Anna McFarlin, MD · Case reports in pediatric ventilated status asthmaticus Continuous infusion of...
Transcript of Anna McFarlin, MD · Case reports in pediatric ventilated status asthmaticus Continuous infusion of...
Anna McFarlin, MD
Most common chronic disease of childhood◦ 9.5% of children in the US
More than 1 million ED visits per year◦ 1/4 children ages 0-4 with asthma visit the ED annually◦ 2005-2007: 174 deaths/year in children from asthma
Current evidence clearly supports the use of inhaled bronchodilators and systemic steroids as first-line agents.
In those who fail to respond to initial therapies, a variety of adjunct therapies and interventions are available with varying degrees of evidence to support their use
Akinbami 2011
To review current national guidelines for standard management of acute asthma
To describe strategies for refractory “near-fatal” asthma including mechanical ventilation and adjunct therapies
Diagnosis Pathophysiology Long term management Asthma Severity Assessment Asthma Action Plans Prevention
3 yo male with history of asthma presented to ED in respiratory arrest◦ HPI ~1 day URI sx. No previous admits for asthma◦ PE: Cyanotic, unresponsive, strong tachycardic
pulse, undetectable SaO2 Difficult BVM with minimal air mvmt
Next steps? Medications? Ventilation strategies?
Airway narrowing Extensive plugging of airways with mucus
and inflammatory infiltrates Hyperinflation Atelectasis Ventilation and perfusion mismatch
Doubling of beta agonist usage in the previous month◦ Overdependence on beta agonists (>1-2 canister monthly)
Current/recent use of glucocorticoids or not on ICS Frequent admissions (≥2/yr) or ED visits (≥3/yr) Admission to ICU or intubation Adolescents Non-Hispanic black Low socioeconomic status Illicit drug use History of psychiatric disease Difficulty recognizing severity of symptoms No written action plan
Mitchell, Martin, Belessis
Work-up◦ Vitals◦ Pulse ox◦ H&P◦ Blood gas◦ CXR
Therapy◦ Oxygen◦ Beta-agonists◦ Ipratropium◦ Corticosteroids
Routine use of ABG testing in all children with acute asthma is NOT justified◦ Pulse ox to evaluate oxygenation
No set values for pH, PCO2, PO2 that are diagnostic for respiratory failure
Do NOT be reassured by a normal blood gas In a child with severe, acute asthma, a rising
PCO2 is worrisome and predictive of respiratory failure
Moses, Casati, Langhan, Kanis, Carruthers
Rarely affect patient management Usually abnormal: Hyperinflation, atelectasis Consider if:◦ Fever◦ Hypoxia◦ Focal abnormalities on exam◦ Not responding to treatment◦ No personal or family history of asthma ◦ R/O foreign body, Pneumothorax,
pneumomediastinum
Tsai, Roback, Mahabee-Gittens
>90% of children with asthma exacerbations have a transient VQ mismatch and hypoxemia ◦ Temporarily worse by inhaled β-agonist treatment
Oxygen is recommended for most patients Guidelines:◦ >90-93% for severe exacerbations◦ >95% in children (GINA), pregnant women (NIH),
patient’s with heart disease (NIH)
GINA 2014, NAEPP 2007
Firmly established as the standard first-line therapy in the treatment of children with asthma
MDI with spacer: most cost effective & efficient Nebulized dose: 0.15-0.3 mg/kg/treatment◦ Max: 10 mg per treatment
Evidence supports continuous therapy◦ 0.5 mg/kg/h (Max 20-45 mg/hr)
Side effects: tremors, tachycardia, headache, hypokalemia◦ Clinical significance of hypokalemia?
