Pediatric Respiratory Emergencies: Beyond the Runny Nose Christopher Strother, MD Mount Sinai School of Medicine Department of Emergency Medicine June 25 – 27, 2009

Quick Preview 6 month old with cough, fever and wheezing 2 year old with fever and stridor 4 year old with dehydration and tachypnea 4 month old with sudden onset distress

Case 1 6 month old male presents with 4 days cough, congestion, fever to 101.5, poor appetite, increased work of breathing today RR 55 HR 150 BP 95/58 SpO2 95% Alert, tired appearing, lots of nasal congestion and runny nose, MM moist Flaring and retractions, tachypnea, scattered wheezing, rhonchi, and upper airway noises

Treatment? A: Reassurance B: Dexamethasone C: Nebulized Albuterol D: Nebulized Epinephrine E: Dexamethasone and Epinephrine

Case 1 Patient responds to albuterol with decreased distress, resolution of wheezing

What next? A: Send him home with some albuterol B: Send him home with albuterol and steroids C: Admit for observation D: Get a chest x-ray first, then decide

Not All That Wheezes is Asthma (Or Bronchiolitis) First time wheezers deserve an x-ray

Although some disagree Mahabee-Gittens EM, et al. Chest radiographs in the pediatric emergency departement for children < or = 18 months of age with wheezing. Clin Pediatr (Phila). 1999 Jul;38(7):395-9. Retrospective review of predictors of CXR findings in wheezing 21% normal 61% c/w RAD or bronchiolitis 18% focal infiltrates (predicted by T, O2, & exam) 1% other Suggests selective use of chest xray

Case 1b Patient fails to improve with albuterol, continued wheezing, tachypnea, mild distress, sats stable

Now What? A: Admit with no further treatment, nothing works for bronchiolitis anyway B: Trial nebulized epinephrine C: Give steroids and continue albuterol every couple of hours as it may help later D: Send him home anyway, SpO2 is OK

Bronchiolitis Viral lower airway infection (RSV #1) Often involves, mimics, or may even cause reactive airway disease At risk for severe disease are the very young (especially < 60 days), ex-premies, and those with chronic disease (both for more severe pulmonary disease and for RSV induced central apnea)

Bronchiolitis Treatment Airway and Oxygen as needed Clear Congestion, Ensure fluid intake Bronchodilators – Studies show no definite benefit, but many recommend a trial, especially if there is asthma in family Albuterol: 0.15mg/kg to 5mg or 4-6 puffs Epinephrine: 0.05ml/kg to 0.5ml Reassess in 1 hour after each to determine effect, continue if helpful Diagnosis and management of bronchiolitis. Pediatrics 2006; 118:1774.

Bronchiolitis: steroids? Mixed evidence and more confusion with reactive airway disease component Meta-analysis and largest study to date show no improvement Patel, H, Platt, R, Lozano, J, Wang, E. Glucocordicoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev 2004; 3:CD004878 Corneli, HM, Zorc, JJ, Majahan, P, et al. A multicenter, randomized controlled trial of dexamethasone for bronchiolitis. N Engl J Med 2007; 357:331

Bronchiolitis: steroids? Recent study showing possible synergy of dexamethasone and epinephrine Randomized trial of 800 infants 6 weeks to 12 months of age Neb epi x 2 and dex x 6days, epi only, dex only, or placebo Individual med groups showed no change Dex and Epi group showed a reduction in hospitalization rate, but analysis adjusting for multiple comparisons rendered it not significant (p = 0.07) Plint, AC et al. Epinephrine and Dexamethasone in Children with Bronchiolitis. N Engl J Med. 2009 May 14;360(20)2130-3.

Bronchiolitis Treatment Antibiotics: If they have another reason Don’t forget to work up fevers! Ribavirin: In select immune-compromised Heliox: Small studies show limited benefit IVIG: Not shown to help Surfactant: Shows promise, but needs study Hypertonic Saline: Promise, but needs study Montelukast: Studies not showing benefit

Case 2 2 year old male with no past medical history or family history URI x 2 days, worsening “barky” cough today, mother heard “wheezing” at home From the hallway he sounds like a seal Alert, nontoxic, no distress, normal exam except clear rhinorrhea, normal VS, lungs clear no wheezing heard Develops mild stridor while crying during med student’s exam, resolves when calm

Treatment? A: Nebulized Albuterol B: Racemic Epinephrine C: Dexamethasone D: Humidified Air E: Reassurance Only

