THE LOWER AIRWAYS Pediatric Respiratory Emergencies.

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Transcript of THE LOWER AIRWAYS Pediatric Respiratory Emergencies.

  • Slide 1
  • THE LOWER AIRWAYS Pediatric Respiratory Emergencies
  • Slide 2
  • Case 1 2M male 3 day history of URTI associated with fever (38.5) Onset of difficulty feeding, increased WOB today Vitals - HR 160 RR 65 SpO2 90% on R/A T 37.9 TT, indrawing, nasal flaring, diffuse crackles and wheezes
  • Slide 3
  • Differential diagnosis of Wheeze Infection (Bronchiolitis, pneumonia) Asthma Cystic Fibrosis CHF Foreign body Anaphylaxis Croup Epiglottis Vocal cord dysfunction GERD Bronchopulmonary dysplasia
  • Slide 4
  • You think he has bronchiolitis What do you tell his parents about his illness and its natural history?
  • Slide 5
  • Bronchiolitis Viral infection RSV, influenza, parainfluenza, echovirus, rhinovirus, adenovirus Mycoplasm, Chlamydia Children < 2 years, peak at 2 M October to May Contact/Droplet Peak at 3-5 d Resolves 2 weeks
  • Slide 6
  • Bronchiolitis Inflammation of terminal and respiratory bronchioles Mucus plug + edema Airway narrowing Decrease compliance, increase resistance Atelectasis and overdistention
  • Slide 7
  • Bronchiolitis Clinical presentation Wheeze, tachypnea, indrawing URT symptoms Fever Hypoxemia Apnea
  • Slide 8
  • What factors put children at increased risk of severe bronchiolitis? History of Prematurity BPD CF Congenital heart disease Immunocompromised
  • Slide 9
  • Management You start oxygen and encourage feeding When patient not feeding well you give 20 mL/kg bolus RT asks you if you want this child to be treated with bronchodilators or steroids What do you think?
  • Slide 10
  • Controversial Many trials done to examine use of Epinephrine -adrenergics Steroids IV PO Inhaled
  • Slide 11
  • Evidence for Epinephrine Epinephrine vs. placebo or salbutamol 5/8 showed short term improvement in clinical scores 1/8 showed fewer hospitalization 1/8 showed shorter duration of hospitalization
  • Slide 12
  • Evidence for Epinephrine Hartling et al, 2003 Meta-analysis Epinephrine vs. bronchodilators or placebo RCT, infants
  • RCT comparing racemic epinephrine, racemic albuterol, normal saline in equivalent doses in mild/moderate bronchiolitis N = 65 (23-albuterol, 17 epi, 25 NS) 5mg of drug in 3 mL at 0 and 30 minutes Clinical assessment pre and post 3 rd dose at 60 minutes if RDAI >8 or O2 saturation < 90% R/A Final assessment at either 60 or 90 minutes
  • Slide 18
  • Required admission/home oxygen 61% albuterol, 59% epinephrine, 64% NS No difference in admission rates No difference in O2 saturation, RR -agonist not useful in Rx bronchiolitis
  • Slide 19
  • -agonists should not be used routinely in management of bronchiolitis Level B A carefully monitored trial of alpha adrenergic or - adrenergic medications is an optionand continued only if there is a documented positive clinical response using objective means of evaluation Level B it would be more appropriate that a bronchodilator trialuse salbutamol rather than racemic epinephrine
  • Slide 20
  • What about steroids?
