part i: upper airway emergencies - · pdf fileupper airway emergencies a. upper airway...

Andrea Marmor, MD May, 2010

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Evidence-Based Update on Pediatric Respiratory Emergencies Andi Marmor, MD ([email protected]) May 26, 2010

Topics: 1. Upper Airway Emergencies

a. Upper Airway Infections b. Anaphylaxis c. Airway Burns

2. Lower Airway Emergencies a. Airway Foreign Bodies b. Asthma

i. Status Asthmaticus ii. Acute Asthma Management

iii. Chronic Asthma Management

PART I: UPPER AIRWAY EMERGENCIES ▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪

A. UPPER AIRWAY INFECTIONS ▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪ Question: What medications are currently recommended for treatment of croup? Background

• Croup has overall incidence of 1.5 to 6% of children, most commonly encountered in the 2nd year of life o Most commonly associated with parainfluenza viruses types 1 and 3 o Croup is a clinical diagnosis, and as a syndrome, is considered a source for fever in infants > 1 mo of age

• Standard treatments for croup include humidified air (mist), racemic epinephrine, and systemic corticosteroids • Moist or cool air has been used to treat croup since the 19th century

o Recommendations for home management often includes placing child in steamy bathroom or cool outside air o However, the utility of treatment with humidified air in the ED has recently come under greater scrutiny

• Racemic epinephrine is well-established as an effective as a treatment for moderate or severe croup in the ED setting o Results in decreased respiratory distress and stridor within 30 minutes of treatment o Duration of action of about 2 hours, and concern has been raised for a “rebound effect” o Early recommendations suggested that patients treated with racemic epinephrine should be admitted

• Corticosteroids may be given orally or via inhaled routes, but the indications, mode of delivery and ideal dosing remain controversial

Evidence • Mist therapy:

o Cochrane review (2006) of RCT’s comparing humidified air vs placebo in children with mild-moderate croup found no significant benefit demonstrated of mist over placebo

Only 3 small studies found, and only one was blinded Trend towards benefit suggest further study needed

o More recent RCT of 140 children with mod/severe croup (Scolnik, 2006) compared 40% to 100% humidity Found no change in symptom score, need for dex/epi or hospitalization, or RR/O2 sat changes 40% humidity felt by authors to represent ambient air humidity, but may vary by location

o Although there are no national guidelines for the management of croup, among two local guidelines (Alberta Medical Association; Monash University in Australia) neither recommend mist in routine treatment of croup

• Racemic epinephrine o Several studies (eg: Ledwith, 1995) have established that when epinephrine is used in conjunction with

glucocorticoids, discharge after an observation period of 3-4 hours is safe and cost-effective • Corticosteroids:

o Cochrane Review (2004) found that corticosteroids resulted in decreased symptoms within 6 h of treatment, fewer return visits/hospitalizations, decreased time in ED and decreased use of epinephrine.

Oral and inhaled steroids seemed to be equally effective, although direct comparisons were limited Trend towards superiority of oral over IM administration

o Newer studies suggest efficacy in mild croup, reduced symptom duration and severity, and costs Eg: RCT with n=720 with mild croup (Bjornsen, 2004): single dose PO dexamethasone (0.6mg/kg)

reduced return visits (↓50%), time to symptom resolution , lost sleep (↓30%) and parental stress Results and cost savings were statistically robust, and have clinical importance

o Dose of dexamethasone: Most studies use 0.6 mg/kg/dose, although a few studies (eg: Geelhoed, 1995) suggest that lower

doses (0.15 to 0.3mg/kg ) may be equally effective o Inhaled steroids:

Although some studies have shown equivalent benefit, data insufficient to recommend inhaled steroids instead of systemic for treatment of croup


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Recommendations: Croup

1. Inhaled racemic epinephrine should be used for children with croup who have stridor at rest or symptoms of severe upper airway obstruction

Dose: 0.5mL (or 0.05 to 0.1 ml/kg) of racemic epinephrine Discharge OK after 3-4 hours of observation if

• Steroids given • No stridor at rest and good mental status

2. Mist therapy is safe and can be considered for mild croup, especially in areas of low humidity, but is unlikely to confer clinically significant benefit

Recommend bathroom vapor or outdoor air for parental use at home 3. Systemic corticosteroids should be given to children with croup in order to reduce symptom severity and duration

Mod/severe croup: reduces hospitalizations and racemic epi use Mild croup: benefits smaller but still may be clinically significant Dose: 0.6mg/kg/dose of dexamethasone PO (preferred) or IM (max: 16 mg)

• IV form of dexamethasone (4mg/mL solution) may be given orally Question: What else are you concerned about in the child with acute fever and stridor? Background

• Potentially life-threatening causes of fever/stridor include epiglottitis, bacterial tracheitis and retropharyngeal abscess Epiglottitis

• Epidemiology o Dramatic decline in incidence in children since 1990 when Hib vaccination became widespread o Interestingly, incidence in adults has risen in same time period o Childhood epiglottitis now more likely to be caused by Strep and Staph spp than by H influenza o Although rare, H. influenza epiglottitis still occurs in both immunized and non-immunized children

• Presentation: o Toxic appearance with rapid progression of fever, stridor, resp distress, drooling, throat pain o Gradual course and subtle symptoms may be seen in younger children

• Diagnosis o Lateral neck film may show “thumbprint” sign of inflamed epiglottis o Radiography should be attempted with caution, and only when airway support is available o Direct visualization via laryngoscopy is diagnostic, but not recommended unless in controlled setting

• Management o IV steroids often used in adults, but no clinical studies of this therapy in kids

Tracheitis • Epidemiology

o Due to Hib immunization and glucocorticoid treatment, tracheitis now exceeds epiglottitis and croup as the most common life-threatening infection of the upper respiratory tract in children

In a 9 year PICU study, Hopkins (2006) found bacterial tracheitis was 3 times more likely to cause respiratory failure than viral croup and epiglottitis combined

o Mortality rates as high as 18-40% o S. aureus most common bacterial cause (+ strep, M. catarrhalis, H. influenza). Influenza viruses also seen

• Presentation: o Toxic appearance with rapid progression of fever, stridor, purulent secretions, throat pain, hoarseness o In a recent case series (Hopkins, 2006) only 11% had drooling, and only half had a WBC count > 10

• Diagnosis o Diagnosis primarily clinical, posterior oropharynx may show exudative pseudomembrane o Direct visualization by bronchoscopy (under anesthesia) is diagnostic o Radiography may show enlarged hypopharynx, but findings are non-specific

Retropharyngeal Infections • Retropharyngeal (RP) space = potential space between post pharyngeal wall and prevertebral fascia • Epidemiology:

o Most commonly in children < 6, with peak incidence at 3. o Usually due to lymphatic spread of infection from pharyngitis, tonsillitis, sinusitis, or cervical lymphadenitis. o Pathogens vary based on origin (Strep and staph species, oral anaerobes, H. influenza , Klebsiella)

• Presentation o Fever, neck swelling/pain and decreased movement (especially extension), drooling/decreased oral intake. o Signs of resp distress (stridor, wheeze) are less common.


