The Outside Hospitalist: Don’t Hold Your Breath: Acute Respiratory Illnesses, Part One

Dr. Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to the Kid Experts, where the complex is our every day. Each episode, we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge, and perhaps change, how you care for kids. Welcome to Talking Pediatrics. I’m your host Dr. Kade Goepferd. Did you know that the majority of pediatric healthcare happens outside the tertiary hospital setting? On today’s episode, The Outside Hospitalist, host Dr. Gabi Hester discusses providing healthcare when you’re limited to what’s in the overhead compartment, the critical access ED, or your own backpack, and how to translate these lessons to your pediatric practice. Dr. Gabi Hester: I guess maybe we should start by introducing ourselves. I’d love to think that everybody just knows you and I by now, but maybe we shouldn’t make assumptions. So I’m Gabi Hester. I’m the outside hospitalist in this situation, I guess. I’m sitting here up north talking today with my good friend Dr. Courtney Herring. And can I define friendship here? Because you and I we’re colleagues, right? Dr. Courtney Herring: Absolutely. Dr. Gabi Hester: But we’re also like go to a Michael Bolton concert at a casino conference room level friendship, right? Dr. Courtney Herring: Yeah, we did. I mean, clarification, we didn’t go to Michael Bolton instead of a conference. It just happened to be held in what seemed to be some ceremonial conference room at a casino. Dr. Gabi Hester: Right. Right. Dr. Courtney Herring: Yeah. Dr. Gabi Hester: Or bingo hall? Various things. Dr. Courtney Herring: Let’s do this. I’m so excited. Every time we chat, things are happening. Dr. Gabi Hester: The inside hospitalist, you are. Dr. Courtney Herring: Yeah. So I’m a pediatric hospitalist, I’m a peer of Gabi’s in that way, but I work at Children’s Minnesota and I’ve been here nine years. So I do a couple of other things, as alluded to, about the Asthma Committee here at Children’s. But long story short, we are both here committed to taking care of children, so another good podcast ready to be started. But what do you think of when you think of croup, Gabi? Dr. Gabi Hester: Well, everybody thinks of that classic bark-y, seal-like cough, but usually there’s a little bit of a prodrome, a little bit of a runny nose, maybe a low-grade fever. And then that stridor or the respiratory element of it can come on fairly quickly, and as a physician pediatrician, certainly we read one thing in a textbook, but I happen to have a child who had croup many times, unfortunately, and so I know that it can present in a number of different ways, but it is quite scary for parents and then actually for providers as well. If you’re there in the emergency room and that kiddo comes in with that really profound stridor, really difficulty breathing, kids get a little panicked too, and so it’s one that gets your heart racing a little bit as a provider, I would say. Dr. Courtney Herring: Yeah, absolutely. And obviously context. You talked about a little runny nose and some fever, but at the same time it is a viral illness, by definition. Croup specifically, if you get the anatomy of it, it’s the larynx and the trachea. So laryngotracheitis is sometimes how you’ll hear it and it gives you an idea of what you’re actually looking for. So stridor, generically you’re thinking of that inspiratory stridor because you’ve changed the laminar flow by all that inflammation that’s going on in swelling in a pretty much very small airway. Croup is kind of a dedicated diagnosis of young pediatric care, not so much our primary school age kids. So once you’re getting to primary school, it’s really less likely and you should be thinking of other things as well. Would you agree with that? Dr. Gabi Hester: I think this just shows the difference between you and I, where I’m talking about barking seals and you’re talking about laminar flow, but our brains operate differently. You mentioned something that I think is really important to keep in mind, and that’s that age of the child. So classically I think of kids with croup being about six months old to about six years of age. And so, as you said, kind of in that older age range, if you’ve got a 12-year-old coming in with stridor and a bark-y cough, could it be viral laryngotracheitis? Maybe, but that would be very atypical. And so really should be thinking of other diagnoses at that point, which really brings up, maybe this is a good time to talk about what are those mimickers of croup? Because croup is the horses, that you’re hearing the hoof beats and you see all these horses, but there are some zebras out there of things you don’t want to miss. And so what do you think of as the “don’t miss” diagnoses with croup. Dr. Courtney Herring: Yeah, I think the call-out to response to racemic epinephrine, which the goal of that, of course, is to vasoconstrict those little blood vessels in the airway, then giving you some partial relief of that obstruction while you’re awaiting what is going to be the primary therapy, which we can get into. But the mimickers, of course, age context, but also how the patient looks is extremely important. As you mentioned, it can be a very mild illness, otherwise outside of the croup symptom of the bark-y cough and the airway obstruction. And so when you have a child who’s having a lot of fever, especially potentially high fevers, and they look sick, even toxic, when I think of out of age range, you think croup by definition is viral. However, bacteria are a great mimicker of that early croup airway obstruction. And so those kids, like bacterial tracheitis, it can be a very acute life-threatening disease. So