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Day 1 | CME- Trauma Symposium | Bronchiolitis pittenger
 

Day 1 | CME- Trauma Symposium | Bronchiolitis pittenger

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Bronchiolitis pittenger

Bronchiolitis pittenger

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  • Understanding how to diagnosis and treat this condition is not a new is not a new problem and the search for something that we can do to impact outcomes is not a new journey. This study appeared in Pediatrics in 1965 and let’s take a moment to read the conclusion…
  • These are the key elements of the practice guideline… We will focus on the evidence related to recommendations theBqip project is highlighting
  • Lets look at the most recent Cochrane reviews. First with beta-agonist::These analysis focused on Hospital admission, LOS, and changes in clinical score
  • Summarize the data of this study…
  • There has, however, been some more recent evidence that suggest the superiority if a bronchodilator is effective in the utilization of raci epinephrine. In a review of over 900 patients and 6 studies. Slight favoring of epi to reduce hospitalization rates..
  • In 2009 this study was published in the NEJM
  • Cochrane review of multple studies on glucocorticoids in bonchiolitis showed no effect on admission rate or LOS….Finally, some limited early reslts that might suggest a benefit with the combination of raciepe on decreasing admission..but wouldn’t go jumping on that band wagon yet…..
  • Advancing Medical Professionalism to Improve Health CareFive Things Physicians and Patients Should Question
  • Simple enough..right?
  • Can guidelines help? The overwhelming answer is yes…
  • Ten reports looking at the effectiveness of guideline implementation…All with success..

Day 1 | CME- Trauma Symposium | Bronchiolitis pittenger Day 1 | CME- Trauma Symposium | Bronchiolitis pittenger Presentation Transcript

  • Bronchiolitis: A Reintroduction to an Old Friend Jaime Pittenger, MD, FAAP Pediatric Hospitalist Assistant Professor Department of Pediatrics University of Kentucky
  • Disclosures  I have no disclosure to make at this time.
  • Objectives  Briefly review basic information about bronchiolitis  Discuss current trends in management of bronchiolitis  Evaluate the evidence for evidence based medicine
  • “Since acute viral bronchiolitis is thus a self-limited disease of relatively good prognosis, the principle of primum non nocere should temper frustrated anxiety to do something-anything-to relieve severe dyspnea. Simple physical exhaustion may determine the fate of an infant laboring to meet his metabolic requirements for oxygen. His energies should not be frittered away by the annoyance of unnecessary or futile medications and procedures. Rest should be treasured.” Pediatrics, 1965 Is This New?
  • A Case  2 month old previously healthy male infant is brought to the Emergency Department with clinical bronchiolitis  Wheezing, nasal congestion, and poor feeding reported by parent; low grade fever noted at home  T 101°F, HR 175, RR 65, SaO2 92% on RA  Infant in moderate respiratory distress, IC and SC retractions, wheezing in all lung fields, CR<3 sec
  • What would you do?  The next step in management should be: A. Place nasal cannula and provide supplemental oxygen B. Provide albuterol by nebulizer C. Provide racemic epinephrine by nebulizer D. Provide nasal suction
  • Risk Factors For Severe Disease  Prematurity  Chronic lung disease of infancy (BPD)  Congenital heart disease  Pulmonary hypertension  Neuromuscular disease  Cystic fibrosis  Immunocompromised infant
  • Hospitalization  Children with severe disease  Toxic with poor feeding, lethargy, dehydration  Moderate to severe respiratory distress (RR > 70, dyspnea, cyanosis)  Apnea  Hypoxemia  Parent unable to care for child at home
  • Prevention  Good hand washing  Avoidance of cigarette smoke  Avoiding contact with individuals with viral illnesses  Influenza vaccine for children > 6 months and household contacts of those children
  • So if all the information is the same, why are we still talking about it?....
