Inpatient Inpatient Bronchiolitis: So Bronchiolitis: So

Much Time and So Much Time and So Little To DoLittle To Do

Alan Schroeder, MDAlan Schroeder, MDDirector, PICUDirector, PICU

Chief, Pediatric Inpatient ServicesChief, Pediatric Inpatient ServicesSanta Clara Valley Medical CenterSanta Clara Valley Medical Center

Case – urgent careCase – urgent care

Otherwise healthy 6 month old Otherwise healthy 6 month old with 3 days cough, runny with 3 days cough, runny nose, fussiness, decreased PO nose, fussiness, decreased PO intake but normal wet diapers. intake but normal wet diapers. On PE, T=101, RR = 50, O2 Sat On PE, T=101, RR = 50, O2 Sat

= 94%, HR = 160, fussy but = 94%, HR = 160, fussy but consolable, adequately hydrated, consolable, adequately hydrated, lots o’ snot, expiratory wheezes, lots o’ snot, expiratory wheezes, mild SC&IC rtxnsmild SC&IC rtxns

ResultsResultsSPO2 = SPO2 = 9494%%

RR = 50RR = 50

(n=119)(n=119)

SPO2 = SPO2 = 9494%%

RR = 65RR = 65

(n=125)(n=125)

SPO2 =SPO2 = 9292%%

RR = 50RR = 50

(n=124)(n=124)

SPO2 = SPO2 = 9292%%

RR = 65RR = 65

(n=117)(n=117)

Would admit Would admit (%)(%)

4343 5858 8383 8585

Bronchodilator Bronchodilator (%)(%)

9292 9595 9797 9898

O2 (%)O2 (%) 3434 3939 7979 8181Nasal Suction Nasal Suction (%)(%)

8080 8282 8585 8080

Steroids (%)Steroids (%) 77 66 88 1111Abx (%)Abx (%) 22 22 22 33Mallory, Pediatrics, 2003

Management Dilemmas in Management Dilemmas in BronchiolitisBronchiolitis

Nebs?Nebs? Albuterol vs racemic epinephrine?Albuterol vs racemic epinephrine? Hypertonic saline?Hypertonic saline?

Suctioning (+/- saline)?Suctioning (+/- saline)? Chest Physiotherapy?Chest Physiotherapy? If febrile, R/O SBI?If febrile, R/O SBI? CXR?CXR? Steroids?Steroids? Decongestants?Decongestants? Abx?Abx? When to admit?When to admit?

O2 Sat criteria?O2 Sat criteria? Risk of apnea?Risk of apnea?

Safe to eat?Safe to eat? When to discharge?When to discharge?

Bronchiolitis OverviewBronchiolitis Overview

#1 cause of infant hospitalization#1 cause of infant hospitalization 1/3 of all children get bronchiolitis in 1/3 of all children get bronchiolitis in

first 2 yearsfirst 2 years 1/30 children get hospitalized 1/30 children get hospitalized 150,000 hospitalizations per year 150,000 hospitalizations per year

1.5M annual outpatient visits for 1.5M annual outpatient visits for RSV aloneRSV alone

$500-700M/year $500-700M/year

Bronchiolitis – DefinitionBronchiolitis – Definition

“a seasonal viral illness characterized by fever, nasal discharge, and dry, wheezy cough. On examination there are fine inspiratory crackles and/or high-pitched expiratory wheeze”

www.nottingham.ac.uk/paediatric-guideline/breathingguideline.pdf.

Why have hospitalization Why have hospitalization rates increased?rates increased?

