pediatric asthma and bronchiolitis (rsv)
TRANSCRIPT
Slide 1Pediatric Asthma and Bronchiolitis (RSV) • UCLA RRMC
Pediatric ED Nurses • November 16, 2021 • Los Angeles, CA
• Sande Okelo, MD, PhD, • Pediatric Pulmonology and Sleep Medicine • UCLA Mattel Children’s Hospital • [email protected] • www.uclahealth.org/pedspulmonology
Case • 14-month-old girl with severe asthma and h/o 2 previous
admissions to the PICU for respiratory failure (mechanically ventilated once)
• Presented with 1-2 days of progressive cough, increased work of breathing and failing q4 Albuterol nebs at home, including 3 back-to-back treatments
Treatment Course • Triaged in the ED at 7:30 am
• 1 dose of levalbuterol and ipratropium at 8:30
• No further interventions until transfer to Pediatrics at 12:55.
• heart rate increased 180's by the time she made it to Peds floor
• No labs or imaging were performed until 3pm
• No continuous albuterol started on floor “because only can be done in the PICU”
• A peripheral iv was ordered at 2:30, but wasn't inserted until 4:30
• “because the patient is being transferred to PICU”
• PICU nurses place iv on Peds floor
• With a NS bolus, her heart rate declined to the 170's.
• Transferred to PICU at 5pm • Continuous Albuterol overnight
• HD#2 • Started on Nasal IMV but worsening tachypnea • Intubated
• Parents report: • Multiple occasions in ED and on ward of under-treatment of sx’s • Multiple instances of provider and nursing under-recognition of sx’s • Lack of confidence in acute asthma care at UCLA
• Could respiratory failure and intubation have been avoided with better treatment in ED and peds floor?
• “Better treatment” = standardized assessment and treatment protocol
• Pediatric Asthma Score (RT and/or RN) • Inhaler Assessment (RT) • Asthma Questionnaire (RT) • Orderset (ED, Admit) • MD Notes (admit, progress) • Asthma Action Plan (MD)
7
• Bronchiolits - an acute usually viral infection of the small airways, generally affecting small infants and those with chronic cardiac or pulmonary disease. Respiratory symptoms result from airways obstruction secondary to inflammation
“To sum up, oxygen is vitally important in bronchiolitis and
there is little convincing evidence that any other
therapy is consistently or even occasionally useful”
Reynolds and Cook, 1963
ETIOLOGY
• 1957 RSV first identified in LRT of infants by Chanock and Finberg
• Subsequently has been found in a majority of infants with bronchiolitis
• Other common viruses -parainfluenza, adeno, entero, influenza
EPIDEMIOLOGY
• RSV epidemics in N. America occur between Oct and June – Last 5 months – Alternate between short (7-12 mos.) and long
(13-16 mos.) intervals between peaks • Uncommon in infants < 1 month • Peak incidence 2 months in large urban
populations • Male=Female
• Lowest attack rate adults (17%) • Highest attack previously uninfected day-
care infants (98%) • Almost all children in a high-pop. urban
setting will acquire by age 2 yrs.
Average Age-Specific Rates of Hospitalization for RSV Infection Among Children <24 Months of Age
(2000 – 2005)
Chart1
N Halasa Vaccine 33 (2015):6479 - 87
Chart1
• Infant may be irritable, feed poorly and vomit
PHYSICAL EXAM
• RR 50-60 bpm • Tachycardic • Fever up to 41 C • Mild conjunctivitis or
otitis in some • Pharyngitis in 50%
• Retractions • Prolonged expiratory
resp distress • Cyanosis is rare
RADIOGRAPHIC FINDINGS
• May be normal
Treatment-Supportive • Supplemental oxygen • Positive pressure ventilation if apnea • IV fluids • Time
• Trial of asthma therapy – to rule-out asthma – more than 1 episode of bronchiolitis
19
ASTHMA IN THE U.S. • 25 million affected
• 7 million children • 1 million in CA
• 200K in LA County • 63K in LAUSD
• 60% miss school (#1 cause) • $0.5 - $1 billion • $80 per missed school day per child (LAUSDE)
• $3+ million/year
• 400, 000 hospitalizations • 200,000 peds
• $20+ billion/year • $5 billion peds
ED & Hospitalized Asthma Patients at High Risk
• 40% of hospitalized patients will relapse to ED/hospital <1 year
• 17% of ED patients will relapse in 2 months
• 10 – 30% follow-up with primary care
• <50% use asthma controller medications
• <35% have an asthma treatment plan
Cydulka RK Ann Amerg Med 2005 (46):316-22; Smith SR Pediatrics 2002:110(2): 323-30 Stingone JA, Claudio L. Ann Allergy Asthma Immunol. 2006; 97(2): 244-50. Andrews AL J Pediatr. 2012; 160(2): 325-30.
