Transcript Inpatient Bronchiolitis: So Much Time and So Little To Do

Inpatient Bronchiolitis:
So Much Time and So
Little To Do
Alan Schroeder, MD
Director, PICU
Chief, Pediatric Inpatient Services
Santa Clara Valley Medical Center
Case – urgent care
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Otherwise healthy 6 month old with
3 days cough, runny nose, fussiness,
decreased PO intake but normal wet
diapers.
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On PE, T=101, RR = 50, O2 Sat =
94%, HR = 160, fussy but consolable,
adequately hydrated, lots o’ snot,
expiratory wheezes, mild SC&IC rtxns
Results
SPO2 = 94%
RR = 50
(n=119)
SPO2 = 94%
RR = 65
(n=125)
SPO2 = 92%
RR = 50
(n=124)
SPO2 = 92%
RR = 65
(n=117)
Would admit (%)
43
58
83
85
Bronchodilator (%)
92
34
95
39
97
79
98
81
80
7
2
82
6
2
85
8
2
80
11
3
O2 (%)
Nasal Suction (%)
Steroids (%)
Abx (%)
Mallory, Pediatrics, 2003
Management Dilemmas in
Bronchiolitis
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Nebs?
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Suctioning (+/- saline)?
Chest Physiotherapy?
If febrile, R/O SBI?
CXR?
Steroids?
Decongestants?
Abx?
When to admit?
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Albuterol vs racemic epinephrine?
Hypertonic saline?
O2 Sat criteria?
Risk of apnea?
Safe to eat?
When to discharge?
Bronchiolitis Overview
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#1 cause of infant hospitalization
1/3 of all children get bronchiolitis in first 2
years
1/30 children get hospitalized
 150,000 hospitalizations per year
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1.5M annual outpatient visits for RSV alone
$500-700M/year
Bronchiolitis – Definition
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“a seasonal viral illness characterized by fever,
nasal discharge, and dry, wheezy cough. On
examination there are fine inspiratory crackles
and/or high-pitched expiratory wheeze”
www.nottingham.ac.uk/paediatric-guideline/breathingguideline.pdf.
Why have hospitalization rates
increased?
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Increased survival of children with
comorbidities
? Virulence
Increase in daycare
Changes in hospitalization criteria
Bronchiolitis seasonality
MMWR, 2009
Pathophysiology
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Inflammed/
edematous
bronchial walls
WBC’s (mostly
monos)
infiltrate
bronchiolar
epithelium
Mucus plugs
block airway
http://www.health-healths.com/tag/prevention/page/5
Pathphysiology
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Mucus plugging  one-way valve 
hyperinflation  absorption atalectasis --> V:Q
mismatch
Smooth-muscle constriction (bronchiolespasm)
not a factor
Clinical presentation
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URI symptoms first
Spreads to LRT – cough, tachypnea more
present
Fever in ~ 50%
Poor po intake, decreased UOP
Exam
Concerning clinical findings
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Lethargy/extreme irritability
Dehydration
Respiratory distress
Apnea
Outline
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Overview
Burden of disease
 Pathophysiology/clinical presentation
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MARC-30 study
Treatment – what’s the evidence?
SCVMC and MARC-30 study
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MARC = Multicenter Airway Research Collaboration
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Part of Emergency Medicine Network (EMNet)
Prospective, multicenter.
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16 sites, 2200 patients over 3 winters (11/07 – 4/10)
NIH funded (NIAID)
PI: Carlos Camargo (Mass General), Jonathan Mansbach
(Boston Children’s)
Aims:
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Elucidate role of co-infections
Identify predictors of PPV
Establish evidence-based discharge criteria
Viral co-infections
Virology - Implications
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Cohorting/isolation?
Comfort of diagnosis?
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Utilization of resources?
Hospital charges:
Flu A, B, RSV ($220)
 Para 1,2,3
($220)
 Bordetella pertussis, B. parapertussis
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($95)
Virology - implications
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My conclusion: run-of-the-mill bronchiolitis
does not warrant viral testing
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Possibly for influenza
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only 19/2200 (~1% of patients in cohort)
Same goes for CXR, labs, even if febrile
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UA/Urine Cx if < 90 days? [Ralston, Arch Pediatr Adol Med 2011]
Outline
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Overview
Burden of disease
 Pathophysiology/clinical presentation
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MARC-30 study
Treatment – what’s the evidence?