Increased survival of children with Increased survival of children with comorbiditiescomorbidities

? Virulence? Virulence Increase in daycareIncrease in daycare Changes in hospitalization criteriaChanges in hospitalization criteria

Bronchiolitis seasonalityBronchiolitis seasonality

MMWR, 2009

PathophysiologyPathophysiology Inflammed/ Inflammed/

edematous edematous bronchial bronchial wallswalls

WBC’s WBC’s (mostly (mostly monos) monos) infiltrate infiltrate bronchiolar bronchiolar epitheliumepithelium

Mucus plugs Mucus plugs block airwayblock airway

http://www.health-healths.com/tag/prevention/page/5

PathphysiologyPathphysiology

Mucus plugging Mucus plugging one-way valve one-way valve hyperinflation hyperinflation absorption absorption atalectasis --> V:Q mismatchatalectasis --> V:Q mismatch

Smooth-muscle constriction Smooth-muscle constriction (bronchiolespasm) not a factor(bronchiolespasm) not a factor

Clinical presentationClinical presentation

URI symptoms firstURI symptoms first Spreads to LRT – cough, tachypnea Spreads to LRT – cough, tachypnea

more presentmore present Fever in ~ 50%Fever in ~ 50% Poor po intake, decreased UOPPoor po intake, decreased UOP

ExamExam

Concerning clinical Concerning clinical findingsfindings

Lethargy/extreme irritabilityLethargy/extreme irritability DehydrationDehydration Respiratory distressRespiratory distress ApneaApnea

OutlineOutline

OverviewOverview Burden of diseaseBurden of disease Pathophysiology/clinical presentationPathophysiology/clinical presentation

MARC-30 studyMARC-30 study Treatment – what’s the evidence?Treatment – what’s the evidence?

SCVMC and MARC-30 SCVMC and MARC-30 studystudy

MARC = Multicenter Airway Research MARC = Multicenter Airway Research CollaborationCollaboration Part of Emergency Medicine Network (EMNet)Part of Emergency Medicine Network (EMNet)

Prospective, multicenter.Prospective, multicenter. 16 sites, 2200 patients over 3 winters (11/07 – 16 sites, 2200 patients over 3 winters (11/07 –

4/10)4/10) NIH funded (NIAID)NIH funded (NIAID) PI: Carlos Camargo (Mass General), Jonathan PI: Carlos Camargo (Mass General), Jonathan

Mansbach (Boston Children’s)Mansbach (Boston Children’s) Aims:Aims:

Elucidate role of co-infectionsElucidate role of co-infections Identify predictors of PPVIdentify predictors of PPV Establish evidence-based discharge criteriaEstablish evidence-based discharge criteria

Viral co-infectionsViral co-infections

Virology - ImplicationsVirology - Implications

Cohorting/isolation?Cohorting/isolation? Comfort of diagnosis?Comfort of diagnosis?

Utilization of resources?Utilization of resources? Hospital charges:Hospital charges:

Flu A, B, RSV   ($220) Flu A, B, RSV   ($220) Para 1,2,3         ($220) Para 1,2,3         ($220) Bordetella pertussis, B. parapertussis      Bordetella pertussis, B. parapertussis     

($95) ($95)

Virology - implicationsVirology - implications

My conclusion: run-of-the-mill My conclusion: run-of-the-mill bronchiolitis does not warrant viral bronchiolitis does not warrant viral testingtesting Possibly for influenza Possibly for influenza

only 19/2200 (~1% of patients in cohort)only 19/2200 (~1% of patients in cohort)

Same goes for CXR, labs, even if Same goes for CXR, labs, even if febrile febrile

UA/Urine Cx if < 90 days? [Ralston, Arch Pediatr UA/Urine Cx if < 90 days? [Ralston, Arch Pediatr Adol Med 2011]Adol Med 2011]

OutlineOutline

OverviewOverview Burden of diseaseBurden of disease Pathophysiology/clinical presentationPathophysiology/clinical presentation

MARC-30 studyMARC-30 study Treatment – what’s the evidence?Treatment – what’s the evidence?

Steroids?Steroids?