To establish a diagnosis of asthma, determine that: • Asthma symptoms occur more than once
• Cough • Wheeze • Chest pain/tightness • Shortness of breath (exertional) • Decreased stamina
• Asthma symptoms improve with asthma medicines • Adequate dose, duration and technique
• Alternative diagnoses are excluded • Habit cough; chronic sinusitis; GERD
22
Anti-cholinergic β2 agonist: multiple doses most effective in mod – severe + exacerbations: admits
Rodrigo G J , and Castro-Rodriguez J A Thorax 2005;60:740-746
Early Steroid Administration Reduces Admit Rates
26 SK Bhogal Annals of Emergency Medicine, Volume 60, Issue 1, 2012, 84 - 91.e3
Pediatric Asthma Score
Expiratory Wheezing Mental Status
Normal
Respiratory Rate
<1 yr: < 50 1 – 5 yr: < 40 6 – 14 yr: <30 >14 yr: <25 29
Score 0 1 2
Normal Selectively diminished
Accessory Muscle Use
Breathlessness None Mild – moderate
Vocalization Speech/ Cry Normal
Orthopnea Tolerates being supine
Respiratory Rate
<1 yr: < 50 1 – 5 yr: < 40 6 – 14 yr: <30 >14 yr: <25
<1 yr: > 50 1 – 5 yr: > 40 6 – 14 yr: >30 >14 yr: >25 30
Score 0 1 2
SpO2 >95% on RA 91 – 95% Requires O2 Inspiratory Breath Sounds
Normal Selectively diminished
Globally decreased/ absent
Accessory Muscle Use
Expiratory Wheezing
Mental Status Normal Depressed/ Agitated Very lethargic; almost no movement; very slow to respond
Breathlessness None Mild – moderate Severe SOB
Vocalization Speech/ Cry Normal
Absent: short phrases, grunting or unable to po
Orthopnea Tolerates being supine
Respiratory Rate
<1 yr: < 50 1 – 5 yr: < 40 6 – 14 yr: <30 >14 yr: <25
<1 yr: > 50 1 – 5 yr: > 40 6 – 14 yr: >30 >14 yr: >25
31
Mild: 0 – 2 Moderate: 3 – 7 Severe: 8 – 12 PICU Consult: 4+
How can PAS be used to improve and guide acute pediatric asthma care?
33
ED Treatment based on PAS Score • Determine Disposition (after 1hr of therapy and 1h obs)
• PAS >1 • Admit to inpatient • Start continuous albuterol while awaiting admission
• PAS >3 • Consult PICU for potential admission • Start continuous albuterol while awaiting evaluation and admission
• PAS = 0 or =1 (for expiratory wheeze or slightly diminished breath sounds)
• Discharge Home • Inhaler assessment • Asthma Action Plan (standardized)
34
•Continuous Albuterol (0.5mg/kg/hr
• Max: 15mg/hour • pt to be admitted to PICU/ Step-down unit with PAS >3
• <30kg • Albuterol 2.5mg Q3h • Additional options:
•Albuterol 5mg Q3h • PAS <3; patient not in PICU
•Continuous Albuterol (0.5mg/kg/hr
• Max: 15mg/hour • pt to be admitted to PICU/ Step-down unit with PAS >3
37
When should an asthma specialist become involved with asthma patients?
