Pediatric Respiratory Emergencies

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Pediatric Respiratory Emergencies

• Emergency Medicine Rounds
• October 3, 2003
• Dr. Edward Les

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Overview

• Croup
• Bronchiolitis
• Status asthmaticus
• others

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Case 1

• 3 year old girl brought to ED with a 2-day
  history of worsening cough and wheezing
• Her mother has been giving her nebulized
  ventolin treatments every 4 hours for the past
  day without much improvement
• In the ED her temp is 38.5, RR is 50, O2 sat 94
• On exam moderate increased work of breathing,
  decreased aeration throughout and diffuse wheezes

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Case 2

• A 6-year-old girl comes to the ED with
  respiratory distress.
• Known asthmatic, wheezing for 4 days
• no response to ventolin MDI as often as q2h at
  home
• She is diaphoretic, RR 60, O2 sat 88 on RA
• Able to speak in short sentences b/w breaths
• You immediately provide supplemental O2 and 3
  back-to-back Ventolin nebs, as well as oral
  roids 30 minutes later no improvement

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Status asthmaticus

• Definition
• Any patient not responding to initial doses of
  nebulized bronchodilating agents
• Helfaer et al Textbook of pediatric intensive
  care, 3rd ed. 1996.

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Epidemiology of asthma

• Clearly on the rise
• Unclear why
• 10 of kids in U.S. have asthma
• Annual hospitalization rates doubled b/w
  1980-1993 for 1-4 year-olds
• Asthma death rates double for 5-14 year age group

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Risk Factors for Potentially Fatal Asthma

• Medical factors
• Previous attack with
• Severe, unexpected, rapid deterioration
• Respiratory failure
• Seizure or loss of consciousness
• Attacks precipitated by food
• Ethnic factors
• Nonwhite children (African American, Hispanic,
  other)
• Psychosocial factors
• Denial or failure to perceive severity of illness
• Associated depression or other psychiatric
  disorder
• Noncompliance
• Dysfunctional family unit
• Inner-city residents

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But

• As many as 1/3 of children who die from asthma
  have only had mild preceding asthma
• Australian study of 51 pediatric deaths
• Only 39 had potentially preventable elements
• Robertson et al, Pediatric Pulmonol 19921395-100

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Clinical presentation assessment

• Signs and sx common knowledge
• Measure pulse ox
• Clinical asthma scores
• Research tool
• PFTs
• Do in kids gt 5-6 years old
• PEF ( of best) based on 3 attempts

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PEF as predictor of asthma severity

• PEF predicted ()
• lt30
• 30-50
• 50-80
• gt80

• Exacerbation severity
• Possibly life-threatening
• Severe
• Moderate
• Mild

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Treatment guidelines

• O2 if needed
• ?2 agonists salbutamol
• Anticholinergics ipratropium
• Steroids
• Magnesium
• Heli-ox
• (Intubation)

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Salbutamol

• Method of delivery?
• nebulization
• lt10 kg 1.25 mg in NS
• 10-20 kg 2.5 mg in NS
• gt 20 kg 5 mg in NS
• Single dose/re-evaluate vs q 20 min X3 vs
  continuous
• O2 flow rate important
• 10-12 LPM in order to deliver particles in 1-3
  mcm range

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Salbutamol

• Method of delivery?
• MDI with spacer
• Australian approach
• lt 6 years 6 puffs
• gt 6 years 12 puffs
• Same frequency as for nebs
• Equivalent (or better) efficacy

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Salbutamol

• Method of delivery?
• IV patients unresponsive to treatment with
  continuous ventolin
• 10 mcg/kg over 10 minutes,
• then 0.2-5 mcg/kg/min
• Need supplemental K

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Anticholinergics ipratropium

• When?
• Immediately in moderate to severe asthma
• Reduces duration and amount of treatment before
  discharge
• Most severely ill kids benefit most
• Schuh et al, J Pediatr 1995126639-645
• 250-500 mcg with salbutamol q20min x 3

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roids

• For everybody in E.D.?
• NAEPP to any patient that doesnt respond
  completely to one inhaled ? agonist treatment,
  even if the patient has a mild exacerbation

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roids

• Route of administration
• PO and IV equal efficacy
• Usually po
• IV when cant tolerate po or very sick
• Methylpredisone 0.5-1 mg/kg q6h, or
• Hydrocortisone 2-4 mg/kg q6h
• 1-2 mg/kg/day prednisone
• 0.15-0.3 mg/kg/day dexamethasone