2003 Cochrane (Patel et al):2003 Cochrane (Patel et al): ““Available evidence suggests that Available evidence suggests that

corticosteroid therapy is corticosteroid therapy is notnot of benefit of benefit in this patient group” in this patient group” 13 trials13 trials

AAP recs (2005): AAP recs (2005): ““Corticosteroids should not be used Corticosteroids should not be used

routinely in the management of routinely in the management of bronchiolitis”bronchiolitis”

B-agonistsB-agonists

Cochrane 2010 (Gadomski and Brower):Cochrane 2010 (Gadomski and Brower): 28 trials (1912 infants)28 trials (1912 infants) No reduction in admission or length of No reduction in admission or length of

hospitalizationhospitalization Transient reduction in clinical scoreTransient reduction in clinical score

AAP (2005):AAP (2005): ““bronchodilators should not be used bronchodilators should not be used

routinely in the management of routinely in the management of bronchiolitis…”bronchiolitis…”

“…“…A carefully monitored trial of beta or alpha A carefully monitored trial of beta or alpha agonist is an option”agonist is an option”

EpinephrineEpinephrine

Cochrane 2011 (Hartling et al)Cochrane 2011 (Hartling et al) 19 studies, 2256 patients19 studies, 2256 patients RR admissions on Day 1 in outpatients RR admissions on Day 1 in outpatients

= .67 (.50-.89) vs placebo= .67 (.50-.89) vs placebo Shorter LOS for epi vs salbutamolShorter LOS for epi vs salbutamol

Epi + dexamethasone?Epi + dexamethasone?

Pediatric Emergency Research Pediatric Emergency Research Canada RCTCanada RCT[Plint et al, NEJM 2009][Plint et al, NEJM 2009]

800 kids800 kids 4 arms:4 arms:

DecadronDecadron Racemic epiRacemic epi Decadron + epiDecadron + epi PlaceboPlacebo

Marginal benefit in admission rate by 7 Marginal benefit in admission rate by 7 days in decadron + epi group (17% vs 26%)days in decadron + epi group (17% vs 26%)

Hypertonic salineHypertonic saline

Zhang et al, Cochrane 2008Zhang et al, Cochrane 2008 4 trials, 254 patients, with/without 4 trials, 254 patients, with/without

bronchodilatorsbronchodilators ↓↓LOS by 1 dayLOS by 1 day Reduced clinical score in outpatientsReduced clinical score in outpatients

4 additional RCTs4 additional RCTs 2 with some benefit (Al-Ansari et al, J Peds 2 with some benefit (Al-Ansari et al, J Peds

2010; Luo et al, Clin Microb Inf, 2011) 2010; Luo et al, Clin Microb Inf, 2011) 2 with no benefit (Kuzik et al, CJEM 2010; 2 with no benefit (Kuzik et al, CJEM 2010;

Grewal et al, Arch Pediatr Adol Med 2009)Grewal et al, Arch Pediatr Adol Med 2009)

Hypertonic salineHypertonic saline

Bronchodilators necessary? [Ralston Bronchodilators necessary? [Ralston et al, Pediatrics, 2010]et al, Pediatrics, 2010] 1 episode of bronchospasm in 377 doses 1 episode of bronchospasm in 377 doses

of HS without bronchodilatorof HS without bronchodilator So why not? So why not?

(We’ve been down this path before…)(We’ve been down this path before…)

Pediatrics, 2011

Increasing inpatient bronchiolitis Increasing inpatient bronchiolitis volume volume reduced steroids, xrays, reduced steroids, xrays, laboratory testslaboratory tests

Pediatrics 2000

6 RCTs, included 2 trials that did not 6 RCTs, included 2 trials that did not exclude prior wheezersexclude prior wheezers

Conclusion: “Published reports of the Conclusion: “Published reports of the effect of systemic corticosteroids on effect of systemic corticosteroids on the course of bronchiolitis suggest a the course of bronchiolitis suggest a statistically significant improvement statistically significant improvement in clinical symptoms, LOS, and DOS.”in clinical symptoms, LOS, and DOS.”