38
• Moderate or severe persistent asthma
• >= 2 ED visits for asthma within 12 month period
• Hospitalization for asthma
39
• Undiagnosed • chronic cough, chest pain, exertional dyspnea, decreased stamina, recurrent pneumonia
• Chronic • Mild – Severe • Poorly controlled/difficult-to-control asthma • Exercise-induced (athletes) • Exacerbations requiring acute care
• urgent care, emergency department [ED], hospitalization
• Short-term follow-up from recent exacerbations that required acute care management (ED, hospital)
41
SMART (Single Maintenance and Rescue Therapy)
• Maintenance = 1 – 2 puffs qD – BID
+ • Rescue = 1 – 2 puffs BID – TID
• Total Puffs/Day: varies by age: • 4 – 11 years old: 8 puffs/day total (maintenance + rescue) • 12+ years old: 12 puffs/day total (maintenance + rescue)
42
43
Limitations of SMART Strategy • Insurance formularies may not cover ICS-formoterol
preparations
• Patient will likely need to always have 2 inhalers • 120 actuations/inhaler • 4 puffs/day 30 days of use • 8 puffs/day 15 days of use • 12 puffs/day 10 days of use • Mail order?
• May need to pursue “traditional” treatment • ICS-salmeterol + as needed albuterol/xopenex
44
(ICS)? Asthma Type
Yes Viral-induced asthma (“recurrent wheezing”)
Budesonide 1mg neb BID + QID Albuterol Fluticasone 750mcg BID + QID Albuterol
x7 – 10 days ↓growth w/ fluticasone
5 – 11 Years
12+ Years
Yes Mild persistent asthma
QVAR 40 q4 hours 2 – 6 puff + Albuterol 2 – 4 puff QVAR 80 q4 hours 1 – 3 puff + Albuterol 2 – 4 puff
SMART?
4 – 11 Years
Dulera/Symbicort 2puffs QID 1-2puff qD – BID if intermittent sx’s
12+ Years
1-2puff qD – BID if intermittent sx’s45
46
Health care in the U.S. is consistently worse for ethnic/ racial minorities
Racial bias (e.g., stereotypes) are a source of racial disparities in health care
Is empathy possible w/o relatability?
Background:
Why Cultural Competency? • Nearly half of the children in California are
Hispanic and/or have a foreign-born parent.
• Currently one of three of families speak a language other than English
• It is projected that by 2020, 76% of our children will be from ethnic or racial “minority” groups
• One out of every 8 children in the United States lives in California
Background: Why Cultural Competency?
Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care, volume I. Washington, D.C.: Georgetown University Child Development Center, CASSP Technical Assistance Center.
Better Asthma Care if Cultural Competency Present
0
0.2
0.4
0.6
0.8
1
0 1--2 3--4 5--6
TA Lieu Peds 2004114(1):2102-110
Odds Of Under- Use of Preventive Meds
1
0.5
0.59
0.15
Sheet1
0
1
1--2
0.5
3--4
0.59
5--6
0.15
To resize chart data range, drag lower right corner of range.
Discussion/Questions
49
Slide Number 2
Average Age-Specific Rates of Hospitalization for RSV Infection Among Children <24 Months of Age(2000 – 2005)
Rates of RSV Hospitalizations by Age (per 1,000 persons)
CLINICAL PRESENTATION
PHYSICAL EXAM
RADIOGRAPHIC FINDINGS
To establish a diagnosis of asthma, determine that:
Slide Number 25
Pediatric Asthma Score
Slide Number 28
Slide Number 29
Slide Number 30
Slide Number 31
Slide Number 32
How can PAS be used to improve and guide acute pediatric asthma care?
ED Treatment based on PAS Score
Albuterol Dosing Guidelines
When should an asthma specialist become involved with asthma patients?
