Cases from Aug 2014 Cases from Aug 2014 Ryan Padrez & Patrick Peebles 9/10/14

 Discussion of Cases Status Asthmaticus

 What is Asthma? 1. Airway obstruction  Bronchoconstriction  Inflammation 2. Reversible  Improves in response to bronchodilators 3. Recurrent  Triggers: Infection, stress, allergens, exercise, cold, foods, smells, etc

 Inhaled beta-agonists: Albuterol  Safe and well-tolerated in kids  HR up to 200 commonly seen  Intermittent albuterol (MDI and nebulizer)  Peak activity at 30 minutes  Dosing: 0.15mg/kg/dose– titrate to effect  Continuous albuterol  Starting dose: 0.5mg/kg/hour (or 5-15 mg/hour)  May go up as tolerated

 Ipratropium bromide (Atrovent)  Anticholinergic  Bronchodilation and decreased secretions  No cardiovascular side effects, very cheap  RCT’s of albuterol/atrovent vs albuterol alone  Clinical improvement  Decreased hospitalization  Especially most severe  Dosing: 3 doses initially, q6h after that  No evidence for continued benefit after first 3 doses

 Steroids  Systemic: short burst (3-5 days)  Prevent hospitalization, reduce duration of symptoms  Most effective when given early in exacerbation  IV/IM equivalent to PO  Options  Solumedrol/prednisone 1-2mg/kg/dose (max 60mg)  Dexamethasone 0.6mg/kg/day  Of note: no established role of inhaled steroids in acute exacerbation

 Zemek (2012): 644 kids >2, before and after protocol for nurse-initiated steroids in triage: 19% 11.7% 72 min 28 min Zemek, Pediatrics, March 2012

 Management of Status Asthmaticus in ED (or 6M Urgent Care) Case #1

  CC: 18mo boy with history of RAD with viral illnesses presents to ER with increased work of breathing  HPI: 1 day viral URI symptoms, tactile fevers, stuffy nose; difficulty breathing overnight, fussy and poor PO intake in the morning, parents brought into ER at 8am on 8/31  Meds: none All: NKDA  PMH: as noted, immunizations up to date until 1yo  Social History: intact family  Family History: mom +allergies/asthma Case #1: 18mo with RAD

  Initial Exam in ER:  T: 37.1, P 170, RR 50-60, O2 sat 85% on RA.  Gen: nasal flaring, obvious respiratory distress, somnolent  Lungs: Supra-clavicular, intercostal, subcostal retractions, scattered expiratory wheezes  Brought to Zone 1, Bed 4 and a Zone 1 ED resident assigned to case Case #1: 18mo with RAD

  8:28am: Neb x1 (albuterol + ipratropium bromide)  8:47am: Neb x2 (albuterol + ipratropium bromide)  9am re-assessment by nurse :  T 37.1, P 178, RR 48, O2 sat 98% RA  VBG: 7.18/49/32/-10 and Lactate 2.5  ~9am: IV Dexamethasone x1 + IV fluids 20ml/kg NS bolus  ~9:30: Neb x3 (albuterol + ipratropium bromide)  10am: repeat labs and CXR  VBG: 7.27/35/70/-10  CBC: 9.9>38.3<234  Chem: 143/4.0/113/12/11/0.22  CXR: no abnormalities  Peds Chief Resident assessment at ~10am:  Reactive to exam but not crying and not verbally interactive, sleepy, obvious respiratory distress, nasal flaring, retractions with faint wheezing  What was done well and what could be different at this point in time? Case #1: ED Management

 Asthma Algorithm

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 Case#1: Continued  To Recap:  ~1 hr 20 min the team gave albuterol/atrovent X3, IV dexamethasone, IV fluid bolus  RR 40-50, HR180s, O2 sat 98% on facemask  Gen: looks sleepy, tachypnea with flaring and retractions, not very verbal  Lungs: faint wheezing  What does this child have? Status Asthmaticus  ED team asks peds team if next steps are to give:  More IV fluids and IV Mag Discussion Question: What could be done to optimize management if we think child has status asthmaticus?

 Status Asthmaticus  Status Asthmaticus definition: “unresponsive to inhaled bronchodilators”  Next steps if concerned for status asthmaticus:  Maximize O2 delivery  Move to continuous bronchodilator  Get IV access  Consider dose of IV steroids What if none of these things work???