Steroids?
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2003 Cochrane (Patel et al):
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“Available evidence suggests that corticosteroid
therapy is not of benefit in this patient group”
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13 trials
AAP recs (2005):
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“Corticosteroids should not be used routinely in the
management of bronchiolitis”
B-agonists
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Cochrane 2010 (Gadomski and Brower):
28 trials (1912 infants)
 No reduction in admission or length of
hospitalization
 Transient reduction in clinical score
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AAP (2005):
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“bronchodilators should not be used routinely in the
management of bronchiolitis…”
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“…A carefully monitored trial of beta or alpha agonist is
an option”
Epinephrine
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Cochrane 2011 (Hartling et al)
19 studies, 2256 patients
 RR admissions on Day 1 in outpatients = .67 (.50.89) vs placebo
 Shorter LOS for epi vs salbutamol
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Epi + dexamethasone?
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Pediatric Emergency Research Canada RCT[Plint et
al, NEJM 2009]
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800 kids
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4 arms:
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Decadron
Racemic epi
Decadron + epi
Placebo
Marginal benefit in admission rate by 7 days in decadron
+ epi group (17% vs 26%)
Hypertonic saline
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Zhang et al, Cochrane 2008
 4 trials, 254 patients, with/without bronchodilators
 ↓LOS by 1 day
 Reduced clinical score in outpatients
4 additional RCTs
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2 with some benefit (Al-Ansari et al, J Peds 2010; Luo et al,
Clin Microb Inf, 2011)
2 with no benefit (Kuzik et al, CJEM 2010; Grewal et al,
Arch Pediatr Adol Med 2009)
Hypertonic saline
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Bronchodilators necessary? [Ralston et al,
Pediatrics, 2010]
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1 episode of bronchospasm in 377 doses of HS
without bronchodilator
So why not?
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(We’ve been down this path before…)
Pediatrics, 2011
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Increasing inpatient bronchiolitis volume 
reduced steroids, xrays, laboratory tests
Pediatrics 2000
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6 RCTs, included 2 trials that did not exclude
prior wheezers
Conclusion: “Published reports of the effect of
systemic corticosteroids on the course of
bronchiolitis suggest a statistically significant
improvement in clinical symptoms, LOS, and
DOS.”
Nasal decongestants
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Ralston et al, J Peds 2008
41 infants, phenylephrine vs placebo
 No benefit
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Chest PT
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Gajdos et al, PLOS, 2010
Multicenter RCT of CPT (forced expiratory
techniques and assisted cough) vs nasal suction
 496 infants, no benefit
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Roque, Cochrane 2012
9 trials (5 vibration/percussion, 4 passive expiratory)
 No benefit
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Heliox
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Less turbulent airflow through resistant airways
When given in ED with racemic epi + via
HFNC, small improvement in clinical scores but
no reduction in admission or LOS [Kim et al, APAM
2011]
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Mixed results in ICU setting [Martinon-Torres et al,
Pediatrics 2002; Liet et al, J Peds 2005]
O2 Sat: why does it matter?
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It can be easily fixed!!
May predict respiratory failure or ICU transfer in
early phase of disease
May predict readmission
?May be deleterious to the developing brain?
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Commentary to 2005 AAP guidelines (Cutoff = “persistently
below 90%”): “It is unfortunate that the recommendation
fails to address another significant consideration, viz, the
impact of chronic or intermittent hypoxia on later cognitive
and behavioral outcomes.”[Bass, Pediatrics 2007]
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Site articles suggesting some detriment at 90-94% (in pts with CHD
or OSA!!!)
Oxygen
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LOS prolonged by perceived need for O2
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26% - 57% of hospitalized patients [Schroeder, Archives Ped
Adol Med 2004; Unger, Pediatrics 2008]
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AAP:
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“As child’s course improves, continuous O2
monitoring is not routinely needed”
Ongoing RCT of continuous vs intermittent
pulse oximetry
Summary
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No frittering
Resist temptation to treat all wheezing
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Racemic epinephrine instead of albuterol?
Limited utility of NP swabs
Search for the holy grail continues
More to come from MARC-30
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Predicting safe discharge
Predicting PPV
Better understanding of apnea and the
associated viruses
Role of vitamin D levels
Development of asthma after bronchiolitis