Pediatric Respiratory Pediatric Respiratory EmergenciesEmergencies
Part 2Part 2
Pediatric Respiratory Pediatric Respiratory EmergenciesEmergencies
Part 2Part 2Mohammed Al Faifi, MD.Mohammed Al Faifi, MD.
Pediatric Emergency ConsultantPediatric Emergency Consultant
Department of Emergency MedicineDepartment of Emergency Medicine
King Faisal Specialist Hospital & Research King Faisal Specialist Hospital & Research Centre Centre
Riyadh, KSARiyadh, KSAKUWAIT, Oct. 2011KUWAIT, Oct. 2011
Topics to be covered Topics to be covered Topics to be covered Topics to be covered
•• BronchiolitisBronchiolitis
• • CroupCroup
2005 National Hospital Ambulatory Medical Care Survey 2005 National Hospital Ambulatory Medical Care Survey
a nationally representative sample of USA patients was analyzeda nationally representative sample of USA patients was analyzed
Data on visits to EDs by childrenData on visits to EDs by children
– – 1 -19 years of age with moderate/severe Asthma1 -19 years of age with moderate/severe Asthma
– – 3 months to 2 years of age with Bronchiolitis3 months to 2 years of age with Bronchiolitis
– – 3 months to 3 years of age with Croup3 months to 3 years of age with Croup
Knapp et al. Pediatrics 2008
ResultsResultsResultsResults
CorticosteroidsAntibioticsRadiographs
69% of the 405,000
visits for moderate/
severe asthma
31% of the estimated
317,000 annual
croup visits
53% of the estimated
228,000 annual visits
for bronchiolitis
72% of bronchiolitis
visits
32% of croup visits
Knapp et al. Pediatrics 2008
ConclusionsConclusionsConclusionsConclusions
Physicians treating children with Physicians treating children with
Asthma, Asthma,
bronchiolitis bronchiolitis
croup croup
In USA Emergency Departments are In USA Emergency Departments are under usingunder using known known effective treatments and effective treatments and overusingoverusing ineffective or ineffective or unproven therapies and diagnostic tests.unproven therapies and diagnostic tests.
Knapp et al. Pediatrics 2008
A 5-month-old presents with cough for 2 daysA 5-month-old presents with cough for 2 days
Preceded by a URI, his feeding has decreased and his Preceded by a URI, his feeding has decreased and his
cough interrupts sleep, Temp. 38° at home. cough interrupts sleep, Temp. 38° at home.
Normal PMHx.Normal PMHx.
Case No. 1
Temp 38.5°, RR 60, Temp 38.5°, RR 60, SaSaOO22 94% in room air 94% in room air
Mild rhinorrhea, air entry good, Mild rhinorrhea, air entry good,
wheezing in all fieldswheezing in all fields
Well Hydrated, feeds wellWell Hydrated, feeds well
No grunting or retractionsNo grunting or retractions
This is a classic case of This is a classic case of
On Exam :•
Bronchiolitis
Diagnosis. Diagnosis. Diagnosis. Diagnosis.
May be necessary for May be necessary for bed placementbed placement
Not all bronchiolitis is RSV (metapneumovirus, Not all bronchiolitis is RSV (metapneumovirus, para virus)para virus)
Yet may Yet may decreasedecrease likelihood of bacteremia likelihood of bacteremia
(but not UTI(but not UTI))
RSV washRSV wash
Febrile infants with Febrile infants with confirmed viral infections are at lower risk for confirmed viral infections are at lower risk for SBI SBI than those in whom a viral infection is not identifiedthan those in whom a viral infection is not identified
Viral diagnostic data can positively contribute to the management of Viral diagnostic data can positively contribute to the management of febrile infants, especially those who are classified as High risk.febrile infants, especially those who are classified as High risk.
Peditrics Vol. 113: 1662, 2004Peditrics Vol. 113: 1662, 2004
Differential Diagnosis Differential Diagnosis Differential Diagnosis Differential Diagnosis
Gastroesophageal reflux disease Gastroesophageal reflux disease
Tracheoesophageal fistula Tracheoesophageal fistula
Tracheomalacia Tracheomalacia
Vascular ring Vascular ring
Cystic fibrosis & immunodeficiencyCystic fibrosis & immunodeficiency
CHDCHD
Foreign body aspiration. Foreign body aspiration.
