INTERN BOOTCAMP: Go with the High Flow: Bronchiolitis with Dr. Brian Alverson

(bell ringing) (upbeat music) - Continuing education credits, including ABP Maintenance of Certification for Physicians and other healthcare professionals are provided by the Pan-Medicine Continuing Medical and Interprofessional Education. Check out our website at www.TheCribSiders.com for more information. (upbeat music) - The CribSiders podcast is for entertainment, education, and informational purposes only. The views and statements expressed in this podcast are solely of those of the hosts. (upbeat music) - Welcome back to the CribSiders. I'm Chris Thichou Manchu, and I'm joined tonight with my co-host, Dr. Sam Azar, what's up buddy? - Hey Chris. - We welcome you back to our summer series that we're calling the intern boot camp. It's a replay of some of our early episodes in the core topics every pediatric intern should know during the early stages of residency. But first, Sam, do you wanna remind us about the show? - So I'd love to. We are the pediatric medicine podcast. We interview leading experts in the fields to bring clinical pearls, practice changing knowledge, and answering literally in questions about core topics in pediatric medicine. - Today's episode is in the way back time machine where we hit episode two, go with the high flow, which is bronchialitis with Dr. Brian Alverson. This original aired back in July of 2020, and it's our evidence-based walkthrough of one of the most common pediatric problems you'll ever see. - So really this is one of our first episodes, and Dr. Alverson walks us through the workup of bronchialitis, the role of chest x-ray, CBC, the respiratory viral panel, and the evidence behind the treatments should and should not consider. These include things like albuterol or steroids or hyphen nasal cannula. He also walks through how to think about oxygenation and what families can do at home. - And here why this one belongs in the top of the intern boot camp list. Bronchialitis is gonna be one of your most common admission diagnoses during respiratory season. It's the poster child for high-value care and pediatrics, which is a disease where doing less is usually doing more. And the instinct to throw test steroids and albuterol at these babies is one of the hardest instincts to unlearn. This episode is how you unlearn it early. - So let's go directly to the episode, and we're gonna jump in as our producer for this episode, Jess, reads Dr. Alverson's bio. - All right, take away Jess. Let's just go with the flow. Nice. (upbeat music) I'm Jess Kelly. On tonight's episode, we discuss Bronchialitis with our guest, Dr. Brian Alverson, director of the division of hospital medicine at Hasbro Children's Hospital. Dr. Alverson has served on the American Academy at Pediatrics Clinical Practice Guideline Panel on the diagnosis, management, and prevention of bronchialitis. He is the recipient of numerous awards for teaching at Brown University. My co-hosts for this episode are Justin Burke and Chris Chu. We have a fantastic conversation with our guest, Dr. Alverson, who teaches us why all you need is a history and physical exam to diagnose bronchialitis, how high-blown nasal cannula actually works, and the real cost of using bronchodilators and bronchialitis. So without further ado, let's get to it. - Okay, so let's go ahead and get started. So Dr. Alverson, thank you so much for coming onto the show. We'd like to start with some rapid fire questions just to get you know, get to know you a little bit better. And do you mind giving us a one-liner to describe yourself? - Well, who is Brian Alverson? - Sure, I'm the head of the pediatric hospitals program at Hadsbro Children's Hospital in Providence, Rhode Island. And I also run the pediatric's courtship at Brown University. I'm an avid violinist as well. Do lots of different things. - Nice, violence. You recently were in a producer. Tell me about the recent event you were a part of that was related to Beethoven and COVID? - Oh yeah, totally. So we did this really, I thought, fun and innovative look at Beethoven's life and his illnesses. And then we over time looked at his string quartets. And then I had this amazing string quartet called Brooklyn Rider, who came onto the program and broke down one of his very late quartets, the slow movement of his Opus 132 quartet. And they broke it down into pieces and we were able to break it down and explain how it related to illness and recovery. And then they performed the piece at the end. It was a lot of fun. A lot of people went. It was about maybe 800 people have seen it so far. So that was a lot of fun. - Holy cow, wow, nice. - Very Chris, do you want to do a question? - Yeah. So my question is, what is your favorite failure and what did you learn from it? - Oh yeah, so, oh my goodness, out of so many to choose