Pediatric Respiratory Pediatric Respiratory EmergenciesEmergencies

Part 2Part 2

Pediatric Respiratory Pediatric Respiratory EmergenciesEmergencies

Part 2Part 2Mohammed Al Faifi, MD.Mohammed Al Faifi, MD.

Pediatric Emergency ConsultantPediatric Emergency Consultant

Department of Emergency MedicineDepartment of Emergency Medicine

King Faisal Specialist Hospital & Research King Faisal Specialist Hospital & Research Centre Centre

Riyadh, KSARiyadh, KSAKUWAIT, Oct. 2011KUWAIT, Oct. 2011

Topics to be covered Topics to be covered Topics to be covered Topics to be covered

•• BronchiolitisBronchiolitis

• • CroupCroup

2005 National Hospital Ambulatory Medical Care Survey 2005 National Hospital Ambulatory Medical Care Survey

a nationally representative sample of USA patients was analyzeda nationally representative sample of USA patients was analyzed

Data on visits to EDs by childrenData on visits to EDs by children

– – 1 -19 years of age with moderate/severe Asthma1 -19 years of age with moderate/severe Asthma

– – 3 months to 2 years of age with Bronchiolitis3 months to 2 years of age with Bronchiolitis

– – 3 months to 3 years of age with Croup3 months to 3 years of age with Croup

Knapp et al. Pediatrics 2008

ResultsResultsResultsResults

CorticosteroidsAntibioticsRadiographs

69% of the 405,000

visits for moderate/

severe asthma

31% of the estimated

317,000 annual

croup visits

53% of the estimated

228,000 annual visits

for bronchiolitis

72% of bronchiolitis

visits

32% of croup visits

Knapp et al. Pediatrics 2008

ConclusionsConclusionsConclusionsConclusions

Physicians treating children with Physicians treating children with

Asthma, Asthma,

bronchiolitis bronchiolitis

croup croup

In USA Emergency Departments are In USA Emergency Departments are under usingunder using known known effective treatments and effective treatments and overusingoverusing ineffective or ineffective or unproven therapies and diagnostic tests.unproven therapies and diagnostic tests.

Knapp et al. Pediatrics 2008

A 5-month-old presents with cough for 2 daysA 5-month-old presents with cough for 2 days

Preceded by a URI, his feeding has decreased and his Preceded by a URI, his feeding has decreased and his

cough interrupts sleep, Temp. 38° at home. cough interrupts sleep, Temp. 38° at home.

Normal PMHx.Normal PMHx.

Case No. 1

Temp 38.5°, RR 60, Temp 38.5°, RR 60, SaSaOO22 94% in room air 94% in room air

Mild rhinorrhea, air entry good, Mild rhinorrhea, air entry good,

wheezing in all fieldswheezing in all fields

Well Hydrated, feeds wellWell Hydrated, feeds well

No grunting or retractionsNo grunting or retractions

This is a classic case of This is a classic case of

On Exam :•

Bronchiolitis

Diagnosis. Diagnosis. Diagnosis. Diagnosis.

May be necessary for May be necessary for bed placementbed placement

Not all bronchiolitis is RSV (metapneumovirus, Not all bronchiolitis is RSV (metapneumovirus, para virus)para virus)

Yet may Yet may decreasedecrease likelihood of bacteremia likelihood of bacteremia

(but not UTI(but not UTI))

RSV washRSV wash

Febrile infants with Febrile infants with confirmed viral infections are at lower risk for confirmed viral infections are at lower risk for SBI SBI than those in whom a viral infection is not identifiedthan those in whom a viral infection is not identified

Viral diagnostic data can positively contribute to the management of Viral diagnostic data can positively contribute to the management of febrile infants, especially those who are classified as High risk.febrile infants, especially those who are classified as High risk.

Peditrics Vol. 113: 1662, 2004Peditrics Vol. 113: 1662, 2004

Differential Diagnosis Differential Diagnosis Differential Diagnosis Differential Diagnosis

Gastroesophageal reflux disease Gastroesophageal reflux disease

Tracheoesophageal fistula Tracheoesophageal fistula

Tracheomalacia Tracheomalacia

Vascular ring Vascular ring

Cystic fibrosis & immunodeficiencyCystic fibrosis & immunodeficiency

CHDCHD

Foreign body aspiration. Foreign body aspiration.