  • Shay DK, et al. JAMA. 1999;282:1440-6. Among U.S. Children Less Than 1-Year Old, 1980-1996 Annual Bronchiolitis Hospitalizations 40,000 50,000 60,000 70,000 80,000 90,000 100,000 110,000 120,000 130,000 140,000 Hospitalizations 0 10,000 20,000 30,000
  • Is It Getting Worse?  Maybe….  Changes in trends:  Routine use of pulse oximetry 1980 vs. Today  Routine use of chest x-ray 1980 vs. Today  Routine utilization of ED services 1980 vs. Today  Flat mortality rate 1979-1996 Shay DK, et al. J Infect Dis 2001;183:16–22
  • Bronchiolitis Management Preferences and the Influence of Pulse Oximetry and Respiratory Rate on the Decision to Admit Mallory MD, et al. Pediatrics 2003;111:e45–e51.  Members of AAP Section of Emergency Medicine  76% Board Certified in Pediatric EM  Mean post-training experience = 10 years  Randomized into 4 groups and sent different questionnaires
  • Bronchiolitis Management Preferences and the Influence of Pulse Oximetry and Respiratory Rate on the Decision to Admit Mallory MD, et al. Pediatrics 2003;111:e45–e51. Measured Outcome Oxygen sat = 94% Oxygen sat = 92% RR=50 (n=119) RR=65 (n=125) RR=50 (n=124) RR=65 (n=117) Decision to admit 43% 58% 83% 85% (Χ2 = 5.021;P = .025) (Χ2 = 0.126;P = 0.723) Treat with bronchodilator 92% 95% 97% 98% 2nd neb if no benefit 60% 56% 62% 62% Supplemental Oxygen 34% 39% 75% 81% Nasal Suction 80% 82% 85% 80% Chest x-ray 55% 58% 64% 67%
  • Here’s the Punch Line…
  • The Baby Goes with the NOSE! Nose suction is the most common, yet unstudied, inte rvention for bronchiolitis
  • Bronchiolitis ALWAYS affects the nose FIX MY nose!!!!
  • 23
  • The diagnosis should be made clinically Bronchodilators are not recommended Corticosteroids are not recommended Ribavirin is not recommended Antibiotics are not recommended Chest physiotherapy is not recommended, oral rehydration is preferred AAP practice guideline: Diagnosis and management of bronchiolitis. Pediatrics 2006;118(4):1774-93.
  • Oxygen saturation threshold is 90% and continuous monitoring not necessary Prophylaxis is recommended for particular subsets of patients Hand hygiene with alcohol hand gel is preferred Secondhand smoke exposure is bad and should be addressed Ask about use of alternative medicine
  • New meta-analyses since last guideline  Beta-agonists: Gadomski AM, Brower M. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2010; (12):CD001266.  Epinephrine: Hartling L, Bialy LM, Vandermeer B. Epinephrine for bronchiolitis. Cochrane Database Syst Rev. 2011;(6):CD003123.
  • Gadomski AM, Brower M. Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2010; (12):CD001266. Authors’ conclusions:  Bronchodilators do not improve oxygen saturation, do not reduce hospital admission after outpatient treatment, do not shorten the duration of hospitalization and do not reduce the time to resolution of illness at home.  The small improvements in clinical scores for outpatients must be weighed against the costs and adverse effects of bronchodilators.
  • Hartling L, Bialy LM, Vandermeer B. Epinephrine for bronchiolitis. Cochrane Database Syst Rev. 2011;(6):CD003123. Author’s Conclusions:  This review demonstrates the superiority of epinephrine compared to placebo for short-term outcomes for outpatients, particularly in the first 24 hours of care.  Exploratory evidence from a single study suggests benefits of epinephrine and steroid combined for later time points. More research is required to confirm the benefits of combined epinephrine and steroids among outpatients.  There is no evidence of effectiveness for repeated dose or prolonged use of epinephrine or epinephrine and dexamethasone combined among inpatients.