from. But probably my favorite failure, it didn't end up being a failure, but it could have been. I had a patient who was 15 years old and came into the hospital. Post-Ton select to me about a week out and he was bleeding and he was spitting up a little blood. And I gave him one of those leader big suction canisters. I said, hang on to this and spit into it. I'm gonna go call the ENT. And the ENT went, was on the phone 'cause I was at a community hospital. It'll be there in 20 minutes and I walked back in and the leader canister was completely full of blood. And that was after about two minutes and I said, yeah, so in five minutes he's dead. So that was really terrifying. And I immediately did rapid sequence innovation and then discovered I couldn't see anything. And it was a motor of moment of complete and utter terror, of brilliant nurse next to me thought of applying topical thrombin to his tonsil of pillars and it gave me the brief second to get that ET tube in. It was still a lucky stab. And if I hadn't made that innovation, I'm quite confident he would have died. And so the lesson for me was, be ready for what you need to do even if it's an emergency, it was, I learned a lot from that experience. - That is like my worst nightmare in a pediatric hospitalist. I can't even imagine the thought for us to go through your head and that situation. - Yup. - Hence nuts. - Yes, it was nuts. - One of my favorite questions to ask guest is about advice. Can you tell us some of the best advice you've ever received as either as a learner or as an educator or at some point in your career, a piece of advice that you think is worth sharing? - You know, I think we all have these mentors out there who seem to us as like bigger characters than God. And the one for me was this guy Steve Ludwig. He was my residency director and one of the fathers of pediatric emergency medicine. And at the time when I finished my chief resident year, he gave me a gift, which is right next to me on my desk right now, which was just a box for pens. And on it, he said, this is the best life advice I can give you. And it was a quote from of all things, the folk singer James Taylor. And the statement was, the secret of life is enjoying the passage of time. And at first, I thought it was sort of a cheesy quote. And I liked James Taylor, but I'm not a huge fan. And I was like, okay, that's my pen box. But it was maybe a year or two later, I was looking at that. And I realized the profound importance of enjoying your job as you're doing it, as opposed to enjoying what you're gonna end up being. And that advice ended up being for me, sort of a life mantra and a sage wisdom is that I really have to enjoy what I'm doing as I do it. I suppose to always think, well, one day I'll get there. And that's really helped me get through some of the more difficult times in my career. - Wow, good advice. - I love that. Especially I think for people like in the residence, when I was a resident, those were things that I needed to hear. And it was trying to make the most of those situations and not just looking towards the light at the end of the tunnel, but taking every day for what it was and trying to enjoy it and stood advice. I like it. - Do we have anything else, Justin? Are we just going right into the cases now? - I should let's go right into it. Let's get to the metathines. And we got a lot to talk about. Bronchiolitis is a big topic. I think let's just do it. What do you think, Chris? - I think that sounds great. (upbeat music) - Hey creeps, setters listeners. On episode 135, we sat down with Dr. Tristan Nichols and talked about how AI is already changing how we practice pediatric medicine. From expanding differentials and tough cases to generating discharge instructions that family can actually understand, one thing that really struck me, the idea that AI shouldn't replace your clinical reasoning, it should support it. And that's exactly why I've been using Cloud. Cloud is the AI for minds that don't stop good enough. It's the collaborator that actually understands your entire workflow and thinks with you. Whether you're debugging code at midnight or strategizing your next business move, Cloud extends your thinking to tackle the problems that matter. What I love about using Cloud is its deep research capability. It goes way beyond a basic web search. I'm talking comprehensive analysis with proper citations, pulling connections across dozens of sources that I would never spotted on my own. It's like having a research partner who never gets tired. Whether it's working through a tricky inpatient diagnosis, reviewing the latest management guidelines or putting together a teaching topic for my residents, Cloud helped me think deeper instead of just skimming the surface. So, creeps, setters listeners. For problems worth solving, get started with Cloud