Pediatric Respiratory Emergencies

1. Pediatric Respiratory Emergencies Mohammed Al Faifi, MD. Director, Emergency Out-Reach Program King Faisal Specialist Hospital & Research Centre Riyadh, KSA Kuwait, Oct. 2011

2. Pediatric Respiratory EmergenciesPart 1 Emergency Management of Asthma

3. QUALITY OF CARE OF ED RESPIRATORY ILNESS Knapp et al. Pediatrics 2008 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

4. Results Knapp et al. Pediatrics 2008

5. Conclusions Knapp et al. Pediatrics 2008 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.

6. Pediatric Respiratory EmergenciesPart 1 Emergency Management of Asthma

7. 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.

8. History • Initial history is brief, focused • Duration of symptoms • Severity of symptoms • Medication use • More comprehensive history follows • Triggers • Fever • Systemic Review

10. Past Medical History • Previous wheezing • Prior admissions for wheezing • Prior admissions to ICU • Chronic lung disease

11. Physical Examination • Level of consciousness • Vital signs • Degree and symmetry of wheezing • Inspiratory and expiratory ratio • Accessory muscle use

12. Differential Diagnosis • Bronchiolitis • Foreign body aspiration • Gastroesophageal reflux • Cystic fibrosis • Anaphylaxis

13. Pulmonary Index Score* * 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.

14. 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%

15. CXRs

16. 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

17. Chest Radiographs • Focal findings • Fever • Severe disease

18. Treatment Options • Beta2-agonists • Inhaled (nebulizer vs. metered-dose inhaler) • Subcutaneously • Intravenously • Corticosteroids • Orally • Nebulized • Intramuscularly • Intravenously • Ipratropium bromide • Magnesium sulfate

19. 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

20. Beta2-Agonist Optimizing Delivery • Small particles • Mouthpiece • Low inspiratory flow rate • Breath-holding

23. AeroChambers

25. 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

26. Ipratropium Bromide Time (mins.) Schuh, et al. J.Pediatrics 1995;126:639-645

27. 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

28. Ipratropium Bromide Recommendations • For children with a moderate or moderate-to-severe exacerbation or for those already receiving Beta2 agonist therapy : • 250-500ug of ipratropium bromide by nebulization to be administered concurrently with the albuterol treatments

29. Steroids in Acute Asthma

30. 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

31. Scarfone, et al Conclusions: Oral Corticosteroids: • Decreases hospitalization rate • Effective within 4 hours • Augments Beta2-agonists therapy

32. 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

33. 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

34. OralPrednisonevs.OralDexamethasone Qureshi F .J Pediatrics 2001

35. 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 • Noncompilance4% 0.4 Qureshi F .J Pediatrics 2001

36. Moderate AsthmaTreatment 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 Beta2agonist treatments • Prednisone should be given early ASAP -If emesis • Methylprednisolone IV • Dexamethasone: orally or IM

37. Albuterol nebulization or MDI Prednisone1 O2 If Pulse Ox < 92% Albuterol q20-30 mins. Ipiatropium with albuterol No improvement Marked Improvement Slightly improved Hospitalize Discharge home Continue albuterol q30 mins. Disposition Management of Moderate Asthma

38. Disposition • Discharge : • PEF > 70% predicted, • Symptoms are minimal or absent, • Sufficient medications can be prescribed and maintained • Outpatient care can be established within a several-days time frame • EDUCATION..

39. 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

40. POST EMERGENCY DEPARTMENT CARE • Short-term Medications - Beta-agonist Therapy - Corticosteroids - Inhaled steroids • Education

42. Pulmonary Index Score* * 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.

43. Severe Asthma • No wheezing 3 • Unable to speak • Dyspnea 2 • Markedly prolonged expiratory phase 3 • Significant work of breathing with • Retractions 2 • Requires oxygen 3

44. Severe Asthma • Oxygen (consider non-rebreather) • Inhaled beta2-agonist • Inhaled ipratropium bromide • Intravenous corticosteroids ASAP • Initial management

45. 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.

46. 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.

48. Subcutaneous Terbutaline • Uncooperative, anxious young children • Very poor inspiratory flow or aeration • Poor response to initial nebulizedalbuterol

49. Continuously NebulizedAlbuterol • Advantages: • Easier to adhere to • Less respiratory therapy time • Safe • May benefit sicker patients • Disadvantages: • Patients may go unobserved • Claustrophobic mask

50. Corticosteroids IV Methylprednisolone ASAP