No evidence for IV or oral β2 agonists
NAEEP 2007, Sabato 2000
R-enantiomer In vitro studies: S-enantiomer may have
detrimental effects tachycardia and jitteriness NIH: “Clinically comparable” No clinical benefit vs albuterol◦ No decrease in tremor, vomiting, palpitations,
nervousness◦ No difference in hospitalization or ED length of stay◦ Higher cost◦ ? Modest decrease in tachycardia ?Cardiac history
NAEPP 2007, Qureshi 2005, Rubin 2012
Anticholinergic Beneficial adjunct – ineffective monotherapy Acute setting only – no benefit to the addition
of ipratropium in the inpatient setting Severe asthma (PEF <40% predicted)◦ Improves pulmonary function◦ Reduces hospitalizations ◦ 1-3 doses during 1st hour of treatment
Moderate asthma (PEF 40-70% predicted)◦ May reduce hospitalizations◦ May reduce length of ED treatment
NAEPP 2007
“Recommended for all but the mildest cases” Reduced symptoms, hospitalizations, relapses Early use decreases hospitalization rates◦ Clinical effect begins within 4 hours◦ Triage nurse initiated corticosteroids Time-series controlled trial (n=644) Admission less likely (OR = 0.56, 95% CI: 0.36-0.87) Improved time to steroid receipt (P<0.001) Improved time to achieving mild status (P=0.04) Improved time to discharge (P=0.02)
NAEPP 2007, Zemek 2012
PO preferred over IV ◦ Equal efficacy (Class A Evidence)◦ Less invasive
1-2 mg/kg Max 40-60 mg Continue in hospital (Class A Evidence) Give supplemental doses to patients who take
them regularly, even if exacerbation mild (Class D Evidence)
NAEPP 2007, Qureshi 2001
Recommendations between 3-10 days Noncompliance with 5 days is common Decadron (0.6 mg/kg)◦ 5d prednisone = dexamethasone (IM/IV x 1d, PO x 2d) Decreased ED relapses and admissions 7-10 days post
discharge Significant cost savings Decreased vomiting Increased compliance
Andrews 2012, Gordon 2000, Greenberg 2008, Gries 2000
Inadequate evidence to recommend their use alone in acute asthma (Evidence B)
Early guidelines: double the dose of inhaled corticosteroid during asthma exacerbation ◦ Not effective
New evidence: ◦ ICS initiated early in adults may obviate the need for
systemic corticosteroids 2 mg flunisolide/hr or 3mg fluticasone/hr x 3hr Data in children inconsistent Data suggestive but not yet enough evidence
Edmonds 2003, FtizGerald 2004, Garrett 1998, Harrison 2004, Rice-McDonald 2005, Rodrigo 2005
Magnesium Methylxanthines Leukotriene Modifiers Terbutaline Antibiotics Mucolytics CPT Isoproteronol Epinephrine
Smooth-muscle relaxation and bronchodilator◦ Effect in 2 min after infusion, plateau 20-25 min,
lasts 1-2 hours Meta-analysis: ◦ Decrease hospital admissions (p=0.0006; NNT=4)
May improve lung function with severe exacerbations
Hypotension, flushing, changes in heart rate, muscle weakness
Blitz 2005, Cheuk 2005, NAEEP 2007
NIH (Evidence B)◦ Indicated for children whose FEV1 fails to improve
above 60% predicted after 1 hour of care Cochrane◦ No clinically important changes in all comers◦ Severe asthma Improved FEV1 by 9.8% (95%CI: 3.8-15.8) Admissions reduced (OR 0.10, 95% CI: 0.04-0.27)◦ Safe and beneficial in severe acute asthma
NAEPP2007, Rowe 2009
Decreased admission and improved pulmfunction?