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• Diagnosis o Lateral neck film: may show expansion of prevertebral RP space

Expansion of prevertebral space: > 1 vertebral body width (> 7 mm at C2, or >14 mm at C7) Most accurate with inspiration and with extension of neck

o CT is the diagnostic standard, but variable utility in distinguishing necrotic LN from RP cellulitis or abscess o Ultrasound may be better for distinguishing between adenitis, RP cellulitis and RP abscess, but may be

technically difficult in distressed young child • Management:

o Recent trend towards initial management with antibiotics, with surgical drainage only if fails to respond Recommendations: Recognition and Management of Upper Airway Infections

1. Epiglottitis Consider in the child with fever, stridor, drooling and a toxic appearance/rapidly advancing symptoms Diagnosis: Lateral neck films may reveal thumbprint appearance, but not necessary for diagnosis

• Obtain radiography only if airway support is available • Avoid direct visualization/laryngoscopy of airway until child in controlled setting (eg: OR).

Treatment: Airway support and IV broad-spectrum antibiotics: ceftriaxone, ampicillin-sulbactam. • Add vancomycin if MRSA suspected • Consider IV steroids (dexamethasone or methylprednisone) if airway compromise imminent

2. Tracheitis Same presentation as epiglottitis, (fever, stridor, drooling, toxic appearance) but more common in post-Hib

era than epiglottitis Diagnosis: Clinical diagnosis (visualization with bronchoscopy is diagnostic) Treatment: Airway support and IV broad-spectrum antibiotics: ceftriaxone, ampicillin-sulbactam

• Add vancomycin if MRSA suspected 3. Retropharyngeal infections

Consider in child with fever, neck pain and stiffness, and drooling or difficulty swallowing • May occur with minimal respiratory symptoms

Diagnosis: Consider lateral neck film to view size of retropharyngeal space; CT or ultrasound definitive Treatment: Airway support and broad-spectrum antibiotics (ceftriaxone, amp/sulbactam)

• Add vancomycin if MRSA suspected • Admit for medical management, surgical drainage if medical management fails

▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪ B. ANAPHYLAXIS

▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪ Question: How can we recognize anaphylaxis in young infants and children?

• Pathophysiology o Acute, life-threatening IgE or non-IgE-mediated response with skin, respiratory, CV and GI manifestations o May occur as a result of pre-formed IgE or direct stimulation of mast cells o Foods, medications and latex tend to cause IgE mediated reactions. Blood products, contrast and some

medications can cause direct stimulation of histamine or immune complexes • Epidemiology

o Most anaphylaxis episodes in infancy are the first manifestation of allergy (Simons, 2007) o However, infants with a history of atopy, asthma, urticaria, bronchiolitis or croup may be at increased risk

of anaphylaxis or fatality from allergic reaction o Up to 50% of cases are idiopathic o Most common triggers in infants are foods (30-50% of cases) (Kobrynski, 2007)

Most common: cow’s milk, egg, soy, peanut May be via direct ingestion, accidental ingestion, or breast milk

o Other triggers: medications (antibiotics, antipyretics) latex, vaccinations and cold exposure o Skin contact with food product/medication can sensitize but is not likely to cause anaphylaxis

• Clinical Presentation o Signs/symptoms typically appear 5-30 minutes after exposure

Cutaneous symptoms typically occur first, but may be delayed if rapid progression of symptoms 5-20% may experience a recurrence within 8-12 hours (risk increased if treatment with epi delayed

or multiple doses required) (Kobrynski, 2007) Protracted symptoms are rare (<1%) and more likely to be fatal Rapid onset of symptoms after exposure associated with more severe course

o Detectable symptoms: (Kobrynski, 2007)


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Cutaneous (>90%): hives, flushing Respiratory (20-50%): swelling of face/mouth/tongue, respiratory distress (wheeze, stridor, cough),

hoarse cry, rhinorrhea GI (20-30%): vomiting, diarrhea, abdominal pain Cardiovascular (15-30%): poor perfusion, diaphoresis, lethargy

o Occult symptoms: may be difficult to detect in young infants, or not recognized as pathologic Itching, warmth, hoarseness, nausea, dizziness, confusion, blurry vision, nasal congestion, drooling,

abdominal pain, diarrhea, sleepiness • Laboratory Testing

o Bottom line: labs cannot rule anaphylaxis in or out o May be useful in making other diagnoses in the differential

Hereditary angioedema, scromboid poisoning, mastocytosis o Elevated serum tryptase may occur

Rises within 60 minutes and may remain elevated for up to 6 hours after onset of symptoms May not be elevated in food-induced anaphylaxis

o Serum histamine rises within minutes, but remains elevated only 30-60 minutes o Radioallergosorbent (RAST) testing for specific IgE to suspected trigger may help confirm sensitivity

Recommendations: Diagnosis of Anaphylaxis

1. Recognize that infants may experience anaphylaxis as the first manifestation of allergy 2. Consider anaphylaxis in infants and young children with urticaria, mental status changes or acute onset of upper

airway obstruction, especially those without fever 3. Diagnosis should be made on clinical grounds, as laboratory testing is unlikely to confirm or reject the diagnosis

Referral for RAST testing may be warranted to confirm suspected trigger Question: What should be done in the ED to manage anaphylaxis? Background

• Rapid initiation of treatment (particularly epinephrine) prevents fatalities • Treatment should address airway, circulatory, skin and GI manifestations • Observation and management should also address possibility of biphasic or protracted symptoms

Evidence • IM administration of epinephrine results in more rapid absorption than SC route (Lieberman, 2005)

o Lateral thigh theoretically faster absorption than deltoid muscle, although not tested clinically • Combination of H1 and H2-antagonists more effective than H1 antagonist alone (Lieberman, 2005)

o Anti-histamines primarily helpful with skin manifestations, and do not reverse life-threatening cardiovascular/respiratory symptoms

o Anti-histamines should never replace epinephrine as first-line treatment • Main role of corticosteroids is to prevent recurrence or protracted symptoms.

o Recurrence occurs in 30-35% Recommendations: Management of Anaphylaxis

1. Assess airway, breathing and circulation Secure airway and administer oxygen if needed Obtain IV access and give NS bolus (20mL/kg, repeat until hemodynamically stable)