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roids

• Inhaled steroids for status asthmaticus?
• Cochrane meta-analysis of six RCTs suggests
  benefit
• Edmonds et al, in The Cochrane Library (Issue 2),
  2001
• But
• Compared inhaled to placebo, not to parenteral
  steroids
• No children with severe asthma enrolled
• PO or IV steroids remain avenue of choice

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roids alert

• Children with acute asthma and recent exposure to
  chickenpox should not receive steroids, unless
  they are considered immune
• Even a single course of corticosteroids can
  increase the risk for fatal varicella
• Kasper et al, Pediatr Infect Dis J,19909 729-32

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Magnesium

• Good evidence for efficacy in children
• Ciarallo, et al, Arch Pediatr Adolesc Med,
  2000154979-983
• 30 patients in RDBPC trial
• Tx group 40mg/kg IV Mg over 20 minutes to
  children with moderate-severe asthma refractory
  to nebulization therapy
• 50 of tx group discharged home
• 100 of placebo group admitted (P 0.002)
• Rowe, Ann Emerg Med, 200036(3)181-90
• Systematic review of literature 7 trials (5
  adult, 2 pediatric)
• Beneficial for patients who present with severe
  acute asthma

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Magnesium

• ? Causes relaxation of smooth muscle by
  inhibiting calcium uptake
• Dose 30-75 mg/kg IV over 20 minutes
• Max dose 2 g
• Safe and well tolerated
• Occasional nausea, flushing, weakness

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Heli-ox

• Not used much in ED
• Theoretical advantage reduces turbulent flow
• Prospective randomized double-blind crossover
  study in in 11 severe non-intubated pediatric
  asthmatics failed to show benefit
• Carter et al, Chest 19961091256-61
• Use limited by patients O2 requirement

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Intubation/mechanical ventilation

• Avoid if at all possible high
  morbidity/mortality
• RSI which sedative?
• Ketamine with atropine
• Ventilation principles
• Low rate, long exp times, controlled pressure,
  permissive hypercarbia

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Case 1 (cont)

• After appropriate treatment she is much improved
  with RR 30 and O2 sat 98 on RA, with minimal
  residual wheezing.
• What are criteria for discharge home?
• What therapy will you prescribe?

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Asthma disposition from the ED

• Asthma flow sheets very helpful
• Patients should be observed for 30-60 minutes
  post-ventolin for symptom recurrence
• Most require at least 2 hours ED care
• Steroids kick in _at_ 4-6 hours

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Asthma disposition

• Consider hospitalization more strongly if
• Prior hx of sudden, severe exacerbation
• Prior intubation or ICU admission
• ? 2 hospitalizations in last year
• ? 3 ED visits in past year
• ? 2 MDIs used in a month
• Current steroid use or recent wean from steroids
• Medical or psychiatric comorbidity
• Poor perceiver of symptoms (adolescents)
• Substance abuse
• Low socioeconomic status
• Baren JM in Emergency Asthma, 1999

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Asthma disposition

• NAEPP guidelines for discharge
• PEF has returned to 70 of predicted
• Exacerbation symptoms minimal or absent
• Observed 30-60 minutes after last tx
• Medications prescribed
• PO steroids, ventolin, inhaled steroids
• OP care can be established with a few days
• Use asthma clinic!

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Case 3

• 4 month old girl brought to ED in February
  wheezing of 2 days duration
• cough, rhinorrhea and fever to 37.8 C
• poor feeding last 24 hours
• wheezing is worsening
• born at 31 weeks gestation required mechanical
  ventilation for 4 days after her birth
• On exam
• alert, RR 56 with mild retractions, O2 sat 94 RA
• Diffuse wheezes bilaterally, scattered creps

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CXR
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Management options?

• Supportive care
• O2, fluids, suctioning, saline nose drops
• Ventolin
• Shuang huang lian
• Racemic epinephrine
• Ribavirin
• Steroids
• Vitamin A

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Management options?