Guideline Reasons for Asthma Specialist Referral
Types of Asthma Specialist Patients
Slide Number 41
Slide Number 43
Slide Number 46
Discussion/Questions
• Sande Okelo, MD, PhD, • Pediatric Pulmonology and Sleep Medicine • UCLA Mattel Children’s Hospital • [email protected] • www.uclahealth.org/pedspulmonology
Case • 14-month-old girl with severe asthma and h/o 2 previous
admissions to the PICU for respiratory failure (mechanically ventilated once)
• Presented with 1-2 days of progressive cough, increased work of breathing and failing q4 Albuterol nebs at home, including 3 back-to-back treatments
Treatment Course • Triaged in the ED at 7:30 am
• 1 dose of levalbuterol and ipratropium at 8:30
• No further interventions until transfer to Pediatrics at 12:55.
• heart rate increased 180's by the time she made it to Peds floor
• No labs or imaging were performed until 3pm
• No continuous albuterol started on floor “because only can be done in the PICU”
• A peripheral iv was ordered at 2:30, but wasn't inserted until 4:30
• “because the patient is being transferred to PICU”
• PICU nurses place iv on Peds floor
• With a NS bolus, her heart rate declined to the 170's.
• Transferred to PICU at 5pm • Continuous Albuterol overnight
• HD#2 • Started on Nasal IMV but worsening tachypnea • Intubated
• Parents report: • Multiple occasions in ED and on ward of under-treatment of sx’s • Multiple instances of provider and nursing under-recognition of sx’s • Lack of confidence in acute asthma care at UCLA
• Could respiratory failure and intubation have been avoided with better treatment in ED and peds floor?
• “Better treatment” = standardized assessment and treatment protocol
• Pediatric Asthma Score (RT and/or RN) • Inhaler Assessment (RT) • Asthma Questionnaire (RT) • Orderset (ED, Admit) • MD Notes (admit, progress) • Asthma Action Plan (MD)
7
• Bronchiolits - an acute usually viral infection of the small airways, generally affecting small infants and those with chronic cardiac or pulmonary disease. Respiratory symptoms result from airways obstruction secondary to inflammation
“To sum up, oxygen is vitally important in bronchiolitis and
there is little convincing evidence that any other
therapy is consistently or even occasionally useful”
Reynolds and Cook, 1963
ETIOLOGY
• 1957 RSV first identified in LRT of infants by Chanock and Finberg
• Subsequently has been found in a majority of infants with bronchiolitis
• Other common viruses -parainfluenza, adeno, entero, influenza
EPIDEMIOLOGY
• RSV epidemics in N. America occur between Oct and June – Last 5 months – Alternate between short (7-12 mos.) and long
(13-16 mos.) intervals between peaks • Uncommon in infants < 1 month • Peak incidence 2 months in large urban
populations • Male=Female
• Lowest attack rate adults (17%) • Highest attack previously uninfected day-
care infants (98%) • Almost all children in a high-pop. urban
setting will acquire by age 2 yrs.
Average Age-Specific Rates of Hospitalization for RSV Infection Among Children <24 Months of Age
(2000 – 2005)
Chart1
N Halasa Vaccine 33 (2015):6479 - 87
Chart1
• Infant may be irritable, feed poorly and vomit
PHYSICAL EXAM
• RR 50-60 bpm • Tachycardic • Fever up to 41 C • Mild conjunctivitis or
otitis in some • Pharyngitis in 50%
• Retractions • Prolonged expiratory
resp distress • Cyanosis is rare
RADIOGRAPHIC FINDINGS
• May be normal
Treatment-Supportive • Supplemental oxygen • Positive pressure ventilation if apnea • IV fluids • Time
• Trial of asthma therapy – to rule-out asthma – more than 1 episode of bronchiolitis
19
ASTHMA IN THE U.S. • 25 million affected
• 7 million children • 1 million in CA
• 200K in LA County • 63K in LAUSD
• 60% miss school (#1 cause) • $0.5 - $1 billion • $80 per missed school day per child (LAUSDE)
• $3+ million/year
• 400, 000 hospitalizations • 200,000 peds
• $20+ billion/year • $5 billion peds
ED & Hospitalized Asthma Patients at High Risk
• 40% of hospitalized patients will relapse to ED/hospital <1 year
• 17% of ED patients will relapse in 2 months
• 10 – 30% follow-up with primary care
• <50% use asthma controller medications
• <35% have an asthma treatment plan
Cydulka RK Ann Amerg Med 2005 (46):316-22; Smith SR Pediatrics 2002:110(2): 323-30 Stingone JA, Claudio L. Ann Allergy Asthma Immunol. 2006; 97(2): 244-50. Andrews AL J Pediatr. 2012; 160(2): 325-30.
