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Pediatric ABC’s

Pediatric ABC’s. Asthma, Bronchiolitis and Croup (and some quickies). David Chaulk Pediatric EM Fellow January, 2004. Case 1.

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Pediatric ABC’s

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  1. Pediatric ABC’s Asthma, Bronchiolitis and Croup (and some quickies) David Chaulk Pediatric EM Fellow January, 2004

  2. Case 1 A seven year old boy presents to the Emergency Department with a 24 hour history of cough, wheeze and increasing shortness of breath which began shortly after the onset of a low grade fever and rhinorrhoea. He has had one previous episode of wheezing. The episode had followed an upper respiratory tract infection. He is not on any medications.

  3. He is agitated and talking in short phrases only, with a respiratory rate of 40 per minute, heart rate of 130 and oxygen saturation in room air of 89%. Examination of the chest reveals moderate intercostal and subcostal retractions. On auscultation, you note reduced breath sounds throughout the lung fields with widespread expiratory wheeze. Other than a clear nasal discharge, the remainder of the physical examination is normal. What treatment would you initiate?

  4. Questions: • Should you give him ipratropium bromide with the first mask? • What about racemic epinephrine instead of salbutamol? • Steroids? PO or IV? Inhaled? When? • What about magnesium ? • Spacer vs nebulizer ?

  5. Question 1: Does the addition of a nebulized anticholinergic agent (ipratropium bromide) to nebulized beta-agonist decrease the risk of admission to hospital?

  6. Should inhaled anticholinergics be added to ß2 agonists for treating acute childhood and adolescent asthma? A systematic reviewPlotnick et al, 1998 • 10 trials involving 836 children. • Outcomes: respiratory function (FEV1) and rates of admission • Addition of a single dose of anticholinergic : improvement in FEV1 at 60 minutes (mean difference 16.1%) but no reduction in hospital admission

  7. Should inhaled anticholinergics be added to ß2 agonists for treating acute childhood and adolescent asthma? A systematic review Plotnick et al, 1998 • In children with more severe asthma who received multiple doses of ipratropium: reduction in hospital admission by 30% • Number of children needed to treat with ipratropium to prevent one hospital admission is 11

  8. Effect of nebulized ipratropium on the hospitalization rates of children with asthma Qureshi et al, 1998 • Double blind RCT • 434 pts, 2-18 yrs • Moderate to severe asthma in ED • All had salbutamol every 20 minutes and oral prednisone at 2mg/kg • Received either ipratropium bromide (500 mcg) or placebo with the second and third inhalations of salbutamol

  9. Effect of nebulized ipratropium on the hospitalization rates of children with asthma Qureshi et al, 1998 • Significant decrease in hospitalization, with an absolute reduction in hospitalization rate of 15.1% • The number of children with severe asthma to be treated with ipratropium to prevent one admission was 6.6

  10. Cochrane Review May 2001 • 8 studies - considerable heterogeneity • Single dose does not work • Multiple dose decreases admissions • NNT 12 overall 95% CI ( 8, 32 ) • NNT 7 severe subgroup 95% CI ( 5,20 )

  11. Question 2: Is racemic epinephrine effective in children who have acute asthma ?

  12. A randomized double blind study comparing the efficacy of racemic epinephrine to salbutamol in acute asthma. Plint et al, 2000 • Double blind RCT • 120 pts, 1-17 yrs • Salbutamol or racemic epinephrine at 0,20,40 min • All had PO dexamethasone. • Outcomes: pulmonary index score (PIS), oxygen saturation, length of stay in ED, hospital admission and relapse rate. • No significant difference between two treatments

  13. Question 3: In children with acute asthma, do IV steroids decrease hospitalization and improve clinical symptoms as compared to oral steroids?

  14. Intravenous versus oral corticosteroids in the management of asthma in children • Barnett, 1997 • Double blind RCT • 49 pts, 18 mo-18 yr with severe asthma • Given 2 mg/kg methylprednisolone either PO or IV 30 min after first albuterol • Outcomes: Pulmonary index score, FEV1, hospital admission rates • No difference in PIS, FEV1 at 4 hours. No difference in hospitalization rates.

  15. Oral versus intravenous corticosteroids in children hospitalized with asthma • Becker et al, 1999 • Double blind RCT • 66 pts, 2-18 yrs • Prednisone 2 mg/kg/dose BID vs methylprednisolone 1 mg/kg/dose QID • Outcomes: length of hospitalization, ß agonist use, duration of Oxygen tx and PFT’s • Oxygen use significantly less in prednisone group (30 vs 59 hours). No other differences noted.

