Download Beta 2 - THE 1st PEDIATRIC EMERGENCY CONFERENCE

Pediatric Respiratory Emergencies
Mohammed Al Faifi, MD.
Director, Emergency Out-Reach Program
King Faisal Specialist Hospital & Research Centre
Riyadh, KSA
Kuwait, Oct. 2011
Pediatric Respiratory Emergencies
Part 1
Emergency Management of
Asthma
QUALITY OF CARE OF ED RESPIRATORY ILNESS
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
Knapp et al. Pediatrics 2008
Results
Corticosteroids
69% of the 405,000
visits for moderate/
severe asthma
Antibiotics
53% of the estimated
228,000 annual visits
for bronchiolitis
Radiographs
72% of bronchiolitis
visits
32% of croup visits
31% of the estimated
317,000 annual
croup visits
Knapp et al. Pediatrics 2008
Conclusions
Physicians treating children with Asthma, bronchiolitis
and croup In USA Emergency Departments are
under using known effective treatments and overusing
ineffective or unproven therapies and diagnostic tests.
Knapp et al. Pediatrics 2008
Pediatric Respiratory Emergencies
Part 1
Emergency Management of
Asthma
Introduction




Asthma is the most common chronic disease seen
in children
Emergency department (ED) visits by children with
acute asthma are a common occurrence
The overall goal of asthma care in the ED is to integrate
with home, outpatient, and inpatient care whenever
possible
Recognition of high-risk patients with acute asthma is
essential.
History


Initial history is brief, focused
• Duration of symptoms
• Severity of symptoms
• Medication use
More comprehensive history follows
• Triggers
• Fever
• Systemic Review
Past Medical History

Previous wheezing

Prior admissions for wheezing

Prior admissions to ICU

Chronic lung disease
Physical Examination

Level of consciousness

Vital signs

Degree and symmetry of wheezing

Inspiratory and expiratory ratio

Accessory muscle use
Differential Diagnosis

Bronchiolitis

Foreign body aspiration

Gastroesophageal reflux

Cystic fibrosis

Anaphylaxis
Pulmonary Index Score*
Score
R.R*
0
< 30
1
Wheezing†
I/E Ratio
Acc.Muscle use
O2 Sat.
None
2:1
None
99-100
31 - 45
End expiration
1:1
+
96 -98
2
46 - 60
Entire expiration
1:2
++
93- 95
3
> 60
Inspiration and
expiration
without
stethoscope
1:3
+++
< 93
* For patients aged 6 or older: through 20, score 0; 21 through 35, score 1;
36 through 50, score 2; > 50, score 3.
† If no wheezing due to minimal air entry, score 3.
Pulse Oximetry




Noninvasive and inexpensive
Can help to predict the need for
hospitalization
Obtain for moderately to severely ill
children
Supplement with oxygen if SaO2 < 92%
CXRs
CXRs for First Time Wheezers

371 children > age 1

94% CXRs normal

20/21 abnormal films would have been
identified by:
• RR > 60
• HR> 160
• Fever
• Focal exam
Gerschel, N Engl J Med 1983
Chest Radiographs

Focal findings

Fever

Severe disease
Treatment Options


Beta2-agonists
• Inhaled (nebulizer vs. metered-dose inhaler)
• Subcutaneously
• Intravenously
Corticosteroids
•
•
•
•
Orally
Nebulized
Intramuscularly
Intravenously


Ipratropium bromide
Magnesium sulfate
Beta2-Agonist Delivery




Beta2-agonists remain the standard of care for
treatment of acute asthma
They should be administered every 20 mins, in
the first hour of care
Delivery by SVN or MDI with holding chamber
are each reasonable options
Steps should be taken to insure optimal drug
delivery
Beta2-Agonist Optimizing Delivery

Small particles

Mouthpiece

Low inspiratory flow rate

Breath-holding
Ipratropium Bromide

An anticholinergic

Low lipid solubility

Less than 1% absorbed

Safe, inexpensive

Most studies show that IB plus a Beta2 agonist is
superior to Beta2 agonist alone
Ipratropium Bromide
Group 1
A, P
A, P
A, P
Group 2
A, I
A, P
A, P
Group 3
A, I
A, I
A, I
0
20
40
Time (mins.)
Schuh, et al. J.Pediatrics 1995;126:639-645
Ipratropium Bromide

Ipratropium plus Beta2 agonist is superior to Beta2
agonist alone

Multi-dose ipratropium is superior to single dose

Safe, inexpensive

Peak effects are in 40-60 minutes
Schuh, et al. J.Pediatrics 1995;126:639-645
Ipratropium Bromide Recommendations

For children with a moderate or moderate-to-severe exacerbation
or for those already receiving Beta2 agonist therapy :
• 250-500 ug of ipratropium bromide by
nebulization to be administered concurrently with the
albuterol treatments
Scarfone, et al,
Pediatrics 1993; 92: 513-518



