1. Pediatric Respiratory Emergencies Mohammed Al Faifi, MD. Director, Emergency Out-Reach Program King Faisal Specialist Hospital & Research Centre Riyadh, KSA Kuwait, Oct. 2011

2. Pediatric Respiratory Emergencies Part 1 Emergency Management of Asthma

3. Data on visits to EDs by children – 1 -19 years of age with moderate/severe asthma – 1 -19 years of age with moderate/severe asthma – 3 months to 2 years of age with bronchiolitis – 3 months to 2 years of age with bronchiolitis – 3 months to 3 years of age with croup – 3 months to 3 years of age with croup Knapp et al. Pediatrics 2008 QUALITY OF CARE OF ED RESPIRATORY ILNESS

4. ResultsResults CorticosteroidsAntibioticsRadiographs 69% of the 405,000 visits for moderate/ severe asthma 31% of the estimated 317,000 annual croup visits 53% of the estimated 228,000 annual visits for bronchiolitis 72% of bronchiolitis visits 32% of croup visits Knapp et al. Pediatrics 2008

5. ConclusionsConclusions Physicians treating children with Asthma, bronchiolitis and croup In USA Emergency Departments are under using known effective treatments and overusing ineffective or unproven therapies and diagnostic tests. Physicians treating children with Asthma, bronchiolitis and croup In USA Emergency Departments are under using known effective treatments and overusing ineffective or unproven therapies and diagnostic tests. Knapp et al. Pediatrics 2008

6. Pediatric Respiratory Emergencies Part 1 Emergency Management of Asthma

7. IntroductionIntroduction Asthma is the most common chronic disease seen in children Asthma is the most common chronic disease seen in children Emergency department (ED) visits by children with acute asthma are a common occurrence Emergency department (ED) visits by children with acute asthma are a common occurrence The overall goal of asthma care in the ED is to integrate with home, outpatient, and inpatient care whenever possible The overall goal of asthma care in the ED is to integrate with home, outpatient, and inpatient care whenever possible Recognition of high-risk patients with acute asthma is essential. Recognition of high-risk patients with acute asthma is essential.

8. HistoryHistory Initial history is brief, focused Initial history is brief, focused Duration of symptomsDuration of symptoms Severity of symptomsSeverity of symptoms Medication useMedication use More comprehensive history follows More comprehensive history follows TriggersTriggers FeverFever Systemic ReviewSystemic Review

10. Past Medical History Previous wheezing Previous wheezing Prior admissions for wheezing Prior admissions for wheezing Prior admissions to ICU Prior admissions to ICU Chronic lung disease Chronic lung disease

11. Physical Examination Level of consciousness Level of consciousness Vital signs Vital signs Degree and symmetry of wheezing Degree and symmetry of wheezing Inspiratory and expiratory ratio Inspiratory and expiratory ratio Accessory muscle use Accessory muscle use

12. Differential Diagnosis Bronchiolitis Bronchiolitis Foreign body aspiration Foreign body aspiration Gastroesophageal reflux Gastroesophageal reflux Cystic fibrosis Cystic fibrosis Anaphylaxis Anaphylaxis

13. Pulmonary Index Score* O 2 Sat. Acc.Muscle use I/E Ratio Wheezing† R.R*Score 99-100None2:1None < 30 0 96 -98 +1:1 End expiration 31 - 45 1 93- 95 ++1:2 Entire expiration 46 - 60 2 < 93 +++1:3 Inspiration and expiration without stethoscope > 60 3 * For patients aged 6 or older: through 20, score 0; 21 through 35, score 1; 36 through 50, score 2; > 50, score 3. † If no wheezing due to minimal air entry, score 3.

14. Pulse Oximetry Noninvasive and inexpensive Noninvasive and inexpensive Can help to predict the need for hospitalization Can help to predict the need for hospitalization Obtain for moderately to severely ill children Obtain for moderately to severely ill children Supplement with oxygen if SaO 2 < 92% Supplement with oxygen if SaO 2 < 92%

15. CXRsCXRs

16. CXRs for First Time Wheezers 371 children > age 1 371 children > age 1 94% CXRs normal 94% CXRs normal 20/21 abnormal films would have been identified by: 20/21 abnormal films would have been identified by: RR > 60RR > 60 HR> 160HR> 160 FeverFever Focal examFocal exam Gerschel, N Engl J Med 1983

