Download Pediatric ABC`s - Calgary Emergency Medicine

Pediatric ABC’s
Asthma, Bronchiolitis and Croup
(and some quickies)
David Chaulk
Pediatric EM Fellow
January, 2004
Case 1
A 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:
• Should you give him ipratropium bromide with the
first mask?
• What about racemic epinephrine instead of
salbutamol?
• Steroids? PO or IV? Inhaled? When?
• 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 ß2 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 ß2
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 2001
• 8 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 children
Barnett, 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 asthma
Becker et al, 1999
•Double blind RCT
•66 pts, 2-18 yrs
•Prednisone 2 mg/kg/dose BID vs methylprednisolone 1
mg/kg/dose QID
•Outcomes: length of hospitalization, ß agonist use, duration
of Oxygen tx and PFT’s
• 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 corticosteroids
• 12 Studies :
• 863 Patients
• 409 Pediatric
• Steroids within 1 hr of arrival in the ED
• Main 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 placebo
• 352 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 pts
• 1-18 yrs
• After receiving B agonist and methylprednisolone
– 75 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 Asthma
Ciarallo, 2003
• Double Blind, Placebo controlled trial
• 30 pts aged 6-18
• At 20 minutes Mg group improved in all aspects
of PFT (PF, FEV1, FVC)
• Still greater improvement at 110 mins
• More 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 2000
• 7 trials
– 5 adult, 2 pediatric
– 665 pts ( 78 pediatric)
• Outcome = Admission Rate
– No benefit when all patients treated
– Severe 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 rate
• 95% CI ( OR: 0.4 to 2.1 )
• Children’s LOS in the ED shorter
• mean diff: -0.62 hours
• 95% CI ( -0.84 to -0.40 )
Metered-dose inhalers with spacers vs nebulizers
for pediatric asthma Chou, 1995
• 152 patients
• > 2 years old
• Unblinded
•
•
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
Spacer
66
Nebulizer 103
Vomiting
HR
9%
+5%
20%
+15%
Case 1- Summary:
• Multiple doses of ipratropium bromide added to
nebulized ßagonist reduce the rate of hospital admission
• Single dose does not appear to be of any benefit
•Racemic epinephrine is equivalent to salbutamol in
children with asthma, with no increased adverse effects
Case 1- Summary:
• Oral steroids given in equipotent doses are equivalent to
intravenous steroids
• Steroids should be given early in the emergency course
• Inhaled steroids may have an adjunctive role
• Magnesium may be beneficial in severe cases
• Spacers may be effective for acute asthma
Pediatric Asthma Guidelines
MILD
• Nocturnal cough
• Exertional SOB
• Increased Ventolin use
• Good response to Ventolin
•O2 sat > 95%
Treatment
• Ventolin
• Consider po Steroids
Pediatric Asthma Guidelines
MODERATE
• Normal mental status
• Abbreviated speech
• SOB at rest
• Ventolin > q4h
• O2 sat 92%-95%
Treatment
• O2 100%
• Ventolin
• Systemic corticosteroids
• Consider anticholinergic
Pediatric Asthma Guidelines
SEVERE
• Altered mental status
• Difficulty speaking
• Laboured respirations
• Persistent tachycardia
• No prehospital relief with Ventolin
• O2 saturation <92%
Treatment
• 100% O2
• Continuous Ventolin
• Systemic corticosteroids
• Anticholinergic
• Consider Magnesium sulfate
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 2
• He 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 (airtrapping) 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?
• Does treatment with steroids reduce symptoms or the
need for hospital admission?
• Does treatment with antibiotics reduce bacterial
complications?
Question 1:
In infants with clinical features of bronchiolitis, does
treatment with bronchodilators improve symptoms and
reduce the need for hospital admission?
Efficacy of Bronchodilator Therapy in Bronchiolitis:
A meta-analysis Kellner et al, 1996
• RCTs of bronchodilator use in bronchiolitis
• 15 of 89 publications met selection criteria
• 8 trials had first time wheezers only
• Total of 734 pts included
• 3 outcomes: clinical score, O2 saturation, and
hospitalization
Efficacy of Bronchodilator Therapy in Bronchiolitis: A