2. Epinephrine: 0.01 mL/kg of 1:1000 epinephrine solution (0.01mg/kg) IM or SC; max = 0.5mg Repeat at 5-10 minute intervals, as needed

3. Additional medications: • Methylprednisolone or prednisone (1-2mg/kg IV/PO; max 125mg; repeat q6h as needed) • Diphenhydramine (1mg/kg ; max 50mg; repeat q 8 hours as needed) • Ranitidine (1mg/kg; max 50mg) • Inhaled beta-agonists (albuterol) if wheezing • Inhaled epinephrine if laryngeal edema • If refractory hypotension: consider IV epinephrine

4. Observe for at least 6-8 hours in ED for late-phase reaction 5. Disposition

D/C ALL anaphylaxis patients with 2 Epi-pens o Infant < 10 kg: consider risks/benefits of DC with epi-pen (Sicherer, 2007) o Child 10-30 kg: Epi-pen Jr (0.15mg) o Child > 30kg: Epi-pen (0.3 mg)


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Consider medical identification patch or bracelet Consider referral to allergist for further testing and education

▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪ C. AIRWAY BURNS

▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪ Background/Evidence:

• Up to 30% of children with burn injury sustain some thermal airway injury (Barrow, 2004) • Thermal injury to the airway can occur from smoke or steam inhalation, or due to aspiration/swallowing of hot liquids

o Aspiration of microwave-heated liquids are seen most commonly in young children • Areas affected

o Typically, burns affect issues above the carina (tongue, uvula, epiglottis, subglottic area, trachea o Thermal epiglottitis is clinically and radiographically similar to infectious epiglottitis, may progress over

several hours • Signs and symptoms:

o Singed nasal hair, facial burns, stridor, hoarseness, dyspnea. Delayed deterioration may be seen in infants presenting with facial burns

o CXR typically normal, oropharyngeal examination may be normal o Direct fiberoptic visualization under general anesthesia is most accurate diagnostic and prognostic tool

• Mortality: inhalation burn increases burn mortality o Mortality for isolated inhalation injury: 23% (Fidkowski, 2009) o Mortality with 73% TBSA is 10% without inhalation injury, and 50% with inhalation injury

• Treatment: o Early airway control essential

Many authors recommend cuffed tubes, for better sealing of airway under anticipated increased ventilatory pressures.

Succinylcholine safe within 24hrs of injury o Steroids: Have not been shown to improve long-term pulmonary function o Inhaled bronchodilators (albuterol, epinephrine): effective if bronchospasm is present

Recommendations: 1. Consider airway thermal injury in children with facial burns, large body burns, evidence of smoke inhalation, or any

respiratory symptoms after a burn 2. Approach children with suspected thermal airway injury with the same precautions as those with acute epiglottitis

Maintain position of comfort, and be prepared for emergency airway management 3. Secure airway electively if any evidence of laryngeal edema (change in voice/cry, stridor)

Cuffed tube recommended 4. Bronchodilators are effective, trial of steroids may be warranted if airway swelling is severe

PART 2: LOWER AIRWAY EMERGENCIES ▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪

A. AIRWAY FOREIGN BODIES ▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪ Question: What is the best diagnostic approach for foreign body (FB) aspiration? Background:

• Findings of FB aspiration may mimic those of pneumona, asthma or bronchiolitis • Epidemiology (Tan, 2000 and Digoy, 2008)

o Most common in children 1-3 years of age o Serious complications more common in infants and younger children o Diagnosis is delayed by > 24 hours in ~50% of patients, and by > 1 month in 10% of cases (Tan, 2000) o Delay in diagnosis is directly associated with morbidity.

• Characteristics of pediatric aspirated FB’s o Most commonly lodged in bronchi, R >L (95%). o Rarely aspirated into larynx or trachea (<5%) o 80% of aspirated objects are radiolucent o Foods such as nuts, seeds, beans and hot dogs are most commonly aspirated objects. o Non-food objects include beads, coins, small toys and pieces of balloon

• History: o Classic history has 3 phases

Initial choking episode, +/- respiratory distress (continued cough, tachypnea, increased WOB)


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Asymptomatic interval (hours to days) Complications (pneumonia, complete airway obstruction, hyperinflation)

o 92% have history of initial choking episode, 84% have wheezing, 57% have classic triad of choking, wheezing and unilaterally reduced breath sounds (Tan, 2000)

• Physical findings o Observation: cough +/- signs of resp distress (tachypnea, retractions, rarely cyanosis) o Auscultation: asymmetric wheeze, unilaterally decreased breath sounds

• Radiographic findings (CXR) o Early: asymmetric hyperinflation (from partial obstruction), mediastinal shift (severe hyperinflation) o Late: atelectasis, or findings consistent with pneumonia (focal infiltrate, volume loss)

Evidence: Diagnosis

• Imaging: radiographic findings are often absent in patients with aspirated FB o Reported sens and spec of CXR varies: 49-88% sens/9-71% spec (Digoy, 2008; Even, 2005)) o Use of inspiratory/expiratory CXR may increase correct diagnosis, but difficult in children < 3

Bilateral decubitus films an option in younger children o Fluoroscopy can be a useful asset, but reported sens/specificities vary

Not necessary if plain radiographs show evidence of foreign body • Physical exam: low specificity, variable sensitivity (14-45% of pts have normal PE) (Digoy, 2008) • 25- 50% of cases may have normal chest radiograph and PE (Digoy, 2008; Tan, 2000) • History the most sensitive and specific of all diagnosis tools– 91% sens and 46% specific (Ciftci, 2003)

Recommendations: Diagnosis of FB aspiration

1. ***Use of radiography in suspected FB aspiration should be limited to children with a stable airway*** Crying/position during imaging may precipitate complete obstruction in child with precariously located FB

2. Bronchoscopy should be performed if any of the 3 diagnostic tools (PE, history or xray) suggests FB aspiration 3. If suspicion is high (classic history or PE, or suspected aspiration with symptoms not responding to initial therapy)

refer for diagnostic bronchoscopy without imaging 4. Radiographs may have a role in aiding diagnosis, in select cases

Limited to situations when the diagnosis is questionable Should not be used to definitively R/O FB, but negative predictive value highest when low clinical suspicion

Question: What can be done in the ED if FB aspiration is suspected? Background

• Although most children with inhaled FB have a stable airway, others may present to the ED with partial or complete airway obstruction

• FB may mobilize to cause complete obstruction in the ED during examination/imaging • ED staff should know the procedures to follow in the event of airway obstruction from a FB

Evidence • New recommendations for pediatric life support discourage the “blind finger sweep” and most other attempts to

dislodge or remove a FB in an uncontrolled setting • Heimlich maneuver (or age-appropriate equivalent) recommended only in acute complete airway obstruction

o Deaths related to foreign body aspiration have dramatically decreased since the introduction of the Heimlich maneuver

