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Pediatric Respiratory Emergencies

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Epiglottitis Bacterial tracheitis Retro-pharyngeal abscess Croup Uvulitis Foreign body obstruction Hemangioma Neoplasm What ... of subglottic area ... – PowerPoint PPT presentation

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Title: Pediatric Respiratory Emergencies


1
Pediatric Respiratory Emergencies
  • Moritz Haager
  • Dr. David Johnson
  • May 09, 2002

2
Case
  • 8 mo male w/ 2/7 Hx of URTI Sx and progressively
    labored breathing
  • Presents w/ tachypnea, indrawing, lethargy, ill
    looking child
  • 380 / 200 / 60 / 88-90 on RA
  • Decd AE and diffuse wheeze bilat., creamy d/c
    from eyes
  • ABG 7.38 / 38 / 51 / 22/ -2
  • WBC 14.6
  • CXR peri-bronchial cuffing in RLL

3
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4
Whats your DDx for wheeze?
  • Bronchiolitis
  • Pneumonia
  • Asthma
  • Foreign body aspiration
  • CHF
  • CF
  • Pertussis
  • Anatomic abnormalities

5
Whats your approach to bronchiolitis?
  • ABCs
  • Oxygen
  • ?Bronchodilators (which one?)
  • ?Steroids
  • ?Antibiotics
  • Supportive care
  • Monitor for complications

6
Bronchiolitis
  • Common contagious LRTI of infants young
    children (0-24 mo)
  • Usually viral and self-limited illness
  • RSV (60-90)
  • Para-influenza, adenovirus, rhinovirus, influenza
  • Affects terminal bronchioles ? necrosis of
    ciliated cells ? inflammation w/ cellular debris
    mucous plugging ? wheezing and incd WOB
  • Seasonal epidemics (winter months)
  • Usually no long-term sequelae but may pre-dispose
    to (or uncover) asthma

7
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8
Are bronchodilators useful?
  • Controversial point in literature
  • Meta-analysis looking at 15 RCTs (mostly
    salbutamol) concluded moderate short-term benefit
    from bronchodilator therapy, but no effect on
    admission rate or oximetry
  • Kellner et al. 1996. Arch Ped Adol Med. 150
    1166-72
  • Cochrane systematic review of 394 kids in 8
    trials showed 54 improved clinically vs.. 25 of
    placebo
  • Concluded modest short-term symptomatic benefit
    need more studies to better elucidate utility
  • Kellner et al. 2002. Coch Data Sys Rev. (1)

9
Salbutamol or Epinephrine?
  • 4 RCTs show epinephrine (racemic or L-epi) as
    appearing to be superior to salbutamol
  • All found significant symptomatic improvement,
    and two found decd admission rate or shortened
    hospital stay no adverse effects noted
  • Only 2 were in ED setting
  • Reijonen et al. 1995. Arch. Ped. Adol. Med. 149
    686-92
  • Menon et al. 1995. J. Ped. 126 1004-007
  • Sanchez et al. 1993. J. Ped. 122 145-51
  • Bertrand et al. 2001. Ped. Pulmonolgy. 31 284-8
  • Hartling and Klassen in process of preparing a
    Cochrane review
  • Epi appears superior based on current evidence

10
What about Atrovent?
  • Double-blind placebo-controlled RCT of 69 infants
    6wks 24 mo w/ acute bronchiolitis
  • Randomized to either salbutamol ipratropium or
    salbutamol placebo
  • No sig difference in admission rate, RR, WOB,
    wheezing, or O2 sats
  • No additional benefit when given in addition to
    salbutamol.
  • Schuh et al. 1992. Pediatrics. 90 920-23