  • 29 1. Randomized, double-blind, placebo controlled trial 2. 5 day course of prednisolone or placebo 3. 700 enrolled , ages 10 months- 60months 4. Primary outcome: LOS 5. Secondary outcomes: Score on Preschool Respiratory Assessment Measure ; Albuterol use; 7 day symptom score
  • Author’s Conclusions:  Current evidence does not support a clinically relevant effect of systemic or inhaled glucocorticoids on admissions or length of hospitalization.  Combined dexamethasone and epinephrine may reduce outpatient admissions, but results are exploratory and safety data limited. Fernandes RM, Bialy LM, Vandermeer B. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev. 2010;(10):CD004878.
  • So why bother?
  • Berwick, D. M. et al. JAMA doi:10.1001/jama.2012.362 Waste in US Healthcare
  • Choosing Wisely  Don’t order chest radiographs in children with uncomplicated asthma or bronchiolitis.  Don’t routinely use bronchodilators in children with bronchiolitis.  Don’t use systemic corticosteroids in children under 2 years of age with an uncomplicated lower respiratory tract infection.  Don’t treat gastroesophageal reflux in infants routinely with acid suppression therapy.  Don’t use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.
  •  Airway clearance: suction first, last, and as needed  Nutritional Support: Often overlooked  Oxygen: recommendations for its use and clear guidelines for its discontinuation.  Eliminate the utilization of unnecessary resources with the implementation of an objective scoring tool to validate the effectiveness and the need for continuation of an intervention. Basic Elements of Evidence – based care for Bronchiolitis. 34
  • Author Intervention/Location Outcomes Adcock 1998 Local Guideline, Kosair Children’s Hospital, Louisville, Kentucky RSV testing Bronchodilator utilization Isolation precautions Readmission rates Antibiotic utilization LOS Perlstein 1999 Local Guideline, Children’s Hospital Medical Center Cincinnati, Ohio Admission rates LOS Beta-agonist utilization RSV testing Chest radiographs Cost Perlstein 2000 Local Guideline (same as above), Children’s Hospital Medical Center Cincinnatti, Ohio Admission rates LOS Beta-agonist utilization RSV testing Chest radiographs Cost Harrison 2001 Local Guideline, Syracuse, NY Albuterol utilization Documentation of response to albuterol Discharged on albuterol Utilization of oxygen Utilization of cardiorespiratory monitoring
  • Study Intervention/Location Outcomes Kotagal 2002 Local Guidelines, Eleven children’s hospitals in the Child Health Accountability Initiative Bronchodilator usage Steroid use LOS Todd 2002 Local Guideline and Respiratory Distress Score, The Children’s Hospital, Denver, Colorado Bronchodilator utilization Antibiotic utilization Chest physiotherapy RSV testing Ribavirin utilization Nosocomial infection rate Muething 2004 ED care algorithm, admission order set, respiratory score; Children’s Hospital Medical Center Cincinnatti, Ohio Bronchodilator Utilization RSV testing Chest radiographs LOS Cheney 2005 Multi-center Pathway, Four hospitals in Australia Readmission rates IV fluid utilization Steroid utilization King 2007 CPOE decision support, Children’s Hospital of Eastern Ontario Albuterol utilization Antibiotic utilization
  • Respiratory Assessment Score 0 - Normal 1 – Mild 2 - Moderate 3 - Severe Resp Rate < 40 40 – 50 50 – 60 > 60 Color O2 Sat on RA Cap Refill Normal >97% < 2 sec. Normal 94-96% on RA < 2 sec. Normal 90-93% on RA < 2 sec. Dusky, Mottled < 90% = > 3 sec. Retractions / WOB None Subcostal Intercostal & Subcostal when Quiet Supraclavicular Sternal Paradoxical respiration Air Entry Wheezing Breath Sounds Clear / Good Good Entry End Exp. Wheeze +/- Rales Fair Air Entry Insp and Exp Wheeze +/- Rales Poor / Grunting Insp and Exp Wheeze +/- Rales LOC Normal / Alert Mild Irritability Restless When Disturbed - Agitated Lethargic, Hard to Arouse Dayton Children’s Medical Center, by permission.
