Pediatric ABC’s

Asthma, Bronchiolitis and Croup(and some quickies)

David ChaulkPediatric EM Fellow

January, 2004

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.

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?

Questions:Questions:

• What about racemic epinephrine instead of salbutamol?

• Steroids? PO or IV? Inhaled? When?

• Should you give him ipratropium bromide with the first mask?

• What about magnesium ?

• Spacer vs nebulizer ?

Question 1:Question 1:

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

Should inhaled anticholinergics be added to ß2 agonists for treating acute childhood and adolescent asthma? A systematic review Plotnick 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

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

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

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

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 )

Question 2:Question 2:

Is racemic epinephrine effective in children who have acute asthma ?

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

Question 3:Question 3:

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

Intravenous versus oral corticosteroids in the management of asthma in childrenBarnett, 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.

Oral versus intravenous corticosteroids in children hospitalized with asthmaBecker 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.

Question 4:

When should you give systemic steroids to the patient ?

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

Question 5

What is the role of inhaled steroids in acute asthma?

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

Question 5

Is magnesium sulfate effective in improving symptoms in children with moderate to severe acute

asthma?

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

Higher Dose Intravenous Magnesium Therapy For Children with Moderate to Severe Acute Asthma

Ciarallo, 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

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)

Question 6Question 6

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

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 )

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

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%

• 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

Case 1- Summary:

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

Pediatric Asthma Guidelines

• Nocturnal cough• Exertional SOB• Increased Ventolin use • Good response to Ventolin

•O2 sat > 95%

• Ventolin• Consider po Steroids

MILD

Treatment

• Normal mental status• Abbreviated speech• SOB at rest• Ventolin > q4h

• O2 sat 92%-95%

• O2 100%• Ventolin• Systemic corticosteroids• Consider anticholinergic

MODERATE

Treatment

Pediatric Asthma Guidelines

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

Case 2Case 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.

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.

Case 2Case 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.

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?

Question 1:Question 1:

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

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

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

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.

Question 2:Question 2:

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

A Meta Analysis of Randomized Controlled Trials Evaluating The Efficacy of Epinephrine For the

Treatment of Acute Viral BronchiolitisHartling, 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

Question 3: Question 3:

In infants with clinical features of bronchiolitis, does treatment with dexamethasone reduce symptoms?

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.

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?

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

Question 4:Question 4:

Is oral salbutamol effective for the outpatient management of bronchiolitis?

Randomized, Double-blind, Placebo-controlled Trial of Oral Salbutamol in Outpatient Infants with Acute Viral

Bronchiolitis Patel 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

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

Randomized, Double-blind, Placebo-controlled Trial of Oral Salbutamol in Outpatient Infants with Acute Viral

Bronchiolitis Patel 2002

• Mean times to resolution of symptoms (days) were similar:– SAL = 8.9 – PLAC = 8.4 (p = 0.5)

• No significant group differences in the secondary outcomes

• No significant group differences in the symptom resolution in infants treated with oral salbutamol versus placebo

Question 5:Question 5:

In infants with RSV bronchiolitis, does treatment with antibiotics reduce bacterial complications or the need for readmission?

Risk of secondary bacterial infection in infants hospitalized with respiratory syncytial viral infection Hall et al, 1988

1706 pts, 565 of these RSV positive.< 3 yrs Prospective

7 of 565 had subsequent bacterial infection: 5 pneumonia (4 Strep. pneumoniae, 1 H.influenzae), 1 meningitis, 1 Salmonella sepsis

-prior antibiotic use in 5 of 7-overall 62% of RSV patients did not receive antibiotics

Overall rate of bacterial infection is 1.2%

Case 2 - Summary:Case 2 - Summary:

• Bronchodilators have a only a modest short term effect on bronchiolitis

• ßagonists not effective for bronchiolitis

• Racemic epinephrine may improve clinical symptoms, reduces hospital admission rates - superior to salbutamol in some studies

Case 2 - Summary:

• Dexamethasone may be effective in bronchiolitis

• Oral salbutamol is not effective

• Antibiotic use in bronchiolitis does not improve outcome or reduce bacterial complications - overall risk of bacterial infection is low

Case 3Case 3

A two-year-old previously healthy, immunized boy is brought to the ED in acute respiratory distress.

