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Pediatric Respiratory Emergencies

Pediatric Respiratory Emergencies. THE LOWER AIRWAYS. 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.

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Pediatric Respiratory Emergencies

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  1. Pediatric Respiratory Emergencies THE LOWER AIRWAYS

  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

  3. Differential diagnosis of Wheeze • Infection (Bronchiolitis, pneumonia) • Asthma • Cystic Fibrosis • CHF • Foreign body • Anaphylaxis • Croup • Epiglottis • Vocal cord dysfunction • GERD • Bronchopulmonary dysplasia

  4. You think he has bronchiolitis • What do you tell his parents about his illness and its natural history?

  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

  6. Bronchiolitis • Inflammation of terminal and respiratory bronchioles • Mucus plug + edema • Airway narrowing • Decrease compliance, increase resistance • Atelectasis and overdistention

  7. Bronchiolitis • Clinical presentation • Wheeze, tachypnea, indrawing • URT symptoms • Fever • Hypoxemia • Apnea

  8. What factors put children at increased risk of severe bronchiolitis? • History of • Prematurity • BPD • CF • Congenital heart disease • Immunocompromised

  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?

  10. Controversial • Many trials done to examine use of • Epinephrine • ß-adrenergics • Steroids • IV • PO • Inhaled

  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

  12. 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 • Epi better than placebo or other bronchodilators in short term (O2 saturation, RR, clinical score)

  13. 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

  14. Evidence for Bronchodilators • 13 RCT • Bronchodilators vs. placebo or ipatropium • 1/13 showed decreased admission • 4/13 showed some clinical improvement

  15. 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

  16. Previous studies used larger doses of epinephrine • Effect may not be due to alpha affects, but higher delivery of ß-agonist

  17. 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

  18. 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

  19. “ß-agonists should not be used routinely in management of bronchiolitis” Level B • “A carefully monitored trial of alpha adrenergic or ß-adrenergic 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”

  20. What about steroids?

  21. 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

  22. IV • 2 RCT • Dexamethasone to placebo • No benefit • Clinical score, admission, time to resolution, duration of oxygen therapy

  23. Inhaled • 6 RCT • Mostly used budesonide • Worse wheeze/cough at 12 months in 1 • Increase readmission • No benefit shown

  24. Evidence for Steroids • Cochrance Systematic Review • 13 RCT • No difference • RR • O2 saturation • Admission • Length of stay • Subsequent visits • Readmission

  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

  26. “Corticosteroid medications should not be used routinely in the management of bronchiolitis” Level B

  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

  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

  29. Any novel treatments?

  30. Hypertonic saline • Mechanism incompletely understood • Osmotic hydration • Reduction of cross-linking • Edema reduction

  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

  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

  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

  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

  35. How do you want to treat this child?

  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

  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

  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%

  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

  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

  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

  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

  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

  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

  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

  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

  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

  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

  49. Other treatments • Heliox • NIPPV

  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

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