Bronchiolitis: What s the latest evidence?

Transcription

1 Bronchiolitis: What s the latest evidence? Leanne DePalma, MD Division of Hospital Medicine Washington University Department of Pediatrics I have no financial disclosures. 1

2 Goals and Objectives Goal: To improve competence in evidence based care of children with bronchiolitis Objectives: Review current statistics and clinical practices related to bronchiolitis Review the evidence on admission criteria and safe discharge for patients with bronchiolitis Review the evidence on lab and imaging workup for patients with bronchiolitis Review the evidence on various treatments used for bronchiolitis Bronchiolitis definition A lower respiratory tract infection in infants characterized by: Acute inflammation, edema and necrosis of epithelial cells in small airways Increased mucous production Bronchospasm Signs and Symptoms include: Rhinitis Tachypnea Wheezing Coughing Crackles Use of accessory muscles or nasal flaring 2

3 Bronchiolitis definition Common definition: first episode of wheezing associated with signs of an upper respiratory tract infection during the peak RSV season AAP definition: a clinical diagnosis consisting of rhinitis, tachypnea, wheezing, cough, crackles, use of accessory muscles, and or nasal flaring. 5 Epidemiology The most common lower respiratory infection in children < 2 years old Accounts for > 90,000 hospital admissions annually Admit rate is 30 per 1000 children < 1 year old Mortality rate is 2 per 100,000 live births (stable since 1979) Admission rate has doubled in the last 10 years Annual hospital costs estimated at $700 million 90% of children are infected with RSV in the first 2 years of life. 40% of them will have a lower respiratory infection 3

4 Epidemiology Bronchiolitis is most often caused by RSV but many other viruses implicated including: Rhinovirus human metapneumovirus Influenza Adenovirus parainfluenza In one study of 2207 patients with bronchiolitis 29.8% were positive for >1 virus 1 6% had no viral pathogen identified 84.5% had RSV or rhinovirus (the top two) Current Practices A 2005 study of 17,397 patients with bronchiolitis at 30 children s hospitals showed wide variation between hospitals in diagnostic testing, treatments used and LOS. 2 4

5 Variation in diagnostic testing Overall 72 % of patients received a CXR Across hospitals the percentage of patients receiving CXR ranged from 38% - 89% Variation in medication used 5

6 Current Practices A 2005 study of 17,397 patients with bronchiolitis at 30 children s hospitals showed wide variation between hospitals in diagnostic testing, treatments used and LOS The study found that use of antibiotics, steroids and obtaining CXR were all factors that increased LOS Obtaining a CXR was a predictor of antibiotic use Christakis DA, Charles A. Cowan, Michelle M. Garrison, Richard Molteni, Edgar Marcuse and Danielle M. Zerr, Variation in Inpatient Diagnostic Testing and Management of Bronchiolitis Pediatrics 2005;115;878 Current Practices Value in Inpatient Pediatrics Network (VIP) formed a voluntary quality improvement collaborative of pediatric hospitalists for the purpose of benchmarking the use of bronchodilators, steroids, chest radiography, chest physiotherapy, and viral testing in bronchiolitis Analyzed 11,568 hospitalizations for bronchiolitis from 17 centers Shared resources within the network, including protocols, scores, order sets, and key bibliographies, and established group norms for decreasing utilization Showed decreased utilization of bronchodilators and chest physiotherapy over the study period ( ) There was no significant change in the use of steroids, Chest X ray or viral testing. Journal of Hospital Medicine Decreasing unnecessary utilization in acute bronchiolitis care: Results from the value in inpatient pediatrics network Volume 8, Issue 1, pages 25-30, 5 OCT 2012 DOI: /jhm

7 Intra hospital change in bronchodilator utilization * Centers failing to improve Journal of Hospital Medicine Decreasing unnecessary utilization in acute bronchiolitis care: Results from the value in inpatient pediatrics network Volume 8, Issue 1, pages 25-30, 5 OCT 2012 DOI: /jhm Diagnostic testing AAP recommendation: Bronchiolitis should be a clinical diagnosis and clinicians should not routinely order laboratory or other diagnostic studies 5 7