17. Chest Radiographs Focal findings Focal findings Fever Fever Severe disease Severe disease

18. Treatment Options Beta 2 - agonists Beta 2 - agonists Inhaled (nebulizer vs. metered-dose inhaler)Inhaled (nebulizer vs. metered-dose inhaler) SubcutaneouslySubcutaneously IntravenouslyIntravenously Corticosteroids Corticosteroids OrallyOrally NebulizedNebulized IntramuscularlyIntramuscularly IntravenouslyIntravenously Ipratropium bromide Ipratropium bromide Magnesium sulfate Magnesium sulfate

19. Beta 2 -Agonist Delivery Beta 2- agonists remain the standard of care for treatment of acute asthma Beta 2- agonists remain the standard of care for treatment of acute asthma They should be administered every 20 mins, in the first hour of care They should be administered every 20 mins, in the first hour of care Delivery by SVN or MDI with holding chamber are each reasonable options Delivery by SVN or MDI with holding chamber are each reasonable options Steps should be taken to insure optimal drug delivery Steps should be taken to insure optimal drug delivery

20. Beta 2 -Agonist Optimizing Delivery Beta 2 -Agonist Optimizing Delivery Small particles Small particles Mouthpiece Mouthpiece Low inspiratory flow rate Low inspiratory flow rate Breath-holding Breath-holding

25. Ipratropium Bromide An anticholinergic An anticholinergic Low lipid solubility Low lipid solubility Less than 1% absorbed Less than 1% absorbed Safe, inexpensive Safe, inexpensive Most studies show that IB plus a Beta 2 agonist is superior to Beta 2 agonist alone Most studies show that IB plus a Beta 2 agonist is superior to Beta 2 agonist alone

26. Ipratropium Bromide A, P Group 1 A, P A, IGroup 2 A, I Group 3 40200 Time (mins.) Schuh, et al. J.Pediatrics 1995;126:639-645

27. Ipratropium Bromide Ipratropium plus Beta 2 agonist is superior to Beta 2 agonist alone Ipratropium plus Beta 2 agonist is superior to Beta 2 agonist alone Multi-dose ipratropium is superior to single dose Multi-dose ipratropium is superior to single dose Safe, inexpensive Safe, inexpensive Peak effects are in 40-60 minutes Peak effects are in 40-60 minutes Schuh, et al. J.Pediatrics 1995;126:639-645

28. Ipratropium Bromide Recommendations For children with a moderate or moderate-to-severe exacerbation or for those already receiving Beta 2 agonist therapy : For children with a moderate or moderate-to-severe exacerbation or for those already receiving Beta 2 agonist therapy : 250-500 ug of ipratropium bromide by nebulization to be administered concurrently with the albuterol treatments250-500 ug of ipratropium bromide by nebulization to be administered concurrently with the albuterol treatments

30. Scarfone, et al, Pediatrics 1993; 92: 513-518 Randomized, double-blind, placebo Randomized, double-blind, placebo 75 children in the ED with a moderate to severe asthma attack 75 children in the ED with a moderate to severe asthma attack 2mg/kg oral prednisone vs. placebo 2mg/kg oral prednisone vs. placebo

31. Scarfone, et al Oral Corticosteroids: Decreases hospitalization rate Decreases hospitalization rate Effective within 4 hours Effective within 4 hours Augments Beta 2- agonists therapy Augments Beta 2- agonists therapy Conclusions:

32. Oral vs IV Steroid Randomized, double-blinded, placebo Randomized, double-blinded, placebo 49 Children in ED with moderate to severe acute asthma 49 Children in ED with moderate to severe acute asthma 2mg/kg methylprednisolone: Oral vs IV 2mg/kg methylprednisolone: Oral vs IV Barnett, et al. Ann Emerg Med, 1997; 29 :212-217

33. Barnett, et al. After 4 hours, there were no differences between the two groups with respect to: After 4 hours, there were no differences between the two groups with respect to: Hospitalization rateHospitalization rate FEV1FEV1 Pulmonary index scorePulmonary index score Oxygen saturationOxygen saturation Respiratory rateRespiratory rate ResultsResults

34. Oral Prednisone vs. Oral Dexamethasone  533 children in ED with mild, moderate, or severe asthma  All got q 20 min RA and IB, in first hour  Prednisone - 2 mg/kg in ED - 1 mg/kg for 4 days  Dexamethasone - 0.6 mg/kg in ED - 0.6 mg/kg for 1 dose, on day 2 Qureshi F.J Pediatrics 2001

35. Oral Prednisone vs Oral Dexamethasone Pred. Dex. Pred. Dex. Admit, from ED 12% 11% Admit, from ED 12% 11% Relapse 7% 7% Relapse 7% 7% Admit, after relapse 17% 20% Admit, after relapse 17% 20% Symptoms at 10 days 21% 22% Symptoms at 10 days 21% 22% Vomited in ED 3% 0.3 Vomited in ED 3% 0.3 Noncompilance 4% 0.4 Noncompilance 4% 0.4 Qureshi F.J Pediatrics 2001

