Cite this article as:
Team DFTB. It’s Only Wheeze – Treatment Is Simple, Isn’t It?: Meredith Borland at DFTB19, Don't Forget the Bubbles, 2020. Available at: https://doi.org/10.31440/DFTB.20828
Meredith Borland is a paediatric emergency physician and the Director of Emergency Medicine at Perth Children’s Hospital in Perth, Western Australia. She was a founding member of the PREDICT Executive and is the current chair of PREDICT.
Last year at DFTB18, Meredith continued an ongoing discussion about the use of steroids in wheeze. This year, she took us on a journey through an emergency department visit for a number of children who may or may not receive various interventions. This was a fun, interactive and thought-provoking talk that highlighted some common differences in practice.
When a medical student starts their paediatric ED rotation they need to know three key illnesses and that will cover the majority of patients that they see. To round out the ABC trifecta of asthma and crapping (acute gastroenteritis) we have bronchiolitis. At #DFTB19 Ed Oakley from PREDICT gave us the latest.
DoodleMedicine sketch by @char_durand-done live from Australia via the DFTB19 streaming video link!
This talk was recorded live at DFTB19 in London, England. With the theme of “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal.
With millions upon millions of journal articles being published every year, it is impossible to keep up. Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in the UK and Ireland) to point out something that has caught their eye.
Salbutamol – there is no benefit in using salbutamol in infants with bronchiolitis (and some evidence of adverse effects)
Nebulised adrenaline – no clinically useful benefit (there is evidence for temporary effect but not for improvement in outcome)
Nebulised hypertonic saline – there is weak evidence of a reduction in length of stay of 0.45 days. However when two studies were removed, both of which used a different discharge criteria than most hospitals, there was no benefit. This is not recommended routinely, although the authors suggest that it should be used only as part of an RCT
Glucocorticoids – no benefit
Antibiotics – not recommended (The risk of a secondary bacterial infection is very low, and there is potential harm from giving antibiotics)
Oxygen – no evidence of benefit in infants with no hypoxia, and low level evidence that maintaining the sats over 91% with oxygen actually prolongs the length of stay. There are no reports of long-term adverse neurodevelopmental outcomes in infants with bronchiolitis, however there is also no data on the safety of targeting sats <92%. Commence oxygen therapy to maintain sats over 91%.
Sats monitoring – there is moderate evidence suggesting that continuous sats monitoring increases the length of stay in stable infants
High flow – there is low to very-low level evidence of benefit with high flow
Chest physiotherapy – not recommended
Saline drops – routine saline drops are not recommended but a trial with feeds may help
Feeds – both NG and IV are acceptable routes for hydration
This is the biggest and most robust trial yet done to assess the value of high-flow in bronchiolitis. The primary outcome shows that there is a role for high-flow in the non-ICU management of this disease. Importantly PARIS has shown in a large cohort of children that high-flow, when used within the parameters of the trial protocol, does not lead to an increase in adverse events which in-turn suggests the increased patient:nurse ratios for kids on high-flow that are often mandated by hospital policies may not be necessary (depending on the severity of disease of course). Some caution must be used around the potential for erroneous use of the high-flow circuits themselves and the interpretation of early warning scores in the context of high-flow use.
PARIS was supported with significant nursing education resources potentially reducing errors to a level that were below what could be expected with the standard resourcing of mixed EDs and other environments where high-flow use in children may be infrequent. As with many grey areas in medicine protocols as to how we use high-flow vary by institution with little more than opinion to guide them.
Though neither the intention nor the conclusion of this paper in showing the progress of such a large number of children on high-flow, this trial also provides a basis for more robust decision making around how we use high-flow itself.
Give fluids by nasogastric or orogastric tube in children with bronchiolitis if they cannot take enough fluid by mouth.
Give intravenous isotonic fluids (see the NICE guideline on intravenous fluids therapy in children) to children who: do not tolerate nasogastric or orogastric fluids; or have impending respiratory failure.
