ped respiratory emergencies: evidence-based …...ped respiratory emergencies: evidence-based...

Ped Respiratory Emergencies: Evidence-Based Practice

Sean M. Fox, MD, FACEP, FAAPProfessor of EM and Professor of Pediatrics

Associate Program DirectorEmergency Medicine Residency Program

Department of Emergency MedicineCarolinas Medical Center

Charlotte, NC

Master Cough and Distress We Will!

Objectives

CroupBronchiolitis

AspiratedForeign Body

Objectives

Asthma

Croup Tracheitis

Bronchiolitis


Objectives

Asthma

•Age: 6 months-3 years = highest attack rate•Etiology: Parainfluenza A = most common

• RSV, Adenovirus, Influenza

•10% require medical treatment•Variable admission rates

Croup

Croup•Associated with low grade fever and URI•Worse at night•Bark-like cough•Harsh inspiratory stridor•May have retractions

Diagnosis•Clinical diagnosis!•Lab testing is of little help.•Imaging not necessary… unless…•Unusual cough or persistent •No response to Tx

Croup

CroupTreatment•Steroids•Epi

•Double-blind trial at 4 Ped EDs•720 kids with Mild Croup•0.6mg Dexamethasone vs placebo

Treatment•Steroids•Epi

Croup

• Double-blind trial at 4 Ped EDs• 720 kids with Mild Croup• 0.6mg Dexamethasone vs placebo

•Dex group: Lower return rates•Dex group: Quicker resolution •Dex group: Less lost sleep and less parental stress


Croup

•38 studies (4,299 pts)•Steroids improved croup score at 6 and 12 hours•Steroids lead to fewer return visits / readmissions•Length of stay was less when steroids given•Less use of Epi if given steroids

CroupTreatment•Steroids•Epi

Dexamethasone• 0.15 - 0.6mg/kg IM/PO/IV• 25X more potent than hydrocortisone• Long biological half-life - up to 54 hours• No statistical difference between IM and PO

Problem: liquid Dex is dilute (1mg/1cc)• Solution: use IV form (4mg/1cc) orally• Can also crush the 4mg tablet


Croup

Epinephrine• 8 studies (225 pts)• Improved score at 30min• Not significant at 2 hrs and 6 hrs• Transient improvement


Croup

Epinephrine• For Stridor AT REST

• Age <6mos: 0.25mL of 2.25% solution in 2mL NS• Older kids: 0.5mL of 2.25% solution in 2mL NS• Observe for 2-3 hours after administration


Croup

Mild Mod Severe

Sx Barking StridorStridor at

Rest

Steroid? Yes Yes Yes

Racemic Epi? No No Yes

Admit No No ??

Croup

Who Stays??•Stridor at rest, despite intervention•Incomplete response to intervention•Multiple doses of racemic epinephrine•Poor social situation•Inability to tolerate po fluids

Croup

Give Dexamethasone to them all!

Croup

Distinguish Moderate from Severe.

Use Racemic Epi for Stridor at Rest.

“Recurrent” Croup


• Viral Croup • Usually once/twice a year

• Recurrent Croup • Occurs > twice a year

• Concern for airway narrowing


•Be suspicious: < 6 months; > 3 years•Relapsing and remitting course •No response to standard therapy

TIMING of STRIDOR• Inspiratory -• Expiratory -• Biphasic -


• Inspiratory - Supraglottic• Expiratory - Tracheal• Biphasic - Glottic or Subglottic

TIMING of STRIDOR• Inspiratory -• Expiratory -• Biphasic -


• Inspiratory - Laryngomalacia• Expiratory - Vascular ring• Biphasic - Subglottic stenosis

• Airway Anomalies• Foreign Bodies• Asthma• Mediastinal Mass• Gastroesophageal Reflux• Congenital CardioVascular Anomaly


“Recurrent” CroupDiagnostic Momentum may steer you off course.

Don’t be cavalier with all “croup.” It may not be.

The old, the young, and those who don’t respond.

Tracheitis

TRACHEITIS?This Seal

Doesn’t Even Have a

Tracheostomy.

Tracheitis• True Medical Emergency• Inflammation of the Trachea• Thick Exudates obstruct airway

• Adjacent structures affected

Tracheitis

• Bacterial Infection• Viral Infection (HSV, Flu)• Chemical Irritation• Thermal Irritation

Tracheitis

Tracheitis

• Challenging to Diagnose.• Can present Dramatically!• Can present Subtly.

TracheitisMay Mimic:• Epiglottitis (yes, this still occurs)

• Tracheal Foreign Body• Retropharyngeal Abscess• Pertussis• Anaphylaxis

Tracheitis

Healthcare Associated Tracheitis

• Less dramatic.• Culture secretions, Tailor Antibiotics.• Supportive care.

Tracheitis

TOXIC APPEARING TRACHEITIS

• Treat like Epiglottitis• Keep Calm• Go to OR

Tracheitis

Not Toxic Appearing… but…

• Atypical “Croup” course.• Worsening stridor.• High Fever, Orthopnea, Dysphagia.

Tracheitis

Not Toxic Appearing… but…

PA & Lat Neck film may help…But… needs…

Flexible Endoscopic evaluation.