36. Moderate Asthma Treatment Recommendations Beta 2 agonists may be delivered by SVNs or MDIs with holding chambers Beta 2 agonists may be delivered by SVNs or MDIs with holding chambers Ipratropium bromide should be given as a single dose or concurrently with first 3 Beta 2 agonist treatments Ipratropium bromide should be given as a single dose or concurrently with first 3 Beta 2 agonist treatments Prednisone should be given early ASAP Prednisone should be given early ASAP -If emesis Methylprednisolone IV Dexamethasone: orally or IM

37. Albuterol nebulization or MDI Prednisone 1 O 2 If Pulse Ox < 92% Albuterol q20-30 mins. Ipiatropium with albuterol Marked Improvement No improvement Discharge home Hospitalize Continue albuterol q30 mins. Slightly improved Disposition Management of Moderate Asthma

38. DispositionDisposition Discharge : Discharge : PEF > 70% predicted, PEF > 70% predicted, Symptoms are minimal or absent, Symptoms are minimal or absent, Sufficient medications can be prescribed and maintained Sufficient medications can be prescribed and maintained Outpatient care can be established within a several- days time frame Outpatient care can be established within a several- days time frame EDUCATION.. EDUCATION..

39. DispositionDisposition Observed for 30 to 60 minutes for symptom recurrence hospitalization : hospitalization : prior history of a sudden, severe exacerbation prior history of a sudden, severe exacerbation prior intubation or ICU Admission prior intubation or ICU Admission ≥ two hospitalizations in the past year ≥ two hospitalizations in the past year current steroid use or recent wean from steroids current steroid use or recent wean from steroids medical or psychiatric comorbidity medical or psychiatric comorbidity low socioeconomic status or urban residence low socioeconomic status or urban residence

40. POST EMERGENCY DEPARTMENT CARE Short-term Medications Short-term Medications - Beta-agonist Therapy - Beta-agonist Therapy - Corticosteroids - Corticosteroids - Inhaled steroids - Inhaled steroids Education Education

42. Pulmonary Index Score* O 2 Sat. Acc.Muscle use I/E Ratio Wheezing† R.R*Score 99-100None2:1None < 30 0 96 -98 +1:1 End expiration 31 - 45 1 93- 95 ++1:2 Entire expiration 46 - 60 2 < 93 +++1:3 Inspiration and expiration without stethoscope > 60 3 * For patients aged 6 or older: through 20, score 0; 21 through 35, score 1; 36 through 50, score 2; > 50, score 3. † If no wheezing due to minimal air entry, score 3.

43. Severe Asthma No wheezing 3 No wheezing 3 Unable to speak Unable to speak Dyspnea 2 Dyspnea 2 Markedly prolonged expiratory phase 3 Markedly prolonged expiratory phase 3 Significant work of breathing with Significant work of breathing with Retractions 2 Retractions 2 Requires oxygen 3 Requires oxygen 3

44. Severe Asthma Oxygen (consider non-rebreather) Oxygen (consider non-rebreather) Inhaled beta2-agonist Inhaled beta2-agonist Inhaled ipratropium bromide Inhaled ipratropium bromide Intravenous corticosteroids ASAP Intravenous corticosteroids ASAP Initial management Initial management

45. OxygenOxygen Simple face mask Simple face mask An oxygen flow rate of 6-10 L/min should provide an oxygen concentration of 35-60%An oxygen flow rate of 6-10 L/min should provide an oxygen concentration of 35-60% Limitations: open exhalation ports allow for the inspiration of room air and exhaled carbon dioxide is rebreathed.Limitations: open exhalation ports allow for the inspiration of room air and exhaled carbon dioxide is rebreathed.

46. OxygenOxygen Non. re-breathing face mask Non. re-breathing face mask Modifications allow for greater oxygen delivery to the patient. These include: Exhalation ports serving as one-way valves. Exhalation ports serving as one-way valves. A reservoir bag with a one-way valve that diverts oxygen-poor exhaled gases thereby maintaining a mix of almost pure oxygen. A reservoir bag with a one-way valve that diverts oxygen-poor exhaled gases thereby maintaining a mix of almost pure oxygen. With flow of 10-12 L/min and proper fitting mask, oxygen concentrations > 90% can usually be achieved. With flow of 10-12 L/min and proper fitting mask, oxygen concentrations > 90% can usually be achieved.