meta-analysis Kellner et al, 1996
• ß2 agonist most commonly used was albuterol.
• Some studies also included ipratropium bromide
and epinephrine.
• With pooled results, only improvement in clinical
sxs was statistically significant. No effect on
hospital admission rates.
• Conclusion: There is a only a modest short-term
effect of bronchodilators on bronchiolitis
Efficacy of ß2 agonists in Bronchiolitis: A
reappraisal and meta-analysis
Flores and
Horowitz, 1997
• ß2 agonists had no impact on hospitalization rates.
• No significant effect on respiratory rate.
• Statistically significant improvement in oxygen
saturation (2.8%) and heart rate (15 bpm) but not
clinically significant.
• Short term outpatient studies do not support the
use of ß2 agonists in bronchiolitis.
Question 2:
Does epinephrine, which has both alpha and betaadrenergic properties, have an advantage over salbutamol
and other beta-agonists?
A Meta Analysis of Randomized Controlled Trials
Evaluating The Efficacy of Epinephrine For the
Treatment of Acute Viral Bronchiolitis
Hartling, et al., Oct 2003
• 14 studies, 7 inpt, 6 outp, 1 unk
• Outpatients
– Epinephrine more effective than placebo in
• clinical score (60 minutes)
• Oxygen saturation (30 mins)
• RR at 30 mins
– Epinephrine more effective than salbutamol in:
• Oxygen saturation at 60 mins
• RR at 60 mins
• HR at 90 mins
– Small number of studies of varying quality
Question 3:
In infants with clinical features of bronchiolitis, does
treatment with dexamethasone reduce symptoms?
Dexamethasone in salbutamol-treated patients with
acute bronchiolitis: a randomized controlled trial.
Klassen et al, 1997
Randomized, double blind study.
67 pts, 6 wks-15 mos. Hospitalized infants.
Oral dexamethasone (0.5 mg/kg first dose, followed by
two daily doses of 0.3mg/kg) or placebo.
Outcomes: readmission rate, length of stay and
improvement in clinical score.
No statistically significant difference between treatment
and placebo groups.
Systemic Corticosteroids in infant bronchiolitis: a metaanalysis. Garrison, 2000
•
•
•
•
6 trials
347 hospitalized pts
< 24 months
Outcomes: Length of stay, duration of symptoms,
clinical scores
• LOS or DOS: .43 days less in steroid group
• Clinical score : - 1.60 (favoring treatment)
• Steroids beneficial?
Efficacy of oral dexamethasone in outpatients with
acute bronchiolitis. Schuh 2002
• Double blind RCT
• 70 children <24 mos
• Dexamethasone 1 mg/kg vs placebo
• Outcomes: Clinical score and admissions
• Admission rate in Dex group 19% vs 44% in
placebo group
Question 4:
Is oral salbutamol effective for the outpatient
management of bronchiolitis?
Randomized, Double-blind, Placebo-controlled Trial of
Oral Salbutamol in Outpatient Infants with Acute Viral
Bronchiolitis Patel 2002
• Randomized, double-blind trial
• Infants with first-time wheezing
• At discharge ED received either salbutamol (0.1
mg/kg/ dose) TID or placebo for 7 days
• Daily telephone interviews inquiring about
symptom frequency and severity were conducted
with caregivers for 14 days
• Outcome: time to resolution of symptoms
Randomized, Double-blind, Placebo-controlled Trial of Oral
Salbutamol in Outpatient Infants with Acute Viral
Bronchiolitis Patel 2002
• Secondary outcomes included time to:
– normal feeding and sleeping
– resolved cough resolved coryza, and quiet
breathing
• Re-visit and hospital admission rates were also
measured
• 127 infants were enrolled
– SAL = 63, PLAC = 64
– mean age 4.9 mos, 60% male
– 76% positive for RSV
Randomized, Double-blind, Placebo-controlled Trial of Oral
Salbutamol in Outpatient Infants with Acute Viral
Bronchiolitis Patel 2002
• Mean times to resolution of symptoms (days) were
similar:
– SAL = 8.9
– PLAC = 8.4 (p = 0.5)
• No significant group differences in the secondary
outcomes
• No significant group differences in the symptom
resolution in infants treated with oral salbutamol
versus placebo
Question 5:
In infants with RSV bronchiolitis, does treatment with
antibiotics reduce bacterial complications or the need
for readmission?
Risk of secondary bacterial infection in infants
hospitalized with respiratory syncytial viral infection
Hall et al, 1988
1706 pts, 565 of these RSV positive.
< 3 yrs Prospective
7 of 565 had subsequent bacterial infection: 5 pneumonia