• • CXRCXR

Diagnosis,

Evaluation of the utility of radiography in Evaluation of the utility of radiography in acute bronchiolitis. acute bronchiolitis. Evaluation of the utility of radiography in Evaluation of the utility of radiography in acute bronchiolitis. acute bronchiolitis.

A prospective study of 265 children aged 2 to 23 A prospective study of 265 children aged 2 to 23

months who presented to the ED with months who presented to the ED with

bronchiolitis analyzed use of routine radiography bronchiolitis analyzed use of routine radiography

in patients with a simple form of the disease in patients with a simple form of the disease

(defined in a child as coryza, cough, and (defined in a child as coryza, cough, and

respiratory distress accompanying a first respiratory distress accompanying a first

episode of wheezing without underlying illness).episode of wheezing without underlying illness).Schuh S, et al. J Pediatr. 2007

Result Result Result Result

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

Schuh S, et al. J Pediatr. 2007

HIGH RISK HIGH RISK HIGH RISK HIGH RISK Premature birth (< 35-37 weeks & Premature birth (< 35-37 weeks &

younger age (< 6-12 weeks of life) younger age (< 6-12 weeks of life)

Full term and younger than 1 month, Full term and younger than 1 month,

Bronchopulmonary , cystic fibrosis Bronchopulmonary , cystic fibrosis

(CHD), and immune deficiency disease (CHD), and immune deficiency disease

Child’s parents or a clinician had Child’s parents or a clinician had already witnessed an apnea episode already witnessed an apnea episode

Management Management Management Management Nasal SuctionNasal Suction

Beta 2 AgonistsBeta 2 Agonists

– – Clinical trials, meta-analyses & systematic Clinical trials, meta-analyses & systematic

reviews (2000-2004) showed some reviews (2000-2004) showed some

differences in short term benefits (oxygen, differences in short term benefits (oxygen,

RR) yet RR) yet no difference in clinically meaningful no difference in clinically meaningful

outcomes (admission, length of stay)outcomes (admission, length of stay)

– – Yet Yet some will respond. some will respond.

Bronchodilators for bronchiolitisBronchodilators for bronchiolitis. . Bronchodilators for bronchiolitisBronchodilators for bronchiolitis. .

A Cochrane review of bronchodilators A Cochrane review of bronchodilators other than epinephrine found that the other than epinephrine found that the

agents produce small, short-term agents produce small, short-term improvements but do not affect rate of improvements but do not affect rate of

hospitalization or length of hospitalhospitalization or length of hospital

Cochrane Database Syst Rev. 2006;(3)

Epinephrine and Bronchiolitis Epinephrine and Bronchiolitis Epinephrine and Bronchiolitis Epinephrine and Bronchiolitis

A meta-analysis suggested a decrease in A meta-analysis suggested a decrease in clinical symptoms when compared with clinical symptoms when compared with either placebo either placebo

Hartling L, et al. Arch Pediatr Adolesc Med. 2003;157;957-64 .

Ipratropium bromide Ipratropium bromide Ipratropium bromide Ipratropium bromide

At this point, use of anticholinergic At this point, use of anticholinergic agents―either alone or in combination agents―either alone or in combination with beta-adrenergic agents―for viral with beta-adrenergic agents―for viral bronchiolitis is not justified in the EDbronchiolitis is not justified in the ED

Bronchiolitis & SteroidsBronchiolitis & SteroidsBronchiolitis & SteroidsBronchiolitis & Steroids

• • CorticosteroidsCorticosteroids

– – 2004 Cochrane Review, 13 trials, 1200 children2004 Cochrane Review, 13 trials, 1200 children

• • No difference in admission rates, no benefits compared to placeboNo difference in admission rates, no benefits compared to placebo