Recommendations: Management of Foreign Body Aspiration

1. For acute upper airway obstruction from suspected FB aspiration: attempt to remove FB with appropriate measures Infant < 1 year of age: 5 back blows with pt supine, followed by 5 abdominal thrusts Toddler or child: Heimlich maneuver

2. If above measures fail, consider ventilating via needle cricothyrotomy (see below) Ventilate with bag-valve-bask until airway can be otherwise secured

3. For acute lower airway obstruction from suspected FB aspiration: Trial of inhaled bronchodilators (albuterol/atrovent) – continue if patient responds Oral, IM or IV systemic corticosteroids: prednisone or methylprednisolone: 2mg/kg or dexamethasone

0.6mg/kg Obtain age-appropriate films if patient is stable, consider fluoroscopy if available

***As noted above, limit use of radiograph y to children with a stable airway*** Referral to pulmonology or surgery for rigid bronchoscopy if clinical suspicion is moderate-high, even if

initial evaluation is negative


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B. ASTHMA: PART I – Status Asthmaticus ▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪ Question: Which adjunctive medications are most effective in pediatric status asthmaticus? Background:

• Initial management for severe asthma exacerbation not responding to initial treatment should include continuous inhaled ß-agonists (albuterol), maximum oxygenation and systemic steroids (IV solumedrol, 1-2mg/kg/dose q6h)

• If an asthma patient fails to respond to these initial management steps, they are consider to be in status asthmaticus • Since the efficacy of inhaled bronchodilators may be limited by severe bronchospasm, adjunctive medications may be

able to relieve bronchospasm in status asthmaticus • Commonly available systemic bronchodilators include magnesium, terbutaline and theophylline • Magnesium

o Acts directly on smooth muscle, side effects include flushing and hypotension • Terbutaline

o The only systemic beta-agonist available in the US, and the most commonly used second-line agent after standard care with inhaled bronchodilators and systemic steroids

o Tremor, tachycardia, nausea are common, hypokalemia may occur with prolonged administration • Theophylline

o Rarely used in comparison with terbutaline, which may be due to concerns for efficacy or toxicity o Potential advantages over terbutaline include

Significantly less expensive, (even when cost of monitoring levels is included) Bronchodilation and improved airflow without adverse effect on VQ matching Removal of excess alveolar fluid through diuresis, and improved mucociliary clearance Increased cardiac output, respiratory drive, and contractility of diaphragm

Evidence: • Magnesium:

o RCT data, as well as a meta-analysis (Rowe, 2000) have established safety and efficacy in kids o Reduces hospitalization rates , most beneficial in severe asthmatics

• Terbutaline o Overall, terbutaline has not been consistently shown to decrease symptoms or length of stay o One recent RCT (Bogie, 2007) showed trend toward improved symptoms and decreased treatment duration,

another (Carroll, 2006) showed decreased ICU stay when dose titrated for severity o No significant cardiac effects have been reported in kids

• Theophylline: o A meta-analysis by (Mitra, 2005) showed that theophylline improved lung function, but did not reduce

symptoms or length of stay in children with status asthmaticus o One recent RCT (Wheeler et al 2005) found theophylline alone as safe, as effective and more cost effective

than either terbutaline or terbutaline/theophylline in children with status asthmaticus • Heliox:

o Mixture of helium and oxygen (80:20 or 60:40 mixture of helium:oxygen) o Adding helium reduces air density, or air “viscosity”, and therefore the force required to carry the air across

obstructed airways. While heliox has been found to improve laminar flow (McGarvey, 2008), no evidence to date supports its efficacy in status asthmaticus (McGarvey, 2008; Rivera, 2006)

o Use of heliox substantially reduces max FiO2 to 40% (if using a 60:40 helium/oxygen mixture) Recommendations: Systemic Bronchodilators in Status Asthmaticus

1. Magnesium should be the first line systemic bronchodilator in pediatric status asthmaticus in the ED Single dose recommended (utility of repeated doses unclear) Dose: 25-75mg/kg (max 2.5g) IV over 20 minutes Adverse effects: flushing, nausea

2. Terbutaline or theophylline can be considered in critically ill patients who have failed 1st-line therapies Terbutaline: can be given IM or IV (Loading dose = 10 mcg/kg; infusion dose = 0.4mcg/kg/min) Theophylline: may be more cost effective, but must monitor for toxicity

Loading dose = 6 mg/kg over 20 mins IV, Infusion dose: 1 mg/kg/hour (neonates: 0.1 to 0.8 mg/kg/h) Monitoring: Check serum theophylline concentrations 3 hrs after load, then q 12 hrs • Therapeutic range : 10 to 20 µg/mL • Mild toxicity: may occur at > 15 µg/mL (nausea and vomiting, tachycardia, and agitation) • Severe toxicity: > 35 µg/mL (cardiac arrhythmias, hypotension, seizures, and death)


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3. Heliox is not recommended, and should be used with caution, as its use substantially decreased available FiO2 Question: What is the role of arterial blood gases/intubation in pediatric status asthmaticus? Background:

• Mechanical ventilation is especially dangerous in asthma as it may worsen bronchospasm/hyperinflation o Should be avoided whenever possible

• Arterial blood gases (ABG) are often obtained in severe asthma exacerbations to guide clinical decisions, such as need for intubation, or to predict clinical course

o ABG gives information about ventilatory status (hypercarbia), and oxygenation Hypercarbia can also be assessed using non-invasive end-tidal CO2, or venous blood gas Oxygenation is more easily assessed using pulse oximetry, at saturations <100%

o Typically shows low paCO2 in early severe asthma, increasing as ventilatory status worsens Evidence:

• Mechanical ventilation o Rates vary widely in the literature: 1-20% for pediatric status asthmaticus o Consistently associated with increased mortality

• When controlled for asthma severity, increased use of blood gases/mechanical ventilation appears to be associated with greater length of stay, but not with improved clinical outcomes (Roberts, 2002)

Recommendations: 1. Arterial blood gases are of limited utility in pediatric status asthmaticus, and should not be routinely performed

Information on hypoxia and hypercarbia, if needed, can be obtained by noninvasive means 2. Mechanical ventilation:

If available, trial of noninvasive positive pressure ventilation should be tried before intubation, to ease work of breathing, and allow medications to take effect

Decisions to intubate asthmatic children should be made on clinical grounds, NOT based on blood gas measurements

o Clinical indications for intubation include: altered mental status, insufficient respiratory effort, severe persistent hypoxemia (if patient is breathing on her own, she is doing a better job than the ventilator will….)