NIH: May be beneficial, more research needed Cochrane: 16 trials, n=896 (adults & kids)◦ Inhaled Mg vs albuterol ?poor lung function, no improvement in admissions
◦ Inhaled Mg plus albuterol No improvement in pulmonary function (95% CI -0.27 to
0.74, n=188) or admissions (95% CI 0.49-1.16, n=249)◦ Inhaled Mg plus albuterol and atrovent +improvement in pulm function
◦ Possible benefit in severe asthma in addition to albuterol +/- atrovent
Blitz 2005, NAEPP 2007, Powell 2012
Direct bronchodilator Immunomodulator, antiinflmmatory effects Theophylline, aminophylline Cochrane: Methodological quality high◦ Improves FEV1 and PEF within 6 hrs
Mitra 2005
NIH: Not recommended (Evidence A)◦ No apparent reduction in symptoms◦ Does not reduce number of treatments or LOS◦ Does not prevent intubation◦ Does not avoid ICU admission◦ May increase critical care unit length of stay and
time to improvement◦ Vomiting, headache, abd pain,
palpitations/arrhythmias, intractable seizures◦ Requires serum drug levels
Dalabih 2012, Mitra 2005, NAEEP 2007
Binds leukotriene in the lungs reducing bronchoconstriction and inflammation
No role oral dose in acute asthma Adult study:◦ Significant improvement in FEV1 after IV Singular◦ Reduction in the risk of hospital admission
Peds study:◦ No benefit, no improvement in FEV1
Camargo 2010, NAEPP 2007, Watts 2012
IV, SQ, nebulized Nebulized terbutaline not as good as
nebulized albuterol Retrospective chart review (n=120)◦ Early administration of continuous IV terbutaline in
the ED resulted in decrease in mechanical ventilation (16 vs 60%, p=0.001) over late administration
Doymaz 2014
Prospective, double blind, RCT pediatric acute severe asthma (n=49)◦ PICU, continuous albuterol, not intubated◦ Continuous IV terbutaline vs NS◦ Terbutaline group Fewer hrs of albuterol (38 vs 52 hrs; p=0.073) Shorter PICU LOS (13 hrs longer for placebo group;
p=0.345) None were statistically significant Terbutaline group had 3 pts with elevated troponin
Bogie 2007
No GINA, NAEPP/NIH recommendations Cochrane◦ Beta2-agonists: IV vs nebulized No evidence to support the use of IV β2-agonists
alone. These drugs should be given by inhalation.◦ IV β2-agonists in addition to continuous nebulized β2-agonists Limited evidence to suggest shorter recovery time and
improved pulmonary index scores
Travers 2001, Travers 2012
NIH (Evidence B)◦ Antibiotics are generally not recommended for the
treatment of acute asthma exacerbations◦ Unless… Evidence for pneumonia Strong suspicion of bacterial sinusitis Fever and purulent sputum
NIH (Evidence C)◦ Avoid mucolytic agents (acetylcysteine, potassium
iodide) because they may worsen cough and airflow obstruction ◦ ?Pulmozyme, Atrovent
NIH (Evidence D)◦ CPT is not beneficial and unnecessarily stressful for
breathless asthma patient◦ Further studies needed for ventilated patients
NAEPP 2007
Β-agonist NIH does not recommend use of IV
isoproterenol in treatment of asthma because of the danger of myocardial ischemia in children
NAEPP 2007
Paucity of literature Systemic (IV, IM, SQ) vs inhaled Beta agonist properties may result in
bronchodilation Vasoconstriction may decrease mucus
production Potential for excessive cardiac stimulation
Retrospective review adults with severe asthma◦ No efficacy data◦ Low rate of major and moderate rate of minor adverse
events SVT, CP with EKG changes, elevated troponin
