease compliance, increase resistance

    • Atelectasis and overdistention


Bronchiolitis2

Bronchiolitis

  • Clinical presentation

    • Wheeze, tachypnea, indrawing

    • URT symptoms

    • Fever

    • Hypoxemia

    • Apnea


What factors put children at increased risk of severe bronchiolitis

What factors put children at increased risk of severe bronchiolitis?

  • History of

    • Prematurity

    • BPD

    • CF

    • Congenital heart disease

    • Immunocompromised


Management

Management

  • You start oxygen and encourage feeding

  • When patient not feeding well you give 20 mL/kg bolus

  • RT asks you if you want this child to be treated with bronchodilators or steroids…

  • What do you think?


Controversial

Controversial

  • Many trials done to examine use of

    • Epinephrine

    • ß-adrenergics

    • Steroids

      • IV

      • PO

      • Inhaled


Evidence for epinephrine

Evidence for Epinephrine

  • Epinephrine vs. placebo or salbutamol

  • 5/8 showed short term improvement in clinical scores

  • 1/8 showed fewer hospitalization

  • 1/8 showed shorter duration of hospitalization


Evidence for epinephrine1

Evidence for Epinephrine

  • Hartling et al, 2003

    • Meta-analysis

    • Epinephrine vs. bronchodilators or placebo

    • RCT, infants<2 years, quantitative outcome

    • 14 studies, 7 inpatient, 6 outpatient, 1 unknown

    • Outpatient results

      • Epi better than placebo or other bronchodilators in short term (O2 saturation, RR, clinical score)


Evidence for epinephrine2

Evidence for Epinephrine

  • Cochrane Systematic Review

  • 14 RCT (1966-2003)

  • Inpatient and outpatient treatment

  • Epinephrine vs. placebo - outpatient (3)

    • Improvement at 60 minutes (1/3studies)

    • No difference in admission or O2 saturation

  • Epinephrine vs. Salbutamol - outpatient (4)

    • O2 saturation, HR, RR improved at 60 minutes

    • No difference in admission


Pediatric respiratory emergencies

Evidence for Bronchodilators

  • 13 RCT

  • Bronchodilators vs. placebo or ipatropium

  • 1/13 showed decreased admission

  • 4/13 showed some clinical improvement


Evidence for bronchodilators

Evidence for Bronchodilators

  • Cochrane Systematic Review

  • 22 RCT (1966-2005)

  • Bronchodilators vs. placebo

  • No difference in admission or duration of hospitalization

  • Minor improvement in oximetry and symptoms in outpatient treatment


Pediatric respiratory emergencies

  • Previous studies used larger doses of epinephrine

    • Effect may not be due to alpha affects, but higher delivery of ß-agonist


Pediatric respiratory emergencies

  • RCT comparing racemic epinephrine, racemic albuterol, normal saline in equivalent doses in mild/moderate bronchiolitis

  • N = 65 (23-albuterol, 17 epi, 25 NS)

  • 5mg of drug in 3 mL at 0 and 30 minutes

  • Clinical assessment pre and post

  • 3 rd dose at 60 minutes if RDAI >8 or O2 saturation < 90% R/A

  • Final assessment at either 60 or 90 minutes


Pediatric respiratory emergencies

  • Required admission/home oxygen

    • 61% albuterol, 59% epinephrine, 64% NS

  • No difference in admission rates

  • No difference in O2 saturation, RR

  • ß-agonist not useful in Rx bronchiolitis


Pediatric respiratory emergencies

  • “ß-agonists should not be used routinely in management of bronchiolitis” Level B

  • “A carefully monitored trial of alpha adrenergic or ß-adrenergic medications is an option…and continued only if there is a documented positive clinical response using objective means of evaluation” Level B

  • “…it would be more appropriate that a bronchodilator trial…use salbutamol rather than racemic epinephrine”


Pediatric respiratory emergencies

  • What about steroids?


Pediatric respiratory emergencies

  • Systematic review

  • Oral, IV and inhaled steroids

  • Oral

    • 6 RCT involving prednisone (1) prednisolone (2) Dexamethasone (2) Prednisolone and albuterol vs. Placebo and albuterol

    • Various outcomes (hospitalization, clinical score, length of stay, duration of ventilation)

    • 1 found decreased rate of admission, 1 found increased rate of admission,1 found shorter duration of ventilation, 1 found improved clinical status

    • Felt data was inconclusive


Pediatric respiratory emergencies

  • IV

    • 2 RCT

    • Dexamethasone to placebo

    • No benefit

      • Clinical score, admission, time to resolution, duration of oxygen therapy


Pediatric respiratory emergencies

  • Inhaled

    • 6 RCT

    • Mostly used budesonide

    • Worse wheeze/cough at 12 months in 1

    • Increase readmission

    • No benefit shown


Pediatric respiratory emergencies

Evidence for Steroids

  • Cochrance Systematic Review

  • 13 RCT

  • No difference

    • RR

    • O2 saturation

    • Admission

    • Length of stay

    • Subsequent visits

    • Readmission


Pediatric respiratory emergencies

  • RCT

    • Comparing admission to hospital and RACS 4 hours after dose of dexamethasone (1mg/kg) versus placebo