(4 Strep. pneumoniae, 1 H.influenzae), 1 meningitis, 1
Salmonella sepsis
-prior antibiotic use in 5 of 7
-overall 62% of RSV patients did not receive
antibiotics
Overall rate of bacterial infection is 1.2%
Case 2 - Summary:
• Bronchodilators have a only a modest short term effect on
bronchiolitis
• ßagonists not effective for bronchiolitis
• Racemic epinephrine may improve clinical symptoms,
reduces hospital admission rates - superior to salbutamol
in some studies
Case 2 - Summary:
• Dexamethasone may be effective in bronchiolitis
• Oral salbutamol is not effective
• Antibiotic use in bronchiolitis does not improve
outcome or reduce bacterial complications overall risk of bacterial infection is low
Case 3
A two-year-old previously healthy, immunized boy is
brought to the ED in acute respiratory distress.
He has a 2 day history of runny nose, cough and low-grade
fever.
Today he has developed a hoarse voice and barky cough.
Case 3
• On arrival, vital signs: RR 40, T 38.5, P 140, BP 90/60,
O2 sat 95%.
• He is sitting upright in his mother's lap with stridulous,
labored breathing. He is not drooling. He has
diminished breath sounds, no crackles or wheezes. His
extremities are pink and warm with brisk capillary refill.
The remainder of his examination is normal.
• You diagnose croup and order racemic epinephrine.
Questions:
• Is steroid therapy effective in reducing acute symptoms?
• Do inhaled steroids give any additional benefit?
• Is dexamethasone 0.15 mg/kg as effective as 0.6 mg/kg?
Questions:
• Is mist therapy effective in reducing acute
symptoms?
• Is L-epinephrine as effective as racemic
epinephrine?
• Following nebulized epinephrine, what period of
observation is needed
Question 1:
In children with croup, is steroid therapy effective in
reducing acute symptoms?
The effectiveness of glucocorticoids in treating croup:
meta-analysis Ausejo, 1999
• Meta-analysis of RCTs of glucocorticoid treatment in
croup
• 24 studies met inclusion criteria.
• 4 mos to 12 yrs (mean ages 13 to 45 mos)
•Trials included:
•17 assessed dexamethasone
• 9 assessed budesonide
• 3 assessed methylprednisolone
The effectiveness of glucocorticoids in treating croup:
meta-analysis Ausejo, 1999
• Fourteen trials involved inpatients and 10 trials
outpatients.
• The studies were small with a median of 40
participants.
• Overall, significant improvement in croup score at
6 and 12 hrs.
• By 24 hrs this improvement was not statistically
significant.
The effectiveness of glucocorticoids in treating croup:
meta-analysis Ausejo, 1999
• Significant decrease in the number of epinephrine
tx needed
- decrease was 9% in the budesonide group and
12% in the dexamethasone group.
• Significant decrease in the length of hospital stay
both in the ED (stay reduced by 11 hours) and for
inpatients (stay reduced by 16 hours).
• NNT for significant improvement in outcome is 57 patients.
The effectiveness of glucocorticoids in treating croup:
meta-analysis Ausejo, 1999
Conclusions:
•Glucocorticoids bring clinical improvement within 6
hours
•Nebulized budesonide, PO and IM Dexamethasone are
equally effective in treating croup
•Use of glucocorticoids associated with lower rate of
cointerventions and shorten hospital stay
Question 2:
Do inhaled steroids give any additional benefit in
children with croup?
Nebulized budesonide and oral dexamethasone for
treatment of croup: A randomized controlled trial
Klassen, 1998
Double blind RCT
Three arms:
- oral dexamethasone 0.6 mg/kg and
nebulized placebo
- oral placebo and nebulized budesonide 2 m
- oral dexamethasone and nebulized budesonide
Outcomes: croup score, hospitalization rates, time in ED,
return visits, symptoms>1 week
Nebulized budesonide and oral dexamethasone
for treatment of croup: A randomized controlled
trial Klassen, 1998
• Change in croup score was:
– -2.3 for Budesonide
– -2.4 for Dex
– -2.4 for combined group
• No differences between treatment groups.
• Conclusion: Based on decreased cost and ease of
administration, dexamethasone alone is preferred
treatment.
A comparison of nebulized budesonide, IM
dexamethasone and placebo for moderately severe
croup
Johnson et al, 1998
Double blind RCT
144 pts, 6 mos-4 yr
Treated with:
•nebulized budesonide
•IM dexamethasone
•placebo