Randomized controlled crossover study:◦ SQ terbutaline demonstrated better improvement in
RR, HR and wheezing than comparable epinephrine Prospective, RCT: ◦ Sus-Phrine plus albuterol vs albuterol alone◦ No significant difference
Kornberg 1991, Putland 2006, Victoria 1989
GINA◦ SQ or IM not indicated for acute asthma
NIH◦ Non-selective beta agonists including epinephrine
are not recommended due to their potential for excessive cardiac stimulation◦ 1:1,000 0.01 mg/kg up to 0.3-0.5 q20 min x 3◦ No proven advantage of systemic therapy over
aerosol
GINA 2014, NAEPP 2007
Double blind, RCT of racemic epinephrine versus albuterol ◦ No significant difference in pulmonary index score,
length of stay, admission, or relapse◦ Epi group had significantly more minor side effects
Meta-analysis of nebulized epinephrine versus β2 agonists in adults and kids◦ Nonsignificant improvement in Peak Flow and FEV1
compared to patients getting epi v salbutamol or terbutaline
Plint 2000, Rodrigo 2006
Ketamine NIPPV/BiPAP Heliox
Bronchodilation and bronchorrhea◦ May aid in clearing mucus plugs
Induction agent of choice in asthma Side effects: Laryngospasm, emergence
phenomenon, lowers seizure threshold
Prospective observational study children with refractory acute asthma in the ED (N=10)
Loading dose of 1 mg/kg followed by 0.75 mg/kg/hr x 1 hr
1 hour post ketamine infusion:◦ Clinical asthma score
decreased from 14 to 9.5 (p<0.05)
◦ RR decreased from 39-30 (p<0.05)
Petrillo 2001
Double-blinded, randomized, placebo-controlled trial
2-18 years with Pulmonary Index Score of 8-14 after 3 nebs/steroids (n=68)
Loading dose 0.2 mg/kg followed by 0.5 mg/kg/hr infusion x 2 hr vs placebo along with continuous albuterol neb
No significant difference in groups◦ Pulmonary Index Scores decreased by 3.2 in
ketamine group and 3.6 in placebo group (95% CI -0.4 to 1.3)
Allen 2005
Case reports using ketamine successfully to avoid mechanical ventilation
Case reports in pediatric ventilated status asthmaticus◦ Continuous infusion of ketamine (1.0-2.5 mg/kg/h)
immediately improved airway obstruction
Denmark 2005, Rock 1986
Cochrane◦ Only single study of non-intubated children◦ Did not show significant benefit◦ No review for adults◦ No studies available for intubated patients◦ Future study needed
NIH◦ Despite theoretical benefits as premedication for
intubation, clinical trials in non-intubated patients have not shown clinical benefit
Jat 2012, NAEPP 2007
BiPAP may facilitate administration of inhaled beta agonists◦ Recruits small airways
May improve oxygenation, decrease WOB/fatigue Safe, well tolerated Requires cooperative patient with spontaneous
respirations No clear age cutoff◦ One study ages 2-11 years◦ Clear guidelines not yet established
May offer alternative to intubation
◦ Retrospective review (n= 83) of ED patients initially designated for admit to PICU 88% tolerated 77% decreased RR (by 24% on average) 88% improved oxygenation (by 7% on average) 10% rescued from PICU admit No adverse events
Beers 2006
Retrospective analysis (n=165) of mod/sevasthmatics <20kg in PED
Improvement in Pediatric Asthma Score (12.1 6.3)
5% patients discharged
Williams 2011
Crossover study (n=20) in PICU◦ 1 intubated◦ 3 discontinued due to discomfort
Clinical Asthma Score and Respiratory Rate improved in all patients
