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

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: Love to think that everybody knows us, but I’m Dr. Gabi Hester, practicing up in a small community hospital up in northern Minnesota, and joined today by Dr. Courtney Herring, who is the inside hospitalist, practicing at Children’s Minnesota for almost a decade now. Is that what we’re coming up on? Dr. Courtney Herring: Yeah, the silvers are definitely coming out, yes. Dr. Gabi Hester: I don’t want to call out your age. We don’t do that to one another. Right? We’ve been around the block a couple of times, and so really excited to talk to you today about bronchiolitis. No hot button issues there whatsoever. You are wise beyond your years in so many things, but in particular one thing I’ve always admired about you is your depth of knowledge about oxygen delivery devices. I did want to take this opportunity to ask you a few rapid fire questions. Do we need to define bronchiolitis? Probably no, but do you want to give a one-liner quick? Dr. Courtney Herring: Yeah. I mean, I would say airway disease of young children, infancy and toddlers. Inflammation that causes obstruction by a cytokine process that causes debris and that’s what causes your obstruction and it causes quite a bit of distress, depending on the patient. So, just think of airway disease versus interstitial disease, and it really focused on that these are not about being a hyperactive airway, which is a subset of patients, but more of, how do you support a patient that doesn’t have a lot of interventions that’s been shown to be very helpful? Dr. Gabi Hester: As you allude to, there’ve been a lot of therapies that have been evaluated over the last decades and there’s always sort of every few years there’s something that seems to be for a little bit. Oh, maybe albuterol will help. Oh, maybe racemic epinephrine will help, or maybe hypertonic saline is the new thing. And I feel like the last few years really the focus of the, hey, maybe this is helpful, is the way we deliver oxygen support. And so, I want to focus a little bit on high-flow nasal cannula because I think it’s having its moment, it’s all the rage. And I think there’s been a little bit of, now that we’re full into it, I do think that there’s some reflection and a little bit like, are we using this the right way? Is it actually making a difference? So, here’s some quick questions. Tell me what a RAM cannula is. Dr. Courtney Herring: Oh, RAM Cannula, a very pediatric centric piece of care. RAM is just the first three letters of actually the creator of the cannula, is his last name. So just for reference, there’s no other acronym for RAM. Dr. Gabi Hester: Love that. Dr. Courtney Herring: RAM Cannula is a nasal cannula system that allows for decreased tubular resistance that really, really pushes non-invasive positive pressure. So, it really is the escalation in my opinion, from high flow. So obviously, multiple layers of oxygen delivery systems with more pressure support, versus non-pressure support. I would say RAM cannula is for at least how we use at Children’s Minnesota, is your escalation from high flow nasal cannula. So, it truly is going to give you some PEP or positive expiratory pressure, whereas we can argue a little bit more about how high flow nasal cannula is not likely going to change your dead space and give you true PEP. So, that’s RAM cannula. Dr. Gabi Hester: Optiflow, with Optiflow. Dr. Courtney Herring: Optiflow is just a trademarked name. The word Optiflow is just from the specific company that trademarked it, which is Fisher and Paykel, out of New Zealand, by the way. One of the biggest distributors and producers of these cannulas. But it is functionally a part of a system of high flow nasal cannula, which is the generic system. So high flow nasal cannula, there is a lot of theoretical benefits of high flow nasal cannula. I’m not going to name them all, I am going to tell you what I feel are the two biggest proponents that truly are beneficial to the patient. Number one is humidification. So, prolonged dry oxygen can cause the, of course, drying of the nasal mucosa and you can actually get epistaxis. So longterm, I am not saying don’t use dry oxygen. I’m saying after a period of time you have to be considerate it, that you can have some complications of dry oxygen. So, humidification is great. It does build comfort for the patients as well. Number two though, in regards to the physiology piece is the overcoming of upper airway resistance. So that oropharyngeal resistance. For some of us, especially when you’re thinking of the target audience and pediatrics, which is going to be your infants and toddlers, but you can use it at any age, adults have high flow nasal cannula. It is functionally a beautiful piece of equipment because it has dual independent functions. You have the tool of having flow rate or flow built in, so your liters per minute, and then you actually have your FiO2, or your concentrated oxygen, and they work independently of each other. That of course helps in escalation but also in de-escalation. So the idea that you can provide individually for a patient up to obviously a certain point, and give them exactly what they need, whether it is a ventilatory oxygenation or a complement problem that is going on. So the two big things, humidification and then overcoming upper airway resistance is really what you’re focused on. It is not truly to get to the deep depths of your airways, unfortunately. And we can talk all day about high flow, but that’s my two cents on high flow. Dr. Gabi Hester: How do you decide what the right amount of flow is for a particular child? Dr. Courtney Herring: There’s a lot of good studies out there, and I will say this, some of the initials came