11
Is there a role for Steroids?
  • 3 RCTs all fail to show benefit
  • Roosevelt et al. 1990. Lancet. 348 292-95
  • Van Woensel et al. 1997. Thorax. 52 634-47
  • Klassen et al. 1997. J. Ped. 130 191-196.
  • 3 more recent studies support this and also fail
    to show any long-term benefit in reducing risk of
    post-bronchiolitis wheezing or asthma
  • Van Woensel et al. 2000. Ped. Pulmonology. 30
    92-6
  • Wong et al. 2000. Euro. Resp. J. 15 388-94
  • Cade et al. 2000. Arch. Dis. Child. 82 126-30
  • Literature does not support use in bronchiolitis
  • Patel et al are preparing a Cochrane review

12
Does this Kid need Antibiotics?
  • Not routinely indicated, but
  • One study shows 86 of kids w/ bronchiolitis
    have concomitant OM
  • 5-10 have M. pneumoniae or Chlamydia
    co-infection
  • Consider Tx in kids with
  • OM and high fever
  • Atypical features
  • More ill than expected
  • CXR evidence of pneumonia (other than
    atelectasis)
  • This child received IV amoxicillin for ill
    appearance

13
Your student suggests Ribavirin
  • Synthetic nucleotide anologue w/ virostatic
    properties
  • Expensive, possibly teratogenic, can cause
    bronchospasm
  • Controversial, but mounting evidence it does not
    work
  • At least 3 RCTs fail to show benefit
  • Everard et al. 2001. Resp. Med. 95 275-80
  • Guerguerin et al. 1999. Am. J. Resp. Crit. Care
    Med. 160 829-34
  • Moler et al. 1996. J. Ped. 128 422-28
  • Cochrane review of 378 infants lt 6mo in 10 trials
    suggests possible decrease in length of stay, but
    studies lack sufficient power.
  • Randolph and Wang. 2002. Coch Data Sys Rev. Issue
    1
  • Bottom line not indicated in ED

14
Other Treatments for Bronchiolitis
  • Shuang huang lian
  • 1 RCT shows decd duration of Sx
  • Heliox
  • One RCT in PICU showing benefit
  • Surfactant
  • Case reports in PICU setting
  • ECMO
  • Case reports of benefit in premies or unstable
    pts refractory to conventional Tx
  • Prevention
  • RSVIG
  • Palivizumab

15
What complication can arise?
  • Hypoxemia / respiratory failure
  • Apnea (esp. in lt6 mo)
  • Hypercarbia
  • Pneumonia (viral or bacterial)
  • Concomitant OM
  • Long-term ? Asthma some studies suggest incd
    risk esp. in kids w/ incd IgE
  • Mortality lt 1, and usually occurs in children w/
    underlying heart dz, lung dz, or prematurity.

16
Are there any predictors of MM?
  • Predictors of severe disease
  • GA lt 34 wks
  • SpO2 lt 95
  • RR gt70
  • Age lt 3 mo
  • Ill or toxic appearance
  • Atelectasis on CXR
  • Presence or absence of all 6 has PPV of 81 and
    NPV of 88 for severe course
  • Shaw et al. 1991. Am. J. Dis. Child. 145 151-55

17
Who needs intubation?
  • 2-7 of hospitalized infants end up requiring
    intubation for resp. failure
  • Indications for intubation
  • Severe resp. distress
  • Apnea
  • Hypoxia or hypercapnea
  • Lethargy
  • Poor perfusion
  • Metabolic acidosis
  • Wright et al. 2002. Emerg Med Clin NA. 20 93-113

18
Case
  • 3 yo female presents w/ 3/7 Hx of coryza, fever,
    and a harsh cough
  • Today started making noise with every breath and
    hoarse voice which is worse at night
  • O/E 386 / 120 / 35 / 96 RA
  • Inspiratory stridor

19
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20
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21
Whats your DDx for stridor?
  • Epiglottitis
  • Bacterial tracheitis
  • Retro-pharyngeal abscess
  • Croup
  • Uvulitis
  • Foreign body obstruction
  • Hemangioma
  • Neoplasm