Ketamine is induction agent of choice, should intubation be necessary ▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪

B. ASTHMA: PART II – Acute Asthma Exacerbation ▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪ Question: What is the best method of administering short-acting β-agonists (SABAs) to children? Background:

• β-agonists should be inhaled (via metered-dose-inhaler or nebulizer) and never given orally • Nebulizers

o Usually used to deliver albuterol in ED’s o Also prescribed for home use for young children o Perceived by some physicians and families as more effective

• MDI with valved holding chamber (VHC) o Allows infant/child to use MDI by blocking exhalation into tube o Advantages over nebulizer include rapid delivery and portability: can be used for attacks away from home

• New formulations of MDI’s o Contain ozone-friendly hydrofluoroalkane (HFA) propellant rather than CFC (chlorofluorocarbon) o CFC-containing MDI’s are being phased out, no longer available in pharmacies

Evidence: • Inhaled routes of administration clearly superior to oral (eg: albuterol syrup) in all studies • Nebulized vs MDI/VHC delivery of β-agonists:

o RCT’s have consistently concluded that equivalent doses* of albuterol delivered by a correctly used MDI/VHC, are just as effective (or more effective) than nebulized albuterol, even in the acute setting

o Expert consensus (the EPR-3) and evidence-based reviews (Osmond, 2004) all concur: MDI/VHC is as effective as nebulizer for mild or moderate asthma exacerbations

o Efficacy established in young infants and children, even during exacerbations of moderate severity o Cost-effectiveness is institution-dependent, depends on availability of meds, equipment o MDI/VHC actually preferred by most parents for ease of use

• HFA propellants: studies show delivery to lungs, efficacy and safety comparable to CFC-MDI’s


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Recommendations: Short-acting β-agonist delivery 1. Consider using MDI/VHC for β-agonist delivery for children with mild or moderate asthma exacerbations in the ED

This reinforces use for the parent, and may be cost-effective depending on setting When nebulizer is not available, may be appropriate for use during severe exacerbations as well

2. *Dosing: 8 puffs from MDI approximately equivalent to a 2.5 mg unit dose in nebulizer 3. Teach age-appropriate VHC technique before discharge to ALL patients 4. Write outpatient prescriptions for formulary SABA (albuterol or levalbuterol) to assure prescription is filled promptly

Question: Is levalbuterol better than albuterol? Background:

• Levalbuterol (brand name: Xopenex) consists of the R-enantiomer of racemic albuterol o The R-enantiomer is the “active” enantiomer o The S-enantiomer may have bronchoconstrictive properties, remains in bronchial tissue longer

• Developed with thought that more selective drug would produce more effective bronchodilation with fewer side effects (eg: tachycardia)

Evidence: • Early studies suggested improved efficacy, but overall studies have failed to demonstrate therapeutic or side-effect

advantages of levalbuterol over racemic albuterol, at equivalent doses o Equivalent doses are based on the R-enantiomer: o 1.25 mg of levalbuterol therapeutically equivalent to 2.5 mg of racemic albuterol

• Studies with decreased side effects used lower doses of levalbuterol (eg: 0.63mg in comparison to 2.5 mg of albuterol) Recommendations:

1. Routine use of levalbuterol is NOT recommended, due to increased cost in comparison with albuterol and lack of consistent advantages in efficacy or decreased side effects

2. Consider trial of levalbuterol (0.63-1.25 mg/dose) in select patients (cardiac dz, excess tachycardia, albuterol overuse) 3. Outpatient considerations:

Levalbuterol HFA is preferred outpatient SABA for some insurance plans (including Medi-cal!) MDI: 1 puff of Levalbuterol HFA (45 mcg/puff ) = 1 puff of albuterol HFA (90mcg/puff)

Question: What are the administration options for systemic steroids? Background:

• Short bursts of systemic corticosteroids are beneficial for many children with acute asthma exacerbations o Reduce hospitalizations and duration of symptoms

• Oral and IV/IM routes of corticosteroids have been shown equivalent in efficacy in multiple studies • Oral prednisone formulation poorly tolerated, and compliance with 5 days of therapy is variable • Dexamethasone has a longer half-life than prednisone (36-72 hours), safety is well-established in children

Evidence: • In several studies, the IV form of dexamethasone (4mg/ml) has been shown safe and well-tolerated for oral administation • One RCT (Qureshi, 2001) found 2 doses of dex, 24 h apart, better tolerated and equal in efficacy to 5 d of prednisone • One RCT (Gordon, 2007) found a single dose of IM dex (0.6mg/kg) as effective as 5 days of prednisone

Recommendations: 1. Consider oral dexamethasone for children in whom a short course of systemic corticosteroids is indicated 2. Dosing: 0.6mg/kg/day, for 2 doses: Give 2nd dose 24-36 hours after the first.

Second dose can be prescribed as tablet form, to crush in pudding, applesauce or jam 3. Consider this option for croup as well!

▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪

B. ASTHMA: PART III – Chronic Asthma ▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪ Question: What is the ED provider’s role in management of chronic asthma? 1. Classify severity or control according to the 2007 NHLBI EPR-3 guidelines

• In August, 2007, the NHLBI released revised guidelines (EPR-3). The major differences include o Health care providers should assess asthma severity OR control at acute asthma visits and at preventive

health visits Classify severity in children who are not currently on long-term controller medication Classify control in children who are currently taking a long-term controller medication

o Severity is now classified as intermittent, mild persistent, moderate persistent or severe persistent


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Mild intermittent classification no longer exists, as pts with intermittent asthma represent 1/3 of asthma deaths

o Control is classified as well-controlled, not well-controlled and poorly controlled o Within the domains of severity and control, provider should consider both impairment and risk

Impairment of normal function: frequency of day/night symptoms, SABA use, activity restriction, and FEV1/FVC ratio (in children >4)

Risk of severe exacerbation: hospitalizations, # of exacerbations with oral steroids in last year Recommendations:

The approach to assessment of severity and control can be boiled down to a simple “Rule of 2’s” The NEW Rule of 2’s: An updated method for recognizing persistent or not well-controlled asthma

≥2 daytime /exercise symptoms/ week or ≥2 episodes of SABA use/week or ≥2 nighttime awakenings/month or ≥2 systemic corticosteroid courses or hospitalizations in last year = PERSISTENT OR NOT WELL-CONTROLLED ASTHMA

2. Start treatment for chronic asthma in the ED

• The children with asthma who are most at risk for undertreatment and severe asthma exacerbations are also the most likely to use the ED for episodic care (Finkelstein, 2002)

• EPR-3 recommends initiating or stepping up controller medication during an acute exacerbation based on assessment of asthma severity and control