  • Nebulizer Trial SCORE RESPIRATORY TREATMENT OTHER THERAPY 0-2 NORMAL Assess Q6 PRN Normal Saline Nose Drops; Bulb Syringe Suction for Home 3-6 MILD Aerosol Trial with Racemic Epinephrine or Albuterol; If response is positive continue aerosol Q6; If not responsive assess Q6 PRN Oxygen per Protocol (SpO2>91%); Suction PRN with Bulb Syringe, Neotech Little Sucker™ or Catheter 7-10 MODERATE Aerosol Trial with Racemic Epi or Albuterol; If response is positive continue aerosol Q4. If not responsive, trial alternate medication. Assess Q4 PRN Consider Chest X-ray; consider capillary blood gas; Normal Saline Nose Drops; Suction PRN with Bulb Syringe, Neotech Little Sucker™ or Catheter; IV fluids if patient exhibits dehydration or failure to feed; Oxygen per Protocol 11-15 SEVERE Aerosol Trial with Racemic Epi or Albuterol, If response is positive continue aerosol Q2-4, If not responsive trial alternate medication. Assess Q2 PRN Chest X-Ray; IV fluids; Blood Gas; Excessive PCO2, acidosis or hypoxia should be transferred to ICU; Oxygen per Protocol
  • ED Algorithm Admit as 23-hr Observation Admit as Inpatient Admit to PICU DC Home Nebulizer Trial Admit to PICU Assess Clinical Symptoms, including Respiratory Score Pt < 24 months presents with upper respiratory infection symptoms & wheezing Meets DC Criteria? Does Pt Require IV Fluids Or O2? Symptoms Improve? Symptoms Resolve with Nasal Suctioning? Witnessed Apnea? Yes Yes Yes Yes Yes Yes No Meets ICU Criteria? No No No No No No Modified from Bronchiolitis CPG, Children’s Medical Center, Dayton, OH
  • Nebulizer Trial is Recommended For a Post Suction Score of 3 or Higher (Racemic Epinephrine if no history of wheezing; Albuterol if history of wheezing) BRONCHIOLITIS SCORING SHEET Pre Suction Score Post Suction Score (Pre Nebulizer) Post Nebulizer Score Pre Suction Score Post Suction Score (Pre Nebulizer ) Post Nebulizer Score Respiratory Rate 0),<40 2)50-60 1)40-50 3)>60 Color, Room Air Saturation, Capillary Refill 0),>97,<2seconds 2),90-93,<2seconds 1),94-96,<2seconds 3)Dusky/mottled,<90,>3seconds Retractions 0)None 2)Intercostal and subcostal when quiet 1)Subcostal 3)Supraclavicular,sternal,paradoxical respiration Air Entry, Breath Sounds (insp=inspiratory, exp=expiratory) 0)Good,clear 2)Fair,insp and exp wheeze +/- rales 1)Good,exp wheeze 3)Poor,insp and exp wheeze +/- rales LOC 0)Normal/alert 2)Restless when disturbed/agitated 1)Mild irritability 3)Lethargic/hard to arouse Total Nebulizer trial recommended Yes____ No____ Medication Used: Albuterol or Racemic Epinephrine Date/Time___________ Initials_______ Date/Time__________ Initials_______ Positive Response Yes___ No___ Positive Response Yes___ No___ (A positive response is defined as a decrease in the post nebulizer score by 2 or more.) Continued Management/Education/Comments: ___________________________________________________________________________________________ ___________________________________________________________________________________________
  •  New AAP guideline currently being developed and will be published in mid to late 2014  Will not change the basic recommendations in the 2006 guideline but will be a little clearer about not routine using albuterol and what to trial – evidence favors epi over albuterol  Will not recommend hypertonic saline Evidence on the horizon 41
  • ~2900 Studies later….