22
Whats your approach to Croup?
  • ABCs
  • Oxygen
  • ?Humidification
  • ?Epinephrine
  • ?Steroids
  • ?Intubation

23
Croup
  • Laryngotracheobronchitis, viral croup
  • Common URTI and cause of stridor in infants and
    children 6 mo 6 yo
  • Viral infection ? inflammation of subglottic area
    ? stridor (can be biphasic in severe cases) ?
    potentially hypoxia and death (rare)
  • Biphasic peaks in fall and winter
  • Etiology
  • Parainfluenza 1 3 (gt65) gt RSV gt Parainfluenza
    2 gt Influenza A gt M. pneumoniae gt Influenza B

24
Humidification does it work?
  • Long-standing first-line Tx at home
  • Anecdotal evidence
  • studies to date fail to show objective benefit
    from mist therapy, one of which was an RCT of 16
    pts receiving either RA or humidified air
  • Bourchier et al. 1984. Aust. Pediatr. J.
    20289-91
  • Reports of Pseudomonas contamination and
    hyper-sensitivity reactions
  • We need a larger RCT to clear this up
  • Cochrane review by Moore and Little in progress

25
Epinephrine
  • a- effects decd bronchial secretions edema
  • b- effects bronchodilation, tachycardia
  • Most studies on racemic epinephrine but at least
    one double-blind RCT suggests equivalence to
    L-epi
  • Waisman et al. 1992d. Pediatrics. 89 302-06
  • 0.5 ml 2.25 racemic epinephrine 5 ml 11000
    L-epinephrine
  • L-epi more available and less expensive

26
Does Epi work in Croup?
  • 5 prospective double-blind RCTs of epinephrine
    in croup
  • 4 demonstrate decreased airway obstruction with
    effect lasting 2 hours
  • Kuusela et al. 1988. Acta Paed. Scand. 77 99-104
  • Taussig et al. 1978. Am J Dis Child 132 484-87
  • Westley et al. 1978. Am J Dis Child 132 484
  • Fogel et al. 1982. J. Ped. 101 1028-31
  • One failed to show any benefit but unsure of
    length of observation time
  • Gardner et al. 1973. Pediatrics 52 52-55
  • Epinephrine appears to offer symptomatic benefit

27
Does Epi help decrease admission?
  • 3 studies totaling 166 pts who got epi
    steroids, observed for 2-3 hrs and then
    discharged w/ arranged f/u in 48 hrs
  • 47/50 required no further Tx in one study, while
    the other 2 were able to D/C 55 and 51 of pts
    w/ only 1 recurrence of resp. distress in pts who
    otherwise would have been admitted
  • Kelly et al. 1992. Am J Emerg 10 181-83
  • Ledwith et al. 1995. Ann Emerg Med 25 331-37
  • Prendergast et al. 1994. Am J Emerg Med. 12
    613-16

28
How much epi can we safely give?
  • Studies give 0.05 ml/kg or 0.25-0.5 ml a of
    2.25 RE soln dont often quote frequency
  • Locally known to give 0.5 ml q2h O/N
  • Case report of MI in pediatric pt following
    multiple doses of RE via neb
  • Developed short run of VT, and mild transient CP
  • Abnormal ECG and elevated CK-MB
  • Structurally normal heart as per echo angio but
    small infarct seen by nuclear stress scan
  • Butte et al. 1999. Pediatrics 104 e9
  • Suggests we should be more cautious

29
Steroids
  • Postulated to work by anti-inflammatory effect to
    decrease edema, but exact mechanism uncertain
  • Onset of effect usually quoted as being 6 hrs,
    but some have observed effect as early as 2 hrs