Do you know how to set up high flow? (8 minutes)
How to set up Airvo 2 (Optiflow) (3.5mins)
How to use Airvo 2 (6 mins)
You have a 12 month old, with two days of coryza and one day of increased work of breathing symptoms.
How do you manage them?
How do you figure out whether they have bronchiolitis or VIW?
Practically speaking, we know that bronchiolitis and viral induced wheeze have two quite different management pathways, but it is not as if a child moves from being 12 months old to 13 months old and therefore cannot have bronchiolitis (or vice versa for viral induced wheeze). These conditions as previously mentioned, exist on a spectrum.
What would you look for on history and examination to help you decide?
What has been the onset of symptoms? Progressive over days is most consistent with bronchiolitis. Onset of wheeze and respiratory distress over hours is most consistent with bronchospasm (viral induced wheeze).
What has been the pattern of their work of breathing?
How significant is the work of breathing?
What are the auscultation findings – is there presence of focal findings? Wheeze? Crackles?
Is this affecting the child functionally with feeding or sleeping difficulties?
If auscultation is suggestive of possible viral induced wheeze or at least, a component of wheeze that may be responsive to bronchodilators (If wheeze is present and no crackles or focal findings) and presuming the child has more than just mild work of breathing -then we suggest this may be a possible candidate for viral induced wheeze.
At what age would be appropriate to consider a trial of ventolin for potential viral induced wheeze vs bronchiolitis?
(Note – This is a good opportunity to survey your team and colleagues to see what the practice is at your local department).
Regarding this grey area question, in Australian practice, some clinicians will trial salbutamol for potential viral induced wheeze if the child is 12 months or older. Other doctors may wish to trial if the child is slightly younger (e.g. from 10 months) if they have a strong family history of asthma and atopy or if they have had previous ventolin use reported by their family with good effect. The younger the child is, the less likely that the story and case is to fit viral induced wheeze.
If you have decided to trial ventolin – would you give only an initial 6 puffs and reassess or would you give a burst (x puffs x 20 minutely x 3) ?
It would be prudent to give 6 puffs (or do you use another number?) and reassess following to see if there is any improvement or change.
You’ve started high flow 2L/kg for a four month old with bronchiolitis, moderate work of breathing and saturations of 88% and titrated FiO2 up to 30% to maintain saturations.However they are still intermittently desaturating so you titrate them up to 40% FiO2.
They have ongoing work of breathing with a respiratory rate of 60-70.
What are your next steps?
How would you reassess the patient?
Consider revisiting history, respiratory examination and consider adjuncts to assessment such as a capillary or venous blood gas.
Is their nutrition optimised to minimise work of breathing?
For example, Do they have an NG tube on free drainage, are they nil by mouth and on IV fluid support at ⅔ maintenance
Are their family actually compliant with this or have also been feeding them via a bottle?
Are they working harder to breathe because they are getting “hangry” and might actually tolerate a continuous NG or comfort feed?
Have you accurately assessed the effect of the intervention (HFNP)?
Consider whether the HFNP has led to no change, improvement and then deterioration or simple worsening of symptoms due to patient distress.
If no improvement was observed on commencement – it may be worth de-escalating them – ie. lower flow rates or low flow nasal prongs
What could be missing?
Consider your confidence of whether you have the right diagnosis or if there is need to assess for a secondary pathology such as pneumonia, foreign body, cardiac contribution? Do you need to further investigate with bloods, CXR? Do you need to append your management and provide antibiotic coverage? Do you need to assess for a complication from treatment e.g. pneumothorax.
Have you sought a senior review/notified the admitting paediatrician?
Do you need an ICU consult, NETS consult or retrieval to a tertiary centre?
How long are you comfortable to wait to see if there is a response to high flow?
Non invasive ventilation – switching to CPAP
What settings would you start on?
Where could you move up to (in terms of peep, FiO2)
How soon would you reassess – what are you looking for?
Does this child need to be intubated?
How would you determine this?