• Inhaled corticosteroids (ICS) are the safest and most effective anti-inflammatory medication available for children of all ages, and the preferred treatment for persistent asthma of all severities

o Although no controlled trials have directly examined the impact of prescribing ICS at discharge from ED for children with persistent asthma, several RCT’s including both adults and children have concluded that initiating ICS at discharge reduces relapses

o A Cochrane review (2004) concluded that adult/child ED patients who started ICS after an acute exacerbation suffered fewer relapses and had fewer hospitalizations, although the benefit was less significant in those also receiving systemic steroids

o In a 2005 editorial in Annals of Internal Medicine, two authors reviewed the evidence regarding the role of the ED in management of chronic asthma in both adults and children (Singer, Rowe 2005) and agreed that initiation of ICS in the ED should be considered in appropriate patients

o Adverse effects of ICS in children: Risk of adverse effects increase with dose and with prolonged use

• Growth effects seen in long-term trials are mild (final height loss <1cm), and dose dependent Overall, experts concur that the benefits far outweigh the risks (eg: even high doses of ICS for

prolonged periods of time have LESS potential for adverse effect than systemic corticosteroids used for poorly controlled asthma)

Recommendations: 1. Start controller medication in the ED for any child with persistent or not well-controlled asthma 2. ICS still the safest and most effective anti-inflammatory medication available for children of all ages, and the

preferred treatment for persistent asthma of all severities 3. Use the lowest dose required to achieve control 4. Always use ICS with valved holding chamber (VHC) or spacer, which will allow use of lower dose with improved

efficacy and reduce local side effects Summary of Recommendations: Management of Chronic Asthma in the ED

1. Increasing evidence and expert consensus supports the initiation of chronic disease assessment and management strategies in the ED for children with asthma.

2. The 2007 EPR-3 recommends that ED providers: Assess asthma severity and control at the acute visit Initiate or step up controller medication based on assessment of asthma severity and control

o For children with persistent asthma are not on controller medication: initiate inhaled corticosteroids o For children poorly controlled on current regimen: increase to next step of management

Provide education and a symptom-based action plan for acute and chronic symptoms to all pediatric patients Refer to follow up care within 1-4 weeks


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***Tables for classification and management of pediatric asthma can be found in Figures 4-1 through 4-4 of the EPR-3, reprinted at the end of this syllabus: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm***

REFERENCES: Upper Airway Infections

1. Alcaide ML. Pharyngitis and epiglottitis. Infect Dis Clin North Am Jun 2007; 449-69, vii 2. Bjornson CL. Randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med 2004;351:1306-

13 3. Craig FW, Schunk JE. Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current

management. Pediatrics 2003;111: 1394-1398. 4. D’Agostino J. Pediatric airway nightmares. Emerg Clin N Am 2010; 28:119-126 5. Hegenbarth MA and the Committee on Drugs. Preparing for pediatric emergencies: drugs to consider. Pediatrics Feb

2008; 121(2): 433-443 6. Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus

0.6 mg/kg. Pediatr Pulmonol 1995;20:362–8 7. Ledwith C, Shea L, Mauro R: Safety and efficacy of nebulized racemic epinephrine in conjunction with oral

dexamethasone and mist in the outpatient treatment of croup. Ann Emerg Med 1995;25:331-337 8. Moore M, et al. Humidified air inhalation for treating croup. Cochrane Database Syst Rev 2006;(3):CD002870 9. Rafei K. Airway infectious disease emergencies. Pediatr Clin North Am Apr 2006; 53(2): 215-42 10. Hopkins A, et al. Changing epidemiology of life-threatening upper airway infections: The reemergence of bacterial

tracheitis. Pediatrics Oct 2006; 118(4): 1418-1421 11. Rittichier KK, Ledwith CA. Outpatient treatment of moderate croup with dexamethasone: intramuscular versus oral

dosing. Pediatrics 2000;106:1344–8. 12. Russell K. Glucocorticoids for croup. Cochrane Database Syst Rev Jan 2004(1): CD001955 13. Scolnik D, et al. Controlled delivery of high vs low humidity vs mist therapy for croup in emergency departments: A

randomized controlled trial. JAMA 2006;295:1274-80 14. Shah RK, Roberson DW, Jones DT. Epiglottitis in the Haemophilus influenzae type B vaccine era: changing

trends. Laryngoscope 2004; 114: 557-560 15. Sobol SE, Zapata S. Epiglottitis and croup. Otolaryn Clin N Amer June 2008; 41(3): 551-566 16. Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-

blind study. Am J Dis Child 1978;132:484–7. 17. Wheeler DS. Pediatric emergency preparedness in the office. Am Fam Physician Jun 2000; 61(11): 3333-42

Other Upper Airway Obstructions:

1. Barrow RE, Spies M, Barrow LN, et al. Influence of demo- graphics and inhalation injury on burn mortality in children. Burns 2004; 30: 72–77

2. Fidkowski CW, Fuzaylov G, Sheridan RL, Cote CJ. Inhalation burn injury in children. Paediatr Anaesth July 2009:19 Suppl 1: 147-154

3. Kobrynski LJ. Anaphylaxis. Clin Ped Emerg Med 2007; 8(2):110-116 4. Lieberman P, et al. The diagnosis and management of anaphylaxis: an updated practice parameter. J Allergy Clin

Immunol Mar 2005; 115 (3 suppl 2): S483-523 5. Mlcak RP, Suman OE, Herndon DN. Respiratory management of inhalation injury. Burns 2007; 33: 2–13 6. Rosen D, Avishai-Eliner S, Borenstein A, et al. Life-threatening laryngeal burns in toddlers following hot liquid

aspiration. Acta Paediatr 2000; 89(8):1018-22 7. Sicherer S, Simons ER. Self-injectable epinephrine for first-aid management of anaphylaxis. Pediatrics 2007; 119(3):

638-646 8. Simons FER. Anaphylaxis in infants: Can recognition and management be improved? J Allergy Clin Immunol Sept

2007; 120(3); 537-540 9. Tatachar P, Kumar S. Food-induced anaphylaxis and oral allergy syndrome. Pediatrics in Review 2008; 29:e23-e27

Foreign Body Aspiration

1. Ciftci AO, Bingol-Kololu M, et al. Bronchoscopy for evaluation of foreign body aspiration in children. J Pediatr Surg 2003; 38(8): 1170-1176

2. Digoy GP. Diagnosis and management of upper aerodigestive tract foreign bodies. Otolaryngol Clin N Amer 2008; 41(3): 485-496

3. Even L, Heno N, Talmon Y, et al. Diagnostic evaluation of foreign body aspiration in children: a prospective study. J Pediatr Surg 2005; 40(7): 1122-1127


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4. Radharakrishna SM, Nagler J. Images in emergency medicine. Foreign body aspiration. Ann Emerg Med June 2007; 49(6): 822, 829