  16. Question 4:When should you give systemic steroids to the patient ?

  17. Cochrane Review May 2001 Early emergency department treatment of acute asthma with systemic corticosteroids • 12 Studies : • 863 Patients • 409 Pediatric • Steroids within 1 hr of arrival in the ED • Main outcome: need for admission • Number needed to treat with steroids in the first hour to prevent one admission = 6

  18. Question 5What is the role of inhaled steroids in acute asthma?

  19. The effectiveness of inhaled corticosteroids in the emergency department treatment of acute asthma: a meta-analysis Edmonds, 2002 • 6 trials ( 4 adult, 2 pediatric) • 2 compared inhaled steroids in addition to systemic steroids, 4 comparison to placebo • 352 pts • Less likely to be admitted (OR 0.3) • Small improvement in peak exp flows ( 8%) • Unable to determine if as effective as systemic steroids

  20. Question 5Is magnesium sulfate effective in improving symptoms in children with moderate to severe acute asthma?

  21. A randomized trial of magnesium in the emergency department treatment of children with asthma. Scarfone, 2000 • 54 pts • 1-18 yrs • After receiving B agonist and methylprednisolone • 75 mg/kg of MgSO4 or placebo • Outcomes: pulmonary index score, admissions • No significant differences between groups

  22. Higher Dose Intravenous Magnesium Therapy For Children with Moderate to Severe Acute AsthmaCiarallo, 2003 • Double Blind, Placebo controlled trial • 30 pts aged 6-18 • At 20 minutes Mg group improved in all aspects of PFT (PF, FEV1, FVC) • Still greater improvement at 110 mins • More likely to be discharged (8/16 compared to 0/14) • Compare this study with Scarfone, Ciarallo had sicker pateints

  23. Cochrane Review Magnesium sulfate for treating exacerbations of acute asthma in the emergency department Sep 2000 • 7 trials • 5 adult, 2 pediatric • 665 pts ( 78 pediatric) • Outcome = Admission Rate • No benefit when all patients treated • Severe sub-group showed significant benefit (90% --> 48% adm)

  24. Question 6 Does the Salbutamol need to be given by nebulization or can a spacer device be used?

  25. Cochrane Review July 2001 • 16 studies: • 686 children • 375 adults • No difference in admission rate • 95% CI ( OR: 0.4 to 2.1 ) • Children’s LOS in the ED shorter • mean diff: -0.62 hours • 95% CI ( -0.84 to -0.40 )

  26. Metered-dose inhalers with spacers vs nebulizers for pediatric asthma Chou, 1995 • 152 patients • > 2 years old • Unblinded • 3 puffs q20 minutes via aerochamber vs. • 0.15mg/kg Ventolin via nebulizer

  27. Metered-dose inhalers with spacers vs nebulizers for pediatric asthma Chou, 1995 Time in ED Vomiting HR Spacer 66 9% +5% Nebulizer 103 20% +15%

  28. Case 1- Summary: • Multiple doses of ipratropium bromide added to nebulized ßagonist reduce the rate of hospital admission • Single dose does not appear to be of any benefit • Racemic epinephrine is equivalent to salbutamol in children with asthma, with no increased adverse effects

  29. Case 1- Summary: • Oral steroids given in equipotent doses are equivalent to intravenous steroids • Steroids should be given early in the emergency course • Inhaled steroids may have an adjunctive role • Magnesium may be beneficial in severe cases • Spacers may be effective for acute asthma

  30. Pediatric Asthma Guidelines MILD Treatment • Nocturnal cough • Exertional SOB • Increased Ventolin use • Good response to Ventolin • O2 sat > 95% • Ventolin • Consider po Steroids

  31. Pediatric Asthma Guidelines • Normal mental status • Abbreviated speech • SOB at rest • Ventolin > q4h • O2 sat 92%-95% • O2 100% • Ventolin • Systemic corticosteroids • Consider anticholinergic MODERATE Treatment

  32. Pediatric Asthma Guidelines • Altered mental status • Difficulty speaking • Laboured respirations • Persistent tachycardia • No prehospital relief with Ventolin • O2 saturation <92% • 100% O2 • Continuous Ventolin • Systemic corticosteroids • Anticholinergic • Consider Magnesium sulfate SEVERE Treatment

  33. Case 2 • A four month old infant is seen in your emergency department with a history of fever and difficulty breathing. • He has had nasal congestion and cough for several days and today developed increased respiratory difficulties.

  34. Case 2 • He was born at 32 weeks gestation and had an uncomplicated neonatal course, requiring no oxygen or ventilatory support. He has been well since discharge from the neonatal unit and is on no regular medications. • There is no history of atopy.

