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Cases from Aug 2014 Ryan Padrez & Patrick Peebles 9/10/14 Discussion of Cases Status Asthmaticus What is Asthma? 1. Airway obstruction Bronchoconstriction Inflammation 2. Reversible Improves in response to bronchodilators 3. Recurrent Triggers: Infection, stress, allergens, exercise, cold, foods, smells, etc Inhaled beta-agonists: Albuterol Safe and well-tolerated in kids HR up to 200 commonly seen Intermittent albuterol (MDI and nebulizer) Peak activity at 30 minutes Dosing: 0.15mg/kg/dose– titrate to effect Continuous albuterol Starting dose: 0.5mg/kg/hour (or 5-15 mg/hour) May go up as tolerated Ipratropium bromide (Atrovent) Anticholinergic Bronchodilation and decreased secretions No cardiovascular side effects, very cheap RCT’s of albuterol/atrovent vs albuterol alone Clinical improvement Decreased hospitalization Especially most severe Dosing: 3 doses initially, q6h after that No evidence for continued benefit after first 3 doses Steroids Systemic: short burst (3-5 days) Prevent hospitalization, reduce duration of symptoms Most effective when given early in exacerbation IV/IM equivalent to PO Options Solumedrol/prednisone 1-2mg/kg/dose (max 60mg) Dexamethasone 0.6mg/kg/day Of note: no established role of inhaled steroids in acute exacerbation Case #1 Management of Status Asthmaticus in ED (or 6M Urgent Care) Case #1: 18mo with RAD CC: 18mo boy with history of RAD with viral illnesses presents to ER with increased work of breathing HPI: 1 day viral URI symptoms, tactile fevers, stuffy nose; difficulty breathing overnight, fussy and poor PO intake in the morning, parents brought into ER at 8am on 8/31 Meds: none All: NKDA PMH: as noted, immunizations up to date until 1yo Social History: intact family Family History: mom +allergies/asthma Case #1: 18mo with RAD Initial Exam in ER: T: 37.1, P 170, RR 50-60, O2 sat 85% on RA. Gen: nasal flaring, obvious respiratory distress, somnolent Lungs: Supra-clavicular, intercostal, subcostal retractions, scattered expiratory wheezes Brought to Zone 1, Bed 4 and a Zone 1 ED resident assigned to case Case #1: ED Management 8:28am: Neb x1 (albuterol + ipratropium bromide) 8:47am: Neb x2 (albuterol + ipratropium bromide) 9am re-assessment by nurse : T 37.1, P 178, RR 48, O2 sat 98% RA VBG: 7.18/49/32/-10 and Lactate 2.5 ~9am: IV Dexamethasone x1 + IV fluids 20ml/kg NS bolus ~9:30: Neb x3 (albuterol + ipratropium bromide) 10am: repeat labs and CXR VBG: 7.27/35/70/-10 CBC: 9.9>38.3<234 Chem: 143/4.0/113/12/11/0.22 CXR: no abnormalities Peds Chief Resident assessment at ~10am: Reactive to exam but not crying and not verbally interactive, sleepy, obvious respiratory distress, nasal flaring, retractions with faint wheezing What was done well and what could be different at this point in time? Asthma Algorithm Case#1: Continued To Recap: ~1 hr 20 min the team gave albuterol/atrovent X3, IV dexamethasone, IV fluid bolus RR 40-50, HR180s, O2 sat 98% on facemask Gen: looks sleepy, tachypnea with flaring and retractions, not very verbal Lungs: faint wheezing What does this child have? Status Asthmaticus ED team asks peds team if next steps are to give: More IV fluids and IV Mag Discussion Question: What could be done to optimize management if we think child has status asthmaticus? Status Asthmaticus Status Asthmaticus definition: “unresponsive to inhaled bronchodilators” Next steps if concerned for status asthmaticus: Maximize O2 delivery Move to continuous bronchodilator Get IV access Consider dose of IV steroids What if none of these things work??? nd 2 Line Medications Magnesium Epinephrine Terbutaline Evidence: Magnesium Bronchodilation via SM relaxation Single IV dose: RCT data in children has established safety and efficacy Most beneficial in severe asthmaticus Repeated doses: utility unclear Must be infused over 20 minutes Adverse effects: flushing, nausea, hypotension Epinephrine Easily available! Found on code cart, easy to dose Fastest absorption when IM, in lateral thigh Previously standard of therapy, now less favorable due to cardiac effects Evidence: Terbutaline IV beta-agonist, Less B2-selective than albuterol Efficacy: no consistent decrease in symptoms or length of stay shown Recent trials: trend toward improvement? Minor side effects common Can be given SC or IV Loading dose of 10 mcg/kg SC or IV Infusion of 0.4mcg/kg/min Recommendations: Systemic Bronchodilators Magnesium first-line systemic bronchodilator, for pediatric status asthmaticus Consider terbutaline as second-line agents IM Epinephrine if no others available Back to Case In ED Peds Team Ordered: Continuous Albuterol at 20mg/hr IV solumedrol IV magnesium sulfate 40mg/kg x1 IV bolus of fluids #3 followed by 1x maintenance Admit to 4E (after mag, patient began to look better, crying, better air movement, more prominent wheezing) Key Points for Case #1 For ED Management of Severe Asthma Ensure systemic steroids given <1 hour consider IV route if severe presentation Duo-nebs x3 with poor response move to continuous nebulized albuterol and can start 5-15mg/hr and titrate up to effect Get IV access early IV magnesium the most effective systemic bronchodilator for status asthmaticus Case #2 Management of Status Asthmaticus in 4E ICU Case #2: 11yo M with Severe Asthma ID: 11yo M with history of asthma on Qvar with very poor compliance presents to ED with significant increased work of breathing. HPI: normal state of health, but recently moved in with father in SF x1 week with cats and cigarette smoke in home; coupled with poor compliance with Qvar (ICS controller). Brought to ER by ambulance. In route received two albuterol nebs by EMS. Meds: Qvar, singulair, albuterol PRN All: NKDA PMH: multiple admissions for asthma, no intubations, immunizations UTD Family History: 2 family members with asthma Case #2: In ED Exam (s/p 2 nebs in ambulance) Vitals: RR 40-50, O2 sats 92% room air Gen: tripod position, significant respiratory distress, 2-3 word sentences Lungs: retractions prominent, decreased air movement ED Management: Continuous albuterol 10mg/hr with 100% O2 face mask IM Epi x1 IV solumedrol IV Mag x1 Repeat IM Epi VBG: 7.3/52/-0.8 CXR: no focal infiltrate Admitted to 4E ICU with “status asthmaticus” Case #2: In ICU Pediatric Team Management: Continue albuterol 20mg/hr HFNC 20L/min IV solumedrol q6h IVF at maintenance Respiratory Therapy Teaching • Different devices to provide O2 support on 4E vs 6A vs 6M • Different ways to deliver continuous albuterol • Optimal flow rate when giving albuterol with HFNC Case #2: In ICU Pediatric Team Management: Continue albuterol 20mg/hr HFNC 20L/min IV solumedrol q6h IVF at maintenance Case #2: In ICU Continuous albuterol neb ran out in early morning hours for uncertain amount of time Significant respiratory distress resulting in: Epi #3 IM given IV Mag #2 given Continuous Albuterol 20mg/hr neb with HFNC Discussion Question: What system issues that may have lead to this error? Back to Case#2: In ICU Hospital Night #2: Overnight peds team weaned from 20mg/hr continuous albuterol to 15mg/hr In AM worsening respiratory distress and increased expiratory wheezes Team elected to increase albuterol back to 20mg/hr Discussion Question: Was this patient weaned too quickly? What resources or metrics can we use to guide our weaning management? Review of Key Points Inhaled bronchodilators are first line agent in mild, mod and severe asthma Use aggressively, including moving to continuous early Start steroids early <1 hr Magnesium is the most beneficial systemic bronchodilator in status asthmaticus Consider systematic approach to weaning