Tracheitis

TREATMENT

• Protect the Airway• Ampicillin-clavulanic acid PLUS• 3rd gen Cephalosporin.

TracheitisRare, but deadly!

May be dramatic - treat like epiglottis.

May be subtle - remain vigilant.

Atypical “Croup” course.

Needs endoscopic look!

Bronchiolitis

2 month old, ex-35 week premie, with 2 days of cough and rhinorrhea. No other chronic medical problems.

Respiratory Rate of 70. Alert, fussy, but consolable.

Copious rhinorrhea present with diffuse crackles and wheeze. There are subcostal retractions.

Risk Factors for Apnea?Seriously, What Do You Do?

What to Do When it is Bad?

Who Needs to Stay?

The most common lower respiratory tract infection (LRTI) in infants

• Commonly seen between 2-6 months of age• Primarily a winter season illness

A leading cause of hospitalization in infants

Bronchiolitis

RSV is the Leader of the pack• Highest incidence: December to March• There are others, however:

• Human metapneumovirus • Influenza, Parainfluenza• Adenovirus, coronavirus, enterovirus• Rhinovirus (more typical in older infants)• Human bocavirus

Bronchiolitis

A Word on RSV…

• ~90% of children are infected with RSV by age 2 years• 40% of these kids will have lower respiratory tract

infections• Infection does NOT confer immunity

• Testing for RSV (and other viruses) is available, but…• Not necessary for the diagnosis• May be used to cohort patients in the hospital• Results do not affect individual management

Bronchiolitis

Bronchiolitis

•The Diagnosis is Clinical• Upper respiratory infection (rhinitis) and • Lower respiratory infection

• Wheezing, cough, tachypnea, accessory muscle use, nasal flaring, or hypoxia

Bronchiolitis

Supportive Care!!• Suctioning (clear those secretions)• Oxygen if hypoxic• Nasogastric Feeds or IV Fluids

• No other therapy is proven to be efficacious in studies• Many have been studied… all have been disappointing• What to do, then, when the patient is in distress??

Bronchiolitis

CORTICOSTEROIDS• Multiple trials have not shown any benefit• They do not improve respiratory status• They do not decrease LOS or admissions

Bronchiolitis

BETA-AGONIST• Studies suggest no benefit• Occasionally demonstrate modest short-term

improvements… • But no reduction in hospitalization

Bronchiolitis

EPINEPHRINE• Some limited data suggest that Epi nebulized can

perform better than beta-agonists alone• Unfortunately you cannot D/C a child on Epi nebs

Bronchiolitis

Who Stays??• Hypoxic• Unable to maintain adequate hydration• High risk for complications (namely, apnea)• Social considerations

Bronchiolitis

High Risk for Complications??• Prematurity (gestational age <37weeks;

post conception age <48 weeks)• Age <2 months• Chronic lung disease (ex, CF, BPD)• Hemodynamically significant heart disease• Neurologic disease with hypotonia• Immunocompromised state• Airway anomalies

Bronchiolitis

Respiratory Support• ~2% will require some support• Attempt to prevent intubation• High-Flow Nasal Cannula - promising studies• Heliox - promising studies• Surfactant - promising studies• CPAP/BiPap - very promising!

Bronchiolitis

Suction the Airway! Reassess.

Know the Apnea Risk Factors.

Bronchiolitis is a Dynamic Condition.

Use Continuous High-Flow Nasal Cannula.

Bronchiolitis

•In 2001, ~ 17,537 children < 14 yrs seen in EDs for choking•Rates highest for infants (<1 yr) and decreased with age.

•Candy/gum – 19%•Coins – 12.7%

•In 2000, 160 children < 14 yrs died from aspirated FBs.•Food substances were involved in 41% of cases


Classic Presentation•Cough, wheeze, and diminished breath sounds

•Seen only in 40% of cases of aspiration•Looks like many other conditions


TRACHEAL FB• Dyspnea• Present more classically• Diagnosed early on

BRONCHIAL FB• Decreased BS• Alternative diagnosis upon first presentation

• Delayed Diagnosis


UNDIAGNOSED FB leads to:• Peristent febrile illness• Chronic cough• Recurrent pneumonia• Recurrent “croup”• Poorly controlled “asthma”• Lung abscess• Hemoptysis• Progressive respiratory distress• Death


FACTORS RELATED TO DELAYED DX:• Younger Age (< 3 years of age)• Negative CXR (~50% will be normal)• No history of witnessed choking event• Lack of “typical symptoms” • We were not vigilant


BELIEVE THE PARENTSWitnessed aspiration event is the most sensitive clinical indicator


Core Concepts

• Dexamethasone for all croup• “Recurrent Croup?” Are you Sure?• Tracheitis can be dramatic or subtle• Believe parents about choking• Remain vigilant!

Thank you!“Silent gratitude isn’t much use to

anyone.”G.B. Stern

Sean M. Fox, MD@PedEMMorsels

www.pedemmorsels.com

http://www.pedemmorsels.com

ped respiratory emergencies: evidence-based …...ped respiratory emergencies: evidence-based...

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