1 / 35

Inpatient Bronchiolitis: So Much Time and So Little To Do

Inpatient Bronchiolitis: So Much Time and So Little To Do. Alan Schroeder, MD Director, PICU Chief, Pediatric Inpatient Services Santa Clara Valley Medical Center. Case – urgent care.

watson
Download Presentation

Inpatient Bronchiolitis: So Much Time and So Little To Do

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Inpatient Bronchiolitis: So Much Time and So Little To Do Alan Schroeder, MD Director, PICU Chief, Pediatric Inpatient Services Santa Clara Valley Medical Center

  2. Case – urgent care • Otherwise healthy 6 month old with 3 days cough, runny nose, fussiness, decreased PO intake but normal wet diapers. • On PE, T=101, RR = 50, O2 Sat = 94%, HR = 160, fussy but consolable, adequately hydrated, lots o’ snot, expiratory wheezes, mild SC&IC rtxns

  3. Results Mallory, Pediatrics, 2003

  4. Management Dilemmas in Bronchiolitis • Nebs? • Albuterol vs racemic epinephrine? • Hypertonic saline? • Suctioning (+/- saline)? • Chest Physiotherapy? • If febrile, R/O SBI? • CXR? • Steroids? • Decongestants? • Abx? • When to admit? • O2 Sat criteria? • Risk of apnea? • Safe to eat? • When to discharge?

  5. Bronchiolitis Overview • #1 cause of infant hospitalization • 1/3 of all children get bronchiolitis in first 2 years • 1/30 children get hospitalized • 150,000 hospitalizations per year • 1.5M annual outpatient visits for RSV alone • $500-700M/year

  6. Bronchiolitis – Definition • “a seasonal viral illness characterized by fever, nasal discharge, and dry, wheezy cough. On examination there are fine inspiratory crackles and/or high-pitched expiratory wheeze” www.nottingham.ac.uk/paediatric-guideline/breathingguideline.pdf.

  7. Why have hospitalization rates increased? • Increased survival of children with comorbidities • ? Virulence • Increase in daycare • Changes in hospitalization criteria

  8. Bronchiolitis seasonality MMWR, 2009

  9. Inflammed/ edematous bronchial walls WBC’s (mostly monos) infiltrate bronchiolar epithelium Mucus plugs block airway Pathophysiology http://www.health-healths.com/tag/prevention/page/5

  10. Pathphysiology • Mucus plugging  one-way valve  hyperinflation  absorption atalectasis --> V:Q mismatch • Smooth-muscle constriction (bronchiolespasm) not a factor

  11. Clinical presentation • URI symptoms first • Spreads to LRT – cough, tachypnea more present • Fever in ~ 50% • Poor po intake, decreased UOP

  12. Exam

  13. Concerning clinical findings • Lethargy/extreme irritability • Dehydration • Respiratory distress • Apnea

  14. Outline • Overview • Burden of disease • Pathophysiology/clinical presentation • MARC-30 study • Treatment – what’s the evidence?

  15. SCVMC and MARC-30 study • MARC = Multicenter Airway Research Collaboration • Part of Emergency Medicine Network (EMNet) • Prospective, multicenter. • 16 sites, 2200 patients over 3 winters (11/07 – 4/10) • NIH funded (NIAID) • PI: Carlos Camargo (Mass General), Jonathan Mansbach (Boston Children’s) • Aims: • Elucidate role of co-infections • Identify predictors of PPV • Establish evidence-based discharge criteria

  16. Viral co-infections

  17. Virology - Implications • Cohorting/isolation? • Comfort of diagnosis? • Utilization of resources? • Hospital charges: • Flu A, B, RSV   ($220) • Para 1,2,3         ($220) • Bordetella pertussis, B. parapertussis      ($95)

  18. Virology - implications • My conclusion: run-of-the-mill bronchiolitis does not warrant viral testing • Possibly for influenza • only 19/2200 (~1% of patients in cohort) • Same goes for CXR, labs, even if febrile • UA/Urine Cx if < 90 days? [Ralston, Arch Pediatr Adol Med 2011]

  19. Outline • Overview • Burden of disease • Pathophysiology/clinical presentation • MARC-30 study • Treatment – what’s the evidence?