5. Tan H, Brown K, McGill T, et al. Airway foreign bodies (FB) : a 10-year review. Int J Pediatr Otorhinolaryngol 2000; 56: 91-99

6. Verghese ST, Hannallah RS. Pediatric otolaryngologic emergencies. Anesthes Clin N Amer 2001; 19(2): 237-56 7. Tokar B, Ozkan R, Ilan, H. Tracheobronchial foreign bodies in children: importance of accurate history and plain

chest radiography in delayed presentation. Clin Radiol2004; 59: 609-615 Asthma Status Asthmaticus

1. Blitz M, Blitz S, Beasely R, et al. Inhaled magnesium sulfate in the treatment of acute asthma. Cochrane Database Syst Rev 2005; 4:CD003898

2. Bogie AL. Comparison of intravenous terbutaline versus normal saline in pediatric patients on continuous high-dose nebulized albuterol for status asthmaticus. Pediatr Emerg Care Jun 2007; 23(6):355-61

3. Carroll CL. Protocol-based titration of intravenous terbutaline decreases length of stay in pediatric status asthmaticus. Pediatr Pulmonol Apr 2006; 41(4): 350-6

4. Cheuk DK, Chau TC, Lee SL. A meta-analysis on intravenous magnesium sulphate for treating acute asthma. Arch Dis Child 2005; 90:74–7

5. Ciarallo L, et al. Intravenous magnesium therapy for moderate to severe pediatric asthma: Results of a randomized, placebo-controlled trial. J Pediatr 1996; 129 :809-814.

6. Ciarallo L, Brousseau D, Reinert S. Higher-dose intravenous magnesium therapy for children with moderate to severe acute asthma. Arch Pediatr Adolesc Med, 2000; 154: 979-983

7. Mannix R, Bachur R. Status asthmaticus in children. June 2007; 19(3):281-287 8. McGarvey JM. Heliox in airway management. Emerg Med Clin North Am, Nov 2008; 26(4): 905-920 9. Ream RS. Efficacy of IV theophylline in children with severe status asthmaticus. Chest May 2001; 119(5): 1480-1488 10. Rivera ML. Albuterol nebulized in heliox in the initial ED treatment of pediatric asthma: a blinded, randomized

controlled trial. Am J Emerg Med Jan 2006; 24(1): 38-42 11. Roberts JS; Bratton SL; Brogan TV. Acute severe asthma: differences in therapies and outcomes among pediatric

intensive care units. Crit Care Med. 2002 Mar;30(3):581-5. 12. Rowe BH, Bretzlaff JA, Bourdon C. Intravenous magnesium sulfate treatment for acute asthma in the emergency

department. A systematic review of the literature. Ann Emerg Med, 2000; 36: 181-189. 1. Wheeler DS. Theophylline vs terbutaline in treating critically ill children with status asthmaticus: a prospective,

randomized, controlled trial. Ped Crit Care Med Mar 2005; 6(2):142-7 2. Yung M, South M. Randomised controlled trial of aminophylline for severe acute asthma. Arch Dis Child 1998; 79:405-

410 Acute Exacerbation

1. Delagado A, et al. Asthma therapy: metered-dose inhalers preferred for infants and toddlers. Arch Pediatric Adolesc Med. 2003; 157: 76-80

2. Gordon S. Randomized trial of single-dose intramuscular dexamethasone compared with prednisolone for children with acute asthma. Pediatr Emerg Care Aug 2007; 23(8): 521-7

3. Jones MA, Wagener JS. Managing acute pediatric asthma: keeping it short. J Pediatr July 2001; 139(1): 3-5 4. Osmond M. Evidence-based emergency medicine: Nebulizers vs inhalers with spacers for acute asthma in pediatrics.

Ann Emerg Med Mar 2004; 43(3): 413-415 5. Ploin D, et al. High dose albuterol by metered-dose inhaler plus a spacer device versus nebulization in preschool

children with recurrent wheezing: a double-blind randomized equivalence trial. Pediatrics 2000; 106(2): 311-317 6. Qureshi F, et al. Comparative efficacy of oral dexamethasone versus oral prednisone in acute pediatric asthma. J

Pediatr 2001; 139: 20-6 7. Schuh S, et al. Comparison of albuterol delivered by metered dose inhaler with spacer versus a nebulizer in children

with mild acute asthma. J Pediatr 1999; 135(1): 22-27 Chronic Asthma Management

1. Castro-Rodriguez JA, Rodrigo GJ. Efficacy of inhaled corticosteroids in preschoolers with recurrent wheezing. A systematic review with meta-analysis. Pediatrics March 2009; 123:e519-e525

2. Commentary: Doing the most to ensure the least emergency department asthma visits: Asthma experts consider preliminary project findings. Pediatrics April 2006; 117(4):S159

3. Edmonds ML, et al. Inhaled steroids for acute asthma following emergency department discharge. (Cochrane Review). The Cochrane Library, 2004; Issue 3. Chichester, United Kingdom: John Wiley & Sons, Ltd.


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4. Finkelstein JA, et al. Underuse of controller medications among Medicaid-insured children with asthma. Arch Pediatr Adolesc Med 2002; 156(6): 562-7

5. Lieu T, et al. Outpatient management practices associated with reduced risk of pediatric asthma hospitalization and emergency department visits. Pediatrics 1997; 100 (3 Pt 1): 334-41

6. Nelson HS, et al. The Salmeterol Multicenter Asthma Research Trial. A Comparison of Usual Pharmacotherapy for Asthma or Usual Pharmacotherapy Plus Salmeterol. Chest Jan 2006; 129(1): 15-26

7. NHLBI Third Expert Panel Report (EPR3): Guidelines for the diagnosis and management of asthma. NIH Publication No. 08-4051 (prepublication copy at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm ). Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute; August 2007.