  • January 2004 - April 2006

  • N = 600 (305 dexamethasone, 295 placebo)

  • Admission

    • 39.7% in dex vs. 41% in placebo - no difference

  • RACS - sum of change in RDAI minus standardized score for change in RR (negative value = good response)

    • No difference


Pediatric respiratory emergencies

“Corticosteroid medications should not be used routinely in the management of bronchiolitis” Level B


Pediatric respiratory emergencies

  • CANBEST study

    • RDBCT

    • N=800

    • 4 treatment arms

    • Primary outcome

      • Hospital admission up to 7 days after enrollment

    • Epi + Dex NNT 11.4 to prevent one hospitalization


Palivizumab

Palivizumab

  • Humanized, mouse monoclonal anti-RSV antibody

  • Monthly X 5 months, 15 mg/kg IM

  • Prevention of serious RSV lower respiratory tract infection

    • Children < 2 years

    • Chronic lung disease of prematurity

    • Premature ≤ 32 weeks

    • Hemodynamically significant cyanotic or acyanotic congenital heart disease


Pediatric respiratory emergencies

  • Any novel treatments?


Hypertonic saline

Hypertonic saline

  • Mechanism incompletely understood

    • Osmotic hydration

    • Reduction of cross-linking

    • Edema reduction


Pediatric respiratory emergencies

  • RCT, multicentre (KGH, VGH) comparing length of stay in admitted patients receiving treatment with 3% HS vs. NS

  • N=93 (47 - HS, 49 - NS)

  • Doses q 2h X3, q4h X5, q6h until D/C

  • Any other treatments mixed with appropriate solution


Pediatric respiratory emergencies

  • Length of stay

    • HS 2.6 days +/- 1.9 days

    • NS 3.5 days +/- 2.9 days

    • 26% reduction in LOS

    • P = 0.05


Pediatric respiratory emergencies

  • RCT comparing epinephrine 1.5 mg in 4 mL NS vs. epinephrine 1.5 mg in 4 mL of HS

  • N = 53 (25 NS, 27 HS)

  • Length of stay, change in clinical severity

  • NS 4 +/- 1.9, HS 3 +/- 1.2, p < 0.05


Case 3

Case 3

  • 6 yo M with PMH of asthma

  • URTI X4 days, using blue puffer

  • Increase WOB today

  • HR 130, RR 35, 90% on R/A

  • Indrawing, Audible wheeze

  • Decreased breath sounds to R

  • Wheeze


How do you want to treat this child

How do you want to treat this child?


New therapies

New therapies

  • Chest 2006 129(2)246-256

  • RDBCT

  • N=697 (age 11-79)

  • Budesonide/Formoterol vs. budesonide + terbutaline

  • Budesonide/Formoterol as maintenance/reliever

    • 54% decrease in severe exacerbation

    • 90% fewer hospitalizations/ED visits

    • 77% fewer days with oral steroids


Evidence for anti cholinergics

Evidence for Anti-cholinergics

  • NEJM 1998

  • RDBCT

  • Albuterol vs. albuterol+ IB x 2 dose

  • N=434 (2-18 years)

  • IB

    • Decreased hospitalization (27 vs 36%, p = 0.05)

      • Similar hospitalization rates in moderate exacerbation

      • Markedly different rates in severe exacerbations


Evidence for anti cholinergics1

Evidence for Anti-cholinergics

  • 32 studies, 16 pediatric

  • 10 studies - admission (1786 children)

    • Lower admission rate

    • NNT =13, 7 if only severe exacerbations included

  • 9 studies - spirometry

    • 1 or 2 doses had FEV1 difference of 12.4%

    • >2 doses had FEV1 difference of 16.3%


Evidence for anti cholinergics2

Evidence for Anti-cholinergics

  • Cochrane Systematic Review 2000

  • 13 trials

  • Multiple doses decreased risk of admission by 25%

  • Single doses improved lung function at 60 and 120 minutes, but no admission

  • NNT= 12 to avoid 1 admission in kids with either moderate or severe exacerbation

  • NNT = 7 if severe exacerbations


Nebulizer vs mdi spacer

Nebulizer vs. MDI/Spacer

  • RDBCT

  • N = 168 (2m to 24 months)

  • Nebulizer vs. Spacer

  • Primary outcome

    • Admission rates

  • Results

    • Controlled for difference in PIS

    • Spacer group admitted less

      • 5% vs. 20% p=0.05


Nebulizer vs mdi spacer1

Nebulizer vs. MDI/Spacer

  • RDBCT

  • N=90 (5 -17 years) baseline FEV1 50-79%

  • Treatment groups

    • 6-10 puffs

    • 2 puffs

    • 0.15mg/kg nebulized

  • Primary outcome

    • Improvement in % predicted FEV1

  • Results

    • No significant difference in % predicted FEV1 between groups


Nebulizer or mdi spacer

Nebulizer or MDI/Spacer

  • Cochrane Systematic Review 2006

  • Beta agonist via wet nebulizer vs. spacer

  • 25 outpatient trials

  • N = 2066 children, 614 adults

  • MDI+spacer was equivalent to wet nebulizer wrt hospital admission rates

  • MDI+spacer in kids

    • Decreased length of stay in ED


Continuous vs intermittent

Continuous vs. Intermittent

  • Cochrane Systematic Review 2003

  • Continuous or near continuous (q 15 minutes or >4 treatments/h) vs. intermittent nebulization