• Supportive care
• O2, fluids, suctioning, saline nose drops
• Ventolin ?
• Shuang huang lian
• Racemic epinephrine ?
• Ribavirin
• Steroids ?
• Vitamin A

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Bronchiolitis

• Primarily b/w 0 and 24 months
• Peak 2-8 months
• Infects almost all children
• May be predictive of future asthma if
  hospitalized
• 1 of all hospitalizations of children in 1st
  year of life
• 300 million per year in U.S.
• Mostly seasonal
• 60-90 RSV
• Extremely contagious
• Affects terminal bronchioles in young children
• Symptoms peak around day 5

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Bronchiolitispredictors of severe disease

• Ill or toxic appearing
• SaO2 lt 95
• Gestational age lt 34 weeks
• RR gt 70 breaths per minute
• Atelectasis on CXR
• Age less than 3 months
• Single best objective predictor infants SaO2
  while feeding
• Shaw et al, Am J Dis Child, 1991145151-55

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Salbutamol in bronchiolitis

• Many studies
• 1996 meta-analysis by Kellner et al in Arch
  Pediatr Adolesc Med 1501166-72 suggested benefit
• Multiple conflicting reports since
• Despite that used widely

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Racemic epinephrine in bronchiolitis

• Again, many studies
• Generally more positive than salbutamol studies
• Sanchez et al, J Pediatr 1993122145-51
• Reijonen et al, Arch Pediatr Adolesc Med
  1995149686-92
• Menon et al, J Pediatr 19951261004-1007
• Certainly safe
• Dose 0.25 0.5 mL neb in NS
• L-isomer alone may be more effective

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Steroids in bronchiolitis

• Theoretically sound
• Recent Sick Kids study
• 1st study based in the ED
• DBRPC trial involving 70 kids under 2 yrs
• Dexamethasone group had hospitalization rate less
  than ½ of placebo group
• Schuh et al, J Pediatr 2002140(1)
• Recent meta-analysis also suggested statistical
  improvement with dexamethasone
• Garrison, Pediatrics 2000105(4)E44
• Overall, however, the bulk of individual studies
  have not shown benefit

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Prevention of bronchiolitis

• Palivizumab (Synergis)
• Monoclonal antibody
• effective
• Given only to high risk infants
• CLD
• prems

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Bronchiolitis indications for admission

• Age generally if less than 1-2 months
• Apnea
• Oxygen requirement
• Poor feeding
• If received racemic epi in ED?
• seems logical criteria given this is a med you
  cant prescribe for home management!
• Underlying condition
• e.g.
• Prematurity
• Congenital heart disease

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Case 4

• A 2 year old boy arrives at triage at 1 a.m with
  his Dad
• Youre awakened by..
• Hes brought back to obs
• Sat is 90, moderate retractions, very hoarse
  voice, continued noisy breathing
• Dad gives you xray taken one hour ago at walk-in
  clinic

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Croup acute laryngotracheobronchitis

• Stridor, barky cough, hoarseness
• 6 months to 6 years of age
• Often preceding URTI
• Typically worse at night
• Severe cases have biphasic stidor
• Diagnosis is clinical

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croup
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Croup - treatment

• Humidification
• Often occurs on way to hospital
• Corticosteroids
• PO equivalent to IM
• Dose 0.6 mg/kg (0.15 mg/kg may be adequate)
• Nebulized budesonide also effective may be
  additive
• Racemic epinephrine
• Need to observe in ED 2-3 hours post admin
  potential rebound mucosal edema

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Case 5

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Epiglottitis

• RARE now with Hib gone
• Pneumococcus, Staph, Strep now more common as
  cause
• 3 7 years of age
• Rapid onset
• Medical emergency
• Dont bug the kid but dont let him out of your
  sight
• Call anesthesia intubate in OR

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Case 6

• 3 year old with progressive stridor, fever,
  meningismus
• Diagnosis?

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Retropharyngeal abscess

• 1-6 years
• Retropharyngeal LNs gone after this
• GAS, anaerobes, S. aureus
• Need good film for diagnosis
• Neck extended in inspiration
• Width of prevertebral soft tissue gt ½ C3
  vertebral body
• Loss of cervical lordosis
• IV abx, ENT consult

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Case 7

• 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

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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

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Case 8

• 15-month-old girl
• Acute onset wheeze and cough 2 hours ago
• Previously well
• Has past hx bronchiolitis sib has asthma
• On exam
• afebrile, sat 95 RA, RR 44, AE sl decreased on
  left, wheeze LgtR

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CXR

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CXR- forced expiratory view
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• Miller time