PEDIATRIC ASTHMA MANAGEMENT: WHAT S NEW? CAEP 2015 Annual Conference Lighting the Way

PEDIATRIC ASTHMA MANAGEMENT: WHAT S NEW? CAEP 2015 Annual Conference Lighting the Way

Talk Outline Typical case Will address these questions Inhalation delivery: MDI/spacer vs nebulization? Frequency of beta-agonist therapy Add ipratropium to salbutamol? Corticosteroids: when, what type, what dose, what duration? IV magnesium? When?

You are in your ED.. 3 yr old boy with known asthma 24 hrs increasing cough, wheeze, & respiratory distress Hx 4 hospitalizations, 3 recent ED visits On fluticasone 250 mcg BID PRN & salbutamol 2 puffs PRN via spacer Both started earlier today VS RR 56, O2SatRA 89%, HR 160, T 37.5 TM, BP 90/72

HOW SEVERE IS THIS CHILD?

Severity Pyramid Severe ~ 1 in 30 to 50 Moderate ~ 1/3 Mild ~ 2/3

INHALATION DELIVERY: MDI/SPACER VS NEBULIZATION?

Why MDIs & spacers More efficient Better drug delivery At least as effective Shorter ED stay Fewer side effects Less drug deposited at back of mouth Less of infection risk Optimal in era of H1N1/SARs Parents like it better

Evidence Evidence: Cochrane Review MDI with spacer vs. Nebulizer 25 RCTs ED & Community Settings 2066 children & 614 adults 6 RCTs in-patients with acute asthma 213 children and 28 adults Children in ED Admission RR 0.65 (95% CI: 0.4 to 1.06) ED LOS mean difference -0.5 hrs (95% CI: -0.4 to -0.6) Peak flow & FEV1 were similar Heart Rate mean difference -8% baseline (95% CI: -10 to -5% baseline Most Children s Hospital EDs in last decade Ste. Justine Hospital since late 80 s

Why MDIs & spacers More efficient Better drug delivery At least as effective Shorter ED stay Fewer side effects Less drug deposited at back of mouth Less of infection risk Optimal in era of SARs/H1N1 Parents like it better

FREQUENCY OF BETA-AGONIST THERAPY

Hourly vs. Q 20 min. nebulized agonists J Pediatr 1985;106:672 FEV1 < 50%

Continuous Bronchodilator Evidence: Cochrane Review Continuous vs. Intermittent Aerosols 8 RCTs 461 patients total Hospital Admission = RR: 0.68; 95% CI: 0.5 to 0.9 Greater improvement in pulmonary function No difference in side-effects

Salbutamol frequency? Depends on severity BOTTOM LINE RECOMMENDATION Mild 1 or 2 via MDI/Spacers Moderate Q 20 min X 3 via MDI/spacer Severe Continuous large volume nebulizer

Efficient Hi-Flo (8 L/min) 30 ml reservoir 1 hour of nebulization at 8 L/min Optimal 2-3 μm particles Mix three 5 mg (>20 kg) or 2.5 mg (<20kg) ampules salbutamol three 250 mcg ampules of ipratropium plus enough normal saline to make 20 ml total volume

ADD IPRATROPIUM TO SALBUTAMOL?

Ipratropium Evidence: Cochrane Review Addition of ipratropium to 2 agonist in children (18 months to 17 years) Single Dose - 5 RCTs, 453 patients Small difference in PFTs, no difference in admissions Multiple Doses 7 RCTs, 1045 patients Greater improvement in PFT Admission RR 0.75 (95% CI 0.62 to 0.89) NNT 12.5

Ipratropium BOTTOM LINE RECOMMENDATION Mild no additional benefit Moderate Likely benefit (but no consensus) 4 puffs regardless of size q 20 minutes x 3, alternate with salbutamol Severe Clear benefit Three 250 mcg nebules given over 1 hour

CORTICOSTEROIDS: WHEN, WHAT TYPE, WHAT DOSE, WHAT DURATION?

Early Steroids Evidence: Cochrane Review Early steroids in ED (< 60 minutes) 12 RCTs, 863 patients Admission RR 0.4 (95% CI 0.2 to 0.8) 3 RCTs using oral steroids in children Admission RR 0.24 (95% CI.11 to 0.53)

Synergy between agonists & steroids Steroid Both enhance each other camp R agonist GR DNA

Steroids orally unless impending arrest Parenteral dexamethasone solution given orally Rapid peak serum concentrations (~ 30 minutes) Multiple RCTs suggesting no difference between PO & IV

Corticosteroid BOTTOM LINE RECOMMENDATION Dexamethasone 0.3 mg/kg PO Immediately before first salbutamol treatment

IV MAGNESIUM?

SR IV magnesium, Mohammed. Emerg Med J. 2007;24:823-30. 5 pediatric IV RCTs (182 children) Respiratory Function Hospital Admission

IV Magnesium BOTTOM LINE RECOMMENDATION Administer IVMgSO4 40 mg/kg to patients with severe asthma who do not substantially improve after first 60 minutes of bronchodilator and steroid therapy

QUESTIONS?

Alberta Childhood Asthma ED Pathway Web-based learning module {www.ahschildhoodpathways.com} Continuing Education Credit

Asthma education after discharge Evidence: Cochrane SR, 2009. 38 RCTs, 7,843 children, educational interventions directed at children and/or parents who present to ED Subsequent ED visit, RR 0.73, 95% CI 0.65 to 0.81 Hospital admission, RR 0.79, 95% CI 0.69 to 0.92 Unscheduled MD visit, RR 0.68, 95% CI 0.57 to 0.81

Assessment of severity Gestalt clinical assessment? Mild, moderate, severe, impending respiratory failure Peak flows are not reliable even in school-aged children Spirometry is not practical Validated clinical score Pediatric Respiratory Assessment Measurement (PRAM) Score Journal of Pediatrics, 2000:136;762-768 Journal of Pediatrics, 2008;152:476-480

PRAM Score

Impending Respiratory Arrest 100% oxygen via non-rebreather facemask Continuous salbutamol and ipratropium Consider IM epinephrine Consider IV access and fluids Contact RAAPID SOUTH or NORTH Avoid intubation if at all possible {www.pedsrespfailure.ca}

Salbutamol MDI/spacer dosage 10 puffs for > 20 kgs q 20 minutes x 3 5 puffs for < 20 kgs q 20 minutes x 3

PRE-SCHOOL WHEEZE IS IT ASTHMA?