Discontinuation of NIPPV associated with increased RR and CAS
Thill 2004
Prospective, RCT (n=20) in PICU Standard care +/- NIPPV In NIPPV group: ◦ Improvement in CAS improved at 2, 4-8, 12-16,
and 24 hrs after initiation of interventions (P<0.01)◦ Improvement in RR (p=0.01)◦ Fewer children required adjunct therapy (11% v 50%,
p=0.07)◦ No major adverse events◦ 9/10 tolerated NIPPV
Basnet 2012
Cochrane◦ Paucity of data◦ Suggestion of decreased need for intubation in adults◦ Meta-analysis not possible◦ No pediatric recommendations
NIH◦ No recommendations
Possible additional benefit
Lim 2012
Mixture of helium and oxygen Promotes less-turbulent airflow through
narrowed airways Increased laminar flow may reduce WOB and
promote inhaled drug delivery May enhance diffusion effect on elimination of
CO2 Decreases auto-PEEP May prevent respiratory failure in children when
used early Oxygen concentrations >30% significantly reduce
the efficacy of heliox
Lee 2001
Much literature is anecdotal Controlled cohort of 2m-12y with mod-sev
obstructive disease in the ED Nebs x 6 in Heliox (80:20) v O2 over 2 hours
in ED (n=60)◦ 55% required more treatment in Heliox group v 95%
in O2 group (p=0.034)◦ At 12 hr: 35% of Heliox group still requiring obs v
68% O2 group (p=0.02)
Braun Filho 2010, Lee 2005
RCT of Albuterol in Heliox v control (n=40) No statistically sig difference at 10-20 min
with Heliox (p=0.169 and p=0.062) No statistically sig difference in admission
rate
Rivera 2005
Study: RCT of 2-18 yrs with mod-sev asthma received nebs via 100% O2 v 70:30 Heliox◦ Change in Pulmonary index scores: Heliox 6.67 v
O2 3.33 (p = <0.001)◦ Discharge: Heliox 73% v O2 33% (p = 0.05)
Kim 2005
Case series of pediatric ventilated patients◦ Addition of Heliox Decreased PIP (40.5 to 35.3) Increased pH (7.26 to 7.32) Decreased CO2 (58.2-50.5)
Abd-Allah 2003
Cochrane Review◦ 10 trials (3 pediatrics)◦ Total 544 patients◦ No significant differences in admission or pulm function◦ Some improvement in pulm function only pts with the
most severe pulmonary function impairment◦ Interpret with caution: “No role to play in initial
treatment of patients with acute asthma” NIH: ◦ Discrepancy in findings due to small sample sizes◦ “Consider heliox-driven albuterol nebulization for
patients who have life-threatening exacerbations and for those patients whose exacerbation remain in the severe category after 1 hours of intensive conventional therapy”
NAEPP 2007, Rodrigo 2014
Mechanical Ventilation Precedex Inhalational Anesthetics ECMO
Poor response to therapy Rising CO2 (PCO2 >50) Severe hypoxia (PaO2 <60) Waning mental status Impending respiratory arrest Cardiopulmonary arrest
Avoid if possible:◦ High risk of worsened hyperinflation, barotrauma &
hypotension◦ ETT is noxious stimuli – worsens bronchospasm◦ Longer PICU duration and longer length of stay
when adjusted for severity Concerns:◦ High lung inflation pressures◦ Auto-PEEP◦ Dynamic changes in lung compliance, airway
resistance, VQ mismatch
Roberts 2002, Sabato 2000
No gold standard Cuffed ETT Anticipate hypotension Pressure vs Volume Modes◦ PCV has decelerating inspiratory flow Ideal for short inspiratory time Consistent MAP, requires less FiO2
◦ PCV decreased duration of ventilation (29 vs 24-52 hrs) and time to achieve normocarbia (5 vs 15-20 hrs)
◦ Dual-control mode – Pressure control with volume assured ventilation ideal?