48. Subcutaneous Terbutaline Uncooperative, anxious young children Uncooperative, anxious young children Very poor inspiratory flow or aeration Very poor inspiratory flow or aeration Poor response to initial nebulized albuterol Poor response to initial nebulized albuterol

49. Continuously Nebulized Albuterol Advantages: Advantages: Easier to adhere toEasier to adhere to Less respiratory therapy timeLess respiratory therapy time SafeSafe May benefit sicker patientsMay benefit sicker patients Disadvantages: Disadvantages: Patients may go unobservedPatients may go unobserved Claustrophobic maskClaustrophobic mask

50. CorticosteroidsCorticosteroids IV Methylprednisolone ASAP

51. Magnesium Sulfate Is It Safe Is It Safe Mild side effects during infusion:Mild side effects during infusion: Facial flushing, nausea, dry mouth, malaise Significant adverse effects have not been reportedSignificant adverse effects have not been reported Hypotension and cardiac conduction disturbances are seen only with serum magnesium levels > 8 mg/dlHypotension and cardiac conduction disturbances are seen only with serum magnesium levels > 8 mg/dl

52. Magnesium Sulfate Conclusions Conclusions The routine administration of magnesium to moderately to severely ill asthmatic children as an adjunct to initial treatment with albuterol and corticosteroids was not efficacious.The routine administration of magnesium to moderately to severely ill asthmatic children as an adjunct to initial treatment with albuterol and corticosteroids was not efficacious. Future studies will be needed to determine the optimal dose of magnesium, the optimal duration of infusion, and the subgroup of asthmatic children most likely to benefit from magnesium.Future studies will be needed to determine the optimal dose of magnesium, the optimal duration of infusion, and the subgroup of asthmatic children most likely to benefit from magnesium. Severely ill asthmatics experience the greatest benefit from magnesiumSeverely ill asthmatics experience the greatest benefit from magnesium

53. IV Beta 2 Agonists Recommendations: Recommendations: Not recommended as a first-line agent even for severely ill childrenNot recommended as a first-line agent even for severely ill children For severely ill who are poorly responsive to initial measuresFor severely ill who are poorly responsive to initial measures

54. IV Terbutaline 10 ug/kg over 10 minutes; infusion 0.5 ug/kg/min 10 ug/kg over 10 minutes; infusion 0.5 ug/kg/min Increase by 0.2 ug/kg/min to max of 5ug/kg/min Increase by 0.2 ug/kg/min to max of 5ug/kg/min Largely empiric titrate to effect Largely empiric titrate to effect Expect side effects at therapeutic doses Expect side effects at therapeutic doses Decrease infusion rate by 50% if patient is receiving theophylline Decrease infusion rate by 50% if patient is receiving theophylline

55. IV Beta 2 Agonists Potential Toxicities Tachycardia Tachycardia Dysrhythmia Dysrhythmia Hypertension Hypertension Myocardial ischemia Myocardial ischemia Hyperglycemia Hyperglycemia Hypokalemia Hypokalemia Rhabdomyolysis Rhabdomyolysis Lactic acidosis Lactic acidosis

56. Severe Asthma Arterial blood gas Arterial blood gas Heliox Heliox Intubation Intubation -ketamine -ketamine -Decompress stomache -Decompress stomache -Beware of barotrauma -Beware of barotrauma -Permissive hypercapnia -Permissive hypercapnia -Low tidal volumes and peak pressures -Low tidal volumes and peak pressures -Slow rate, no PEEP, I/E ratio=1/3 -Slow rate, no PEEP, I/E ratio=1/3 Inhaled nitic oxide Inhaled nitic oxide Nakagawa et al, J Pediatr 2000 Nakagawa et al, J Pediatr 2000  Other Considerations

57. Supplemental Oxygen Vital Signs & oxygen saturation Severe Status Asthmaticus IV Terbutaline infusion 2mg/kg IV Methylprednisolone 0.01cc/kg of subcutaneous terbutaline Continue with approach to moderately ill patient 0.15mg/kg albuterol by nebulization 250-500 micgm Ipratropium Bromide Continuously nebulized albuterol 75mg/kg IV Magnesium sulfate Good response Poor response

59. Clinical Role of MDI’s When used with a (mask) spacer device, multiple pediatric studies show MDI effectiveness comparable to nebulization therapy Chou et al. Arch Pediatr Adolesc Med 1995 Chou et al. Arch Pediatr Adolesc Med 1995 Williams et al. Pediatr Emerg Care 1996 Williams et al. Pediatr Emerg Care 1996 Leversha et al. J Pediatr 2000 Leversha et al. J Pediatr 2000 Delgado et al. Arch Pediatr Adolesc Med 2003 Delgado et al. Arch Pediatr Adolesc Med 2003

