Wheezy? Easy Peasy! The Emergent Management of Asthma & Bronchiolitis Maneesha Agarwal MD Assistant Professor of Pediatrics & Emergency Medicine
Asthma Defined National Asthma Education and Prevention Program. Expert panel report 3 guidelines for the diagnosis and management of asthma. 2007. 2
From the American Lung Association. 3
Pediatric Asthma in Georgia Affects 260,000 children (10%) Costs $200 million 130,000 ED visits 2011 15 (2 nd ) 13,000 hospitalizations 2011 15 (4 th ) Online Analytical Statistical Information System (OASIS) GA DPH: The Strategic Plan for Addressing Asthma in Georgia 2013 2018
Clinical Scoring Systems PRAM = Preschool Respiratory Assessment Measure PASS = Pediatric Asthma Severity Score PAS = Pediatric Asthma Score PAS = Pulmonary Asthma Score 5
Clinical Respiratory Score 6
Albuterol (SABA) Bronchodilator Loosens mucous, improves mucociliary clearance Improves diaphragm contractility Inhibits mast cell release Modality MDI + Spacer = Nebulizer Intermittent = Continuous 7
Albuterol (SABA) Bronchodilator Loosens mucous, improves mucociliary clearance Improves diaphragm contractility Inhibits mast cell release Modality Levalbuterol Photo removed for copyright compliance 8
Ipratropium = Anticholinergic Reduces secretions Reduces bronchoconstriction Reduces cough Reduces admissions in moderate to severe patients NNT: 11 No evidence for settings beyond ED 9
Steroids Reduces inflammation Reduces mucus production Potentiates beta agonists Effects in 6hrs 10
Steroids: Options Prednisone Prednisolone Methylprednisone (IV) 1 2mg/kg/day for 3 5 days Dexamethasone (IM or oral) Cost effective 1 2 doses enhanced compliance Improved palatability Caregiver preference Inhaled steroids 11
Positive Expiratory Pressure (PEP) Recruits collapsed alveoli Better distal deposition of beta agonists 12
Magnesium Sulfate Muscle relaxer bronchodilator Reduces inflammation & mucus Reduces hospitalization Hypotension IVFs 13
IV / IM / SC Beta-Agonists Epinephrine anaphylaxis dosing IM or SC Terbutaline SC x 3 Drip 14
Heliox Decreases turbulence Drives air & medicine more distally Decreases hospitalizations Cannot use if: Poor mask face fit High oxygen requirement Air leak syndromes 15
BiPAP & HFNC Drives air & medicine more distally Recruits collapsed bronchioles / alveoli Reduces work of breathing Hard to tolerate 16
Ketamine Sympathomimetic Can increase mucus production Bolus and infusions used 17
Intubation High risk for rapid decompensation High rates of complications (esp: air leak) If required: Ketamine & atropine Push IVF Prep code dose epi, sodium bicarb Consider BiPAP pre oxygenation 18
Sodium Bicarbonate Reverses severe acidosis Improves catecholamine effects Improves cardiac function 19
Emergent Management of Asthma Mild Moderate Severe Cough Some wheeze Tachypnea Moderate retractions Dyspnea Diffuse wheeze Prolonged expiratory phase Mild hypoxia Minimal air movement Profound dyspnea Obvious prolonged expiration Grunting Hypoxia Albuterol Ipratropium Oral steroids Additional nebs PEP IVFs IV Magnesium Admit Epinephrine Terbutaline Heliox BiPAP HFNC Ketamine Sodium bicarb 20
Bronchiolitis Defined Viral induced inflammation RSV (70%) Rhinovirus Metapneumovirus Co infection in 1/3 Clinical diagnosis Most common cause of hospitalization in <1yo (3%) 21
Presentation URI symptoms WOB Rapid variability in symptoms Gradual resolution 20% still with symptoms at 3wks 22
Emergent Management of Bronchiolitis Supportive Consider UTI eval No role for CBC, CXR, or other labs 23
Emergent Management of Bronchiolitis Sicker patients: Still supportive IV / NG hydration Supplemental oxygen Suctioning 24
Emergent Management of Bronchiolitis CXR Viral testing Bronchodilators Epinephrine Steroids Chest PT Antibiotics / antivirals Hypertonic saline Not in ED? in patient Meissner HC. NEJM 2016;374:62 72. 25
Emergent Management of Bronchiolitis Suction as needed Fever control IV / NG fluids if dehydrated Consider albuterol off guideline Supplemental oxygen: NC vs HFNC Consider racemic epinephrine Intubation if needed 26
Patients of Special Concern Prematurity (< 46wks PMA) Congenital heart disease Bronchopulmonary dysplasia Immunocompromised 27