8 Pulse oximetry Has been correlated with clinical outcomes 5 x increased risk of hospitalization for SpO2 < 94% Mild hypoxemia correlates with more severe disease Pulse oximetry should be monitored and supplemental O2 started for levels <90% Oximetry has been associated with prolonged LOS in inpatients, so continuous monitoring should be stopped as the child improves Viral testing Generally does not alter management or outcomes for outpatients For infants < 2 months old with fever When RSV + there is a low, but not insignificant, rate of SBI, mostly UTI Rates of SBI are similarly low when making a clinical diagnosis of bronchiolitis without viral testing For inpatients viral testing is useful for cohorting One study showed 1 in 3 patients with bronchiolitis had more than 1 virus 1 More expansive viral testing (multiplex) may be more useful for cohorting than just RSV +/ 8

9 Chest X ray AAP Recommendation: Radiography may be useful when child does not improve at expected rate, the severity of disease requires further evaluation or if another diagnosis is suspected 5 Toronto Study: 6 5 times as many children received antibiotic therapy post radiography as compared with their intended management plan pre radiography Only 2 of 265 patients had radiographs inconsistent with bronchiolitis. Infants with both a baseline oxygen saturation >92% and a RDAI score <10 of 17 possible points were 3.9 times more likely to have a simple radiograph than their counterparts with more hypoxia or more distress Suzanne Schuh, MD, Amina Lalani, MD, Upton Allen, MBBS, David Manson, MD, Paul Babyn, MD, Derek Stephens, MSC, Shannon Macphee, MD, Matthew Mokanski, RN, Svetlana Khaikin, RN, And Paul Dick, MDCM, MSC Evaluation of the Utility of Radiography in Acute Bronchiolitis, The Journal of Pediatrics April Predictors of safe discharge: 3 Age >2 months No history of intubation + history of eczema Respiratory rate normal for age* No or mild retractions Initial O2 saturation >94% Adequate oral intake Fewer albuterol or epinephrine treatments in first hour Admit or discharge? Mansbach, JM, S Clark, NC Christopher, F LoVecchio, S Kunz, U Acholonu, Ca Carmarga Jr, Prospective Multicenter Study of Bronchiolitis: Predicting Safe Discharges From the Emergency Department, Pediatrics, 2008;121;680 Factors not affecting disposition: Gender Race ED visit in previous week Symptoms > 7 days Family history of asthma Presence of wheeze *Age specific Respiratory rates 0 to 1.9 mo 45 bpm 2 to 5.9 mo 43 bpm 6 to 23.9 mo 40 bpm 9

10 Disposition from ED 4 Following up the discharged patients from the previous study: 722 patients discharged 121 (17%) had an unscheduled visit in the 2 weeks following the initial ED visit. Most of these visits (65%) occurred within 2 days of the initial ED visit 80 (11%) had an unscheduled visit that resulted in escalation of therapy or admission (6%) Factors that increase likelihood of unscheduled visit Age < 2 mo Male gender History of previous hospitalization Factors that do not contribute to likelihood of unscheduled visit Clinical presentation at initial visit Underlying medical condition Medications used in past week Agatha Norwood, MD, Jonathan M. Mansbach, MD, Sunday Clark, MPH, ScD, Muhammad Waseem, MD, and Carlos A. Camargo Jr, MD, DrPH Prospective Multicenter Study of Bronchiolitis: Predictors of an Unscheduled Visit After Discharge From the Emergency Department Academic Emergency Medicine, April 2010, Vol. 17, No Treating Bronchiolitis 10

11 Bronchodilators (Albuterol) Background: Short acting bronchodilators that can be prescribed for home use may improve the symptoms of bronchiolitis Infants with bronchiolitis are usually wheezing because their airways are obstructed as opposed to broncho constricted. Therefore may be less likely to respond to bronchodilators. Studies have looked at reducing admission rates, LOS and clinical scores Evidence has been contradictory The Evidence Shows: Bronchodilators Inpatients: No change in LOS Minority of studies show any improvement in clinical scores Outpatients: No change in admission rates May slightly improve oxygenation Short term improvements in clinical scores 11