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  • Systematic review Oral, IV and inhaled steroids Oral 6 RCT involving prednisone (1) prednisolone (2) Dexamethasone (2) Prednisolone and albuterol vs. Placebo and albuterol Various outcomes (hospitalization, clinical score, length of stay, duration of ventilation) 1 found decreased rate of admission, 1 found increased rate of admission,1 found shorter duration of ventilation, 1 found improved clinical status Felt data was inconclusive
  • Slide 22
  • IV 2 RCT Dexamethasone to placebo No benefit Clinical score, admission, time to resolution, duration of oxygen therapy
  • Slide 23
  • Inhaled 6 RCT Mostly used budesonide Worse wheeze/cough at 12 months in 1 Increase readmission No benefit shown
  • Slide 24
  • Cochrance Systematic Review 13 RCT No difference RR O2 saturation Admission Length of stay Subsequent visits Readmission Evidence for Steroids
  • Slide 25
  • RCT Comparing admission to hospital and RACS 4 hours after dose of dexamethasone (1mg/kg) versus placebo January 2004 - April 2006 N = 600 (305 dexamethasone, 295 placebo) Admission 39.7% in dex vs. 41% in placebo - no difference RACS - sum of change in RDAI minus standardized score for change in RR (negative value = good response) No difference
  • Slide 26
  • Corticosteroid medications should not be used routinely in the management of bronchiolitis Level B
  • Slide 27
  • CANBEST study RDBCT N=800 4 treatment arms Primary outcome Hospital admission up to 7 days after enrollment Epi + Dex NNT 11.4 to prevent one hospitalization
  • Slide 28
  • Palivizumab Humanized, mouse monoclonal anti-RSV antibody Monthly X 5 months, 15 mg/kg IM Prevention of serious RSV lower respiratory tract infection Children < 2 years Chronic lung disease of prematurity Premature 32 weeks Hemodynamically significant cyanotic or acyanotic congenital heart disease
  • Slide 29
  • Any novel treatments?
  • Slide 30
  • Hypertonic saline Mechanism incompletely understood Osmotic hydration Reduction of cross-linking Edema reduction
  • Slide 31
  • RCT, multicentre (KGH, VGH) comparing length of stay in admitted patients receiving treatment with 3% HS vs. NS N=93 (47 - HS, 49 - NS) Doses q 2h X3, q4h X5, q6h until D/C Any other treatments mixed with appropriate solution
  • Slide 32
  • Length of stay HS 2.6 days +/- 1.9 days NS 3.5 days +/- 2.9 days 26% reduction in LOS P = 0.05
  • Slide 33
  • RCT comparing epinephrine 1.5 mg in 4 mL NS vs. epinephrine 1.5 mg in 4 mL of HS N = 53 (25 NS, 27 HS) Length of stay, change in clinical severity NS 4 +/- 1.9, HS 3 +/- 1.2, p < 0.05
  • Slide 34
  • Case 3 6 yo M with PMH of asthma URTI X4 days, using blue puffer Increase WOB today HR 130, RR 35, 90% on R/A Indrawing, Audible wheeze Decreased breath sounds to R Wheeze
  • Slide 35
  • How do you want to treat this child?
  • Slide 36
  • New therapies Chest 2006 129(2)246-256 RDBCT N=697 (age 11-79) Budesonide/Formoterol vs. budesonide + terbutaline Budesonide/Formoterol as maintenance/reliever 54% decrease in severe exacerbation 90% fewer hospitalizations/ED visits 77% fewer days with oral steroids
  • Slide 37
  • Evidence for Anti-cholinergics NEJM 1998 RDBCT Albuterol vs. albuterol+ IB x 2 dose N=434 (2-18 years) IB Decreased hospitalization (27 vs 36%, p = 0.05) Similar hospitalization rates in moderate exacerbation Markedly different rates in severe exacerbations
  • Slide 38
  • Evidence for Anti-cholinergics 32 studies, 16 pediatric 10 studies - admission (1786 children) Lower admission rate NNT =13, 7 if only severe exacerbations included 9 studies - spirometry 1 or 2 doses had FEV1 difference of 12.4% >2 doses had FEV1 difference of 16.3%
  • Slide 39
  • Evidence for Anti-cholinergics Cochrane Systematic Review 2000 13 trials Multiple doses decreased risk of admission by 25% Single doses improved lung function at 60 and 120 minutes, but no admission NNT= 12 to avoid 1 admission in kids with either moderate or severe exacerbation NNT = 7 if severe exacerbations
  • Slide 40
