Pediatric Respiratory Emergencies Part 2

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. Knapp et al. Pediatrics 2008 • 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 Knapp et al. Pediatrics 2008

5. Conclusions Knapp et al. Pediatrics 2008 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. Case No. 1 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. On Exam: • Bronchiolitis • 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. RSV wash • May be necessary for bed placement • Not all bronchiolitis is RSV (metapneumovirus, para virus) • Yet may decreaselikelihood 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. Diagnosis, • CXR

13. Evaluation of the utility of radiography in acute bronchiolitis. Schuh S, et al. J Pediatr. 2007 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 Schuh S, et al. J Pediatr. 2007 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. Cochrane Database Syst Rev. 2006;(3) 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 Hartling L, et al. Arch Pediatr Adolesc Med. 2003;157;957-64. 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 Dexamethasonein 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 daysafter the day of enrollment (the initial visit to the emergency department) N Engl J Med 2009; 360:2079-2089

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. Case No. 2 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. Treatment Options: • 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

29. Thank you