To establish a diagnosis of asthma, determine that: • Asthma symptoms occur more than once
• Cough • Wheeze • Chest pain/tightness • Shortness of breath (exertional) • Decreased stamina
• Asthma symptoms improve with asthma medicines • Adequate dose, duration and technique
• Alternative diagnoses are excluded • Habit cough; chronic sinusitis; GERD
22
Anti-cholinergic β2 agonist: multiple doses most effective in mod – severe + exacerbations: admits
Rodrigo G J , and Castro-Rodriguez J A Thorax 2005;60:740-746
Early Steroid Administration Reduces Admit Rates
26 SK Bhogal Annals of Emergency Medicine, Volume 60, Issue 1, 2012, 84 - 91.e3
Pediatric Asthma Score
Expiratory Wheezing Mental Status
Normal
Respiratory Rate
<1 yr: < 50 1 – 5 yr: < 40 6 – 14 yr: <30 >14 yr: <25 29
Score 0 1 2
Normal Selectively diminished
Accessory Muscle Use
Breathlessness None Mild – moderate
Vocalization Speech/ Cry Normal
Orthopnea Tolerates being supine
Respiratory Rate
<1 yr: < 50 1 – 5 yr: < 40 6 – 14 yr: <30 >14 yr: <25
<1 yr: > 50 1 – 5 yr: > 40 6 – 14 yr: >30 >14 yr: >25 30
Score 0 1 2
SpO2 >95% on RA 91 – 95% Requires O2 Inspiratory Breath Sounds
Normal Selectively diminished
Globally decreased/ absent
Accessory Muscle Use
Expiratory Wheezing
Mental Status Normal Depressed/ Agitated Very lethargic; almost no movement; very slow to respond
Breathlessness None Mild – moderate Severe SOB
Vocalization Speech/ Cry Normal
Absent: short phrases, grunting or unable to po
Orthopnea Tolerates being supine
Respiratory Rate
<1 yr: < 50 1 – 5 yr: < 40 6 – 14 yr: <30 >14 yr: <25
<1 yr: > 50 1 – 5 yr: > 40 6 – 14 yr: >30 >14 yr: >25
31
Mild: 0 – 2 Moderate: 3 – 7 Severe: 8 – 12 PICU Consult: 4+
How can PAS be used to improve and guide acute pediatric asthma care?
33
ED Treatment based on PAS Score • Determine Disposition (after 1hr of therapy and 1h obs)
• PAS >1 • Admit to inpatient • Start continuous albuterol while awaiting admission
• PAS >3 • Consult PICU for potential admission • Start continuous albuterol while awaiting evaluation and admission
• PAS = 0 or =1 (for expiratory wheeze or slightly diminished breath sounds)
• Discharge Home • Inhaler assessment • Asthma Action Plan (standardized)
34
•Continuous Albuterol (0.5mg/kg/hr
• Max: 15mg/hour • pt to be admitted to PICU/ Step-down unit with PAS >3
• <30kg • Albuterol 2.5mg Q3h • Additional options:
•Albuterol 5mg Q3h • PAS <3; patient not in PICU
•Continuous Albuterol (0.5mg/kg/hr
• Max: 15mg/hour • pt to be admitted to PICU/ Step-down unit with PAS >3
37
When should an asthma specialist become involved with asthma patients?
