Transcript Pediatric respiratory emergencies

Pediatric Respiratory
Emergencies
Emergency Medicine Rounds
October 3, 2003
Dr. Edward Les
Overview
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Croup
Bronchiolitis
Status asthmaticus
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others
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Case 1
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3 year old girl brought to ED with a 2-day
history of worsening cough and wheezing
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Her mother has been giving her nebulized
ventolin treatments every 4 hours for the past day
without much improvement
In the ED her temp is 38.5, RR is 50, O2 sat 94%
On exam: moderate increased work of breathing,
decreased aeration throughout and diffuse
wheezes
Case 2
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A 6-year-old girl comes to the ED with
respiratory distress.
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Known asthmatic, wheezing for 4 days
no response to ventolin MDI as often as q2h at
home
She is diaphoretic, RR 60, O2 sat 88% on RA
Able to speak in short sentences b/w breaths
You immediately provide supplemental O2
and 3 back-to-back Ventolin nebs, as well as
oral ‘roids; 30 minutes later: no
improvement
Status asthmaticus
Definition:
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Any patient not responding to initial doses
of nebulized bronchodilating agents
Helfaer et al; Textbook of pediatric intensive care,
3rd ed. 1996.
Epidemiology of asthma
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Clearly on the rise
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Unclear why
10% of kids in U.S. have asthma
Annual hospitalization rates doubled
b/w 1980-1993 for 1-4 year-olds
Asthma death rates double for 5-14
year age group
Risk Factors for Potentially Fatal
Asthma
Medical factors
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Previous attack with:
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Severe, unexpected, rapid deterioration
Respiratory failure
Seizure or loss of consciousness
Attacks precipitated by food
Ethnic factors
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Nonwhite children (African American, Hispanic, other)
Psychosocial factors
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Denial or failure to perceive severity of illness
Associated depression or other psychiatric disorder
Noncompliance
Dysfunctional family unit
Inner-city residents
But…
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As many as 1/3 of children who die
from asthma have only had mild
preceding asthma
Australian study of 51 pediatric deaths
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Only 39% had potentially preventable
elements
Robertson et al, Pediatric Pulmonol 1992;13:95-100
Clinical presentation &
assessment
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Signs and sx: common knowledge
Measure pulse ox
Clinical asthma scores
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Research tool
PFT’s
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Do in kids > 5-6 years old
PEF (% of best): based on 3 attempts
PEF as predictor of asthma
severity
PEF predicted (%)
Exacerbation severity
<30
30-50
50-80
>80
Possibly life-threatening
Severe
Moderate
Mild
Treatment guidelines
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O2 if needed
2 agonists: salbutamol
Anticholinergics: ipratropium
Steroids
Magnesium
Heli-ox
(Intubation)
Salbutamol
Method of delivery?
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nebulization
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<10 kg: 1.25 mg in NS
10-20 kg: 2.5 mg in NS
> 20 kg: 5 mg in NS
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Single dose/re-evaluate vs q 20 min X3 vs continuous
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O2 flow rate important
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10-12 LPM in order to deliver particles in 1-3 mcm range
Salbutamol
Method of delivery?
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MDI with spacer
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Australian approach
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< 6 years:
> 6 years:
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Same frequency as for nebs
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6 puffs
12 puffs
Equivalent (or better) efficacy
Salbutamol
Method of delivery?
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IV: patients unresponsive to treatment with
continuous ventolin
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10 mcg/kg over 10 minutes,
then 0.2-5 mcg/kg/min
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Need supplemental K+
Anticholinergics: ipratropium
When?
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Immediately in moderate to severe asthma
Reduces duration and amount of treatment
before discharge
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Most severely ill kids benefit most
Schuh et al, J Pediatr 1995;126:639-645
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250-500 mcg with salbutamol q20min x 3
‘roids
For everybody in E.D.?
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NAEPP: to any patient that doesn’t
respond completely to one inhaled 
agonist treatment, even if the patient
has a mild exacerbation
‘roids
Route of administration
PO and IV: equal efficacy
 Usually po
 IV when can’t tolerate po or very sick
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Methylpredisone 0.5-1 mg/kg q6h, or
Hydrocortisone 2-4 mg/kg q6h
1-2 mg/kg/day prednisone
0.15-0.3 mg/kg/day dexamethasone
‘roids
Inhaled steroids for status asthmaticus?