from actually the manufacturing companies. Right? So then you had to bill clinically for the practice what this really means. So how we look at high flow in children is weight-based, not dissimilar to a lot of other things we do in pediatric care. So for adults it’s easier, adults in a lot of times you’re starting on anywhere from 20 to 30 liters per minute, and that could be just for moderate distress. You can work yourself up to 60 and 70 liters per minute, but there’s a lot of coefficients you got to worry about here. You got to worry about, what is the underlying problem you’re treating? And number two is the comfort to the patient. Imagine that blowing into your face and your nose at 60 liters per minute is quite forceful. So it’s a lot of pressure in the nares, and so you will get some studies from ICUs around comfort levels based on the liter flow. So again, in adults which even in children, obviously children are adult size at times, they can have to 60 to even 70 liters per minute. But I would say for us, we do weight-based early. We do anywhere from one to two liters per kilo per minute. But as you recognize with any guideline, and we do have a high flow nasal cannula guideline, whew, hard piece of work because used to do it, but we did it. Dr. Gabi Hester: [inaudible 00:07:31]. Dr. Courtney Herring: We start off at one to two liters per kilo per minute, but in our kind of setting of utilization of resources, meaning even our nursing cares, our RT cares, obviously have to recognize what care unit should that patient be on. And recognizing that’s important for anyone building these type of guidelines. You can do up to X amount of liters per minute for these patients, but at the same time, you have to recognize you’re putting some monikers on those patients or higher even FiO2 that you’re putting on these patients. So for us, we do up to 20 liters, just general. There’s some age things going on, but about 20 liters per minute in our acute care units, and up to 50% FiO2. And I will be clear, I as a hospitalist taking care of children, I always get more concerned with the FiO2 concentration. I really focus on, are we truly having an oxygenation problem? That is one of the first initial signs of respiratory failure. And so just being conscientious of that, so building guidelines is important, recognize those two independent things into the algorithm of escalation and de-escalation. Dr. Gabi Hester: So, when I am taking care of a kiddo here at my community hospital, we’ve got one unit, and so we don’t have that intensive care. So there’s a factor in there of, what can we do? So we have equipment for high flow, we have a certain max ceiling based on the equipment of how high we can go. But then there’s this element that I’m trying to really bring in of, what should we be doing here? So if the child is needing really, really high settings of high flow, do they actually need something else? Do they need to be at a place where we can go up to those more again noninvasive, but truly providing more positive pressure type interventions? And so, I think that a new nuance that as outside hospitalist I am now learning about is thinking about and anticipating, well, if this amount of high flow doesn’t work for this patient, what is my next step? And really planning for that next step. I think I mentioned in the sepsis episode, transportation is very challenging and particularly we’re talking about bronchiolitis, right? So we have this surge season coming up where there might not be beds available for me to send a critically ill child to. So I need to be thinking two steps ahead of, what trajectory is this patient on? Am I continually turning up that high flow? Where can I turn it up to? And when I get to the ceiling, where can I get them and what’s it going to take to get them there? Because of the transportation challenges. And the ability to deliver high flow on most of the ambulances, actually, at least in our area, is very limited. So we had to actually procure some of our own equipment to be able to send for transport because the inability to deliver high flow, particularly to children in some of these setups. I wanted to ask you, you brought up FiO2, and I totally get what you’re saying about getting those higher levels of FiO2. One thing I’ve always wanted to ask about and truly understand at a deeper level is, when a kid’s on a high flow setting but 21% FiO2, does that make any sense? Sometimes I come in and I’m kind of like, really? Tell me a little bit about that. Is that something that makes sense or is there a sort of lower limit to the FiO2 that we should be using on some of those oxygen delivery devices? Dr. Courtney Herring: In reference, we don’t do a lot of 21% or what we consider room air, on our high flow nasal cannulas at Children’s. It’s not that we don’t do it at all, but usually our algorithm gets down to 40 and 30% FiO2, and then you’re really looking at another modality of respiratory support to either deescalate. This, what you bring up is, do you use high flow nasal cannula just to support that airway, that oropharyngeal resistance that you’re trying to overcome for those moderate to even getting closer to severely impaired distressful patients? I would say the rule of thumb is that we do not usually include 21% in our guidelines. It does happen clinically. We usually again stop at 30% and work on the flow rate, deescalation, and wean. And then come off, whether that’s to a nasal cannula to a low flow nasal cannula, or obviously just to room air without support. So you can, it is physically possible to use those machines that way, but I would encourage you that if you’re getting the space where you’re doing it for the breathing, one of my goals in the second part of my career, I feel like I’m almost 15 