  • Nebulizer vs. MDI/Spacer RDBCT N = 168 (2m to 24 months) Nebulizer vs. Spacer Primary outcome Admission rates Results Controlled for difference in PIS Spacer group admitted less 5% vs. 20% p=0.05
  • Slide 41
  • Nebulizer vs. MDI/Spacer RDBCT N=90 (5 -17 years) baseline FEV1 50-79% Treatment groups 6-10 puffs 2 puffs 0.15mg/kg nebulized Primary outcome Improvement in % predicted FEV1 Results No significant difference in % predicted FEV1 between groups
  • Slide 42
  • Nebulizer or MDI/Spacer Cochrane Systematic Review 2006 Beta agonist via wet nebulizer vs. spacer 25 outpatient trials N = 2066 children, 614 adults MDI+spacer was equivalent to wet nebulizer wrt hospital admission rates MDI+spacer in kids Decreased length of stay in ED
  • Slide 43
  • Continuous vs. Intermittent Cochrane Systematic Review 2003 Continuous or near continuous (q 15 minutes or >4 treatments/h) vs. intermittent nebulization Continuous beneficial Decreased admission Most pronounced if severe exacerbation
  • Slide 44
  • Evidence for use of steroids Cochrane Systematic Review 2001 Benefit of treatment within 1 hour of ED presentation 12 trials N = 863 Reduced admission rates, NNT = 8 Most benefit Not currently Rx with steroids Severe exacerbation Oral steroids worked well for kids
  • Slide 45
  • Evidence for MgSO4 5 trials IV MgSO4 at any dose vs. placebo in patients < 18 y treated with beta-agonists and steroids MgSO4 reduced hospitalization NNT=4 for avoiding hospitalization
  • Slide 46
  • Evidence for MgSO4 Cochrane Systematic Review 7 trials (5 adult, 2 pediatric) N= 665 In severe subgroup Improved PEFR, FEV1, admission rates Improvements not seen if all patients included
  • Slide 47
  • Evidence for MgSO4 Cochrane Systematic Review 2005 Inhaled MgSO4 6 trials N=296 (2 pediatric) Heterogenous studies therefore difficult to make definitive conclusion MgSO4 with beta-agonists showed benefit Pulmonary function Admission rates In severe exacerbations
  • Slide 48
  • Evidence for IV Salbutamol Cochrane Systematic Review 2001 IV salbutamol in addition to other Rx vs. placebo 15 trials N=584 No benefit Pulmonary function Arterial gases Vital signs AE Clinical success
  • Slide 49
  • Other treatments Heliox NIPPV
  • Slide 50
  • Case 3 5 M Male Cough, fever, decreased energy and intake Tachypnea, increased wob SpO2 90% on R/A, RR 60 Crackles in RLL CXR Consolidation in RLL
  • Slide 51
  • Epidemiology 4% of kids/y in U.S. Decreases with increasing age < 2 years 80% viral > 4 years 40% viral
  • Slide 52
  • Clinical features Cough, fever, CP, tachypnea, grunting (infants), increased wob (indrawing, seesaw) Typical presentation - bacterial Rapid onset Fever, chills, chest pain, cough Atypical presentation viral Gradual onset Malaise, h/a, cough, fever (low-grade) Significant overlap
  • Slide 53
  • Pneumonia bugs
  • Slide 54
  • Specific bugs B. pertussis 3 stages Catarrhal phase Coryza, cough lasting 1-2 weeks Paroxysmal phase Coughing fits associated with gagging, cyanosis Whoop is uncommon in infants Lasts ~ 4 weeks Recovery Cough improves over months Treatment
  • Slide 55
  • Specific bugs S. aureus Rapid and severe C. trachomatis 50% of exposed will get conjunctivitis 5-20% pneumonia 2-19 weeks Rarely febrile or systemically unwell Staccatto cough
  • Slide 56
  • CXR in ambulatory setting N = 522 (2M to 59M) Randomized to CXR or no CXR Primary outcome Results Median 7 days to recovery in both groups CXR group More diagnosed with pneumonia 60% vs. 52% treated with antibiotics More follow-up appts. No difference in consultation, admission, repeat CXR at 28 days
  • Slide 57
  • CXR Bacterial Lobar or segmental consolidation Viral and atypical bacterial Interstitial infiltrates Peribronchial thickening Atelectasis Significant overlap Not useful in determining etiological agent
  • Slide 58
  • CXR May want to avoid in mild acute LRTI Use if 39 or toxic
  • Slide 59
  • Admission SpO270 (infant), >50 (older children) Respiratory distress Apnea/grunting Not feeding or dehydrated Social concerns
  • Slide 60
  • Acknowledgements Thanks to Sarah McPherson and Jeremy Wojtowicz