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

2. 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

3. 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

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

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

6. 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

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

8. 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) 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

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

10. 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

11. 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)

12. 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.

13. 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

14. 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 May 14;360(20)

15. 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

16. 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

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

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

19. 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

20. 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

21. 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

22. 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

23. 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)

24. 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

25. 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

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

27. 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

28. 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

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

30. CXR

31. Normal CXR may miss a non-opaque FB

32. Bilateral decubitus films can reveal unilateral hyperinflation

33. 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

34. Any Questions?
Thank you!!!!

35. 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 May 14;360(20)
Mahabee-Gittens EM, et al. Chest radiographs in the pediatric emergency department for children < or = 18 months of age with wheezing. Clin Pediatr (Phila) 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