Randomized, double-blind, placebo
75 children in the ED with a moderate to
severe asthma attack
2mg/kg oral prednisone vs. placebo
Conclusions:
Scarfone, et al
Oral Corticosteroids:

Decreases hospitalization rate

Effective within 4 hours

Augments Beta2-agonists therapy
Oral vs IV Steroid



Randomized, double-blinded, placebo
49 Children in ED with moderate to severe
acute asthma
2mg/kg methylprednisolone: Oral vs IV
Barnett, et al. Ann Emerg Med, 1997; 29 :212-217
Barnett, et al.
•Results

After 4 hours, there were no differences between
the two groups with respect to:
• Hospitalization rate
• FEV1
• Pulmonary index score
• Oxygen saturation
• Respiratory rate
Oral Prednisone vs. Oral Dexamethasone
 533 children in ED with mild, moderate, or severe
asthma
 All got q 20 min RA and IB, in first hour
 Prednisone
- 2 mg/kg in ED
- 1 mg/kg for 4 days
 Dexamethasone
- 0.6 mg/kg in ED
- 0.6 mg/kg for 1 dose, on day 2
Qureshi F .J Pediatrics 2001
Oral Prednisone vs Oral Dexamethasone
Pred.
Dex.

Admit, from ED
12%
11%

Relapse
7%
7%

Admit, after relapse
17%
20%

Symptoms at 10 days
21%
22%

Vomited in ED
3%
0.3

Noncompilance
4%
0.4
Qureshi F .J Pediatrics 2001
Moderate Asthma
Treatment Recommendations



Beta2 agonists may be delivered by SVNs or MDIs with
holding chambers
Ipratropium bromide should be given as a single dose
or concurrently with first 3 Beta2 agonist treatments
Prednisone should be given early ASAP
-If emesis
• Methylprednisolone IV
• Dexamethasone: orally or IM
Management of
Moderate Asthma
Albuterol nebulization or MDI
Prednisone1
O2 If Pulse Ox < 92%
Albuterol q20-30 mins.
Ipiatropium with albuterol
No improvement
Hospitalize
Marked Improvement
Slightly
improved
Discharge
home
Continue albuterol q30 mins.
Disposition
Disposition

Discharge :

PEF > 70% predicted,

Symptoms are minimal or absent,



Sufficient medications can be prescribed and
maintained
Outpatient care can be established within a severaldays time frame
EDUCATION..
Disposition
Observed for 30 to 60 minutes for symptom recurrence

hospitalization :

prior history of a sudden, severe exacerbation

prior intubation or ICU Admission

≥ two hospitalizations in the past year

current steroid use or recent wean from steroids

medical or psychiatric comorbidity

low socioeconomic status or urban residence
POST EMERGENCY DEPARTMENT CARE

Short-term Medications
- Beta-agonist Therapy
- Corticosteroids
- Inhaled steroids

Education
Pulmonary Index Score*
Score
R.R*
0
< 30
1
Wheezing†
I/E Ratio
Acc.Muscle use
O2 Sat.
None
2:1
None
99-100
31 - 45
End expiration
1:1
+
96 -98
2
46 - 60
Entire expiration
1:2
++
93- 95
3
> 60
Inspiration and
expiration
without
stethoscope
1:3
+++
< 93
* For patients aged 6 or older: through 20, score 0; 21 through 35, score 1;
36 through 50, score 2; > 50, score 3.
† If no wheezing due to minimal air entry, score 3.
Severe Asthma

No wheezing
3

Unable to speak

Dyspnea

Markedly prolonged expiratory phase 3

Significant work of breathing with

Retractions
2

Requires oxygen
3
2
Severe Asthma
Initial management


Oxygen (consider non-rebreather)

Inhaled beta2-agonist

Inhaled ipratropium bromide

Intravenous corticosteroids ASAP
Oxygen

Simple face mask
• An oxygen flow rate of 6-10 L/min
should provide an oxygen
concentration of 35-60%
• Limitations: open exhalation ports
allow for the inspiration of room
air and exhaled carbon dioxide is
rebreathed.
Oxygen

Non. re-breathing face mask
Modifications allow for greater oxygen
delivery to the patient. These include:



Exhalation ports serving as one-way
valves.
A reservoir bag with a one-way valve
that diverts oxygen-poor exhaled
gases thereby maintaining a mix of
almost pure oxygen.
With flow of 10-12 L/min and proper
fitting mask, oxygen concentrations
> 90% can usually be achieved.
Subcutaneous Terbutaline

Uncooperative, anxious young children

Very poor inspiratory flow or aeration

Poor response to initial nebulized albuterol
Continuously Nebulized Albuterol

Advantages:
• Easier to adhere to
• Less respiratory therapy time
• Safe

• May benefit sicker patients
Disadvantages:
• Patients may go unobserved
• Claustrophobic mask
Corticosteroids
IV Methylprednisolone ASAP
Magnesium Sulfate

Is It Safe
• Mild side effects during infusion:
Facial flushing, nausea, dry mouth, malaise
• Significant adverse effects have not been reported
• Hypotension and cardiac conduction disturbances
are seen only with serum magnesium levels > 8
mg/dl
Magnesium Sulfate