  20. Steroids? • 2003 Cochrane (Patel et al): • “Available evidence suggests that corticosteroid therapy is not of benefit in this patient group” • 13 trials • AAP recs (2005): • “Corticosteroids should not be used routinely in the management of bronchiolitis”

  21. B-agonists • Cochrane 2010 (Gadomski and Brower): • 28 trials (1912 infants) • No reduction in admission or length of hospitalization • Transient reduction in clinical score • AAP (2005): • “bronchodilators should not be used routinely in the management of bronchiolitis…” • “…A carefully monitored trial of beta or alpha agonist is an option”

  22. Epinephrine • Cochrane 2011 (Hartling et al) • 19 studies, 2256 patients • RR admissions on Day 1 in outpatients = .67 (.50-.89) vs placebo • Shorter LOS for epi vs salbutamol

  23. Epi + dexamethasone? • Pediatric Emergency Research Canada RCT[Plint et al, NEJM 2009] • 800 kids • 4 arms: • Decadron • Racemic epi • Decadron + epi • Placebo • Marginal benefit in admission rate by 7 days in decadron + epi group (17% vs 26%)

  24. Hypertonic saline • Zhang et al, Cochrane 2008 • 4 trials, 254 patients, with/without bronchodilators • ↓LOS by 1 day • Reduced clinical score in outpatients • 4 additional RCTs • 2 with some benefit (Al-Ansari et al, J Peds 2010; Luo et al, Clin Microb Inf, 2011) • 2 with no benefit (Kuzik et al, CJEM 2010; Grewal et al, Arch Pediatr Adol Med 2009)

  25. Hypertonic saline • Bronchodilators necessary? [Ralston et al, Pediatrics, 2010] • 1 episode of bronchospasm in 377 doses of HS without bronchodilator • So why not? • (We’ve been down this path before…)

  26. Increasing inpatient bronchiolitis volume  reduced steroids, xrays, laboratory tests Pediatrics, 2011

  27. 6 RCTs, included 2 trials that did not exclude prior wheezers • Conclusion: “Published reports of the effect of systemic corticosteroids on the course of bronchiolitis suggest a statistically significant improvement in clinical symptoms, LOS, and DOS.” Pediatrics 2000

  28. Nasal decongestants • Ralston et al, J Peds 2008 • 41 infants, phenylephrine vs placebo • No benefit

  29. Chest PT • Gajdos et al, PLOS, 2010 • Multicenter RCT of CPT (forced expiratory techniques and assisted cough) vs nasal suction • 496 infants, no benefit • Roque, Cochrane 2012 • 9 trials (5 vibration/percussion, 4 passive expiratory) • No benefit

  30. Heliox • Less turbulent airflow through resistant airways • When given in ED with racemic epi + via HFNC, small improvement in clinical scores but no reduction in admission or LOS [Kim et al, APAM 2011] • Mixed results in ICU setting [Martinon-Torres et al, Pediatrics 2002; Liet et al, J Peds 2005]

  31. O2 Sat: why does it matter? • It can be easily fixed!! • May predict respiratory failure or ICU transfer in early phase of disease • May predict readmission • ?May be deleterious to the developing brain? • Commentary to 2005 AAP guidelines (Cutoff = “persistently below 90%”): “It is unfortunate that the recommendation fails to address another significant consideration, viz, the impact of chronic or intermittent hypoxia on later cognitive and behavioral outcomes.”[Bass, Pediatrics 2007] • Site articles suggesting some detriment at 90-94% (in pts with CHD or OSA!!!)

  32. Oxygen • LOS prolonged by perceived need for O2 • 26% - 57% of hospitalized patients [Schroeder, Archives Ped Adol Med 2004; Unger, Pediatrics 2008] • AAP: • “As child’s course improves, continuous O2 monitoring is not routinely needed” • Ongoing RCT of continuous vs intermittent pulse oximetry

  33. Summary • No frittering • Resist temptation to treat all wheezing • Racemic epinephrine instead of albuterol? • Limited utility of NP swabs • Search for the holy grail continues

  34. More to come from MARC-30 • Predicting safe discharge • Predicting PPV • Better understanding of apnea and the associated viruses • Role of vitamin D levels • Development of asthma after bronchiolitis

More Related