• • CXRCXR
Diagnosis,
Evaluation of the utility of radiography in Evaluation of the utility of radiography in acute bronchiolitis. acute bronchiolitis. Evaluation of the utility of radiography in Evaluation of the utility of radiography in acute bronchiolitis. acute bronchiolitis.
A prospective study of 265 children aged 2 to 23 A prospective study of 265 children aged 2 to 23
months who presented to the ED with months who presented to the ED with
bronchiolitis analyzed use of routine radiography bronchiolitis analyzed use of routine radiography
in patients with a simple form of the disease in patients with a simple form of the disease
(defined in a child as coryza, cough, and (defined in a child as coryza, cough, and
respiratory distress accompanying a first respiratory distress accompanying a first
episode of wheezing without underlying illness).episode of wheezing without underlying illness).Schuh S, et al. J Pediatr. 2007
Result Result Result Result
The findings were consistent with The findings were consistent with bronchiolitis except in only 2 cases, bronchiolitis except in only 2 cases, and in neither case did the findings and in neither case did the findings change short-term management. change short-term management.
Schuh S, et al. J Pediatr. 2007
HIGH RISK HIGH RISK HIGH RISK HIGH RISK Premature birth (< 35-37 weeks & Premature birth (< 35-37 weeks &
younger age (< 6-12 weeks of life) younger age (< 6-12 weeks of life)
Full term and younger than 1 month, Full term and younger than 1 month,
Bronchopulmonary , cystic fibrosis Bronchopulmonary , cystic fibrosis
(CHD), and immune deficiency disease (CHD), and immune deficiency disease
Child’s parents or a clinician had Child’s parents or a clinician had already witnessed an apnea episode already witnessed an apnea episode
Management Management Management Management Nasal SuctionNasal Suction
Beta 2 AgonistsBeta 2 Agonists
– – Clinical trials, meta-analyses & systematic Clinical trials, meta-analyses & systematic
reviews (2000-2004) showed some reviews (2000-2004) showed some
differences in short term benefits (oxygen, differences in short term benefits (oxygen,
RR) yet RR) yet no difference in clinically meaningful no difference in clinically meaningful
outcomes (admission, length of stay)outcomes (admission, length of stay)
– – Yet Yet some will respond. some will respond.
Bronchodilators for bronchiolitisBronchodilators for bronchiolitis. . Bronchodilators for bronchiolitisBronchodilators for bronchiolitis. .
A Cochrane review of bronchodilators A Cochrane review of bronchodilators other than epinephrine found that the other than epinephrine found that the
agents produce small, short-term agents produce small, short-term improvements but do not affect rate of improvements but do not affect rate of
hospitalization or length of hospitalhospitalization or length of hospital
Cochrane Database Syst Rev. 2006;(3)
Epinephrine and Bronchiolitis Epinephrine and Bronchiolitis Epinephrine and Bronchiolitis Epinephrine and Bronchiolitis
A meta-analysis suggested a decrease in A meta-analysis suggested a decrease in clinical symptoms when compared with clinical symptoms when compared with either placebo either placebo
Hartling L, et al. Arch Pediatr Adolesc Med. 2003;157;957-64 .
