Pediatric Respiratory Emergencies:Beyond the Runny Nose

Christopher Strother, MDMount Sinai School of MedicineDepartment of Emergency MedicineJune 25 – 27, 2009

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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 diseaseAt 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 neededClear Congestion, Ensure fluid intakeBronchodilators – Studies show no definite

benefit, but many recommend a trial, especially if there is asthma in familyAlbuterol: 0.15mg/kg to 5mg or 4-6 puffs

Epinephrine: 0.05ml/kg to 0.5mlReassess in 1 hour after each to determine

effect, continue if helpfulDiagnosis 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 changeDex 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 LaryngotracheitisSupportive Care

Warm mist, cool nights, drink fluidsMist has not been scientifically shown to work, but parents

swear by it

Dexamethasone for everybody0.6 mg/kg up to 10mg (PO, IM or IV)

Nebulized Rac - Epi: 0.05ml/kg to 0.5mlFor distress or strider at restRepeat 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: 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