60. MDI / Spacer Tips 10 puffs or detergent wash to eliminate electrostatic charge of new spacer 10 puffs or detergent wash to eliminate electrostatic charge of new spacer – Avoids initial 70% delivery reduction Shake MDI before each puff, administer 1 puff at a Shake MDI before each puff, administer 1 puff at a time one minute apart, 5 tidal breaths per puff – 6 puffs / rx for acute exacerbation (Q 20” x 3) – 2 puffs / rx for maintenance (Q 3-6 hours) Count total puffs per MDI (200 std.) Count total puffs per MDI (200 std.) – “shake” or “float” tests unreliable

61. Dexamethasone in Asthma Dexamethasone in Asthma Random, non-blinded, 3-16 years, N = 42 Random, non-blinded, 3-16 years, N = 42 IM dexamthasone, 0.3 mg/kg (up to 15 IM dexamthasone, 0.3 mg/kg (up to 15 mg), effective as 3 day course of oral mg), effective as 3 day course of oral prednisone, 2 mg/kg/day prednisone, 2 mg/kg/day Oral dexamethsone 0.6 mg/kg (up to 16 Oral dexamethsone 0.6 mg/kg (up to 16 mg) x 2 days vs. pred x 5 days. Similar mg) x 2 days vs. pred x 5 days. Similar efficacy fewer side effects. efficacy fewer side effects. Klig et al. J Asthma 1997 and Qureshi et al. J Pediatr 2001 Klig et al. J Asthma 1997 and Qureshi et al. J Pediatr 2001

62. Magnesium Sulfate Magnesium Sulfate Bronchodilation through smooth muscle Bronchodilation through smooth muscle relaxation relaxation Inhibits cellular calcium uptake Inhibits cellular calcium uptake Inhibits histamine release Inhibits histamine release

63. Mg IV vs. Placebo Mg IV vs. Placebo RCT (double blind), placebo, 1-18 yrs, RCT (double blind), placebo, 1-18 yrs, N=54 N=54 Mg 75 mg/kg IV over 20 minutes vs. Mg 75 mg/kg IV over 20 minutes vs. placebo after 1st albuterol placebo after 1st albuterol No different in PFTs or admit rate No different in PFTs or admit rate No adverse effects or BP changes with Mg No adverse effects or BP changes with Mg Scarfone et al. Ann Emerg Med 2000 Scarfone et al. Ann Emerg Med 2000

64. IV Magnesium Sulfate in Asthma IV Magnesium Sulfate in Asthma Meta-analysis of 5 RCTs (with placebo) Meta-analysis of 5 RCTs (with placebo) 182 pediatric patients with moderate to severe 182 pediatric patients with moderate to severe asthma asthma Received beta agonists and steroids Received beta agonists and steroids Mg prevents hospitalization (NNT = 4) Mg prevents hospitalization (NNT = 4) Short term PFTs and clinical scores improved Short term PFTs and clinical scores improved ? Dose, 25-75 mg/kg over 20 minutes ? Dose, 25-75 mg/kg over 20 minutes Cheuk et al. Arch Dis Child 2005 Cheuk et al. Arch Dis Child 2005

65. PICU Case Reports PICU Case Reports 3 children in status asthmaticus 3 children in status asthmaticus Maximized traditional therapy Maximized traditional therapy Failure to improve after 2-3 hours Failure to improve after 2-3 hours BiPAP delivered an average of 12-17 hours BiPAP delivered an average of 12-17 hours Resolution of hypercarbia, and improved Resolution of hypercarbia, and improved clinical state clinical state 2/3 used continuous IV ketamine as adjunct 2/3 used continuous IV ketamine as adjunct Olugbenga A, et al. Pediatr Crit Care Med 2002 Olugbenga A, et al. Pediatr Crit Care Med 2002

66. Factors Associated with Long Factors Associated with Long Asthma Therapy Asthma Therapy Previous ICU admit Previous ICU admit Baseline sat ≤ 92% Baseline sat ≤ 92% Higher ( 6 / 9 ) clinical asthma score at four hours Higher ( 6 / 9 ) clinical asthma score at four hours 4 hour sat ≤ 92% 4 hour sat ≤ 92% 4 hour albuterol more often than q1 hour 4 hour albuterol more often than q1 hour If none, 82% chance short therapy only If none, 82% chance short therapy only ≥ 3 predictors 92% chance long therapy ≥ 3 predictors 92% chance long therapy Keogh et al. J Pediatr 2001 Keogh et al. J Pediatr 2001