understanding that. And then foreign body, bless our hearts. I will say, coming up we did a button battery ingestion guideline as well as a podcast. At the same time, foreign body is a big thing we see in emergency departments. We had talked about just button batteries alone was over 4,000 encounters a year across the nation, so I think keeping those two in prime opportunity of history and clinical context when you’re seeing the patient. Gabi, anything else from your side? Dr. Gabi Hester: No, I think those are really good ones to highlight. I think of bacterial tracheitis and epiglottitis being two of the key croup mimickers. There’s obviously airway hemangiomas and a few other more uncommon things, of course. Dr. Courtney Herring: True zebras, but yes. Dr. Gabi Hester: Right. But I think that response to racemic epinephrine is really important. So if a child does not respond to racemic epinephrine, if their stridor does not significantly improve, then we really need to be thinking of something other than just viral laryngotracheitis, which would be something that we don’t have the scope of really talking about the management of at this particular podcast, but is really important to consider, and so would be sort of off of our croup guideline there. So Courtney, you mentioned a little bit about racemic epinephrine and how that helps reduce some of that airway inflammation and sort of has a limited time of duration, of course, for its effect. So can you talk a little bit about the treatments for croup? Dr. Courtney Herring: Absolutely. Racemic epinephrine is buying you time. It’s quick-on, quick-off, and so being understanding that it is supposed to help in the first 10 to 15 minutes, that’s why we love it, alleviates some of our stress, as well as the parents at bedside, but what you’re getting to is what really should be your primary therapy, which is systemic steroids. In our case, a lot of studies are done around dexamethasone, and part of that is just because many studies show that even one dose can be enough. And the idea is, because of the pharmacokinetics involved with an onset of four to six hours, you have to wait it out a little bit. And so your racemic epinephrine is really pulling in that idea of buying you time, knowing that the long-term therapy or even the subacute therapy, per se, is not going to most likely be your racemic epinephrine. It’s when the actual systemic steroid takes effect and starts taking care of that airway inflammation. So that’s how I look at it from an emergency department or an urgent care who’s trying to figure out how long do you actually observe these patients. That’s a really important thing. And I know, Gabi, you’ve done a lot of work on croup at Children’s in your time and even out at your time at Children’s, and so speaking of where we went from our new guidelines, where they’re not new anymore, but they’re very important, and what we changed up for croup. I’d love for you to chat a little bit about that. Dr. Gabi Hester: When we were developing the guideline, it was really a multi-step process because first we really wanted to understand what was going on before we put out new recommendations, because there is not, and was not at the time, a national guideline for kids with croup. And so we really wanted to develop a rich evidence base, review the existing evidence base, and then put out some recommendations. And so we looked at thousands of kids who presented to Children’s Minnesota over a couple year period with symptoms consistent with croup and what happened to them. And so the vast majority of them are treated in the emergency room and sent home, I think about 98%, if I remember, all told. But then of the kids who were admitted, which, again, is a very small percentage of kids with croup, need admission. Of those, what percentage needed additional interventions after they came in? So we looked at kids, did they need racemic epinephrine after admission? Did they need did be intubated? Did they get a heliox or oxygen? Really any of those airway interventions that we were focused on. And we found that kids who had received two doses of racemic epinephrine before decision to admit, really very few of them needed anything else after admission, and if they were going to need something that was within a few hours of admission. So based on that recommendation, we said, “Hey, there’s probably a way that we can reduce the need to admit a large number of kids without negatively impacting their outcomes.” And so we implemented a new clinical guideline where we said this very, very cool tagline of, “Three is the new two.” So instead of two doses of racemic epinephrine before admission, we really recommended that those kids who got two doses be observed for an additional two hours in the emergency room. And if they did fine at that two hour mark, you can send them home assuming there’s no other barriers to outpatient management, those kinds of things, of course. And then if they needed a third, we said, “Hey, this kid’s sort of on that outlier. They need more interventions than the typical kid with croup, and so let’s admit them.” Those kids still very infrequently, I think less than a quarter of them needed additional interventions after admission. But we were able to sort of take this large chunk of kids who previously had been admitted and get them discharged safely home from the emergency room. We, of course, looked at our balancing measure of readmissions and found no difference after implementing that recommendation. I’d have to look at the numbers, but I think we reduced the admission rate by about 30-40% if I recall. Dr. Courtney Herring: And I would say, Gabi, it’s been a good collaborative between