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Cochrane meta-analysis of six RCT’s suggests
benefit
Edmonds et al, in The Cochrane Library (Issue 2), 2001
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But…
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Compared inhaled to placebo, not to parenteral
steroids
No children with severe asthma enrolled
PO or IV steroids remain avenue of choice
‘roids alert
Children with acute asthma and recent
exposure to chickenpox should not
receive steroids, unless they are
considered immune
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Even a single course of corticosteroids can
increase the risk for fatal varicella
Kasper et al, Pediatr Infect Dis J,1990;9: 729-32
Magnesium
Good evidence for efficacy in children
Ciarallo, et al, Arch Pediatr Adolesc Med, 2000;154:979-983
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30 patients in RDBPC trial
Tx group: 40mg/kg IV Mg over 20 minutes to children
with moderate-severe asthma refractory to nebulization
therapy
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50% of tx group discharged home
100% of placebo group admitted (P = 0.002)
Rowe, Ann Emerg Med, 2000;36(3):181-90
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Systematic review of literature: 7 trials (5 adult, 2 pediatric)
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Beneficial for patients who present with severe acute asthma
Magnesium
? Causes relaxation of smooth muscle by
inhibiting calcium uptake
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Dose: 30-75 mg/kg IV over 20 minutes
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Max dose 2 g
Safe and well tolerated
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Occasional nausea, flushing, weakness
Heli-ox
Not used much in ED
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Theoretical advantage: reduces turbulent
flow
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Prospective randomized double-blind crossover
study in in 11 severe non-intubated pediatric
asthmatics failed to show benefit
Carter et al, Chest 1996;109:1256-61
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Use limited by patients’ O2 requirement
Intubation/mechanical
ventilation
Avoid if at all possible: high morbidity/mortality
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RSI: which sedative?
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Ketamine with atropine
Ventilation principles
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Low rate, long exp times, controlled pressure,
permissive hypercarbia
Case 1 (cont)
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After appropriate treatment she is much
improved with RR 30 and O2 sat 98%
on RA, with minimal residual wheezing.
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What are criteria for discharge home?
What therapy will you prescribe?
Asthma:
disposition from the ED
Asthma flow sheets very helpful
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Patients should be observed for 30-60
minutes post-ventolin for symptom
recurrence
Most require at least 2 hours ED care
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Steroids kick in @ 4-6 hours
Asthma: disposition
Consider hospitalization more strongly if:
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Prior hx of sudden, severe exacerbation
Prior intubation or ICU admission
 2 hospitalizations in last year
 3 ED visits in past year
 2 MDI’s used in a month
Current steroid use or recent wean from steroids
Medical or psychiatric comorbidity
Poor perceiver of symptoms (adolescents)
Substance abuse
Low socioeconomic status
Baren JM in Emergency Asthma, 1999
Asthma: disposition
NAEPP guidelines for discharge
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PEF has returned to 70% of predicted
Exacerbation symptoms minimal or absent
Observed 30-60 minutes after last tx
Medications prescribed
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PO steroids, ventolin, inhaled steroids
OP care can be established with a few days
Use asthma clinic!
Case 3
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4 month old girl brought to ED in February:
wheezing of 2 days duration
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cough, rhinorrhea and fever to 37.8 C
poor feeding last 24 hours
wheezing is worsening
born at 31 weeks gestation; required mechanical
ventilation for 4 days after her birth
On exam
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alert, RR 56 with mild retractions, O2 sat 94% RA
Diffuse wheezes bilaterally, scattered creps
CXR
Management options?
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Supportive care
 O2, fluids, suctioning, saline nose drops
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Ventolin
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Shuang huang lian
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Racemic epinephrine
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Ribavirin
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Steroids
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Vitamin A
Management options?
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Supportive care
 O2, fluids, suctioning, saline nose drops
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Ventolin
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Shuang huang lian
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Racemic epinephrine
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Ribavirin
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Steroids
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Vitamin A
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Bronchiolitis
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Primarily b/w 0 and 24 months
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1% of all hospitalizations of children in 1st year of life
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Peak 2-8 months
Infects almost all children
May be predictive of future asthma if hospitalized
$300 million per year in U.S.
