Management of Common Respiratory Disorders in Children. Whitney Pressler, MD Pediatric Brown Bag Series Webinar June 14, PDF Free Download

Management of Common Respiratory Disorders in Children Whitney Pressler, MD Pediatric Brown Bag Series Webinar June 14, 2016

Disclosures I have no financial relationships to disclose I will not be discussing off label or investigational use of any medications

Roadmap Objectives Asthma Acute management Escalation/de escalation of management Bronchiolitis Pneumonia Take home reminders

Objectives After the presentation, attendees should be able to: Manage pediatric asthma, including escalation and deescalation of medical management when appropriate Provide focused care for bronchiolitis in urgent care or hospital setting State indications for radiography use in pediatric pneumonia Provide appropriate treatment for pneumonia for age and clinical findings Discuss and anticipate common complications of bronchiolitis and pneumonia

Case 1 A 5 year old male presents to an urgent care clinic complaining of cough and difficulty breathing. His mother states this started after he got sick last week, and he is not getting better. Your examination reveals HR 120, RR 28, SpO2 91%. The child has diminished breath sounds in both lung bases and wheezes throughout. He also has subcostal and supraclavicular retractions. The remainder of his examination is normal.

Asthma Lower respiratory disease characterized by exaggerated bronchoconstriction (airway hyperresponsiveness) Also associated with airway inflammation/edema and increased mucus Wide variety of phenotypes and triggers Significant variance in prevalence across states, cities, and neighborhoods

Acute Asthma Exacerbation Supplemental oxygen administer when oxygen saturation is consistently <91%, wean when >94% Short acting inhaled beta 2 agonists (albuterol) administer for rapid relief of bronchoconstriction Can give every 10 20 minutes for initial therapy (no clinical difference between MDI and nebulizer) Alternative method includes continuous albuterol

Acute Asthma Exacerbation Inhaled ipratropium bromide (Atrovent, Duonebs) up to 3 doses in urgent care or emergency department setting can reduce need for hospitalization Corticosteroids 1 2mg/kg/day of prednisone, prednisolone, or methylprednisolone RESPONSE to initial treatment is the best measure of severity and predictor of disposition

Acute Asthma Exacerbation Before leaving the hospital, ED, or clinic, make sure the patient has: Asthma Action Plan Daily controller medications if indicated Follow up in place Avoid: routine x rays, chest physiotherapy, incentive spirometry, mucolytics

Case 1, Continued The same child now presents to your clinic for a 7 year old well child examination. His growth and development have been normal, and he denies any recent asthma exacerbations. He takes an inhaled corticosteroid daily and albuterol as needed. His mother asks how long he will need to continue his daily medication.

Long Term Asthma Management First step: Determine asthma control Peak flow measurements Standardized questionnaires for patient and parent What are the patient s specific triggers?

Allergy Asthma Immunol Res. 2010 an: 2(1): 1 13.

Long Term Asthma Management If poorly controlled Assess adherence to medications Look at inhaler technique Think about environmental control THEN step up medical therapy PRACTALL, NAEPP EP3, ERS Task Force, GINA all have similar recommendations in guidelines

Allergy Asthma Immunol Res. 2010 an: 2(1): 1 13.

Long Term Asthma Management If well controlled, don t forget to STEP DOWN! Follow up to discuss control again in few months Don t forget the Asthma Action Plan before they go

Case 2 A 10 month old female presents for an office visit with a chief complaint of cough. She also has a runny nose and fever with Tmax 101.3F. On examination, you note tachypnea, copious clear nasal discharge, and moderate retractions. Lung auscultation reveals transmitted upper airway sounds and scattered wheezes.

Bronchiolitis Commonly caused by viral lower respiratory tract infection Characterized by acute inflammation, edema, and necrosis of epithelial cells with increased mucus Screen for risk factors for severe disease: <3 months of age History of prematurity Underlying cardiopulmonary disease Immunodeficiency

Bronchiolitis Clinical diagnosis only Treatment is entirely supportive Should not administer albuterol, corticosteroids, or epinephrine Can consider nebulized hypertonic saline in hospitalized children Supplemental oxygen if persistently less than 90% SpO2; no need for continuous pulse oximetry USUALLY

Case 2, continued How might management change if this patient was 10 weeks old instead of 10 months? What if they had a strong personal or family history of atopy?

Case 3 A 3 year old male presents to clinic for persistence of severe cold symptoms. Initial URI symptoms began 1 2 weeks ago, and cough has now worsened over the last 2 days. Patient is now having fevers daily up to 103F and has decreased activity and PO intake.