12 Albuterol vs. Placebo: LOS Percentage of patients discharged at 24, 48 and 72 hours. Joseph V. Dobson, Susan M. Stephens-Groff, Shawn R. McMahon, Margaret M Stemmler, Susan L. Brallier and Curtis Bay The Use of Albuterol in Hospitalized Infants With Bronchiolitis Pediatrics 1998;101;361. Albuterol vs Placebo: Improvement in clinical scores 17 Gadomski AM, Bhasale AL, Bronchodilators for bronchiolitis (Review) The Cochrane Library, 2009, Issue 1 12

13 Bronchodilators / Albuterol Recommendation: May improve short term clinical scores in a subset of children Use only after trial of the medicine with a documented responsiveness Nebulized epinephrine Background: A fast acting bronchodilator which may improve symptoms of bronchiolitis. Studies have looked at both reduction in admission rates and LOS There is some concern that use of epinephrine in outpatients may provide transient clinical benefits which could lead to premature decision to discharge. The Evidence Shows: Cochrane review (2004) compared to placebo there are short term improvements in clinical scores but no change in admission rates Cochrane review (2011) compared to placebo decreased admission rate on day 1 but not on day 7. RCT (2013 ) racemic Epi vs inhaled saline showed no difference between groups. No studies show change in LOS 13

14 Recommendation: Nebulized Epinephrine There is no indication for routine use of nebulized Epinephrine in inpatients Use in outpatient settings may decrease admission rates Of the bronchodilators, epinephrine is preferred in the outpatient/emergency department setting. Steroids Background: Anti inflammatory action of corticosteroids might alleviate the symptoms of bronchiolitis Many studies have looked at effect of oral, IM or IV steroids Several different steroids have been used including prednisone, dexamethasone, methylprednisone and hydrocortisone. 14

15 The Evidence Shows: Steroids Overall: studies have not shown a significant difference in clinical scores, hospitalization rates or LOS between steroids or placebo Many of these studies have been small and may not be adequately powered to show a difference Steroids Reduction in mean LOS Improved Clinical scores at 24 hours 2000 Meta Analysis 1 dose of Dex vs Placebo No change in admit rate or clinical score at 4 hours 2007 RCT of 600 pts 6 days of Dex vs Placebo No change in admit rates over 21 days 2009 RCT of 800 pts 15

16 Nebulized Epi and Dexamethasone 13 Amy C. Plint, M.D., M.Sc., David W. Johnson, M.D., Hema Patel, M.D., M.Sc., Natasha Wiebe, M.Math., Rhonda Correll, H.B.Sc.N., Rollin Brant, Ph.D., Craig Mitton, Ph.D., Serge Gouin, M.D., Maala Bhatt, M.D., M.Sc., Gary Joubert, M.D., Karen J.L. Black, M.D., M.Sc., Troy Turner, M.D., Sandra Whitehouse, M.D., and Terry P. Klassen, M.D., M.Sc., Epinephrine and Dexamethasone in Children with Bronchiolitis N Engl J Med 2009;360: Recommendation: Steroids There is not enough evidence to support the routine use of steroids in patients with bronchiolitis Evidence that a synergistic effect between epinephrine and steroids exists should still be considered preliminary. 16

17 Hypertonic Saline Background: Has been shown to improve mucociliary clearance in asthma, CF, and bronchiectasis Hypertonic saline (usually 3%) is proposed to improve bronchiolitis in several ways: Induces osmotic flow of water into the mucus layer, improving mucous clearance Breaks ionic bonds within mucous lowering viscosity of mucous Stimulates cilia to beat via prostaglandin release Absorbs water from mucosa reducing airways edema Induces cough to help clear sputum There is some concern that hypertonic saline may induce bronchospasm so it is often administered with bronchodilators Hypertonic Saline The Evidence Shows: 3% saline compared to 0.9% saline (n = 581 in 7 studies) 4 inpatient studies have shown a decrease LOS (mean 1.16 days shorter) No significant change in rate of admission 4 studies showed a decrease in post inhalation clinical score 2 studies of patients in ED showed no short term improvement ( min) in clinical scores Adverse Events In the above studies low rate of adverse events, none of which were bronchospasm In 6 out of the 7 trials hypertonic saline was administered with bronchodilator In the final study 60% of patient received bronchodilator 17