30
Are Steroids useful in Croup?
  • One meta-analysis comprising 1286 pts in 10 RCTs
    and 2 RCTs quoted as strong evidence
    demonstrating faster clinical improvement, decd
    likelihood of intubation, and shorter admissions.
    Also suggests better effect w/ higher doses.
  • Kairys et al. 1989. Pediatrics. 83 683-93
  • Super et al. 1989. J Ped. 115 323-29
  • Kuusela and Vesikari. 1988. Acta Paed Scand.
    77 99-104
  • More recent meta-analysis of 24 RCTs ( incl. 15
    new studies) demonstrates symptomatic
    improvement, fewer interventions, and shorter
    hospital stays in steroid-treated children w/ NNT
    of 5-7, but did not show decd risk of intubation
  • Ausejo et al. 1999. BMJ. 319 595-600
  • Cochrane review concluded CS are effective in
    relieving the Sx of croup and decreasing need for
    co-interventions, and length of stay in hospital
  • Ausejo et al. 2002. Coch Data Sys Rev Issue1

31
What steroid, what route, what dose?
  • IM Dexamethasone was shown to be superior to
    budesonide in one RCT
  • Johnson et al. 1998. N Engl J med. 339 498-503
  • Dexamethasone can be given IM or PO no
    head-to-head comparison studies
  • Dose more controversial
  • Kairys et al incd benefit w/ doses gt 0.3 mg/kg
  • Another double-blind RCT of 120 children
    concluded a dose of 0.15 mg/kg just as effective
  • Geelhoed and Macdonald. 1995. Ped Pulmonolgy. 20
    362-68
  • No studies have shown any safety concerns or
    adverse effects with dexamethasone even at doses
    up to 0.6 mg/kg
  • Current recommendation is Dex 0.6 mg/kg PO
  • Ausejo et al. 1999. BMJ. 319 595-600

32
Does giving steroids early in the ED affect
disposition or Outcome?
  • At least 4 RCTs, all suggesting improved
    clinical status with early steroids
  • 1 study only had 80 power to detect 67
    difference in admission rate
  • Johnson et al. 1996. Arch Ped Adol Med 150
    349-55
  • 2 suggest decreased admission rate
  • Johnson et al. 1998. N Engl J Med. 339 498-503
  • Klassen et al. 1994. N Engl J Med. 331 285-89
  • 1 study suggest no sig benefit from nebulized
    budesonide in addition to PO dex
  • Klassen et al. 1998. JAMA 279 1629-32
  • Steroids early appear to be helpful

33
Who do you admit?
  • Most pts can be discharged
  • Admission for
  • Marked distress / ill looking
  • Hypoxia
  • Dehydration
  • Poor Tx response / persistent stridor other Sx
  • Other medical co-morbidities (prem, cardiac,
    pulm)
  • Young age
  • Social far from hospital, questionable f/u,
    scary story, anxious parents

34
Who do you intubate?
  • Very rare since advent of steroids
  • Use ½ size smaller than calculated
  • No clear guidelines exercise clinical judgment

35
Case
  • 13 yo boy w/ known asthma presents w/ runny nose,
    cough, and incd SOB
  • O/E 373 / 100 / 22 / 96 RA
  • Mild exp wheezes
  • PEF 300 compared to usual of 375

36
Whats your DDx for wheezing?
  • Asthma
  • Foreign body
  • Bronchiolitis
  • CHF
  • Anatomic (vascular ring, laryngomalacia..)
  • CF
  • Pertussis
  • Pneumonia

37
Asthma
  • Most common chronic dz of children
  • Rising M M mortality doubled 1977-85
  • Chronic inflammatory dz characterized by
    exacerbations remissions, w/ airway obstruction
    partially reversible w/ meds
  • Specific triggers
  • Goal of ED care is to coordinate w/ existing care
    plan as much as possible

38
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39
Whats your approach?
  • Initial assessment
  • ABCs
  • Initial management
  • Oxygen, bronchodilators, steroids,
  • Identify risk factors and assess Tx response
  • Disposition and F/U