HFOV contraindicated due to dynamic air-trapping
Sabato 2000, Sarnaik 2004, Stewart 1996
NIH Class C evidence Goal: ◦ Adequate oxygenation and ventilation ◦ Minimizing high airway pressures and barotrauma
Hypercapnia due to increased physiologic dead space from hyperinflation
No controlled studies comparing normocapnia with hypercapnia
Underventilation agitates patients – generous sedation/muscle relaxation may be required
Leatherman 2007, Mutlu 2002, NAEPP 2007
No consensus Animal studies: CO2>100 decreased
perfusion Increased intracranial pressure◦ Extreme = myocardial depression, cerebral
hemorrhage, herniation, quadriparesis (>120-135) Decreased cardiac contractile force Avoid with preexisting cerebral disease or
myocardial dysfunction Keep PCO2<90-100 and pH>7.15-7.2◦ May buffer with tromethamine
Leatherman 2007, Mutlu 2002, NAEPP 2007
“Low and slow”◦ Low tidal volume: 5-6 mL/kg◦ RR = half normal for age◦ Minute ventilation ~100 mL/kg
Goal plateau pressures <25-30 Allow time for exhalation◦ I:E ratio = 1:3 or longer
PEEP:◦ Initial PEEP = 0-3◦ Adjust PEEP to measured auto-PEEP Expiratory hold maneuver
◦ PEEP above auto-PEEP is not recommended
NAEPP 2007, Duval 2000; Sabato 2000, Sarnaik 2004, Stewart 1996
Every attempt should be made to keep ventilator days to a minimum
EtCO2 monitoring◦ EtCO2 does not reflect PaCO2 well in VQ mismatch◦ Capnogram Assess severity of air trapping, eval bronchodilator
therapy, guide appropriate ventilation paramenters
Sabato 2000
Selective alpha2-adrenoceptor agonist In vitro studies:◦ Smooth muscle relaxation and prevention of
bronchoconstriction Animal studies:◦ Completely blocked histamine-induced
bronchoconstriction in 5 dogs Case reports: ◦ Facilitates induction of NPPV in adults
Groeben 2004, Takasaki 2009
Airway smooth muscle relaxation Within 30 min Anecdotal case reports Practical limitations Safety: ◦ Hypotension◦ Withdrawal/encephalopathy◦ ?renal or hepatic injury
Restrepo 2005, Shankar 2006, Tobias 2009, Wheeler 2000
Retrospective case series of 6 children with PIP >40◦ Isoflurane: ↓ PIP, ↑ pH, ↓ PaCO2
Retrospective case series of 10 children with PIP >45, pH <7.25, PaCO2>80◦ Improved minute ventilation, decreased peak
pressures, shortened expiratory phase, improved PaCO2 (p=0.032) and pH (p=0.028)
Restrepo 2005, Shankar 2006, Wheeler 2000
Evidence?◦ Database review of >40 children’s hospitals 2004-
2008 3% of asthmatic pts requiring mechanical ventilation
(n=47) Longer lengths of stay, duration of ventilation, and
higher hospital charges No mortality benefit
Possible additional benefit above conventional therapy
Char 2013
Indication◦ Severe refractory respiratory
acidosis, hypercarbia ECMO ◦ ELSO registry data 1986-2007 64 children with severe refractory asthma Ages 1-10, median PCO2 = 130, pH = 6.89 Survival = 83% -95%
Pumpless Extracorporeal Lung Assist Risks hemolysis, post-decannulation thrombosis,
sepsis, renal insufficiency, neurologic sequelae
Florchinger 2008, Hebbar 2009, Tobias 1997
Diagnosis/Predictive◦ Exhaled nitric oxide in diagnosis◦ Urinary leukotriene E4
Treatment: ◦ Nebulized lidocaine◦ Nebulized Heparin◦ Nebulized TPA◦ Anti-IgE therapy with omalizumab◦ IVIG, hydroxychloroquine, colchicine, cyclosporin,
methotrexate◦ Antifungal therapy◦ Complimentary and alternative treatments
Intubated after induction with Ketamine Treated in ED with continuous albuterol,
magnesium, solumedrol, and terbutaline Initial blood gas: 6.80/110 Remained mechanically ventilated using
permissive hypercapnia strategies in the PICU x 2 weeks on high dose continuous albuterol, magnesium, Precedex, ketamine, terbutaline, solumedrol◦ Severe VQ mismatch – high need for FiO2◦ Bacterial trachiitis
O2 to relieve hypoxemia SABA for all patients (Evidence A) Inhaled ipratropium in severe exacerbations
in ED (Evidence A) Systemic corticosteroids (Evidence A) Adjunct treatments (magnesium, heliox)
merit consideration to decrease likelihood of intubation (Evidence B)
Does not recommend methylxanthines, antibiotics, aggressive hydration, CPT, mucolytics, sedation, increased dosing of ICS
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