years in, so I know how long this is going to go. So we’ll say for part deux, I would love to bring the motto that some work of breathing is still okay. We are not here to cure bronchiolitis, we’re not here to cure asthma. We are here to make that process better with other interventions or port. With bronchiolitis, it’s mainly just supportive care. In asthma, of course, we could talk for days about that. So what I mean by that is, a kid comes in with a known disease process, we know they’re ill, we know they have this process, we are not going to make them look normal. That’s not our job. Our job is to get them to a space where we are not going to let them hopefully progress to failure, and even that can’t always be 100%. Again, how are you catching these patients? It is the initial clinical context. It’s, how are you assessing these patients? And moving on to the idea that you catch escalation when you need to and you catch de-escalation when you need to, right? That is the goal of this. It’s not to make a patient look normal by using high flow. Dr. Gabi Hester: Is there a certain way that we should wean these patients off of high flow once they’ve been on it? Dr. Courtney Herring: I do it pretty quickly, I will call that out. And you are privy to this too. There is a HiFlo, H-I-F-L-O, study out of the AAP [inaudible 00:13:13]. This is a great study to look up because what they did look at as a part of one big arm of that study, of course, was the weaning. And so what they really found was even in the ICU or intermediate care, if you have that kind of subset of levels of care in your hospital, you could pretty much rapidly come off every couple hours down on flow rate. And there was a lot of focus on flow rate but of course, FiO2 was discussed, giving the duality of high flow. And so I would push, if a child meets criteria, you should have criteria, usually clinical, and you should follow it. And so for us, we actually reassess every one to two hours on our high flow systems. And that could be for escalation or for weaning, but in current state, our guidelines says every one hour. Dr. Gabi Hester: Do we overuse high flow? Is this going to be the hypertonic saline story where we loved it, we used it, and then we kind of found out, hey, maybe it actually wasn’t as great as we thought? Dr. Courtney Herring: There’s some opinion-y thing to it, but there’s also data. I mean, one of the fortunate things we do have nationally is the PHIS database, and we can look at high flow utilization across children’s hospitals in the United States. And so I would say at some points we have looked at that. Where does Children’s Minnesota look at this versus others? But I would say even national, Cincinnati did a great study now years ago, my gosh, we’re aging, where they looked at the use of high flow specifically for bronchiolitis and what the utility was in trying to find that cushion of, who’s going to do well just on low flow? Who’s those kids versus who really needs the high flow? And I still think there’s nuance to that and we’re still evolving, but the bottom line is generically, I think we are in a culture of high flow and that tends to swing the pendulum one way first, which is usually overuse as we figure the clinical context out, which we are still doing. I still think we’re in that phase. I think we have even at Children’s Minnesota, some opportunity for optimization of how we pick the initial respiratory support system and also how we de-escalate quicker off some of the high flow nasal cannula systems. So, work to be done. I don’t think we’re alone, and I do think it is the pendulum of anything when it comes into power. We have to kind of re-equilibrate where we really need to be to use that. Dr. Gabi Hester: Now that I am an outside hospitalist and not an inside hospitalist, I have totally changed how I think about these kids. I mentioned some of that when we were talking about high flow and some peak settings and things like that, but I think it also has played in a little bit into some of my prescribing practices. Dr. Courtney Herring: Being in the quaternary center, we really hemmed into what we think is all evidence-based, right? No intervention. The evidence at this point initially is a small cache of patients that are going to be truly beneficial off of bronchodilator or albuterol. However, who are those kids? Is it the kid with just the family history? Who knows? I don’t think we’ve well defined that. And beyond that, and yes, the hypertonic, which you and I know is a small power study about maybe hypertonic could have been helpful, I don’t know. But then further studies have showed, probably not. The thing is, what is it actually doing to the airways? Do you need to make the patient cough? Do you need to make it where the debris is coming out, and is it really effective, right? There’s some theoreticals that are important. So I agree, I think you come from a great lens. You’ve obviously done wonderful work in a quaternary children’s system for years and experienced that, and done the evidence-based work behind it. And now you’re in a community-based emergency department and facility, still taking care of a lot of children. So, I lean into what you have to see every day and how you help your ED partners, because that really I think has to be important part of a pediatric hospital, is really being there to help your care team who isn’t going to see 90,000 children encounters that we do at Children’s Minnesota every year. Dr. Gabi Hester: Yeah, I mean, I think you’re right on. And I think albuterol is one of the areas where I’ve really changed my tune. People would whisper in the team room when they were signing out and they had a bronchiolidic patient on albuterol if I was in there, because they didn’t want me to hear. They