40
Mortality Risk Factors
  • Prior sudden exacerbations
  • Prior intubations / ICU stays
  • gt2 admissions in past year
  • gt3 ED visits in past yr
  • Admission or ED visit in past month
  • gt2 ventolin inhalers per month
  • Currently on, or recent weaning from, steroids
  • Poor perception of airflow obstruction
  • Co-morbid disease
  • Low SE status, urban residence
  • Psychiatric dz
  • Sensitivity to Alternaria

41
Clinical Scoring Systems
  • Most common is pulmonary index
  • Based on physical exam findings including RR,
    wheezing, I-E ratio, and use of accessory muscles
  • None have sufficient validation to be used in
    disposition decisions

42
Pulmonary Function Tests
  • Formal PFTs are best to measure degree of
    obstruction but not convenient in ED
  • PEF commonly used
  • correlates w/ FEV1
  • Effort-dependant, pt needs to stand
  • Compare w/ personal best or standard tables
  • PEF pred Severity
  • lt30 possibly life-threatening
  • lt50 severe
  • 50-80 moderate
  • gt80 mild

43
Pulse Oximetry Oxygen
  • No official agreement on normal values
  • NAEPEP states anyone lt90 should get O2
  • Common practice in the region is lt92
  • Acute asthma pts w/ SaO2 lt95 were more likely to
    be admitted and more likely to return to ED if
    discharged
  • Geelhoed et al. 1990. J Ped. 117 907-09
  • SaO2 lt93 found to be 35 sensitive and 93
    specific fro admission
  • Mayefsky and el_Shianway. 1992. Ped Emerg Care
    8 262-4
  • Limitations of pulse oximetry
  • Decd O2-carrying capacity
  • Low perfusion state
  • Provides no information on ventilation

44
b-agonists
  • Salbutamol is 1st line therapy in asthma
  • Epinephrine has no benefit over salbutamol
  • Klassen et al. 2000. Acad Emerg Med 7 1097-103
  • Mechanism of action
  • Relax bronchial smooth muscle
  • Increase secretion of water from mucous glands
  • Increase mucociliary clearance
  • Controversies
  • Route of administration in ED
  • New pure R isomers (levalbuterol)
  • Continuous therapy

45
MDI or Nebulizer?
  • Nebulizers enormously popular in ED
  • Cost of nebulizer is 50 greater
  • Most people use MDIs at home
  • 5 studies show either equivalence, or even
    superiority of MDI over nebulizer
  • One double-blind RCT in 5-17 yo subjects showed
    no difference
  • Schuh et al. 1999. J Ped. 135 22-27
  • Similar study in pts aged 1-4 yo showed decd
    admission rate less wheezing in MDI group
  • Leversha et al. 2000. J Ped 136 497-502
  • Ploin et al. 2000. Pediatrics. 106 311-17
  • MDI makes more sense in ED

46
IV Salbutamol
  • Few well designed trials
  • Cardiotoxicity need to monitor cardiac funxn
    K
  • Rationale may get to non-ventilated lung areas
  • One double-blind RCT of IV salbutamol in addition
    to continuous nebulized salbutamol showed more
    rapid improvement than control group
  • Did not follow cardiac enzymes
  • Browne et al. 1997. Lancet. 349 301-305
  • Current recommendation is to consider early on in
    severe Tx-refractory cases

47
Continuous b-agonist therapy
  • Usually administered as 0.5 mg/kg/h , to a
    maximum of 15 mg
  • Requires cardiopulmonary monitoring
  • some studies (mostly adult) showing improved
    asthma scores, but no difference in PEFs,
    admission rates, or adverse effects
  • Besbes-Ouanes et al. 2000. Ann Emerg Med
    36198-203
  • Jury still out may consider if tx-refractory

