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Pediatric ABCs. Asthma, Bronchiolitis and Croup (and some quickies). David Chaulk Pediatric EM Fellow January, 2004. Case 1. - PowerPoint PPT Presentation

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  • Pediatric ABCsAsthma, Bronchiolitis and Croup(and some quickies)

    David ChaulkPediatric EM FellowJanuary, 2004

  • Case 1A seven year old boy presents to the Emergency Department with a 24 hour history of cough, wheeze and increasing shortness of breath which began shortly after the onset of a low grade fever and rhinorrhoea.

    He has had one previous episode of wheezing. The episode had followed an upper respiratory tract infection.

    He is not on any medications.

  • He is agitated and talking in short phrases only, with a respiratory rate of 40 per minute, heart rate of 130 and oxygen saturation in room air of 89%.

    Examination of the chest reveals moderate intercostal and subcostal retractions. On auscultation, you note reduced breath sounds throughout the lung fields with widespread expiratory wheeze. Other than a clear nasal discharge, the remainder of the physical examination is normal.

    What treatment would you initiate?

  • Questions:

    What about racemic epinephrine instead of salbutamol? Steroids? PO or IV? Inhaled? When? Should you give him ipratropium bromide with the first mask? What about magnesium ? Spacer vs nebulizer ?

  • Question 1:

    Does the addition of a nebulized anticholinergic agent (ipratropium bromide) to nebulized beta-agonist decrease the risk of admission to hospital?

  • Should inhaled anticholinergics be added to 2 agonists for treating acute childhood and adolescent asthma? A systematic review Plotnick et al, 1998

    10 trials involving 836 children.

    Outcomes: respiratory function (FEV1) and rates of admission

    Addition of a single dose of anticholinergic : improvement in FEV1 at 60 minutes (mean difference 16.1%) but no reduction in hospital admission

  • Should inhaled anticholinergics be added to 2 agonists for treating acute childhood and adolescent asthma? A systematic review Plotnick et al, 1998

    In children with more severe asthma who received multiple doses of ipratropium: reduction in hospital admission by 30%

    Number of children needed to treat with ipratropium to prevent one hospital admission is 11

  • Effect of nebulized ipratropium on the hospitalization rates of children with asthma Qureshi et al, 1998

    Double blind RCT 434 pts, 2-18 yrs Moderate to severe asthma in ED

    All had salbutamol every 20 minutes and oral prednisone at 2mg/kg

    Received either ipratropium bromide (500 mcg) or placebo with the second and third inhalations of salbutamol

  • Effect of nebulized ipratropium on the hospitalization rates of children with asthma Qureshi et al, 1998

    Significant decrease in hospitalization, with an absolute reduction in hospitalization rate of 15.1%

    The number of children with severe asthma to be treated with ipratropium to prevent one admission was 6.6

  • Cochrane Review May 20018 studies - considerable heterogeneity

    Single dose does not work

    Multiple dose decreases admissions

    NNT 12 overall 95% CI ( 8, 32 )

    NNT 7 severe subgroup 95% CI ( 5,20 )

  • Question 2:

    Is racemic epinephrine effective in children who have acute asthma ?

  • A randomized double blind study comparing the efficacy of racemic epinephrine to salbutamol in acute asthma. Plint et al, 2000

    Double blind RCT 120 pts, 1-17 yrs

    Salbutamol or racemic epinephrine at 0,20,40 min All had PO dexamethasone.

    Outcomes: pulmonary index score (PIS), oxygen saturation, length of stay in ED, hospital admission and relapse rate.

    No significant difference between two treatments

  • Question 3:

    In children with acute asthma, do IV steroids decrease hospitalization and improve clinical symptoms as compared to oral steroids?

  • Intravenous versus oral corticosteroids in the management of asthma in childrenBarnett, 1997

    Double blind RCT 49 pts, 18 mo-18 yr with severe asthma

    Given 2 mg/kg methylprednisolone either PO or IV 30 min after first albuterol

    Outcomes: Pulmonary index score, FEV1, hospital admission rates

    No difference in PIS, FEV1 at 4 hours. No difference in hospitalization rates.

  • Oral versus intravenous corticosteroids in children hospitalized with asthmaBecker et al, 1999

    Double blind RCT66 pts, 2-18 yrs

    Prednisone 2 mg/kg/dose BID vs methylprednisolone 1 mg/kg/dose QID

    Outcomes: length of hospitalization, agonist use, duration of Oxygen tx and PFTs

    Oxygen use significantly less in prednisone group (30 vs 59 hours). No other differences noted.

  • Question 4:

    When should you give systemic steroids to the patient ?

