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Pediatric Respiratory Emergencies Emergency Medicine Rounds October 3, 2003 Dr. Edward Les Overview Croup Bronchiolitis Status asthmaticus others Case 1 3 year old girl brought to ED with a 2-day history of worsening cough and wheezing 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 A 6-year-old girl comes to the ED with respiratory distress. 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: 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 Clearly on the rise 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 Previous attack with: Severe, unexpected, rapid deterioration Respiratory failure Seizure or loss of consciousness Attacks precipitated by food Ethnic factors Nonwhite children (African American, Hispanic, other) Psychosocial factors Denial or failure to perceive severity of illness Associated depression or other psychiatric disorder Noncompliance Dysfunctional family unit Inner-city residents But… As many as 1/3 of children who die from asthma have only had mild preceding asthma Australian study of 51 pediatric deaths Only 39% had potentially preventable elements Robertson et al, Pediatric Pulmonol 1992;13:95-100 Clinical presentation & assessment Signs and sx: common knowledge Measure pulse ox Clinical asthma scores Research tool PFT‟s 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 Possibly life-threatening 30-50 Severe 50-80 Moderate >80 Mild Treatment guidelines O2 if needed 2 agonists: salbutamol Anticholinergics: ipratropium Steroids Magnesium Heli-ox (Intubation) Salbutamol Method of delivery? nebulization <10 kg: 1.25 mg in NS 10-20 kg: 2.5 mg in NS > 20 kg: 5 mg in NS Single dose/re-evaluate vs q 20 min X3 vs continuous O2 flow rate important 10-12 LPM in order to deliver particles in 1-3 mcm range Salbutamol Method of delivery? MDI with spacer Australian approach < 6 years: 6 puffs > 6 years: 12 puffs Same frequency as for nebs Equivalent (or better) efficacy Salbutamol Method of delivery? IV: patients unresponsive to treatment with continuous ventolin 10 mcg/kg over 10 minutes, then 0.2-5 mcg/kg/min Need supplemental K+ Anticholinergics: ipratropium When? Immediately in moderate to severe asthma Reduces duration and amount of treatment before discharge Most severely ill kids benefit most Schuh et al, J Pediatr 1995;126:639-645 250-500 mcg with salbutamol q20min x 3 „roids For everybody in E.D.? 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 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? Cochrane meta-analysis of six RCT‟s suggests benefit Edmonds et al, in The Cochrane Library (Issue 2), 2001 But… 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 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 30 patients in RDBPC trial Tx group: 40mg/kg IV Mg over 20 minutes to children with moderate-severe asthma refractory to nebulization therapy 50% of tx group discharged home 100% of placebo group admitted (P = 0.002) Rowe, Ann Emerg Med, 2000;36(3):181-90 Systematic review of literature: 7 trials (5 adult, 2 pediatric) Beneficial for patients who present with severe acute asthma Magnesium ? Causes relaxation of smooth muscle by inhibiting calcium uptake Dose: 30-75 mg/kg IV over 20 minutes Max dose 2 g Safe and well tolerated Occasional nausea, flushing, weakness Heli-ox Not used much in ED Theoretical advantage: reduces turbulent flow 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 Use limited by patients‟ O2 requirement Intubation/mechanical ventilation Avoid if at all possible: high morbidity/mortality RSI: which sedative? Ketamine with atropine Ventilation principles Low rate, long exp times, controlled pressure, permissive hypercarbia Case 1 (cont) After appropriate treatment she is much improved with RR 30 and O2 sat 98% on RA, with minimal residual wheezing. What are criteria for discharge home? What therapy will you prescribe? Asthma: disposition from the ED Asthma flow sheets very helpful Patients should be observed for 30-60 minutes post-ventolin for symptom recurrence Most require at least 2 hours ED care Steroids kick in @ 4-6 hours Asthma: disposition Consider hospitalization more strongly if: 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 PEF has returned to 70% of predicted Exacerbation symptoms minimal or absent Observed 30-60 minutes after last tx Medications prescribed PO steroids, ventolin, inhaled steroids OP care can be established with a few days Use asthma clinic! Case 3 4 month old girl brought to ED in February: wheezing of 2 days duration 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 alert, RR 56 with mild retractions, O2 sat 94% RA Diffuse wheezes bilaterally, scattered creps CXR Management options? Supportive care • O2, fluids, suctioning, saline nose drops Ventolin • Shuang huang lian • Racemic epinephrine • Ribavirin • Steroids • Vitamin A • Management options? Supportive care • O2, fluids, suctioning, saline nose drops Ventolin ? • Shuang huang lian • Racemic epinephrine ? • Ribavirin • Steroids ? • Vitamin A • Bronchiolitis Primarily b/w 0 and 24 months Peak 2-8 months Infects almost all children May be predictive of future asthma if hospitalized 1% of all hospitalizations of children in 1st year of life $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 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 1996 meta-analysis by Kellner et al in Arch Pediatr Adolesc Med 150:1166-72 suggested benefit 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 Theoretically sound Recent Sick Kids study 1 st study based in the ED 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) 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 Palivizumab (Synergis®) Monoclonal antibody effective $$$$$ Given only to high risk infants CLD prems Bronchiolitis – indications for admission Age – generally if less than 1-2 months Apnea Oxygen requirement Poor feeding If received racemic epi in ED? seems logical criteria given this is a med you can‟t prescribe for home management! Underlying condition e.g. Prematurity Congenital heart disease Case 4 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 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 Humidification Often occurs on way to hospital Corticosteroids 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 Need to observe in ED 2-3 hours post admin: potential rebound mucosal edema Case 5 Epiglottitis RARE now with Hib gone Pneumococcus, Staph, Strep now more common as cause 3 – 7 years of age Rapid onset Medical emergency 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 Diagnosis? Retropharyngeal abscess 1-6 years Retropharyngeal LN‟s gone after this GAS, anaerobes, S. aureus Need good film for diagnosis Neck extended in inspiration Width of prevertebral soft tissue > ½ C3 vertebral body Loss of cervical lordosis IV abx, ENT consult Case 7 4 year old fully immunized girl 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 Can mimic croup quite closely; may be a complication of croup 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 15-month-old girl Acute onset wheeze and cough 2 hours ago Previously well Has past hx bronchiolitis; sib has asthma On exam afebrile, sat 95% RA, RR 44, AE sl decreased on left, wheeze L>R CXR CXR- forced expiratory view Miller time
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