48
Levalbuterol
  • Salbutamol (albuterol) R S isomers
  • R isomer ? bronchodilation
  • S isomer ? bronchoconstriction
  • Manifests clinically as tolerance after repeated
    use
  • Levalbuterol is pure R isomer
  • 5x cost of salbutamol
  • One double-blind crossover study of 33 kids
    suggests better than or equivalent to salbutamol
    w/ less side effects, but in stable pts (not ED
    setting)
  • Gawchik et al. 1999. J Allergy Clin Immunol 103
    615-21
  • No head-to-head trials in ED setting
  • Not indicated for use at this time needs further
    study

49
Anti-Cholinergics
  • Ipratropium bromide
  • Similar to atropine bromide group prevents
    systemic effect
  • Inhibits Ach-mediated bronchoconstriction
  • Only useful in addition to b-agonist
  • Takes 60-90 min to reach peak effect
  • Given as 250 mg x3 doses or 500 mg x2 doses by
    nebulizer over 1 hour repeat q2-4h prn
  • One meta-analysis and a Cochrane review show
  • Multiple doses (but not single doses) decrease
    admissions in mod - severe exacerbations w/ NNT
    of 12
  • No conclusive evidence for use in mild-moderate
    cases
  • Plotnick and Ducharme. 1998. BMJ. 317 971-977
  • Plotnick and Ducharme. 2002. Coch Data Sys Rev.
    Issue 1
  • NAEPP use in severely ill kids, and those not
    responding to high dose b-agonist therapy

50
Steroids
  • Meta-analysis of 30 RCTs recent Cochrane
    review show
  • Early steroids decd admission rates (NNT 8)
  • IV PO in efficacy no significant adverse
    effects
  • Rowe et al. 1992. Am J Emerg Med. 10 301-310
  • Rowe et al 2002. Coch Data Sys Rev. Issue 1
  • Speed resolution of obstruction
  • Potentiate effects of b-agonists
  • Steroids prevent relapse w/ NNT 13, and decrease
    need for b-2 agonists
  • Rowe et al 2002. Coch Data Sys Rev. Issue 1
  • Indicated for most pts in ED

51
Early inhaled steroids?
  • Controversial
  • One double-blind RCT comparing PO prednisone and
    inhaled budesonide in 185 acute asthma pts d/cd
    from ED suggests equivalence in preventing
    relapse
  • FitzGerald et al. 2000. Can Resp J. 7 61-7
  • Double-blind RCT of 22 kids treated w/ either
    budesonide or PO prednisolone showed similar
    benefit
  • Volovitz et al. 1998. J Allergy Clin Immunol.
    102 605-9
  • Another double-blind RCT of 188 pts (no kids)
    found additional benefit of inhaled budesonide in
    addition to PO prednisone in preventing relapse
    in pts discharged from ED
  • Rowe et al. 1999. JAMA. 281 2119-26

52
Early inhaled steroids?
  • 2 separate Cochrane reviews looking at ICS
  • One looked at role of ICS in ED
  • 7 trials (2 pediatric) involving 352 pts
  • ICS alone can decrease admission rates
  • ICS other CS ? non-sig trend towards decd
    admission
  • Inconclusive evidence for benefit of adding ICS
  • Edmonds et al. 2002. Coch Data Sys Rev. Issue 1
  • 2nd review looked at role of ICS after discharge
  • 3 trials of 909 pts found non-sig trend towards
    decd relapse in ICS and other CS
  • ICS vs. other CS alone no sig differences
    (severe cases excluded)
  • Concluded no evidence to support addition or
    substitution of ICS for systemic CS, but may have
    yet undefined role in mild exacerbations
  • Edmonds et al. 2002. Coch Data Sys Rev. Issue 1

53
Magnesium
  • Being re-discovered
  • ?MOA counters Ca ions preventing smooth muscle
    contraction
  • Can cause N V, weakness, facial flushing.
  • Low cost, easy administration, availability
  • Good evidence for efficacy in kids
  • Dose 25 40 mg/kg IV higher doses appear to
    produce greater improvement