  • Continuous beneficial

    • Decreased admission

    • Most pronounced if severe exacerbation


Evidence for use of steroids

Evidence for use of steroids

  • Cochrane Systematic Review 2001

  • Benefit of treatment within 1 hour of ED presentation

  • 12 trials

  • N = 863

  • Reduced admission rates, NNT = 8

  • Most benefit

    • Not currently Rx with steroids

    • Severe exacerbation

  • Oral steroids worked well for kids


Evidence for mgso4

Evidence for MgSO4

  • 5 trials

  • IV MgSO4 at any dose vs. placebo in patients < 18 y treated with beta-agonists and steroids

  • MgSO4 reduced hospitalization

  • NNT=4 for avoiding hospitalization


Evidence for mgso41

Evidence for MgSO4

  • Cochrane Systematic Review

  • 7 trials (5 adult, 2 pediatric)

  • N= 665

  • In severe subgroup

    • Improved PEFR, FEV1, admission rates

    • Improvements not seen if all patients included


Evidence for mgso42

Evidence for MgSO4

  • Cochrane Systematic Review 2005

  • Inhaled MgSO4

  • 6 trials

  • N=296 (2 pediatric)

  • Heterogenous studies therefore difficult to make definitive conclusion

  • MgSO4 with beta-agonists showed benefit

    • Pulmonary function

    • Admission rates

    • In severe exacerbations


Evidence for iv salbutamol

Evidence for IV Salbutamol

  • Cochrane Systematic Review 2001

  • IV salbutamol in addition to other Rx vs. placebo

  • 15 trials

  • N=584

  • No benefit

    • Pulmonary function

    • Arterial gases

    • Vital signs

    • AE

    • Clinical success


Other treatments

Other treatments

  • Heliox

  • NIPPV


Case 31

Case 3

  • 5 M Male

  • Cough, fever, decreased energy and intake

  • Tachypnea, increased wob

  • SpO2 90% on R/A, RR 60

  • Crackles in RLL

  • CXR

    • Consolidation in RLL


Epidemiology

Epidemiology

  • 4% of kids/y in U.S.

    • Decreases with increasing age

  • < 2 years – 80% viral

  • > 4 years – 40% viral


Clinical features

Clinical features

  • Cough, fever, CP, tachypnea, grunting (infants), increased wob (indrawing, seesaw)

  • Typical presentation - bacterial

    • Rapid onset

    • Fever, chills, chest pain, cough

  • Atypical presentation – viral

    • Gradual onset

    • Malaise, h/a, cough, fever (low-grade)

  • Significant overlap


Pneumonia bugs

Pneumonia bugs


Specific bugs

Specific bugs

  • B. pertussis

  • 3 stages

    • Catarrhal phase

      • Coryza, cough lasting 1-2 weeks

    • Paroxysmal phase

      • Coughing fits associated with gagging, cyanosis

      • Whoop is uncommon in infants

      • Lasts ~ 4 weeks

    • Recovery

      • Cough improves over months

    • Treatment


Specific bugs1

Specific bugs

  • S. aureus

    • Rapid and severe

  • C. trachomatis

    • 50% of exposed will get conjunctivitis

    • 5-20% pneumonia

    • 2-19 weeks

    • Rarely febrile or systemically unwell

    • Staccatto cough


Cxr in ambulatory setting

CXR in ambulatory setting

  • N = 522 (2M to 59M)

  • Randomized to CXR or no CXR

  • Primary outcome

  • Results

    • Median 7 days to recovery in both groups

    • CXR group

      • More diagnosed with pneumonia

      • 60% vs. 52% treated with antibiotics

      • More follow-up appts.

      • No difference in consultation, admission, repeat CXR at 28 days


Pediatric respiratory emergencies

CXR

  • Bacterial

    • Lobar or segmental consolidation

  • Viral and atypical bacterial

    • Interstitial infiltrates

    • Peribronchial thickening

    • Atelectasis

  • Significant overlap

    • Not useful in determining etiological agent


Pediatric respiratory emergencies

CXR

  • May want to avoid in mild acute LRTI

  • Use if <5 and if fever >39 or toxic


Admission

Admission

  • SpO2<90-93%

  • Young age

  • Toxic

  • Immunocompromised

  • RR>70 (infant), >50 (older children)

  • Respiratory distress

  • Apnea/grunting

  • Not feeding or dehydrated

  • Social concerns


Acknowledgements

Acknowledgements

  • Thanks to Sarah McPherson and Jeremy Wojtowicz


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