hospital medicine and the emergency department, our emergency providers, because they know croup the best, they’re great at triaging croup in my opinion, and this was a little bit of a culture change, but they really took it on patient forward and have been really great. And so, as a collective, I just felt like, especially from our process at Children’s, it really went well. And it’s a continued process, as in obviously I was on last week and took a handful of croup admissions, but it was after that third racemic Epi. So no questions asked, just needed a little history, and then we were good to go. I think it’s been a very successful process here at Children’s. Dr. Gabi Hester: Just to continue the kudos to the emergency room, Dr. Kelly Bergmann, one of the Children’s emergency medicine physicians, he is leading a national collaborative that I’m also a part of through the American Academy of Pediatrics that is rolling out right now, looking at quality improvement interventions for kids with croup. And so a great opportunity for him to lend his expertise really across the country, and also to share the success story of our clinical guideline with those around the country. We’ve done some subsequent studies on croup looking at what do other people at other hospitals do as far as their clinical guidelines. First of all, only, like, half of children’s hospitals have a clinical guideline for croup, which was shocking to me. But of those, only 15%, it was actually only three hospitals of the 40 that we studied, had a clinical guideline that recommended admission after three doses of racemic epinephrine. There were a whole bunch of them recommending after two, a couple after one, and then a number where it was unspecified. So just getting a little bit of more guidance around when to admit kids, the risk factors that we should be looking for, I think is really important. Dr. Courtney Herring: Gabi, you probably have heard this, but more intimate to Children’s in current state, is that we are actually updating our dexamethasone dosing for croup. I know. I think you’re going to like it. So you remember the old days. The OG was we maxed out like 16 milligrams per dose, and then we actually had some of our amazing clinical pharmacists a part of kind of a retrospective review, but also looking at the pharmacokinetics and just the general pharmacologics of dexamethasone itself. And what was found was we reduced it to 12 milligrams per dose. Well, in current state, actually, our order sets have just been updated that our max dose for croup indication is 10 milligrams per dose. So we’re really looking at, again, we’re trying to do our best, not just for antibiotic stewardship, which is what we preach all the time in some of these podcasts, but also just generically, what is the optimal benefit per dose of a medicine? And again, looking at the treatment need and the side effect profile. And so just letting you know, we just did that. And that’s all thanks to our, of course, a big consortium of our wonderful pharmacists here at Children’s. Dr. Gabi Hester: Talk about a hot-button topic, and that is dexamethasone dosing in croup. I know People Magazine is probably going to be covering, it’s scintillating, but there’s some emerging literature that’s suggesting that maybe different doses, aside from that 0.6 mg/kg regimens, might be equally efficacious, or non-inferior, as they say. Dr. Courtney Herring: Yep. Dr. Gabi Hester: But I’m not quite convinced yet. There’s some pretty well-designed studies that have been published in pretty high journals like Pediatrics, but they’re not adequately powered to look at the outcomes that I really care about. So one in particular that was looking at 0.6 mg/kg versus 0.15mg/kg of dexamethasone also versus 1 mg/kg of Pred, just to throw another comparison group in there, their outcome was one hour croup scores and they found that there was no difference in the three study groups for that. But then later in the depths of the article, they say, “But actually at two and three hours, the standard dose, the 0.6 mg/kg, had a little bit better croup scores than in those lower dose dexamethasone groups.” There were a couple of other nuances of the study that I found very interesting. Like in their background they said that their readmission or revisit rate was around 5%, and in their study they found it was like 17% or something in all these groups. So they were saying it wasn’t different, but there was something going on, something that was a little bit different. They only enrolled about one out of seven kids who came into their hospital with croup, and it was a convenient sample. So again, no shade on the authors. They did some really cool things with this study, I think it’s a really important topic, but just didn’t quite convince me yet that we’re there for the low dose. Do I think it’s probably equally efficacious? Probably. For most kids it probably wouldn’t matter, but I think as far as what would I recommend for every kid at this point in time as we’re recording, I’d stand behind the 0.6 mg/kg dosing. But I think 10 milligrams as max very reasonable. Certainly we worry about could it possibly lead to adrenal insufficiency or suppression if we use higher doses? I know that was something that was sort of looked at by our pharmacists too. So quality improvement is iterative, right, Courtney? We learn, we change, we study. Some might also say we plan, do, study, act. I don’t know. Dr. Courtney Herring: Oh, yeah, I’ve heard about that cycle before. Dr. Gabi Hester: Yeah. Yeah. Courtney, thanks so much for coming on today to talk to me about croup. It’s been illuminating, as always, and really appreciate chatting with you today.