Ipratropium bromide Ipratropium bromide Ipratropium bromide Ipratropium bromide
At this point, use of anticholinergic At this point, use of anticholinergic agents―either alone or in combination agents―either alone or in combination with beta-adrenergic agents―for viral with beta-adrenergic agents―for viral bronchiolitis is not justified in the EDbronchiolitis is not justified in the ED
Bronchiolitis & SteroidsBronchiolitis & SteroidsBronchiolitis & SteroidsBronchiolitis & Steroids
• • CorticosteroidsCorticosteroids
– – 2004 Cochrane Review, 13 trials, 1200 children2004 Cochrane Review, 13 trials, 1200 children
• • No difference in admission rates, no benefits compared to placeboNo difference in admission rates, no benefits compared to placebo
– – PECARN multicenter trialPECARN multicenter trial
• • Compared Dexamethasone and placebo in ED patients with Compared Dexamethasone and placebo in ED patients with
bronchiolitisbronchiolitis
• • No difference in admission at 4 hoursNo difference in admission at 4 hours
Bronchiolitis & Steroids Bronchiolitis & Steroids Bronchiolitis & Steroids Bronchiolitis & Steroids
70 children, 3 winters, one center70 children, 3 winters, one center
2-23 months, first wheezing with distress and 2-23 months, first wheezing with distress and URIURI
Dexamethasone (36) vs. placebo (34)Dexamethasone (36) vs. placebo (34)
Dexamethasone groupDexamethasone group
– – More improved clinical scoreMore improved clinical score
– – Few hospitalizations (19% vs 44%)Few hospitalizations (19% vs 44%)
Schuh et al. J Pediatr 2002Schuh et al. J Pediatr 2002
Dexamethasone for Bronchiolitis, A Multicenter, Dexamethasone for Bronchiolitis, A Multicenter, Randomized, Controlled Trial:Randomized, Controlled Trial:Dexamethasone for Bronchiolitis, A Multicenter, Dexamethasone for Bronchiolitis, A Multicenter, Randomized, Controlled Trial:Randomized, Controlled Trial:
The study compare The study compare single dose single dose of oral dexamethasone (1 mg per of oral dexamethasone (1 mg per
kilogram of body weight) with placebo in 600 children (age range, 2 kilogram of body weight) with placebo in 600 children (age range, 2
to 12 months) with a to 12 months) with a first episode of wheezing first episode of wheezing diagnosed in the diagnosed in the
ED as moderate-to-severe bronchiolitis. ED as moderate-to-severe bronchiolitis. 20 emergency departments during the months of November through 20 emergency departments during the months of November through
April over a 3-year periodApril over a 3-year period
NEJM 2007; 357:331-9NEJM 2007; 357:331-9
Epinephrine and Dexamethasone in Children with Epinephrine and Dexamethasone in Children with BronchiolitisBronchiolitisEpinephrine and Dexamethasone in Children with Epinephrine and Dexamethasone in Children with BronchiolitisBronchiolitis
Multicenter, double-blind, placebo-controlled trial Multicenter, double-blind, placebo-controlled trial
• • 800 infants (6 weeks to 12 months of age) with bronchiolitis randomly assigned to one of four 800 infants (6 weeks to 12 months of age) with bronchiolitis randomly assigned to one of four study groupsstudy groups
• • The primary outcome was The primary outcome was hospital admission within 7 dayshospital admission within 7 days after the day of enrollment (the after the day of enrollment (the initial visit to the emergency department)initial visit to the emergency department)
N Engl J Med 2009; 360:2079-2089
ConclusionsConclusionsConclusionsConclusions
Among infants with bronchiolitis treated in the ED, combined therapy with Dexamethasone and Epinephrine may significantly reduce hospital admissions,
Admission Criteria: Admission Criteria:
• • Hypoxemia and poor feeding
• Less than 34 weeks
• Heart disease
• Atelectasis
• Less than 2 months,
A 3-year-old with cough at 2 AM, The child had a URI for 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.days and then began to cough, with hoarseness and stridor.
In the ED he is febrile (38°), running around the room, In the ED he is febrile (38°), running around the room,
without stridor at rest.without stridor at rest.
• • No droolingNo drooling
• • Lungs clearLungs clear
Case No. 2
CXR CXR
NONO
• • Mist therapy???Mist therapy???
• • CorticosteroidsCorticosteroids
– – Effective in moderate to severe croup—Effective in moderate to severe croup—PO / IMPO / IM
– – Dexamethasone (0.15 - 0.6 mg/kg) PO/ IMDexamethasone (0.15 - 0.6 mg/kg) PO/ IM
• • Aerosolized Racemic epinephrine Aerosolized Racemic epinephrine
– – No rebound---reserve for kids with stridor at restNo rebound---reserve for kids with stridor at rest
If clinically fine after 2 hours may , send homeIf clinically fine after 2 hours may , send home
Treatment Options :