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Pediatric respiratory emergencies

VIEWS: 2 PAGES: 53

									   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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