– – PECARN multicenter trialPECARN multicenter trial

• • Compared Dexamethasone and placebo in ED patients with Compared Dexamethasone and placebo in ED patients with

bronchiolitisbronchiolitis

• • No difference in admission at 4 hoursNo difference in admission at 4 hours

Bronchiolitis & Steroids Bronchiolitis & Steroids Bronchiolitis & Steroids Bronchiolitis & Steroids

70 children, 3 winters, one center70 children, 3 winters, one center

2-23 months, first wheezing with distress and 2-23 months, first wheezing with distress and URIURI

Dexamethasone (36) vs. placebo (34)Dexamethasone (36) vs. placebo (34)

Dexamethasone groupDexamethasone group

– – More improved clinical scoreMore improved clinical score

– – Few hospitalizations (19% vs 44%)Few hospitalizations (19% vs 44%)

Schuh et al. J Pediatr 2002Schuh et al. J Pediatr 2002

Dexamethasone for Bronchiolitis, A Multicenter, Dexamethasone for Bronchiolitis, A Multicenter, Randomized, Controlled Trial:Randomized, Controlled Trial:Dexamethasone for Bronchiolitis, A Multicenter, Dexamethasone for Bronchiolitis, A Multicenter, Randomized, Controlled Trial:Randomized, Controlled Trial:

The study compare The study compare single dose single dose of oral dexamethasone (1 mg per of oral dexamethasone (1 mg per

kilogram of body weight) with placebo in 600 children (age range, 2 kilogram of body weight) with placebo in 600 children (age range, 2

to 12 months) with a to 12 months) with a first episode of wheezing first episode of wheezing diagnosed in the diagnosed in the

ED as moderate-to-severe bronchiolitis. ED as moderate-to-severe bronchiolitis. 20 emergency departments during the months of November through 20 emergency departments during the months of November through

April over a 3-year periodApril over a 3-year period

NEJM 2007; 357:331-9NEJM 2007; 357:331-9

Epinephrine and Dexamethasone in Children with Epinephrine and Dexamethasone in Children with BronchiolitisBronchiolitisEpinephrine and Dexamethasone in Children with Epinephrine and Dexamethasone in Children with BronchiolitisBronchiolitis

Multicenter, double-blind, placebo-controlled trial Multicenter, double-blind, placebo-controlled trial

• • 800 infants (6 weeks to 12 months of age) with bronchiolitis randomly assigned to one of four 800 infants (6 weeks to 12 months of age) with bronchiolitis randomly assigned to one of four study groupsstudy groups

• • The primary outcome was The primary outcome was hospital admission within 7 dayshospital admission within 7 days after the day of enrollment (the after the day of enrollment (the initial visit to the emergency department)initial visit to the emergency department)

N Engl J Med 2009; 360:2079-2089

ConclusionsConclusionsConclusionsConclusions

Among infants with bronchiolitis treated in the ED, combined therapy with Dexamethasone and Epinephrine may significantly reduce hospital admissions,

Admission Criteria: Admission Criteria:

• • Hypoxemia and poor feeding

• Less than 34 weeks

• Heart disease

• Atelectasis

• Less than 2 months,

A 3-year-old with cough at 2 AM, The child had a URI for 2 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.days and then began to cough, with hoarseness and stridor.

In the ED he is febrile (38°), running around the room, In the ED he is febrile (38°), running around the room,

without stridor at rest.without stridor at rest.

• • No droolingNo drooling

• • Lungs clearLungs clear

Case No. 2

CXR CXR

NONO

• • Mist therapy???Mist therapy???

• • CorticosteroidsCorticosteroids

– – Effective in moderate to severe croup—Effective in moderate to severe croup—PO / IMPO / IM

– – Dexamethasone (0.15 - 0.6 mg/kg) PO/ IMDexamethasone (0.15 - 0.6 mg/kg) PO/ IM

• • Aerosolized Racemic epinephrine Aerosolized Racemic epinephrine

– – No rebound---reserve for kids with stridor at restNo rebound---reserve for kids with stridor at rest

If clinically fine after 2 hours may , send homeIf clinically fine after 2 hours may , send home

Treatment Options :