  35. Case 2 • On examination, he is in moderate respiratory distress. Vital signs are as follows: HR 180, RR 60, T 38.9o C. Oxygen saturation 91%. He has widespread wheeze and fine crackles on auscultation. Remainder of exam is normal. • The chest x-ray shows evidence of hyperinflation (air-trapping) and some infiltrates in the lower lobes. • A diagnosis of viral bronchiolitis is made.

  36. Questions: • Does treatment with bronchodilators reduce symptoms or the need for hospital admission? • Is epinephrine more effective than beta-agonists? • Does treatment with steroids reduce symptoms or the need for hospital admission? • Does treatment with antibiotics reduce bacterial complications?

  37. Question 1: In infants with clinical features of bronchiolitis, does treatment with bronchodilators improve symptoms and reduce the need for hospital admission?

  38. Efficacy of Bronchodilator Therapy in Bronchiolitis: A meta-analysis Kellner et al, 1996 • RCTs of bronchodilator use in bronchiolitis • 15 of 89 publications met selection criteria • 8 trials had first time wheezers only • Total of 734 pts included • 3 outcomes: clinical score, O2 saturation, and hospitalization

  39. Efficacy of Bronchodilator Therapy in Bronchiolitis: A meta-analysis Kellner et al, 1996 • ß2 agonist most commonly used was albuterol. • Some studies also included ipratropium bromide and epinephrine. • With pooled results, only improvement in clinical sxs was statistically significant. No effect on hospital admission rates. • Conclusion: There is a only a modest short-term effect of bronchodilators on bronchiolitis

  40. Efficacy of ß2 agonists in Bronchiolitis: A reappraisal and meta-analysis Flores and Horowitz, 1997 • ß2 agonists had no impact on hospitalization rates. • No significant effect on respiratory rate. • Statistically significant improvement in oxygen saturation (2.8%) and heart rate (15 bpm) but not clinically significant. • Short term outpatient studies do not support the use of ß2 agonists in bronchiolitis.

  41. Question 2: Does epinephrine, which has both alpha and beta-adrenergic properties, have an advantage over salbutamol and other beta-agonists?

  42. A Meta Analysis of Randomized Controlled Trials Evaluating The Efficacy of Epinephrine For the Treatment of Acute Viral Bronchiolitis Hartling, et al., Oct 2003 • 14 studies, 7 inpt, 6 outp, 1 unk • Outpatients • Epinephrine more effective than placebo in • clinical score (60 minutes) • Oxygen saturation (30 mins) • RR at 30 mins • Epinephrine more effective than salbutamol in: • Oxygen saturation at 60 mins • RR at 60 mins • HR at 90 mins • Small number of studies of varying quality

  43. Question 3: In infants with clinical features of bronchiolitis, does treatment with dexamethasone reduce symptoms?

  44. Dexamethasone in salbutamol-treated patients with acute bronchiolitis: a randomized controlled trial. Klassen et al, 1997 Randomized, double blind study. 67 pts, 6 wks-15 mos. Hospitalized infants. Oral dexamethasone (0.5 mg/kg first dose, followed by two daily doses of 0.3mg/kg) or placebo. Outcomes: readmission rate, length of stay and improvement in clinical score. No statistically significant difference between treatment and placebo groups.

  45. Systemic Corticosteroids in infant bronchiolitis: a meta-analysis. Garrison, 2000 • 6 trials • 347 hospitalized pts • < 24 months • Outcomes: Length of stay, duration of symptoms, clinical scores • LOS or DOS: .43 days less in steroid group • Clinical score : - 1.60 (favoring treatment) • Steroids beneficial?

  46. Efficacy of oral dexamethasone in outpatients with acute bronchiolitis. Schuh 2002 • Double blind RCT • 70 children <24 mos • Dexamethasone 1 mg/kg vs placebo • Outcomes: Clinical score and admissions • Admission rate in Dex group 19% vs 44% in placebo group

  47. Question 4: Is oral salbutamol effective for the outpatient management of bronchiolitis?

  48. Randomized, Double-blind, Placebo-controlled Trial of Oral Salbutamol in Outpatient Infants with Acute Viral BronchiolitisPatel 2002 • Randomized, double-blind trial • Infants with first-time wheezing • At discharge ED received either salbutamol (0.1 mg/kg/ dose) TID or placebo for 7 days • Daily telephone interviews inquiring about symptom frequency and severity were conducted with caregivers for 14 days • Outcome: time to resolution of symptoms

  49. Randomized, Double-blind, Placebo-controlled Trial of Oral Salbutamol in Outpatient Infants with Acute Viral Bronchiolitis Patel 2002 • Secondary outcomes included time to: • normal feeding and sleeping • resolved cough resolved coryza, and quiet breathing • Re-visit and hospital admission rates were also measured • 127 infants were enrolled • SAL = 63, PLAC = 64 • mean age 4.9 mos, 60% male • 76% positive for RSV

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