54
Magnesium is it useful?
  • two RCTs showed improved PFTs, decd admission,
    and no adverse effects with Mg
  • Ciarallo et al. 1996. J Ped 129 809-814
  • Ciarallo et al. 2000. Arch Ped Adol Med. 154
    979-83
  • 2 meta-analyses both agreed current evidence
    supports use of Mg in adults w/ severe asthma
    exacerbations
  • Rowe et al. 2000. Ann Emerg Med. 36 181-190.
  • Alter et al. 2000. Ann Emerg Med. 36 191-97
  • Consider in moderately severely ill pts failing
    to respond to salbutamol

55
Who would use Aminophylline?
  • Good evidence that it has no benefit over
    salbutamol
  • Significant toxicity
  • Some suggestion it may be useful in the most
    severe pts in an ICU setting
  • Cochrane review
  • Found significant improvement in FEV1 but no
    effect on length of stay or need for
    co-interventions
  • Incd risk of vomiting (RR 3.69)
  • Concluded should be considered in admitted
    Tx-refractory cases of severe asthma
  • Mitra et al. 2002. Coch Data Sys Rev. Issue 1
  • Not indicated in ED

56
Other Tx
  • Heliox
  • Helium O2 decd density improves air flow
  • Often get hypoxia b/c need at least 60 helium
  • Cochrane review of 4 RCT's (1 peds) in ED
    concluded no evidence for use in ED
  • Rodrigo et al. 2002. Coch Data Sys Rev. Issue 1
  • Leukotriene Antagonists
  • One abstract describes improved outcome in ED
    setting, but no RCTs
  • Silvermanm et al. 1999. Ann Emer Med. 34(suppl)1

57
Who gets intubated?
  • Last resort
  • RSI protocol using ketamine
  • Careful to prevent incd intrathoracic pressure ?
    decd venous return ? arrest
  • Indications (Rosen)
  • Apnea
  • PaCO2 gt 42 mm Hg and worsening, or no response to
    Tx
  • Signs of impending resp failure

58
Any predictors of admission?
  • Model for predicting admission
  • Age 6 yo or younger
  • Male gender
  • Requiring O2
  • Interval severity of asthma
  • Severity of wheeze at initial presentation
  • Post-Tx SpO2 (most imp)
  • Predictive accuracy of 90, with 86 sensitivity
    and 88 specificity
  • Chey et al. 1999. J Clin Epi 52(2) 1157-63

59
Case
  • 2 yo male w/ fever, cough, vomiting x 2/7
  • Looks moderately ill but not lethargic
  • O/E 389 / 198 / 60 / 87 RA
  • Mild incd WOB, decd AE on RUL
  • Normal WBC

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61
Pneumonia
  • Usually in 1st year of life
  • Viral causes account for 60-90 (RSV, paraflu)
  • 75 of deaths due to bacterial causes
  • Bacteriology is age-dependent
  • GBS, E. coli, Listeria, Ureaplasma in neonate
  • Chlamydia at 3-19 wks
  • Strep pneumoniae most common all other age groups
  • Mycoplasma pneumoniae usually gt5yo
  • Bordetella pertussis usually lt 6mo

62
Pneumonia
  • Treatment decisions based on
  • Age
  • Likely pathogen
  • Degree of illness
  • lt 3mo ? amp gent or amp 3d gen ceph
  • gt 3mo
  • Inpatients IV cefuroxime or cefotaxime /-
    erythro
  • Outpatients macrolide (azithro) or clavulin or
    TMP-SMX must be reassessed in 24 hrs
  • If Mycoplasma use macrolide or TMP-SMX

63
Who needs admission?
  • No CAP score in kids
  • Toxic appearance
  • Vomiting or dehydration
  • Respiratory distress
  • Pleural effusion (needs investigation)
  • Immunocompromised
  • Psycho-social factors
  • Age lt 6 mo

64
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