8. Salpeter SR. Meta-analysis: effect of long-acting beta-agonists on severe asthma exacerbations and asthma-related deaths. Ann Intern Med, Jun 2006; 144(12): 904-12

9. Singer AJ et al. A call for expanding the role of the emergency physician in the care of patients with asthma. Ann Emerg Med Mar 2005; 45(3):295-8

APPENDIX

PROCEDURE: NEEDLE CRICOTHYROTOMY A potentially life-saving procedure in acute upper-airway obstruction

Materials: 1. 14-guage angiocath 2. 3-10 ml syringe (empty or filled with saline) 3. Oxygen source and oxygen tubing 4. Bag-valve-mask apparatus

If BVM not available, then use the T-connector from an aerosol setup (see below) 5. Povidone-iodine solution or alcohol for cleansing 6. Adapter from pediatric 3.0 mm endotracheal tube

Alternative: adapter from a 7.5 mm ETT, inserted into the barrel of a 3ml syringe with plunger removed

Procedure: 1. Locate cricothyroid membrane (run fingers up tracheal rings until you reach the cricoid ring, the

membrane is just above this ring) 2. Cleanse anterior neck with povidone-iodine solution or alcohol, if available 3. Insert angiocath caudally at a 45 degree angle, applying negative pressure with the syringe, until air

enters the syringe 4. Advance catheter, and remove syringe and needle from angiocath, leaving catheter in trachea 5. Insert 3.0mm ET adapter into hub of angiocath

Alternative: insert 3ml syringe (with 7.5mm ETT adapter in barrel, as above) into hub of angiocath

6. To ventilate: Attach bag-valve-mask apparatus to ETT adapter and turn oxygen flow up to >15L. Attempt to ventilate.

If no BVM available, hook an aerosol T-adapter to the ETT adapter, and attach to wall oxygen. Use thumb to occlude 3rd port for 1 second, then release for 4 seconds


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▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪ TABLE OF MEDICATIONS FOR PEDIATRIC RESPIRATORY EMERGENCIES

Modified from: Hegenbarth MA and the Committee on Drugs. Preparing for pediatric emergencies: drugs to consider. Pediatrics Feb 2008; 121(2): 433-443

Medication Indication Dosage/Administration Notes Albuterol/

Levalbuterol (Xopenex)

Acute asthma Bronchospasm

Doses listed for albuterol. Levalbuterol dose is ½ albuterol dose Metered-dose inhaler with valved holding chamber: 4–8 puffs every 15–20 min*, then every 1–4 h prn Nebulized, intermittent: 2.5 mg (or 0.15-0.30mg/kg up to 10mg) every 20 min*, then every 1–4 h as needed Nebulized, continuous: 0.5 mg/kg per h up to 10–15 mg/h *Repeat dose until desired clinical effect unless patient develops symptomatic tachycardia.

• Formulations: o MDI-albuterol: 90 µg per puff

(Levalbuterol: 45 mg/puff) o Neb solution-albuterol: 2.5 mg

unit dose or 5 mg/mL solution • (Levalbuterol: 0.63 mg and 1.25

mg unit dose) • Oxygen is the preferred gas

source for nebulization. • Dilute in a minimum of 2–3 mL

of saline solution and use flow of > 10L/min for adequate nebulization

Dexamethasone (Decadron)

Croup Acute asthma FB aspiration Airway edema

IV/IM/PO: 0.6mg/kg* (max 16mg) Repeat dosing as indicated by

clinical course *IV solution (4mg/ml) may be given

orally

• No advantage of IV or IM over PO route if gastrointestinal absorption is not impaired

• For elevated ICP:1-2 mg/kg • For meningitis:0.15mg/kg q6h

Diphenhydramine (Benadryl)

Anaphylaxis Acute hypersensitivity

reaction Urticaria

IV/IM/PO: 1–2 mg/kg (max initial dose: 50 mg).

• Also useful for dystonic reaction • May cause sedation, respiratory

suppression, hypotension specially if using other sedatives.

• Rapid IV administration may precipitate seizures.

• All doses may cause paradoxical excitement or agitation

Anaphylaxis IM/SC*: 0.01 mg/kg of 1:1000 sol’n (max: 0.5 mg), repeat every 5–20

min. * IM route preferred for anaphylaxis. Severe reactions may require IV epi

Severe asthma exacerbation

SC: 0.01 mg/kg of 1:1000 sol’n (max: 0.5 mg); repeat every 20 min

up to 3 doses* *always accompanied by β-agonists

and systemic steroids

Epinephrine

Cardiopulmonary resuscitation

Newborn infants: IV/IO: 0.01–0.03 mg/kg of 1:10 000

sol’n* ET:0.03–0.10 mg/kg of 1:10,000

sol’n * Older infants/children:

IV/IO: 0.01 mg/kg of 1:10,000 sol’n * (max: 1 mg)

ET:0.1 mg/kg of 1:1000 sol’n (max: 10 mg)*

*Repeat every 3–5 min.

• Two solutions available: o 1:10,000 (for IV use) and o 1:1000 (for IM, SC, ET)

• To convert mg/kg to mL/kg: o 0.01mg/kg = 0.1mL/kg of 1:10

000 solution or 0.01 mL/kg of 1:1000 solution

o 0.1mg/kg = 1mL/kg of 1:10000 solution or 0.1 mL/kg of 1:1000 solution

• IV high-dose epinephrine (0.1 mg/kg) no longer recommended for routine use in resuscitation.

• Follow ET administration with saline flush or dilute in isotonic saline (1–5 mL) based on patient size.


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Refractory shock IV infusion: 0.1–1.0 µg/kg per min* *Start at lowest dose and titrate to

desired clinical effect. Doses as high as 5 µg/kg per min

may be necessary

Epinephrine, racemic (for nebulization)

Airway edema (anaphylaxis, FB

aspiration) Croup

Standard unit dose: 0.5mL Or 0.05 mL/kg (max 0.5mL) of

2.25% inhalation solution in 2 mL of normal saline

• Single-isomer L-epinephrine (1:1000) can be substituted at does of 0.5 mL/kg up to 5 mL.

• 1-3 hours of observation recommended after administration for rebound

• Always administer systemic steroid if using racemic epinephrine for croup

Ipratroprium bromide (Atrovent)

Adjunct to β-agonists for bronchospasm

Nebulized solution = 0.25 mg/mL Child <12: 0.25 mg q 20 min X 3

Children 12: 0.5 mg q 20 min X3

• Should not be used as monotherapy for bronchospasm/asthma

• No advantage shown to > 3 doses • May mix with albuterol

Magnesium sulfate Refractory status asthmaticus

25-75mg/kg (max 2g) IV/IO over 20 minutes*

*Utility of repeat doses unclear

• Rapid infusion may cause hypotension/bradycardia

• Calcium chloride will reverse toxicity

Methylprednisolone (Solu-medrol)

Acute asthma Anaphylaxis

Foreign body aspiration Croup (alt to

dexamethasone)

1-2mg/kg initial dose IM/IV (max 125mg)

Repeat dose q6 h if necessary


• Must use acetate salt for IM route

Prednisone/ Prednisolone (Ora-

pred)

Acute asthma Anaphylaxis

Foreign body aspiration Croup (alt to

dexamethasone)

1-2 mg/kg PO (max: 60 mg) initial dose

Repeat dose q24 h if necessary


• No need to taper steroid dose if used for < 10 days

Ranitidine Anaphylaxis 1mg/kg IV (max 50mg) • Always use in conjunction with epinephrine, H1 blockers and systemic steroids


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