Who should be involved in the conversation? Who should perform the intubation?
In bronchiolitis, children do not respond to salbutamol because:
A: They don’t have beta receptors until they are older.
B: The beta receptors are immature and do not begin functioning correctly until the child is older.
C: The large amount of secretions interfere with it and prevent it binding to the receptors
D: There is no bronchospasm for the salbutamol to act on.
The correct answer is D.
All humans have beta receptors. Foetuses develop them from around 15 weeks gestation and are therefore born with them. Developing beta receptors after 1 year of age is a common paediatric myth! In fact, in bronchiolitis, there is no bronchospasm in the same way as there is in viral induced wheeze. Bronchiolitis is a illness developing gradually over 4 days and then slowly improving. Patients have increased mucous rather than bronchospasm, which does not respond to a bronchodilator.
A 3 month old baby presents to ED with coryza, cough, and poor feeding. Breastfeeding is going ok, but the baby is feeding for shorter periods, more frequently than usual. She is having wet nappies as normal. Saturations are 93% on room air, RR is 62, and there is moderate subcostal recession with some nasal flaring. Which of the following is an indication to admit this baby to hospital?
A: The reduced breastfeeding
B: The oxygen sats
C: The work of breathing
D: The age of the baby
The correct answer is C.
The criteria for admission usually are:
feeding less than half of usual, or less wet nappies
saturations less than 92% on air
Risk factors such as:
Age less than 12 weeks or less than 37 weeks CGA
history of lung disease or congenital heart disease or neurological problems
In clinical practice, you would use your judgement to assess if hospitalisation was necessary. Social concerns should always be considered.
In this case, the baby is maintaining good urine output and the feeds, although shorter, are more frequent. The age alone is not an indication for admission. Obviously, an O2 requirement would be an indication for admission but most units would consider sats of 92% or less as reduced. There is significantly increased work of breathing with recession and nasal flaring, however, so this would be the main indication for admission.
You have a 10 month old baby with bronchiolitis who is to be commenced on high flow. Which of the following is false?
A: Nasal prongs size should be estimated based on the width of the patient’s nostrils.
B: Patients can be NG fed immediately once on high flow.
C: High flow improves the functional residual capacity.
D: The humidified oxygen help clearing mucous secretions.
The correct answer is B.
Patients on high flow will likely need an NG inserted due to abdominal distention, but should usually not be fed for the first couple of hours on high flow. The aim of high flow is to provide humidified, high flow to improve clearance of secretions and to increase the functional residual capacity. Together this should reduce the work of breathing.
Cite this article as:
Team DFTB. PREDICT: from knowledge generation to knowledge translation – Meredith Borland at DFTB19, Don't Forget the Bubbles, 2020. Available at: https://doi.org/10.31440/DFTB.21930
Meredith Borland is the current chair of PREDICT and is well-known for her work on the use of steroids in croup. The aim of PREDICT is not just to generate multi-centre research but also to share it and measure its impact. That is where DFTB comes in.
One of the key pieces of work that has informed a lot of Australian practice over the last few years is the CRIB study.
Oakley E, Babl FE, Acworth J, Borland M, Kreiser D, Neutze J, Theophilos T, Donath S, South M, Davidson A, Paediatric Research in Emergency Departments International Collaborative (PREDICT. A prospective randomised trial comparing nasogastric with intravenous hydration in children with bronchiolitis (protocol) The comparative rehydration in bronchiolitis study (CRIB). BMC pediatrics. 2010 Dec 1;10(1):37.
By challenging the long held belief that children with bronchiolitis should get an IV they have saved many of us countless hours.
This talk was recorded live at DFTB19 in London, England. With the theme of “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.
We are delighted to release our first guest podcast brought to you by the team at Fontanelle. ‘Tis the season to be snotty – and so host Dr Caroline Storey talks to General Paediatric Consultant Dr Claire Hollingsworth about everything bronchiolitis. Essential listening this time of year, particularly for trainees staring their paediatric rotations.