  Magnesium  Epinephrine  Terbutaline 2 nd Line Medications

 Evidence: Magnesium  Bronchodilation via SM relaxation  Single IV dose:  RCT data in children has established safety and efficacy  Most beneficial in severe asthmaticus  Repeated doses: utility unclear  Must be infused over 20 minutes  Adverse effects: flushing, nausea, hypotension

 Epinephrine  Easily available!  Found on code cart, easy to dose  Fastest absorption when IM, in lateral thigh  Previously standard of therapy, now less favorable due to cardiac effects

 Evidence: Terbutaline  IV beta-agonist,  Less B2-selective than albuterol  Efficacy: no consistent decrease in symptoms or length of stay shown  Recent trials: trend toward improvement?  Minor side effects common  Can be given SC or IV  Loading dose of 10 mcg/kg SC or IV  Infusion of 0.4mcg/kg/min

 Recommendations: Systemic Bronchodilators  Magnesium first-line systemic bronchodilator, for pediatric status asthmaticus  Consider terbutaline as second-line agents  IM Epinephrine if no others available

  In ED Peds Team Ordered:  Continuous Albuterol at 20mg/hr  IV solumedrol  IV magnesium sulfate 40mg/kg x1  IV bolus of fluids #3 followed by 1x maintenance  Admit to 4E (after mag, patient began to look better, crying, better air movement, more prominent wheezing) Back to Case

  For ED Management of Severe Asthma  Ensure systemic steroids given <1 hour  consider IV route if severe presentation  Duo-nebs x3 with poor response move to continuous nebulized albuterol and can start 5-15mg/hr and titrate up to effect  Get IV access early  IV magnesium the most effective systemic bronchodilator for status asthmaticus Key Points for Case #1

 Discussion Question Should we change our asthma algorithm to include continuous albuterol for “severe” classification?

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  Only RCT included  Only in ED  “Continuous” can mean 1 neb q15m or >4 nebs in 1 hr

  Admission to hospital reduced in continuous group  Patients with “severe” asthma scores benefited most from continuous  Side effects of albuterol were the same in both groups

 UCSF Asthma Algorithm

 Management of Status Asthmaticus in 4E ICU Case #2

  ID: 11yo M with history of asthma on Qvar with very poor compliance presents to ED with significant increased work of breathing.  HPI: normal state of health, but recently moved in with father in SF x1 week with cats and cigarette smoke in home; coupled with poor compliance with Qvar (ICS controller). Brought to ER by ambulance. In route received two albuterol nebs by EMS.  Meds: Qvar, singulair, albuterol PRN All: NKDA  PMH: multiple admissions for asthma, no intubations, immunizations UTD  Family History: 2 family members with asthma Case #2: 11yo M with Severe Asthma

  Exam ( s/p 2 nebs in ambulance)  Vitals: RR 40-50, O2 sats 92% room air  Gen: tripod position, significant respiratory distress, 2-3 word sentences  Lungs: retractions prominent, decreased air movement  ED Management:  Continuous albuterol 10mg/hr with 100% O2 face mask  IM Epi x1  IV solumedrol  IV Mag x1  Repeat IM Epi  VBG: 7.3/52/-0.8  CXR: no focal infiltrate  Admitted to 4E ICU with “status asthmaticus” Case #2: In ED

  Pediatric Team Management:  Continue albuterol 20mg/hr  HFNC 20L/min  IV solumedrol q6h  IVF at maintenance Case #2: In ICU

 Respiratory Therapy Teaching Different devices to provide O2 support on 4E vs 6A vs 6M Different ways to deliver continuous albuterol Optimal flow rate when giving albuterol with HFNC

  Pediatric Team Management:  Continue albuterol 20mg/hr  HFNC 20L/min  IV solumedrol q6h  IVF at maintenance Case #2: In ICU

  Continuous albuterol neb ran out in early morning hours for uncertain amount of time  Significant respiratory distress resulting in:  Epi #3 IM given  IV Mag #2 given  Continuous Albuterol 20mg/hr neb with HFNC Discussion Question: What system issues that may have lead to this error? Case #2: In ICU

  Hospital Night #2:  Overnight peds team weaned from 20mg/hr continuous albuterol to 15mg/hr  In AM worsening respiratory distress and increased expiratory wheezes  Team elected to increase albuterol back to 20mg/hr Discussion Question : Was this patient weaned too quickly? What resources or metrics can we use to guide our weaning management? Back to Case#2: In ICU

 Kelly CS, Andersen CL, Pestian JP. Improved outcomes for hospitalized asthmatic children using a clinical pathway. Ann Allergy Asthma Immunol. 2000;84(5):509–516. et al.

 Review of Key Points  Inhaled bronchodilators are first line agent in mild, mod and severe asthma  Use aggressively, including moving to continuous early  Start steroids early <1 hr  Magnesium is the most beneficial systemic bronchodilator in status asthmaticus  Consider systematic approach to weaning

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 Evidence: Theophylline  Methylxanthine (related to caffeine)  Fallen out of favor due to fear of toxicity, need for monitoring  Efficacy:  2005 meta-analysis: improved lung function, but did not reduce symptoms or length of stay  2005 RCT: more cost-effective than terbutaline