He has a 2 day history of runny nose, cough and low-grade fever.

Today he has developed a hoarse voice and barky cough.

Case 3• On arrival, vital signs: RR 40, T 38.5, P 140, BP 90/60,

O2 sat 95%.

• He is sitting upright in his mother's lap with stridulous, labored breathing. He is not drooling. He has diminished breath sounds, no crackles or wheezes. His extremities are pink and warm with brisk capillary refill. The remainder of his examination is normal.

• You diagnose croup and order racemic epinephrine.

Questions:

• Is steroid therapy effective in reducing acute symptoms?

• Do inhaled steroids give any additional benefit?

• Is dexamethasone 0.15 mg/kg as effective as 0.6 mg/kg?

Questions:

• Is mist therapy effective in reducing acute symptoms?

• Is L-epinephrine as effective as racemic epinephrine?

• Following nebulized epinephrine, what period of observation is needed

Question 1:Question 1:

In children with croup, is steroid therapy effective in reducing acute symptoms?

The effectiveness of glucocorticoids in treating croup: meta-analysis Ausejo, 1999

• Meta-analysis of RCTs of glucocorticoid treatment in croup

• 24 studies met inclusion criteria.• 4 mos to 12 yrs (mean ages 13 to 45 mos)

•Trials included: •17 assessed dexamethasone• 9 assessed budesonide• 3 assessed methylprednisolone

The effectiveness of glucocorticoids in treating croup: meta-analysis Ausejo, 1999

• Fourteen trials involved inpatients and 10 trials outpatients.

• The studies were small with a median of 40 participants.

• Overall, significant improvement in croup score at 6 and 12 hrs.

• By 24 hrs this improvement was not statistically significant.

The effectiveness of glucocorticoids in treating croup: meta-analysis Ausejo, 1999

• Significant decrease in the number of epinephrine tx needed

- decrease was 9% in the budesonide group and 12% in the dexamethasone group.

• Significant decrease in the length of hospital stay both in the ED (stay reduced by 11 hours) and for inpatients (stay reduced by 16 hours).

• NNT for significant improvement in outcome is 5-7 patients.

The effectiveness of glucocorticoids in treating croup: meta-analysis Ausejo, 1999

Conclusions:

•Glucocorticoids bring clinical improvement within 6 hours

•Nebulized budesonide, PO and IM Dexamethasone are equally effective in treating croup

•Use of glucocorticoids associated with lower rate of cointerventions and shorten hospital stay

Question 2: Question 2:

Do inhaled steroids give any additional benefit in children with croup?

Nebulized budesonide and oral dexamethasone for treatment of croup: A randomized controlled trial Klassen, 1998

Double blind RCT

Three arms: - oral dexamethasone 0.6 mg/kg and nebulized placebo- oral placebo and nebulized budesonide 2 m- oral dexamethasone and nebulized budesonide

Outcomes: croup score, hospitalization rates, time in ED, return visits, symptoms>1 week

Nebulized budesonide and oral dexamethasone for treatment of croup: A randomized controlled

trial Klassen, 1998

• Change in croup score was:– -2.3 for Budesonide– -2.4 for Dex– -2.4 for combined group

• No differences between treatment groups.

• Conclusion: Based on decreased cost and ease of administration, dexamethasone alone is preferred treatment.

A comparison of nebulized budesonide, IM dexamethasone and placebo for moderately severe croup Johnson et al, 1998

Double blind RCT

144 pts, 6 mos-4 yr

Treated with:•nebulized budesonide•IM dexamethasone •placebo

A comparison of nebulized budesonide, IM dexamethasone and placebo for moderately severe croup Johnson et al, 1998

• Hospitalization rates: • 71% placebo• 38% budesonide• 23% dexamethasone

• Statistically significant difference steroids vs placebo• No difference between bud and dex

• Croup scores: • significant improvement with dex or bud better than placebo and dex better than budesonide

Question 3:Question 3:

In children with croup, is single-dose decadron 0.15 mg/kg PO as effective as 0.6 mg/kg PO in reducing acute symptoms?

Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Geelhoed, 1995

RCT164 pts>3mos

No differences in croup score at 1-8 hours, hospitalization rate, length of stay or need for racemic epinephrine.

Question 4: Question 4:

Is mist therapy effective in reducing acute symptoms?

Humidification in viral croup: a controlled trialBourchier,1984

RCT. Not blinded16 ptsHumidified air delivered in croup tent for 12 hours vs room air.

No difference in croup score, RR, HR, oxygen saturation at one hour intervals.

A randomized controlled trial assessing the effectiveness of mist in the acute treatment of croup. Neto, 2002

71 pts

Randomized to receive humidified oxygen via mist stick vs. no mist

All received Dexamethasone 0.6 mg/kg

Outcome measures: croup score, oxygen saturation, HR, RR, length of stay, admission rate. Assessed at 0,30,60,90,120 min.

No significant difference in any of the outcome measures between the two groups.

Question 5: Question 5:

In children with croup, is a comparable dose of L-epinephrine as effective in reducing acute symptoms as racemic epinephrine?

Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine in the treatment of laryngotracheitis Waisman, 1995

Double blind RCT31 pts, 6 mos-6 yrsRacemic epinephrine 0.5 ml in 4.5 ml saline vs L-epinephrine 5 ml of 1:1000 solution.

Both had reduction in croup score with no difference seen at 5,15,30,60,120 min.

No differences in HR, RR, BP, Oxygen saturation.

Question 6: Question 6:

In children with croup who improve following nebulized racemic epinephrine, how long should they be observed to demonstrate no 'rebound' worsening of symptoms?

The disposition of children with croup treated with racemic epinephrine and dexamethasone in the emergency department Rizos et al, 1998

Prospective, cohort study82 pts

All received IM dexamethasone and racemic epinephrine. Discharged home if free of retractions and stridor at 2 hours.

Telephone follow up. 6 required follow up within 48 hours. 2 were admittedNo adverse outcomes.

Case 3 - SummaryCase 3 - Summary:

• Steroid therapy: • improves clinical symptoms within 6 hours• shortens hospital stay• decreases need for epinephrine treatments

• Oral dexamethasone equivalent to nebulized budesonide

• no increased benefit of adding inhaled steroids

• Dexamethasone at 0.15 mg/kg as effective as 0.6 mg/kg

• If patient is symptom free, may be discharged at 2 hrs post racemic epinephrine

Case 3 - Summary:Case 3 - Summary:

• No proven benefit of mist therapy

• L-epinephrine as effective as racemic epinephrine with no increased adverse effects

Quickies

EpiglottitisRARE now with Hib gone

Pneumococcus, Staph, Strep now more common as cause

3 – 7 years of ageRapid onsetMedical emergency

Don’t bug the kid but don’t let him out of your sightCall anesthesia; intubate in OR

Quickies

Retropharyngeal abscess1-6 years

Retropharyngeal LN’s gone after thisGAS, anaerobes, S. aureusNeed good film for diagnosis

Neck extended in inspirationWidth of prevertebral soft tissue > ½ C3 vertebral bodyLoss of cervical lordosis

IV abx, ENT consult

Quickies4 year old fully immunized girl

Febrile, croupy cough, drooling, stridorLooks unwell, but no acute distressCoryza and sore throat for one day No rashes; no choking episodes

You give racemic epi… no responseYou order lateral neck XR… no FB, no steeple sign, epiglottis normal, upper airway has irregular margins

Bacterial tracheitisUncommon

Can mimic croup quite closely; may be a complication of croup

sicker, high fever, gradual onset of illnessS. aureus usual cause

“Shaggy trachea” on XR secondary to pseudomembrane formationAdmit to ICU for iv antibiotics and observation

“not all croup is viral croup”