Pediatric ABC

1
Pediatric ABCs

• Asthma, Bronchiolitis and Croup
• (and some quickies)

David Chaulk Pediatric EM Fellow January, 2004
2
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.

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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?
4
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 ?

5
Question 1 Does the addition of a nebulized
anticholinergic agent (ipratropium bromide) to
nebulized beta-agonist decrease the risk of
admission to hospital?
6

• 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

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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

8

• 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

9
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

10
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 )

11
Question 2 Is racemic epinephrine
effective in children who have acute asthma ?
12

• 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

13
Question 3 In children with acute asthma, do
IV steroids decrease hospitalization and improve
clinical symptoms as compared to oral steroids?
14

• 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.

15

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

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Question 4When should you give systemic
steroids to the patient ?

17
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

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Question 5What is the role of inhaled steroids
in acute asthma?
19
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

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Question 5Is magnesium sulfate effective in
improving symptoms in children with moderate to
severe acute asthma?
21
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

22
Higher Dose Intravenous Magnesium Therapy For
Children with Moderate to Severe Acute
AsthmaCiarallo, 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

23
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 --gt 48 adm)

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• Question 6
• Does the Salbutamol need to be given by
  nebulization or can a spacer device be used?

25
Cochrane Review July 2001

• 16 studies
• 686 children
• 375 adults
• No difference in admission rate
• 95 CI ( OR 0.4 to 2.1 )
• Childrens LOS in the ED shorter
• mean diff -0.62 hours
• 95 CI ( -0.84 to -0.40 )

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

• 152 patients
• gt 2 years old
• Unblinded
• 3 puffs q20 minutes via aerochamber vs.
• 0.15mg/kg Ventolin via nebulizer

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

• Time in ED Vomiting
  HR
• Spacer 66 9 5
• Nebulizer 103 20 15

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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

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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

30
Pediatric Asthma Guidelines

• Nocturnal cough
• Exertional SOB
• Increased Ventolin use
• Good response to Ventolin
• O2 sat gt 95
• Ventolin
• Consider po Steroids

MILD Treatment
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Pediatric Asthma Guidelines

• Normal mental status
• Abbreviated speech
• SOB at rest
• Ventolin gt q4h
• O2 sat 92-95
• O2 100
• Ventolin
• Systemic corticosteroids
• Consider anticholinergic

MODERATE Treatment
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Pediatric Asthma Guidelines

• Altered mental status
• Difficulty speaking
• Laboured respirations
• Persistent tachycardia
• No prehospital relief with Ventolin
• O2 saturation lt92
• 100 O2
• Continuous Ventolin
• Systemic corticosteroids
• Anticholinergic
• Consider Magnesium sulfate

SEVERE Treatment
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• 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.

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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.

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• 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.

37

• 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?

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Question 1 In infants with clinical features
of bronchiolitis, does treatment with
bronchodilators improve symptoms and reduce the
need for hospital admission?
39

• 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

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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

41
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.

42
Question 2 Does epinephrine, which has both
alpha and beta-adrenergic properties, have an
advantage over salbutamol and other
beta-agonists?
43
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

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Question 3 In infants with clinical features
of bronchiolitis, does treatment with
dexamethasone reduce symptoms?
45
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.
46
Systemic Corticosteroids in infant bronchiolitis
a meta-analysis. Garrison, 2000

• 6 trials
• 347 hospitalized pts
• lt 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?

47
Efficacy of oral dexamethasone in outpatients
with acute bronchiolitis. Schuh 2002

• Double blind RCT
• 70 children lt24 mos
• Dexamethasone 1 mg/kg vs placebo
• Outcomes Clinical score and admissions
• Admission rate in Dex group 19 vs 44 in placebo
  group

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Question 4 Is oral salbutamol effective for
the outpatient management of bronchiolitis?
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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

50
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

51
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

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Question 5 In infants with RSV bronchiolitis,
does treatment with antibiotics reduce bacterial
complications or the need for readmission?
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• Risk of secondary bacterial infection in infants
  hospitalized with respiratory syncytial viral
  infection Hall et al, 1988
• 1706 pts, 565 of these RSV positive.
• lt 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

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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

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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

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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.
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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.

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• 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?

60
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

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Question 1 In children with croup, is steroid
therapy effective in reducing acute symptoms?
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• 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

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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.

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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 5-7
  patients.

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• 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

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Question 2 Do inhaled steroids give any
additional benefit in children with croup?
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• 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, symptomsgt1 week

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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.

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• 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

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• 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

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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?
72
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 gt3mos No differences
in croup score at 1-8 hours, hospitalization
rate, length of stay or need for racemic
epinephrine.
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Question 4 Is mist therapy effective in
reducing acute symptoms?
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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.
75
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.
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Question 5 In children with croup, is a
comparable dose of L-epinephrine as effective in
reducing acute symptoms as racemic epinephrine?

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Prospective randomized double-blind study
comparing L-epinephrine 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 L-epinephrine 5 ml of 11000
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.
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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?
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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.
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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

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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

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Quickies
83

• 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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Quickies
85

• 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

86
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

87

• 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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