Case 4 A 14 year old female presents with a 1 week history of low grade fevers (Tmax 100.9F), cough, and fatigue. She has still been able to complete homework assignments, but her mother is concerned that her cold is not getting better yet.

Pneumonia Occurs in about 2.6% children younger than 17 years in the United States Lower respiratory tract infection with fever, respiratory symptoms, and evidence of parenchymal involvement by physical exam or radiography Inflammatory process of lungs including airways, alveoli, connective tissue, visceral pleura and vascular strictures

Pneumonia Presentation can vary, and symptoms can be nonspecific and subtle Fever and cough are hallmarks Also need some evidence of respiratory impairment (nasal flaring, retractions, hypoxia, tachypnea) and evidence of infiltrate (crackles, rales, decreased breath sounds, egophony, tactile fremitus, dullness to percussion) Radiating neck pain and vague abdominal pain are also fairly common

Pneumonia Viral pneumonia (60% of childhood pneumonias) More likely to have insidious onset and more mild course More likely to have wheezing Diffuse changes in lung exam Bacterial pneumonia Likely more abrupt onset with more severe symptoms More likely to develop complications

Pneumonia Chest radiograph in limited situations: Severe disease requiring hospitalization Inconclusive clinical findings Rule out other causes of respiratory distress (ex, foreign body, heart disease) Prolonged fever/worsening symptoms despite appropriate treatment Workup of young infant with fever without a source

Pneumonia Follow up chest films are NOT indicated in children who are treated and recovered Follow up chest films ARE indicated for complicated pneumonias that are clinically unstable CBC with differential is indicated if the patient is to be hospitalized; it does NOT help with differentiation of viral and bacterial pneumonia Acute phase reactants also can be helpful for hospitalized patients

Pneumonia Young children more likely to be lobar pneumonia S. pneumoniae is still the most common pathogen High dose amoxicillin should be adequate for most cases Clavulanic acid adds additional action against H. influenza and M. catarrhalis School aged children and teens more likely to be atypical pneumonia M. pneumoniae is the most common in this group Consider use of a macrolide in this group (3 5 day course of azithromycin or clarithromycin)

Pneumonia Antiviral treatment if influenza is strongly suspected, you may initiate treatment immediately Inpatient management Ampicillin/sulbactam or ceftriaxone for lobar pneumonia Add vancomycin, linezolid, or clindamycin if there is another comorbidity or reason to suspect S aureus 7 10 day total course is generally adequate

Pneumonia Pleural effusion generally self resolves, but warrants additional monitoring Empyema purulent effusion; association with S aureus, S pneumoniae, and H influenzae Pneumatocele classically occurs with S aureus, may involute spontaneously or require surgery

Pneumonia Necrotizing pneumonia rare, prolonged fever and septic appearance with radiolucent lesion on X ray, confirmed with CT Lung abscess be mindful of risk factors like airway obstruction or lung anomalies Hyponatremia from SIADH

Summary Asthma Acute exacerbations should have albuterol and corticosteroids immediately Increasing/decreasing medical intervention should be routine at all clinical encounters Asthma Control Tests or other standardized assessments have been shown to help with this

Summary Bronchiolitis Clinical diagnosis Supportive care ONLY despite our wanting to do more! Be mindful of additional risk factors

Summary Pneumonia Most cases are still viral No need for blood tests or imaging in most outpatient encounters High dose amoxicillin for lobar pneumonias, azithromycin for atypical Counseling families on return precautions is critical due to possibility of serious complications

References 1. Asthma Guidelines. AAP News, November 2007. 28(11): 30. 2. Link HW, Pediatric Asthma in a Nutshell. Pediatrics in Review 2014; 35 (7) 287 298. 3. Potter P, Current guidelines for the management of asthma in young children. Allergy Asthma Immunol Res. 2010 Jan; 2(1): 1 13. 4. Okelo SO, et al. Interventions to modify health care provider adherence to asthma guidelines: a systematic review. Pediatrics. 2013; 132 (3). 5. Ralston SL, et al. AAP Clinical Practice Guideline: The Diagnosis, management, and prevention of bronchiolitis. Pediatrics 2014; 134:e1474 e1502. 6. Jacobs JD, Foster M, Wan J, Pershad J. 7% Hypertonic saline in acute bronchiolitis: a randomized controlled trial. Pediatrics. 2014;133 (1) 7. Gereige RS and Laufer PM. Pneumonia. Pediatrics in Review. 2013; 34(10) 438 456.

Management of Common Respiratory Disorders in Children. Whitney Pressler, MD Pediatric Brown Bag Series Webinar June 14, 2016