  • Cochrane Review May 2001 Early emergency department treatment of acute asthma with systemic corticosteroids12 Studies : 863 Patients409 Pediatric

    Steroids within 1 hr of arrival in the EDMain outcome: need for admission

    Number needed to treat with steroids in the first hour to prevent one admission = 6

  • Question 5

    What is the role of inhaled steroids in acute asthma?

  • The effectiveness of inhaled corticosteroids in the emergency department treatment of acute asthma: a meta-analysis Edmonds, 2002

    6 trials ( 4 adult, 2 pediatric)2 compared inhaled steroids in addition to systemic steroids, 4 comparison to placebo352 pts

    Less likely to be admitted (OR 0.3)Small improvement in peak exp flows ( 8%)

    Unable to determine if as effective as systemic steroids

  • Question 5

    Is magnesium sulfate effective in improving symptoms in children with moderate to severe acute asthma?

  • A randomized trial of magnesium in the emergency department treatment of children with asthma. Scarfone, 2000

    54 pts1-18 yrsAfter receiving B agonist and methylprednisolone75 mg/kg of MgSO4 or placebo

    Outcomes: pulmonary index score, admissions

    No significant differences between groups

  • Higher Dose Intravenous Magnesium Therapy For Children with Moderate to Severe Acute AsthmaCiarallo, 2003Double Blind, Placebo controlled trial30 pts aged 6-18At 20 minutes Mg group improved in all aspects of PFT (PF, FEV1, FVC)Still greater improvement at 110 minsMore likely to be discharged (8/16 compared to 0/14)Compare this study with Scarfone, Ciarallo had sicker pateints

  • Cochrane Review Magnesium sulfate for treating exacerbations of acute asthma in the emergency department Sep 20007 trials5 adult, 2 pediatric665 pts ( 78 pediatric)

    Outcome = Admission RateNo benefit when all patients treatedSevere sub-group showed significant benefit (90% --> 48% adm)

  • Question 6

    Does the Salbutamol need to be given by nebulization or can a spacer device be used?

  • Cochrane Review July 2001

    16 studies: 686 children 375 adults

    No difference in admission rate95% CI ( OR: 0.4 to 2.1 )

    Childrens LOS in the ED shortermean diff: -0.62 hours95% CI ( -0.84 to -0.40 )

  • Metered-dose inhalers with spacers vs nebulizers for pediatric asthma Chou, 1995

    152 patients > 2 years oldUnblinded

    3 puffs q20 minutes via aerochamber vs. 0.15mg/kg Ventolin via nebulizer

  • Metered-dose inhalers with spacers vs nebulizers for pediatric asthma Chou, 1995 Time in ED Vomiting HRSpacer66 9% +5%

    Nebulizer103 20%+15%

  • Multiple doses of ipratropium bromide added to nebulized agonist reduce the rate of hospital admission Single dose does not appear to be of any benefitRacemic epinephrine is equivalent to salbutamol in children with asthma, with no increased adverse effectsCase 1- Summary:

  • Case 1- Summary:Oral steroids given in equipotent doses are equivalent to intravenous steroidsSteroids should be given early in the emergency courseInhaled steroids may have an adjunctive role Magnesium may be beneficial in severe cases Spacers may be effective for acute asthma

  • Pediatric Asthma Guidelines Nocturnal cough Exertional SOB Increased Ventolin use Good response to Ventolin

    O2 sat > 95%

    Ventolin Consider po SteroidsMILD

    Treatment

  • Normal mental status Abbreviated speech SOB at rest Ventolin > q4h

    O2 sat 92%-95%

    O2 100% Ventolin Systemic corticosteroids Consider anticholinergic MODERATE

    TreatmentPediatric Asthma Guidelines

  • Pediatric Asthma Guidelines Altered mental status Difficulty speaking Laboured respirations Persistent tachycardia No prehospital relief with Ventolin

    O2 saturation

  • Case 2

    A four month old infant is seen in your emergency department with a history of fever and difficulty breathing.

    He has had nasal congestion and cough for several days and today developed increased respiratory difficulties.

  • Case 2He was born at 32 weeks gestation and had an uncomplicated neonatal course, requiring no oxygen or ventilatory support. He has been well since discharge from the neonatal unit and is on no regular medications.

    There is no history of atopy.

  • Case 2

    On examination, he is in moderate respiratory distress. Vital signs are as follows: HR 180, RR 60, T 38.9o C. Oxygen saturation 91%. He has widespread wheeze and fine crackles on auscultation. Remainder of exam is normal.

    The chest x-ray shows evidence of hyperinflation (air-trapping) and some infiltrates in the lower lobes.

    A diagnosis of viral bronchiolitis is made.

  • Questions:

    Does treatment with bronchodilators reduce symptoms or the need for hospital admission?

    Is epinephrine more effective than beta-agonists?