Mostly seasonal
60-90% RSV
Extremely contagious
Affects terminal bronchioles in young children
Symptoms peak around day 5
Bronchiolitis:
predictors of severe disease
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Ill or toxic appearing
SaO2 < 95%
Gestational age < 34 weeks
RR > 70 breaths per minute
Atelectasis on CXR
Age less than 3 months
Single best objective predictor: infant’s SaO2
while feeding
Shaw et al, Am J Dis Child, 1991;145:151-55
Salbutamol in bronchiolitis
Many studies
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1996 meta-analysis by Kellner et al in
Arch Pediatr Adolesc Med 150:1166-72
suggested benefit
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Multiple conflicting reports since
Despite that: used widely
Racemic epinephrine in
bronchiolitis
Again, many studies
 Generally more positive than salbutamol
studies
Sanchez et al, J Pediatr 1993;122:145-51
Reijonen et al, Arch Pediatr Adolesc Med 1995;149:686-92
Menon et al, J Pediatr 1995;126:1004-1007
Certainly safe
Dose: 0.25 – 0.5 mL neb in NS
L-isomer alone may be more effective
Steroids in bronchiolitis
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Theoretically sound
Recent Sick Kids study
st study based in the ED
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 DBRPC trial involving 70 kids under 2 yrs
 Dexamethasone group had hospitalization rate
less than ½ of placebo group
Schuh et al, J Pediatr 2002;140(1)
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Recent meta-analysis also suggested statistical
improvement with dexamethasone
Garrison, Pediatrics 2000;105(4):E44
Overall, however, the bulk of individual studies
have not shown benefit
Prevention of bronchiolitis
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Palivizumab (Synergis®)
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Monoclonal antibody
effective
$$$$$
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Given only to high risk infants
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CLD
prems
Bronchiolitis – indications for
admission
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Age – generally if less than 1-2 months
Apnea
Oxygen requirement
Poor feeding
If received racemic epi in ED?
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seems logical criteria given this is a med you can’t
prescribe for home management!
Underlying condition
e.g.
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Prematurity
Congenital heart disease
Case 4
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A 2 year old boy arrives at triage at 1
a.m with his Dad
You’re awakened by…..
He’s brought back to obs
Sat is 90%, moderate retractions, very
hoarse voice, continued noisy breathing
Dad gives you xray taken one hour ago
at walk-in clinic
Croup – acute
laryngotracheobronchitis
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Stridor, barky cough, hoarseness
6 months to 6 years of age
Often preceding URTI
Typically worse at night
Severe cases have biphasic stidor
Diagnosis is clinical
croup
Croup - treatment
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Humidification
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Corticosteroids
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Often occurs on way to hospital
PO equivalent to IM
Dose 0.6 mg/kg (0.15 mg/kg may be adequate)
Nebulized budesonide also effective; may be
additive
Racemic epinephrine
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Need to observe in ED 2-3 hours post admin:
potential rebound mucosal edema
Case 5
Epiglottitis
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RARE now with Hib gone
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Pneumococcus, Staph, Strep now more common
as cause
3 – 7 years of age
Rapid onset
Medical emergency
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Don’t bug the kid but don’t let him out of your
sight
Call anesthesia; intubate in OR
Case 6
3 year old with
progressive stridor,
fever, meningismus
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Diagnosis?
Retropharyngeal abscess
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1-6 years
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Retropharyngeal LN’s
gone after this
GAS, anaerobes,
S. aureus
Need good film for
diagnosis
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Neck extended in
inspiration
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Width of prevertebral
soft tissue > ½ C3
vertebral body
Loss of cervical lordosis
IV abx, ENT consult
Case 7
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4 year old fully immunized girl
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Febrile, croupy cough, drooling, stridor
Looks unwell, but no acute distress
Coryza and sore throat for one day
No rashes; no choking episodes
You give racemic epi… no response
You order lateral neck XR… no FB, no steeple
sign, epiglottis normal, upper airway has
irregular margins
Bacterial tracheitis
Uncommon
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Can mimic croup quite closely; may be a complication
of croup
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sicker, high fever, gradual onset of illness
S. aureus usual cause
“Shaggy trachea” on XR secondary to
pseudomembrane formation
Admit to ICU for iv antibiotics and observation
“not all croup is viral croup”
Case 8
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15-month-old girl
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Acute onset wheeze and cough 2 hours ago
Previously well
Has past hx bronchiolitis; sib has asthma
On exam
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afebrile, sat 95% RA, RR 44, AE sl decreased on
left, wheeze L>R
CXR
CXR- forced expiratory view
Miller time