thought I’d yell at them. And I use it now in some patients. Like you said, who are those kids that are going to benefit? I don’t know. But if I am seeing a kiddo who is sick with bronchiolitis, who’s working hard, whose settings on high flow are escalating, and I’m thinking about, am I going to transfer this kid in the middle of a blizzard if I can even find an ambulance, if I can even find a bed? That’s a kid, I’m like, you know what? I’m going to try some albuterol because maybe I can help that kid sort of improve that work of breathing. In some of the small studies, albuterol and bronchiolitis, actually showed some improvement again in some kids in their clinical scoring. And I get that that’s not the be-all most studies look at, right? Most studies are actually looking at hospital length of stay, which is very important, of course, super important to look at both for that individual patient as well as overall resource utilization. But if I’m thinking about transferring a kid, I’m not worried about the length of stay at that moment. I’m worried about that clinical score because if I can have that patient have lower oxygen support needs, improved work of breathing, I might not need to transfer that kid, which is a huge resource use and obviously very stressful on individual patients and families as well as the entire system. So, I do see some potential benefit for kids who are having an escalating severity of illness while they’re in the inpatient setting, as potentially trialing some albuterol. When I look back at the AAP guideline back from 2014 now, ages ago, it does call out in there, there is a small subset of kids, we don’t know who, who will benefit from albuterol or who are likely to benefit from albuterol. Very small, but if it could potentially help that patient in front of me, I think that’s important. But when we’re weighing costs and benefits and things like that, you’re part of a system too. So I know particularly in surge season, you need to think about, if I give albuterol to my patient with bronchiolitis, that respiratory therapist is no longer available to be somewhere else helping another patient, whether it’s a child or a newborn or an adult in the ICU in my hospital. So, I think thinking about all the elements of delivering that medication is super important. It’s not just, what’s the dollar price of the cost of that medication itself, it’s the whole process to get the medicine into the patient. So, I think one of the other hot issues right now that we’re seeing, terrible hurricane season. And unfortunately, one of the hurricanes caused really devastating damage to a facility in North Carolina that produces a lot of the IV fluids that our country, healthcare system relies on. And so tell me a little bit about feeding and hydration in kids with bronchiolitis and what your recommendations are there. Dr. Courtney Herring: I would say we are focused on one, is our nasogastric tubes safe in children who have respiratory disease? The answer is yes, that’s been demonstrated. Number two is, is nasogastric tube the only way to feed or hydrate a baby? No, you can do post-pyloric tubes, but even in ICU settings, it has been shown in for most children, there always are different nuanced contexts here, that gastric feeds are probably still safe. And why they’re safe is because of the way you do it, which is generically you can start with a continuous drip of infusion, almost like an IV in that way, versus having bolus like meals like we do when we are in an ideal state for feeding. So I think those are two big things. And then three is, you can a guideline for this sort of nursing policy of how we do this, which I think is really powerful to give nurses who are a big part of this, some power and empowerment to move these plans along and ask good questions and make sure we’re considering gastric use hydration versus intravenous use hydration. So long story short, NG tubes are safe in children, even with bronchiolitis. Even with nasal cannula in place, you can do it. I do warn the family, it’s a full nare, whatever nare, we put that nasal gastric tube in plus the cannula, it’s going to be a relatively full nare. So I would say as a call out to care, just thinking of skin integrity, make sure that you’re aware of that. You should be aware anytime you put artificial plastic or rubber in any orifice, but most importantly, if you’re doubling down with a nasal cannula plus a nasal gastric tube. And then yeah, you could do the four, two, one rule if you’d like, for our pediatric compadres who do hydration under that formulation. We do not have a policy yet, we do not have a guideline yet. We are working on it with the help of our hospital medicine partners here at Children’s. But I think the idea is, you can look at what the hydration levels need and consider there may be some increase in sensible losses, and start and titrate up. So I would say slow and steady wins the race, and yes, trying to find a maximum to that is going to accomplish true hydration in that patient. Dr. Gabi Hester: Courtney, always a pleasure to talk to you. Thanks so much for hitting some of those hot button issues with bronchiolitis with me today. Dr. Courtney Herring: Oh, always my pleasure. I’m sure we will come up with a new topic soon, though. I can’t wait. Dr. Gabi Hester: Sounds great. Dr. Kade Goepferd: Thank you for listening to Talking Pediatrics. Come back next time for a new episode with our caregivers and experts in pediatric health. Our showrunner is Cora Nelson. Episodes are produced, engineered and edited by Jake Beaver and Patrick Bixler. Our marketing representatives are Amie Juba and Krithika Devanathan. For information and additional episodes, check us out on your favorite podcast platform or go to childrensmn.org/talkingpediatrics.