38
• Moderate or severe persistent asthma
• >= 2 ED visits for asthma within 12 month period
• Hospitalization for asthma
39
• Undiagnosed • chronic cough, chest pain, exertional dyspnea, decreased stamina, recurrent pneumonia
• Chronic • Mild – Severe • Poorly controlled/difficult-to-control asthma • Exercise-induced (athletes) • Exacerbations requiring acute care
• urgent care, emergency department [ED], hospitalization
• Short-term follow-up from recent exacerbations that required acute care management (ED, hospital)
41
SMART (Single Maintenance and Rescue Therapy)
• Maintenance = 1 – 2 puffs qD – BID
+ • Rescue = 1 – 2 puffs BID – TID
• Total Puffs/Day: varies by age: • 4 – 11 years old: 8 puffs/day total (maintenance + rescue) • 12+ years old: 12 puffs/day total (maintenance + rescue)
42
43
Limitations of SMART Strategy • Insurance formularies may not cover ICS-formoterol
preparations
• Patient will likely need to always have 2 inhalers • 120 actuations/inhaler • 4 puffs/day 30 days of use • 8 puffs/day 15 days of use • 12 puffs/day 10 days of use • Mail order?
• May need to pursue “traditional” treatment • ICS-salmeterol + as needed albuterol/xopenex
44
(ICS)? Asthma Type
Yes Viral-induced asthma (“recurrent wheezing”)
Budesonide 1mg neb BID + QID Albuterol Fluticasone 750mcg BID + QID Albuterol
x7 – 10 days ↓growth w/ fluticasone
5 – 11 Years
12+ Years
Yes Mild persistent asthma
QVAR 40 q4 hours 2 – 6 puff + Albuterol 2 – 4 puff QVAR 80 q4 hours 1 – 3 puff + Albuterol 2 – 4 puff
SMART?
4 – 11 Years
Dulera/Symbicort 2puffs QID 1-2puff qD – BID if intermittent sx’s
12+ Years
1-2puff qD – BID if intermittent sx’s45
46
Health care in the U.S. is consistently worse for ethnic/ racial minorities
Racial bias (e.g., stereotypes) are a source of racial disparities in health care
Is empathy possible w/o relatability?
Background:
Why Cultural Competency? • Nearly half of the children in California are
Hispanic and/or have a foreign-born parent.
• Currently one of three of families speak a language other than English
• It is projected that by 2020, 76% of our children will be from ethnic or racial “minority” groups
• One out of every 8 children in the United States lives in California
Background: Why Cultural Competency?
Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care, volume I. Washington, D.C.: Georgetown University Child Development Center, CASSP Technical Assistance Center.
Better Asthma Care if Cultural Competency Present
0
0.2
0.4
0.6
0.8
1
0 1--2 3--4 5--6
TA Lieu Peds 2004114(1):2102-110
Odds Of Under- Use of Preventive Meds
1
0.5
0.59
0.15
Sheet1
0
1
1--2
0.5
3--4
0.59
5--6
0.15
To resize chart data range, drag lower right corner of range.
Discussion/Questions
49
Slide Number 2
Average Age-Specific Rates of Hospitalization for RSV Infection Among Children <24 Months of Age(2000 – 2005)
Rates of RSV Hospitalizations by Age (per 1,000 persons)
CLINICAL PRESENTATION
PHYSICAL EXAM
RADIOGRAPHIC FINDINGS
To establish a diagnosis of asthma, determine that:
Slide Number 25
Pediatric Asthma Score
Slide Number 28
Slide Number 29
Slide Number 30
Slide Number 31
Slide Number 32
How can PAS be used to improve and guide acute pediatric asthma care?
ED Treatment based on PAS Score
Albuterol Dosing Guidelines
When should an asthma specialist become involved with asthma patients?
Guideline Reasons for Asthma Specialist Referral
Types of Asthma Specialist Patients
Slide Number 41
Slide Number 43
Slide Number 46
Discussion/Questions