A comparison of nebulized budesonide, IM
dexamethasone and placebo for moderately severe
croup
Johnson et al, 1998
• Hospitalization rates:
• 71% placebo
• 38% budesonide
• 23% dexamethasone
• Statistically significant difference steroids vs placebo
• No difference between bud and dex
• Croup scores:
• significant improvement with dex or bud better than
placebo and dex better than budesonide
Question 3:
In children with croup, is single-dose decadron 0.15
mg/kg PO as effective as 0.6 mg/kg PO in reducing
acute symptoms?
Oral dexamethasone in the treatment of croup: 0.15
mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Geelhoed,
1995
RCT
164 pts
>3mos
No differences in croup score at 1-8 hours, hospitalization
rate, length of stay or need for racemic epinephrine.
Question 4:
Is mist therapy effective in reducing acute symptoms?
Humidification in viral croup: a controlled trial
Bourchier,1984
RCT. Not blinded
16 pts
Humidified air delivered in croup tent for 12 hours vs room
air.
No difference in croup score, RR, HR, oxygen saturation at
one hour intervals.
A randomized controlled trial assessing the effectiveness of
mist in the acute treatment of croup. Neto, 2002
71 pts
Randomized to receive humidified oxygen via mist stick
vs. no mist
All received Dexamethasone 0.6 mg/kg
Outcome measures: croup score, oxygen saturation, HR,
RR, length of stay, admission rate. Assessed at
0,30,60,90,120 min.
No significant difference in any of the outcome measures
between the two groups.
Question 5:
In children with croup, is a comparable dose of Lepinephrine as effective in reducing acute symptoms as
racemic epinephrine?
Prospective randomized double-blind study comparing Lepinephrine and racemic epinephrine in the treatment of
laryngotracheitis
Waisman, 1995
Double blind RCT
31 pts, 6 mos-6 yrs
Racemic epinephrine 0.5 ml in 4.5 ml saline vs Lepinephrine 5 ml of 1:1000 solution.
Both had reduction in croup score with no difference seen
at 5,15,30,60,120 min.
No differences in HR, RR, BP, Oxygen saturation.
Question 6:
In children with croup who improve following nebulized
racemic epinephrine, how long should they be observed to
demonstrate no 'rebound' worsening of symptoms?
The disposition of children with croup treated with
racemic epinephrine and dexamethasone in the
emergency department Rizos et al, 1998
Prospective, cohort study
82 pts
All received IM dexamethasone and racemic epinephrine.
Discharged home if free of retractions and stridor at 2
hours.
Telephone follow up. 6 required follow up within 48 hours.
2 were admitted
No adverse outcomes.
Case 3 - Summary:
• Steroid therapy:
• improves clinical symptoms within 6 hours
• shortens hospital stay
• decreases need for epinephrine treatments
• Oral dexamethasone equivalent to nebulized
budesonide
• no increased benefit of adding inhaled steroids
• Dexamethasone at 0.15 mg/kg as effective as 0.6
mg/kg
Case 3 - Summary:
• No proven benefit of mist therapy
• L-epinephrine as effective as racemic epinephrine
with no increased adverse effects
• If patient is symptom free, may be discharged at 2
hrs post racemic epinephrine
Quickies
Epiglottitis
RARE now with Hib gone

Pneumococcus, Staph, Strep now more common as
cause

3 – 7 years of age

Rapid onset

Medical emergency


Don’t bug the kid but don’t let him out of your sight

Call anesthesia; intubate in OR
Quickies
Retropharyngeal abscess
1-6 years


Retropharyngeal LN’s gone after this
GAS, anaerobes, S. aureus

Need good film for diagnosis


Neck extended in inspiration
Width of prevertebral soft tissue > ½ C3 vertebral
body


Loss of cervical lordosis
IV abx, ENT consult

Quickies
4 year old fully immunized girl


Febrile, croupy cough, drooling, stridor

Looks unwell, but no acute distress

Coryza and sore throat for one day

No rashes; no choking episodes
You give racemic epi… no response

You order lateral neck XR… no FB, no steeple sign,
epiglottis normal, upper airway has irregular margins

Bacterial tracheitis
Uncommon
Can mimic croup quite closely; may be a complication of
croup

sicker, high fever, gradual onset of illness

S. aureus usual cause
“Shaggy trachea” on XR secondary to pseudomembrane
formation

Admit to ICU for iv antibiotics and observation

“not all croup is viral croup”