Pediatric Respiratory Emergencies Part 2

1. Pediatric Respiratory EmergenciesPart 2 Mohammed Al Faifi, MD. Pediatric Emergency Consultant Department of Emergency Medicine King Faisal Specialist Hospital & Research Centre Riyadh, KSA KUWAIT, Oct. 2011

2. Topics to be covered • Bronchiolitis • Croup

3. 2005 National Hospital Ambulatory Medical Care Survey a nationally representative sample of USA patients was analyzed Data on visits to EDs by children – 1 -19 years of age with moderate/severe Asthma – 3 months to 2 years of age with Bronchiolitis – 3 months to 3 years of age with Croup

4. Results

5. Conclusions Physicians treating children with Asthma, bronchiolitis croup In USA Emergency Departments are under using known effective treatments and overusing ineffective or unproven therapies and diagnostic tests.

6. A 5-month-old presents with cough for 2 days Preceded by a URI, his feeding has decreased and his cough interrupts sleep, Temp. 38° at home. Normal PMHx.

7. Temp 38.5°, RR 60, SaO2 94% in room air Mild rhinorrhea, air entry good, wheezing in all fields Well Hydrated, feeds well No grunting or retractions This is a classic case of

9. Diagnosis.  May be necessary for bed placement Not all bronchiolitis is RSV (metapneumovirus, para virus) Yet may decrease likelihood of bacteremia (but not UTI)

10. Febrile infants with confirmed viral infections are at lower risk for SBI than those in whom a viral infection is not identified Viral diagnostic data can positively contribute to the management of febrile infants, especially those who are classified as High risk. Peditrics Vol. 113: 1662, 2004

11. Differential Diagnosis Gastroesophageal reflux disease Tracheoesophageal fistula Tracheomalacia Vascular ring Cystic fibrosis & immunodeficiency CHD Foreign body aspiration.

12. • CXR

13. Evaluation of the utility of radiography in acute bronchiolitis. A prospective study of 265 children aged 2 to 23 months who presented to the ED with bronchiolitis analyzed use of routine radiography in patients with a simple form of the disease (defined in a child as coryza, cough, and respiratory distress accompanying a first episode of wheezing without underlying illness).

14. Result The findings were consistent with bronchiolitis except in only 2 cases, and in neither case did the findings change short-term management.

15. HIGH RISK Premature birth (< 35-37 weeks & younger age (< 6-12 weeks of life) Full term and younger than 1 month, Bronchopulmonary , cystic fibrosis (CHD), and immune deficiency disease Child’s parents or a clinician had already witnessed an apnea episode

16. Management Nasal Suction Beta 2 Agonists – Clinical trials, meta-analyses & systematic reviews (2000-2004) showed some differences in short term benefits (oxygen, RR) yet no difference in clinically meaningful outcomes (admission, length of stay) – Yet some will respond.

17. Bronchodilators for bronchiolitis. A Cochrane review of bronchodilators other than epinephrine found that the agents produce small, short-term improvements but do not affect rate of hospitalization or length of hospital

18. Epinephrine and Bronchiolitis A meta-analysis suggested a decrease in clinical symptoms when compared with either placebo

19. Ipratropium bromide At this point, use of anticholinergic agents?either alone or in combination with beta-adrenergic agents?for viral bronchiolitis is not justified in the ED

20. Bronchiolitis & Steroids • Corticosteroids – 2004 Cochrane Review, 13 trials, 1200 children • No difference in admission rates, no benefits compared to placebo – PECARN multicenter trial • Compared Dexamethasone and placebo in ED patients with bronchiolitis • No difference in admission at 4 hours

21. Bronchiolitis & Steroids  70 children, 3 winters, one center 2-23 months, first wheezing with distress and URI Dexamethasone (36) vs. placebo (34) Dexamethasone group – More improved clinical score – Few hospitalizations (19% vs 44%) Schuh et al. J Pediatr 2002

22. Dexamethasone for Bronchiolitis, A Multicenter, Randomized, Controlled Trial: The study compare single dose of oral dexamethasone (1 mg per kilogram of body weight) with placebo in 600 children (age range, 2 to 12 months) with a first episode of wheezing diagnosed in the ED as moderate-to-severe bronchiolitis. 20 emergency departments during the months of November through April over a 3-year period NEJM 2007; 357:331-9

23. Epinephrine and Dexamethasone in Children with Bronchiolitis Multicenter, double-blind, placebo-controlled trial • 800 infants (6 weeks to 12 months of age) with bronchiolitis randomly assigned to one of four study groups • The primary outcome was hospital admission within 7 days after the day of enrollment (the initial visit to the emergency department)

24. Conclusions Among infants with bronchiolitis treated in the ED, combined therapy with Dexamethasone and Epinephrine may significantly reduce hospital admissions, Admission Criteria: • Hypoxemia and poor feeding • Less than 34 weeks • Heart disease • Atelectasis • Less than 2 months,

25. A 3-year-old with cough at 2 AM, The child had a URI for 2 days and then began to cough, with hoarseness and stridor. In the ED he is febrile (38°), running around the room, without stridor at rest. • No drooling • Lungs clear

26. CXR NO

27. • Mist therapy??? • Corticosteroids – Effective in moderate to severe croup—PO / IM – Dexamethasone (0.15 - 0.6 mg/kg) PO/ IM • Aerosolized Racemic epinephrine – No rebound---reserve for kids with stridor at rest If clinically fine after 2 hours may , send home