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Topics to be covered . Bronchiolitis Croup. 2005 National Hospital Ambulatory Medical Care Survey a nationally representative sample of USA patients was analyzed Data on visits to EDs by children 1 -19 years of age with moderate/severe Asthma 3 months to 2
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1. Pediatric Respiratory EmergenciesPart 2 Mohammed Al Faifi, MD.
Pediatric Emergency Consultant
Department of Emergency Medicine
King Faisal Specialist Hospital & Research Centre
Riyadh, KSA
KUWAIT, Oct. 2011
2. Topics to be covered � Bronchiolitis
� Croup
3. 2005 National Hospital Ambulatory Medical Care Survey
a nationally representative sample of USA patients was analyzed
Data on visits to EDs by children
� 1 -19 years of age with moderate/severe Asthma
� 3 months to 2 years of age with Bronchiolitis
� 3 months to 3 years of age with Croup
4. Results
5. Conclusions Physicians treating children with
Asthma,
bronchiolitis
croup
In USA Emergency Departments are under using known effective treatments and overusing ineffective or unproven therapies and diagnostic tests.
6. A 5-month-old presents with cough for 2 days
Preceded by a URI, his feeding has decreased and his
cough interrupts sleep, Temp. 38� at home.
Normal PMHx.
7. Temp 38.5�, RR 60, SaO2 94% in room air
Mild rhinorrhea, air entry good,
wheezing in all fields
Well Hydrated, feeds well
No grunting or retractions
This is a classic case of
9. Diagnosis. May be necessary for bed placement
Not all bronchiolitis is RSV (metapneumovirus, para virus)
Yet may decrease likelihood of bacteremia
(but not UTI)
10. Febrile infants with confirmed viral infections are at lower risk for SBI than those in whom a viral infection is not identified
Viral diagnostic data can positively contribute to the management of febrile infants, especially those who are classified as High risk.
Peditrics Vol. 113: 1662, 2004
11. Differential Diagnosis Gastroesophageal reflux disease
Tracheoesophageal fistula
Tracheomalacia
Vascular ring
Cystic fibrosis & immunodeficiency
CHD
Foreign body aspiration.
12. � CXR
13. Evaluation of the utility of radiography in acute bronchiolitis. A prospective study of 265 children aged 2 to 23 months who presented to the ED with bronchiolitis analyzed use of routine radiography in patients with a simple form of the disease (defined in a child as coryza, cough, and respiratory distress accompanying a first episode of wheezing without underlying illness).
14. Result The findings were consistent with bronchiolitis except in only 2 cases, and in neither case did the findings change short-term management.
15. HIGH RISK Premature birth (< 35-37 weeks & younger age (< 6-12 weeks of life)
Full term and younger than 1 month,
Bronchopulmonary , cystic fibrosis
(CHD), and immune deficiency disease
Child�s parents or a clinician had already witnessed an apnea episode
16. Management Nasal Suction
Beta 2 Agonists
� Clinical trials, meta-analyses & systematic
reviews (2000-2004) showed some
differences in short term benefits (oxygen,
RR) yet no difference in clinically meaningful
outcomes (admission, length of stay)
� Yet some will respond.
17. Bronchodilators for bronchiolitis. A Cochrane review of bronchodilators other than epinephrine found that the agents produce small, short-term improvements but do not affect rate of hospitalization or length of hospital
18. Epinephrine and Bronchiolitis
A meta-analysis suggested a decrease in clinical symptoms when compared with either placebo
19. Ipratropium bromide At this point, use of anticholinergic agents?either alone or in combination with beta-adrenergic agents?for viral bronchiolitis is not justified in the ED
20. Bronchiolitis & Steroids � Corticosteroids
� 2004 Cochrane Review, 13 trials, 1200 children
� No difference in admission rates, no benefits compared to placebo
� PECARN multicenter trial
� Compared Dexamethasone and placebo in ED patients with
bronchiolitis
� No difference in admission at 4 hours
21. Bronchiolitis & Steroids 70 children, 3 winters, one center
2-23 months, first wheezing with distress and URI
Dexamethasone (36) vs. placebo (34)
Dexamethasone group
� More improved clinical score
� Few hospitalizations (19% vs 44%)
Schuh et al. J Pediatr 2002
22. Dexamethasone for Bronchiolitis, A Multicenter, Randomized, Controlled Trial:
The study compare single dose of oral dexamethasone (1 mg per
kilogram of body weight) with placebo in 600 children (age range, 2
to 12 months) with a first episode of wheezing diagnosed in the
ED as moderate-to-severe bronchiolitis.
20 emergency departments during the months of November through April over a 3-year period
NEJM 2007; 357:331-9
23. Epinephrine and Dexamethasone in Children with Bronchiolitis
Multicenter, double-blind, placebo-controlled trial
� 800 infants (6 weeks to 12 months of age) with bronchiolitis randomly assigned to one of four study groups
� The primary outcome was hospital admission within 7 days after the day of enrollment (the initial visit to the emergency department)
24. Conclusions Among infants with bronchiolitis treated in the ED, combined therapy with Dexamethasone and Epinephrine may significantly reduce hospital admissions,
Admission Criteria:
� Hypoxemia and poor feeding
� Less than 34 weeks
� Heart disease
� Atelectasis
� Less than 2 months,
25. A 3-year-old with cough at 2 AM, The child had a URI for 2
days and then began to cough, with hoarseness and stridor.
In the ED he is febrile (38�), running around the room,
without stridor at rest.
� No drooling
� Lungs clear
26. CXR
NO
27. � Mist therapy???
� Corticosteroids
� Effective in moderate to severe croup�PO / IM
� Dexamethasone (0.15 - 0.6 mg/kg) PO/ IM
� Aerosolized Racemic epinephrine
� No rebound---reserve for kids with stridor at rest
If clinically fine after 2 hours may , send home