Conclusions
• The routine administration of magnesium to
moderately to severely ill asthmatic children as an
adjunct to initial treatment with albuterol and
corticosteroids was not efficacious.
• Future studies will be needed to determine the
optimal dose of magnesium, the optimal duration
of infusion, and the subgroup of asthmatic
children most likely to benefit from magnesium.
• Severely ill asthmatics experience the greatest
benefit from magnesium
IV Beta2 Agonists

Recommendations:
• Not recommended as a first-line agent even
for severely ill children
• For severely ill who are poorly responsive to
initial measures
IV Terbutaline

10 ug/kg over 10 minutes; infusion 0.5 ug/kg/min

Increase by 0.2 ug/kg/min to max of 5ug/kg/min

Largely empiric

Expect side effects at therapeutic doses

titrate to effect
Decrease infusion rate by 50% if patient is receiving
theophylline
IV
Beta2
Agonists
Potential Toxicities

Tachycardia

Hyperglycemia

Dysrhythmia

Hypokalemia

Hypertension

Rhabdomyolysis

Myocardial ischemia

Lactic acidosis
Severe Asthma
Other Considerations

Arterial blood gas

Heliox


Intubation
-ketamine
-Decompress stomache
-Beware of barotrauma
-Permissive hypercapnia
-Low tidal volumes and peak pressures
-Slow rate, no PEEP, I/E ratio=1/3
Inhaled nitic oxide
Nakagawa et al, J Pediatr 2000
Severe Status Asthmaticus
Vital Signs & oxygen saturation
Supplemental Oxygen
0.15mg/kg albuterol by nebulization
250-500 micgm Ipratropium Bromide
Poor response
Good response
0.01cc/kg of subcutaneous terbutaline
Continue with approach
to moderately ill patient
2mg/kg IV Methylprednisolone
Continuously nebulized albuterol
75mg/kg IV Magnesium sulfate
IV Terbutaline infusion
Clinical Role of MDI’s
When used with a (mask) spacer device,
multiple pediatric studies show MDI
effectiveness comparable to nebulization therapy
• Chou et al. Arch Pediatr Adolesc Med 1995
• Williams et al. Pediatr Emerg Care 1996
• Leversha et al. J Pediatr 2000
• Delgado et al. Arch Pediatr Adolesc Med 2003
MDI / Spacer Tips
•
10 puffs or detergent wash to eliminate electrostatic charge of new
spacer
– Avoids initial 70% delivery reduction
• Shake MDI before each puff, administer 1 puff at a
time one minute apart, 5 tidal breaths per puff
– 6 puffs / rx for acute exacerbation (Q 20” x 3)
– 2 puffs / rx for maintenance (Q 3-6 hours)
• Count total puffs per MDI (200 std.)
– “shake” or “float” tests unreliable

Dexamethasone in Asthma

• Random, non-blinded, 3-16 years, N = 42

• IM dexamthasone, 0.3 mg/kg (up to 15

mg), effective as 3 day course of oral

prednisone, 2 mg/kg/day

• Oral dexamethsone 0.6 mg/kg (up to 16

mg) x 2 days vs. pred x 5 days. Similar

efficacy fewer side effects.

Klig et al. J Asthma 1997 and Qureshi et al. J Pediatr
2001

Magnesium Sulfate

• Bronchodilation through smooth muscle

relaxation

• Inhibits cellular calcium uptake

• Inhibits histamine release

Mg IV vs. Placebo

• RCT (double blind), placebo, 1-18 yrs,

N=54

• Mg 75 mg/kg IV over 20 minutes vs.

placebo after 1st albuterol

• No different in PFTs or admit rate

• No adverse effects or BP changes with Mg

Scarfone et al. Ann Emerg Med 2000

IV Magnesium Sulfate in Asthma

• Meta-analysis of 5 RCTs (with placebo)

• 182 pediatric patients with moderate to severe

asthma

• Received beta agonists and steroids

• Mg prevents hospitalization (NNT = 4)

• Short term PFTs and clinical scores improved

• ? Dose, 25-75 mg/kg over 20 minutes

Cheuk et al. Arch Dis Child 2005

PICU Case Reports

• 3 children in status asthmaticus

• Maximized traditional therapy

• Failure to improve after 2-3 hours

• BiPAP delivered an average of 12-17 hours

• Resolution of hypercarbia, and improved

clinical state

• 2/3 used continuous IV ketamine as adjunct

Olugbenga A, et al. Pediatr Crit Care Med 2002

Factors Associated with Long

Asthma Therapy

• Previous ICU admit

• Baseline sat ≤ 92%

• Higher ( 6 / 9 ) clinical asthma score at four hours

• 4 hour sat ≤ 92%

• 4 hour albuterol more often than q1 hour

• If none, 82% chance short therapy only

• ≥ 3 predictors 92% chance long therapy

Keogh et al. J Pediatr 2001