  • The Bottom Line “Ascertainment of optimal care is difficult because our therapies are supportive, not curative, and most children do well irrespective of differences in therapy. Consequently, there is a propensity to persist in care practices that may offer little or marginal benefit.” Willson, et al. Pediatr 2001;108(4):851 16
  • A Case  2 month old previously healthy male infant is brought to the Emergency Department with clinical bronchiolitis  Wheezing, nasal congestion, and poor feeding reported by parent; low grade fever noted at home  T 101°F, HR 175, RR 65, SaO2 92% on RA  Infant in moderate respiratory distress, IC and SC retractions, wheezing in all lung fields, CR<3 sec
  • What would you do?  The next step in management should be: A. Place nasal cannula and provide supplemental oxygen B. Provide albuterol by nebulizer C. Provide racemic epinephrine by nebulizer D. Provide nasal suction E. Obtain a chest x-ray
  • MUST READ!  Diagnosis and Management of Bronchiolitis Subcommittee on Diagnosis and Management of Bronchiolitis Pediatrics 2006;118;1774-1793
  • Further Reading  McBride. RSV and Asthma: Is There a Link? 1998;34.  Lowell et al. Pediatrics. 1987;79:939.  Menon et al. J Pediatr. 1995;126:1004.  Infants have airway tone and responsiveness to ß-agonists similar to older children & adults Goldstein A, et al. Am J Resp Crit Care Med 2001;164:447-54  Responsiveness to bronchodilators in bronchiolitis is not age dependent Modl M et al. J Pediatr 2005;147:617-21  Short acting beta-agonists have no clear benefit in children less than 2 years old Chavasse R, et al. Cochrane Rev 2009  1-2% of nebulized dose reaches lungs of infants Amirav I, et al. J Nucl Med 2002;43(4):487-91  α / β-agonist epinephrine has no clear benefit in inpatients with bronchiolitis Harding L, et al. The Cochrane Database of Systematic Reviews 2004;1.  RSV may reduce β-agonist responsiveness of human airway smooth muscle Moore P, et al. Am J Resp Cell Molec Biol 2006;35:559-64.
  • 1. Al-Shehri MA, Sadeq A, Quli K: Bronchiolitis in Abha, Southwest Saudi Arabia: viral etiology and predictors for hospital admission. West Afr J Med 2005, 24:299-304 2. Anderson LJ, Parker RA, Strikas RA, Farrar JA, Gangarosa EJ, Keyserling HL, Sikes RK: Day-care center attendance and hospitalization for lower respiratory tract illness. Pediatrics 1988, 82:300-308 3. Breese Hall C, Hall WJ, Gala CL, MaGill FB, Leddy JP: Long-term prospective study in children after respiratory syncytial virus infection. J Pediatr 1984, 105:358-364 4. Gurkan F, Kiral A, Dagli E, Karakoc F: The effect of passive smoking on the development of respiratory syncytial virus bronchiolitis. Eur J Epidemiol 2000, 16:465-468. 5. Hayes EB, Hurwitz ES, Schonberger LB, Anderson LJ: Respiratory syncytial virus outbreak on American Samoa. Evaluation of risk factors. Am J Dis Child 1989, 143:316-321 6. McConnochie KM, Roghmann KJ: Parental smoking, presence of older siblings, and family history of asthma increase risk of bronchiolitis. Am J Dis Child 1986, 140:806-812 7. Sims DG, Downham MA, Gardner PS, Webb JK, Weightman D: Study of 8- year-old children with a history of respiratory syncytial virus bronchiolitis in infancy. BMJ 1978, 1:11-14 8. Chatzimichael A, Tsalkidis A, Cassimos D, Gardikis S, Tripsianis G, Deftereos S, Ktenidou-Kartali S, Tsanakas I: The role of breastfeeding and passive smoking on the development of severe bronchiolitis in infants. Minerva Pediatr 2007, 59:199-206 9. Reese AC, James IR, Landau LI, Lesouef PN: Relationship between urinary cotinine level and diagnosis in children admitted to hospital. Am Rev Respir Dis 1992, 146:66-70