Transcript 2008_05_08-Kirkpatrick-Peds_Respiratory_Emergencies

THE LOWER AIRWAYS
Pediatric Respiratory Emergencies
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
Differential diagnosis of Wheeze
 Infection (Bronchiolitis, pneumonia)
 Asthma
 Cystic Fibrosis
 CHF
 Foreign body
 Anaphylaxis
 Croup
 Epiglottis
 Vocal cord dysfunction
 GERD
 Bronchopulmonary dysplasia
You think he has bronchiolitis
 What do you tell his parents about his illness and its
natural history?
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
Bronchiolitis
 Inflammation of terminal and respiratory
bronchioles
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Mucus plug + edema
Airway narrowing
Decrease compliance, increase resistance
Atelectasis and overdistention
Bronchiolitis
 Clinical presentation
 Wheeze, tachypnea, indrawing
 URT symptoms
 Fever
 Hypoxemia
 Apnea
What factors put children at increased risk of
severe bronchiolitis?
 History of
 Prematurity
 BPD
 CF
 Congenital heart disease
 Immunocompromised
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?
Controversial
 Many trials done to examine use of
 Epinephrine
 ß-adrenergics
 Steroids
IV
 PO
 Inhaled
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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
Evidence for Epinephrine
 Hartling et al, 2003
 Meta-analysis
 Epinephrine vs. bronchodilators or placebo
 RCT, infants<2 years, quantitative outcome
 14 studies, 7 inpatient, 6 outpatient, 1 unknown
 Outpatient results
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Epi better than placebo or other bronchodilators in short term (O2
saturation, RR, clinical score)
Evidence for Epinephrine
 Cochrane Systematic Review
 14 RCT (1966-2003)
 Inpatient and outpatient treatment
 Epinephrine vs. placebo - outpatient (3)
 Improvement at 60 minutes (1/3studies)
 No difference in admission or O2 saturation
 Epinephrine vs. Salbutamol - outpatient (4)
 O2 saturation, HR, RR improved at 60 minutes
 No difference in admission
Evidence for Bronchodilators
 13 RCT
 Bronchodilators vs. placebo or ipatropium
 1/13 showed decreased admission
 4/13 showed some clinical improvement
Evidence for Bronchodilators
 Cochrane Systematic Review
 22 RCT (1966-2005)
 Bronchodilators vs. placebo
 No difference in admission or duration of
hospitalization
 Minor improvement in oximetry and symptoms in
outpatient treatment
 Previous studies used larger doses of
epinephrine
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Effect may not be due to alpha affects, but higher
delivery of ß-agonist
 RCT comparing racemic epinephrine, racemic albuterol,
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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
 Required admission/home oxygen
 61% albuterol, 59% epinephrine, 64% NS
 No difference in admission rates
 No difference in O2 saturation, RR
 ß-agonist not useful in Rx bronchiolitis
 “ß-agonists should not be used routinely in management
of bronchiolitis” Level B
 “A carefully monitored trial of alpha adrenergic or ßadrenergic medications is an option…and 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
trial…use salbutamol rather than racemic epinephrine”
 What about steroids?
 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
 IV
 2 RCT
 Dexamethasone to placebo
 No benefit
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Clinical score, admission, time to resolution, duration of oxygen
therapy
 Inhaled
 6 RCT
 Mostly used budesonide
 Worse wheeze/cough at 12 months in 1
 Increase readmission
 No benefit shown
Evidence for Steroids
 Cochrance Systematic Review
 13 RCT
 No difference
 RR
 O2 saturation
 Admission
 Length of stay
 Subsequent visits
 Readmission
 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
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“Corticosteroid medications should not be used
routinely in the management of bronchiolitis”
Level B
 CANBEST study
 RDBCT
 N=800
 4 treatment arms
 Primary outcome
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Hospital admission up to 7 days after enrollment
Epi + Dex NNT 11.4 to prevent one hospitalization
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
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 Any novel treatments?
Hypertonic saline
 Mechanism incompletely understood
 Osmotic hydration
 Reduction of cross-linking
 Edema reduction
 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
 Length of stay
 HS 2.6 days +/- 1.9 days
 NS 3.5 days +/- 2.9 days
 26% reduction in LOS
 P = 0.05
 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
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
How do you want to treat this child?
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
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Evidence for Anti-cholinergics
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NEJM 1998
RDBCT
Albuterol vs. albuterol+ IB x 2 dose
N=434 (2-18 years)
IB
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Decreased hospitalization (27 vs 36%, p = 0.05)
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Similar hospitalization rates in moderate exacerbation
Markedly different rates in severe exacerbations
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%
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
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
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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
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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
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Decreased length of stay in ED
Continuous vs. Intermittent
 Cochrane Systematic Review 2003
 Continuous or near continuous (q 15 minutes or >4
treatments/h) vs. intermittent nebulization
 Continuous beneficial
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Decreased admission
Most pronounced if severe exacerbation
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
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 Oral steroids worked well for kids
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
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
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
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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
Other treatments
 Heliox
 NIPPV
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
Epidemiology
 4% of kids/y in U.S.
 Decreases with increasing age
 < 2 years – 80% viral
 > 4 years – 40% viral
Clinical features
 Cough, fever, CP, tachypnea, grunting (infants),
increased wob (indrawing, seesaw)
 Typical presentation - bacterial
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Rapid onset
Fever, chills, chest pain, cough
 Atypical presentation – viral
 Gradual onset
 Malaise, h/a, cough, fever (low-grade)
 Significant overlap
Pneumonia bugs
Specific bugs
 B. pertussis
 3 stages
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Catarrhal phase
• Coryza, cough lasting 1-2 weeks
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Paroxysmal phase
• Coughing fits associated with gagging, cyanosis
• Whoop is uncommon in infants
• Lasts ~ 4 weeks
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Recovery
• Cough improves over months
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Treatment
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
CXR in ambulatory setting
 N = 522 (2M to 59M)
 Randomized to CXR or no CXR
 Primary outcome
 Results
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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
CXR
 Bacterial
 Lobar or segmental consolidation
 Viral and atypical bacterial
 Interstitial infiltrates
 Peribronchial thickening
 Atelectasis
 Significant overlap
 Not useful in determining etiological agent
CXR
 May want to avoid in mild acute LRTI
 Use if <5 and if fever >39 or toxic
Admission
 SpO2<90-93%
 Young age
 Toxic
 Immunocompromised
 RR>70 (infant), >50 (older children)
 Respiratory distress
 Apnea/grunting
 Not feeding or dehydrated
 Social concerns
Acknowledgements
 Thanks to Sarah McPherson and Jeremy Wojtowicz