Case 2b Patient’s twin sister however, is tachypneic though not retracting, but has some stridulous noise at rest, worse with crying and cough

Treatment for Sister? A: Reassurance / Observation Only B: Nebulized Epinephrine Only C: Dexamethasone Only D: Epinephrine and Dexamethasone E: Call ENT for intubation in the OR

Croup Parainfluenza Laryngotracheitis Supportive Care Warm mist, cool nights, drink fluids Mist has not been scientifically shown to work, but parents swear by it Dexamethasone for everybody 0.6 mg/kg up to 10mg (PO, IM or IV) Nebulized Rac - Epi: 0.05ml/kg to 0.5ml For distress or strider at rest Repeat q 15 minutes as needed (admit if repeat) Observe 3-4 hours before discharge for rebound

Case 2c Triplets! The third child was sick a few days earlier than the other two, now with two days fever of 104+, today with severe distress, no PO intake Distressed, tachypneic, drooling, retracting, sitting forward on the bed, drooling, unwilling to change position for exam

Now What? A: RSI immediately B: Use a tongue depressor to see what the heck is going on in there C: Dexamethasone Only D: Epinephrine and Dexamethasone E: Call ENT for intubation in the OR

Epiglottitis Yes, it still exists (at least on your boards) H. Flu vaccine drastically reduced incidence Strep. Pneumo. and Pyogenes Often super infection of viral DON’T TOUCH!!!! (at least not until you have as much support as possible and tracheotomy set up near by)

Retropharyngeal abscess Another important cause of stridor and fever in children Likely more toxic than croup Likely more neck pain and difficulty moving the neck

Case 3 (Only one this time I promise.) 4 year old male, no past, no family history URI x 5 days, no fever, two days increasing fatigue and respiratory distress Ill appearing, MM dry, tachypneic, retracting Normal sats, clear lungs, no other physical findings

Most likely Diagnosis A: Swine Flu B: Foreign Body Aspiration C: DKA D: Vascular Ring E: Toxic Ingestion

Diabetic Ketoacidosis Acidosis leads to hyperpnea Kussmaul Respirations Can be mistaken for respiratory process, especially in young children atypical age for DKA and other metabolic diseases

Case 4 4 month old male sudden onset respiratory distress, brought in by EMS, lethargic, cyanotic, tachypneic HR 167 RR 40 BP SpO2 92% on RA Increased responsiveness with 100% NRB, more comfortable sitting up, increased distress when laid flat

Most likely Diagnosis A: Swine Flu B: Foreign Body Aspiration C: Congenital Heart Defect D: Epiglottitis E: Toxic Ingestion

CXR

Normal CXR may miss a non-opaque FB

Bilateral decubitus films can reveal unilateral hyperinflation

Quick Review Bronchiolitis: Croup: Trial albuterol and / or racemic epinephrine No evidence for routine steroid use yet Croup: Dexamethasone for everybody Racemic Epi if stridor at rest or distress Watch out for non-pulmonary diseases presenting as respiratory symptoms Always consider aspiration or ingestion in infants and toddlers

Any Questions? Thank you!!!!

References Diagnosis and management of bronchiolitis. Pediatrics 2006; 118:1774. Gadomski, AM, Bhasale, AL. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev 2006; 3:CD001266 Hartling, L, Wiebe, N, Russell, K, et al. Epinephrine for bronchiolitis. Cochrane Database Syst Rev 2004; :CD003123 Patel, H, Platt, R, Lozano, J, Wang, E. Glucocordicoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev 2004; 3:CD004878 Corneli, HM, Zorc, JJ, Majahan, P, et al. A multicenter, randomized controlled trial of dexamethasone for bronchiolitis. N Engl J Med 2007; 357:331 Plint, AC et al. Epinephrine and Dexamethasone in Children with Bronchiolitis. N Engl J Med. 2009 May 14;360(20)2130-3. Mahabee-Gittens EM, et al. Chest radiographs in the pediatric emergency department for children < or = 18 months of age with wheezing. Clin Pediatr (Phila). 1999 Jul;38(7):395-9. Geelhoed, GC, Turner, J, Macdonald, WB. Efficacy of a small single dose of oral dexamethasone for outpatient croup; a double blind placebo controlled clinical trial. BMJ 1996; 313:140 Bjornson, CL, Klassen, TP, Williamson, J, et al. A randomized trial of a single dose of oral dexamethasone for mild croup. N Engl J Med 2004; 351:1306