18 Safety of Hypertonic Saline Without Bronchodilators 444 doses 3% saline 377 doses without bronchodilators 1 bronchospasm 2 events in one patient (cough), treatments stopped after 2 nd event Excessive Coughing in 2 additional patients Shawn Ralston, Vanessa Hill and Marissa Martinez Nebulized Hypertonic Saline Without Adjunctive Bronchodilators for Children with Bronchiolitis Pediatrics 2010;126;e520 Recommendation: Hypertonic Saline Hypertonic Saline reduces LOS in inpatients with moderately severe bronchiolitis Hypertonic Saline with or without use of bronchodilators appears to be safe 18

19 Chest physiotherapy Background: Thought to increase clearance of secretions and decrease ventilatory effort The Evidence shows: 19 Vibration, Percussion and Passive expiratory techniques have been studied No improvement in disease severity, LOS, oxygen requirement, or respiratory parameters compared with no intervention Some mild adverse effects (vomiting, respiratory instability) have been seen with use of Chest PT in one study. Recommendation: Don t use Chest PT in infants with bronchiolitis not on mechanical ventilation Nasal Suctioning Background: Young infants prefer nasal breathing but, the increased mucus production associated with bronchiolitis may inhibit breathing and lead to feeding difficulty. Nasal suctioning is a temporary measure to diminish the work of breathing 19

20 The Evidence Shows: Mussman et al 18 Nasal Suctioning Retrospective study of charts of 740 infants (< 12mo) hospitalized for bronchiolitis were reviewed for first 24 hours of admission Looked at type of suction used (deep vs non invasive) Looked at lapses of > 4 hours between suctioning events (no lapses, 1, 2, or > 3 lapses) Grant M. Mussman, MD; Michelle W. Parker, MD; Angela Statile, MD; Heidi Sucharew, PhD; Patrick W. Brady, MD, MSc, Suctioning and Length of Stay in Infants Hospitalized With Bronchiolitis, JAMA Pediatrics. 2013;167(5): Nasal Suctioning and LOS 20

21 Questions?? References 1. Mansbach, JM PA Piedra, MD; SJ Teach, MD, MPH; AF Sullivan, MS, MPH; T Forgey, MS; S Clark, MPH, ScD; JA Espinola, MPH; CA Camargo Jr, MD, DrPH; Prospective Multicenter Study of Viral Etiology and Hospital Length of Stay in Children With Severe Bronchiolitis Archives of Pediatric Adolescent Medicine, VOL 166 (NO. 8), Aug Christakis DA, Charles A. Cowan, Michelle M. Garrison, Richard Molteni, Edgar Marcuse and Danielle M. Zerr, Variation in Inpatient Diagnostic Testing and Management of Bronchiolitis Pediatrics 2005;115; Mansbach, JM, S Clark, NC Christopher, F LoVecchio, S Kunz, U Acholonu, Ca Carmarga Jr, Prospective Multicenter Study of Bronchiolitis: Predicting Safe Discharges From the Emergency Department, Pediatrics, 2008;121; Agatha Norwood, MD, Jonathan M. Mansbach, MD, Sunday Clark, MPH, ScD, Muhammad Waseem, MD, and Carlos A. Camargo Jr, MD, DrPH Prospective Multicenter Study of Bronchiolitis: Predictors of an Unscheduled Visit After Discharge From the Emergency Department Academic Emergency Medicine, April 2010, Vol. 17, No