Nasal decongestantsNasal decongestants

Ralston et al, J Peds 2008Ralston et al, J Peds 2008 41 infants, phenylephrine vs placebo41 infants, phenylephrine vs placebo No benefitNo benefit

Chest PTChest PT

Gajdos et al, PLOS, 2010Gajdos et al, PLOS, 2010 Multicenter RCT of CPT (forced Multicenter RCT of CPT (forced

expiratory techniques and assisted expiratory techniques and assisted cough) vs nasal suctioncough) vs nasal suction

496 infants, no benefit496 infants, no benefit Roque, Cochrane 2012Roque, Cochrane 2012

9 trials (5 vibration/percussion, 4 9 trials (5 vibration/percussion, 4 passive expiratory)passive expiratory)

No benefitNo benefit

HelioxHeliox

Less turbulent airflow through Less turbulent airflow through resistant airwaysresistant airways

When given in ED with racemic epi When given in ED with racemic epi + via HFNC, small improvement in + via HFNC, small improvement in clinical scores but no reduction in clinical scores but no reduction in admission or LOS admission or LOS [Kim et al, APAM 2011][Kim et al, APAM 2011]

Mixed results in ICU setting Mixed results in ICU setting [Martinon-[Martinon-Torres et al, Pediatrics 2002; Liet et al, J Peds 2005]Torres et al, Pediatrics 2002; Liet et al, J Peds 2005]

O2 Sat: why does it matter?O2 Sat: why does it matter?

It can be easily fixed!!It can be easily fixed!! May predict respiratory failure or ICU May predict respiratory failure or ICU

transfer in early phase of diseasetransfer in early phase of disease May predict readmissionMay predict readmission ?May be deleterious to the developing ?May be deleterious to the developing

brain?brain? Commentary to 2005 AAP guidelines (Cutoff = Commentary to 2005 AAP guidelines (Cutoff =

“persistently below 90%”): “It is unfortunate that the “persistently below 90%”): “It is unfortunate that the recommendation fails to address another significant recommendation fails to address another significant consideration, viz, the impact of chronic or consideration, viz, the impact of chronic or intermittent hypoxia on later cognitive and behavioral intermittent hypoxia on later cognitive and behavioral outcomes.”[Bass, Pediatrics 2007]outcomes.”[Bass, Pediatrics 2007]

Site articles suggesting some detriment at 90-94% (in pts Site articles suggesting some detriment at 90-94% (in pts with CHD or OSA!!!)with CHD or OSA!!!)

OxygenOxygen

LOS prolonged by perceived need for LOS prolonged by perceived need for O2O2 26% - 57% of hospitalized patients 26% - 57% of hospitalized patients

[Schroeder, [Schroeder, Archives Ped Adol MedArchives Ped Adol Med 2004; Unger, 2004; Unger, PediatricsPediatrics 2008] 2008]

AAP:AAP: ““As child’s course improves, continuous As child’s course improves, continuous

O2 monitoring is not routinely needed”O2 monitoring is not routinely needed” Ongoing RCT of continuous vs Ongoing RCT of continuous vs

intermittent pulse oximetryintermittent pulse oximetry

SummarySummary

No fritteringNo frittering Resist temptation to treat all Resist temptation to treat all

wheezingwheezing Racemic epinephrine instead of Racemic epinephrine instead of

albuterol?albuterol? Limited utility of NP swabsLimited utility of NP swabs Search for the holy grail continuesSearch for the holy grail continues

More to come from More to come from MARC-30MARC-30

Predicting safe dischargePredicting safe discharge Predicting PPVPredicting PPV Better understanding of apnea and Better understanding of apnea and

the associated virusesthe associated viruses Role of vitamin D levelsRole of vitamin D levels Development of asthma after Development of asthma after

bronchiolitisbronchiolitis