22 References 5. AAP clinical practice guideline Diagnosis and Management of bronchiolitis Suzanne Schuh, MD, Amina Lalani, MD, Upton Allen, MBBS, David Manson, MD, Paul Babyn, MD, Derek Stephens, MSC, Shannon Macphee, MD, Matthew Mokanski, RN, Svetlana Khaikin, RN, And Paul Dick, MDCM, MSC Evaluation of the Utility of Radiography in Acute Bronchiolitis, The Journal of Pediatrics April Rosalind L Smyth, Peter J M Openshaw Bronchiolitis Lancet 2006; 368: Michael D. Mallory, MD, MPH; David K. Shay, MD, MPH; Joanne Garrett, PhD; W. Clayton Bordley, MD, MPH Bronchiolitis Management Preferences and the Influence of Pulse Oximetry and Respiratory Rate on the Decision to Admit Pediatrics Vol. 111 No. 1 January Shawn Ralston, Vanessa Hill and Marissa Martinez Nebulized Hypertonic Saline Without Adjunctive Bronchodilators for Children with Bronchiolitis Pediatrics 2010;126;e520 References 10. Michelle M. Garrison, Dimitri A. Christakis, Eric Harvey, Peter Cummings, Robert L. Davis, Systemic Corticosteroids in Infant Bronchiolitis: A Meta analysis, Pediatrics 2000; Howard M. Corneli, M.D., Joseph J. Zorc, M.D., Prashant Mahajan, M.D., M.P.H., Kathy N. Shaw, M.D., M.S.C.E., Richard Holubkov, Ph.D., Scott D. Reeves, M.D., Richard M. Ruddy, M.D., Baqir Malik, M.D., Kyle A. Nelson, M.D., M.P.H., Joan S. Bregstein, M.D., Kathleen M. Brown, M.D., Matthew N. Denenberg, M.D., Kathleen A. Lillis, M.D., Lynn Babcock Cimpello, M.D., James W. Tsung, M.D., Dominic A. Borgialli, D.O., M.P.H., Marc N. Baskin, M.D., Getachew Teshome, M.D., M.P.H., Mitchell A. Goldstein, M.D., David Monroe, M.D., J. Michael Dean, M.D., and Nathan Kuppermann, M.D., M.P.H., A Multicenter, Randomized, Controlled Trial of Dexamethasone for Bronchiolitis, N Engl J Med 2007;357: Zhang L, Mendoza Sassi RA, Wainwright C, Klassen TP Nebulized hypertonic saline solution for acute bronchiolitis in infants The Cochrane Library 2011, Issue 3 22

23 References 13. Amy C. Plint, M.D., M.Sc., David W. Johnson, M.D., Hema Patel, M.D., M.Sc., Natasha Wiebe, M.Math., Rhonda Correll, H.B.Sc.N., Rollin Brant, Ph.D., Craig Mitton, Ph.D., Serge Gouin, M.D., Maala Bhatt, M.D., M.Sc., Gary Joubert, M.D., Karen J.L. Black, M.D., M.Sc., Troy Turner, M.D., Sandra Whitehouse, M.D., and Terry P. Klassen, M.D., M.Sc., Epinephrine and Dexamethasone in Children with Bronchiolitis N Engl J Med 2009;360: Glenn Flores and Ralph I. Horwitz Efficacy of b2 Agonists in Bronchiolitis: A Reappraisal and Meta analysis Pediatrics 1997;100; Stemmler, Susan L. Brallier and Curtis Bay, Joseph V. Dobson, Susan M. Stephens Groff, Shawn R. McMahon, Margaret M. The Use of Albuterol in Hospitalized Infants With Bronchiolitis Pediatrics 1998;101; Michelle M. Garrison, Dimitri A. Christakis, Eric Harvey, Peter Cummings, Robert L. Davis, Systemic Corticosteroids in Infant Bronchiolitis: A Meta analysis, Pediatrics 2000;105 References 17. Gadomski AM, Bhasale AL, Bronchodilators for bronchiolitis (Review) The Cochrane Library, 2009, Issue Grant M. Mussman, MD; Michelle W. Parker, MD; Angela Statile, MD; Heidi Sucharew, PhD; Patrick W. Brady, MD, MSc, Suctioning and Length of Stay in Infants Hospitalized With Bronchiolitis, JAMA Pediatrics. 2013;167(5): Roqué i Figuls M, Giné Garriga M, Granados Rugeles C, Perrotta C, Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old (Review), The Cochrane Library, 2012, Issue Ralston, S, et al. Decreasing unnecessary utilization in acute bronchiolitis care: Results from the value in inpatient pediatrics network Journal of Hospital Medicine Volume 8, Issue 1, pages 25 30, 5 OCT