at clod.ai/cribsiders. That's clod.ai/cribsiders. And check out Cloud Pro, which includes access to all the features we mentioned today in this episode. - And so we have a case from Catchlat Children's Hospital. We have Theo. Theo is, he's a two-month-old boy, former 35-weeker. And he came in with Caw four days of some nasal congestion and some fast breathing. Mom's concerned because he's sucking in from his stomach, he's drinking less, only three wet diapers in the past 24 hours. In the ED on a exam, he's febral to 101.2. He has a respiratory rate in the 60s and he does have some nasal flared and sub-costal retractions. His oxygen sat is right around 80%, 86%, And you hear some stuff. wises and diffusely coarse breath sounds. So in this kind of clinical picture, what does it sound like to you? Tell me a little bit about what your thought processes and seeing a patient like this. So I think as medical students, if I can just back out like from the 1,000, 10,000 foot view, as medical students were sort of taught to see a patient like this and formulated differential diagnosis. And I think what a lot of the evidence is in the literature is telling us right now is that instead of thinking about the differential diagnosis with a patient like this, we should literally just presume bronchialitis. The reason for this is complex, but it has to do with the fact that if we worry about a broad differential diagnosis, we start doing things like over-testing and over-treatment, which down the road can actually cause harm. So the more modern thinking about a case like this is presume it's bronchialitis, treat it as such, and then maybe in a day or so, or in two days, or if the kid gets critically ill, then bust open your differential diagnosis and start thinking about what it might be or what it might not be. So just hearing that story, it sounds simplistic, but it's really to prevent over-diagnosis and over-treatment. I'm going to hear that patient say, yep, bronchialitis, but in my heart, I'm going to be saying, but down the road, I might change my mind. So say I'm the parent of this two-month-old boy in the hospital or the nurse department, and you tell me, you say bronchialitis, how do you describe it to a parent? What bronchialitis is to them? Yeah, you've hit on a truism in that. I think a lot of people have a lot of misconceptions about the disease, and it's important to be super clear with families. When I'm talking to parents, I usually am very clear about what I think the pathophysiology is, and I try to avoid a lot of the lingo that we typically use with families. So I would say, your child has a viral infection, and that virus is present not only in those where you see this, where any nose and mucus coming out, but that mucus is also going on inside your child's lungs, and in the small areas of the lungs, which is why this baby is having difficulty breathing. And I'll probably just leave it at that, and then we'll start talking about options for how this child will get better. We have to remember that the parents are universally terrified, and the outcome is virtually universally good. So you say that, but then they hear the word bronchialitis either from like the resident or the nurse or something like that, and they're like, oh, you know, my grandfather had bronchitis in the hospital, or I had a recent bronchitis. Is this the same thing? You know, it can be the same thing, because certainly bronchitis can be caused by a virus, but in older people, bronchitis is often caused by bacteria as well. In infants, this is almost universally a virus. And the reason why that's important is viruses don't respond to antibiotics. That's how I would answer it, I guess. And let's say, let's say I'm the intern or the medical student first seen this patient. And I might be a little concerned, you know, his oxygen level is low. It's 86%. He's, he's wheezing. He's febrile. He's, he's to kipnic. A lot of these things are things were taught are pretty worrisome. Are there, are these red, flat symptoms? Are these things that are risk for severe disease? What should I be looking for? What am I, what am I concerned about? Yeah, Justin, I think you're hitting on an area which I think is broadly misconceived by not only medical students and residents, but by even attendings out there. And it has to do with oxygen. And I, I guess I want to spend a little bit of time on oxygen. It's that's okay. Because I think that understanding the role of hypoxemia is important. We have to remember a few things about hypoxemia. The first is in a two month old or really any infant. Hypoxemia is not particularly dangerous. Having a low oxygen level is quite common and we see it in other conditions and don't really worry about it that much. Let me give you an example. If you saw a three year old with large consults who had sleep apnea and use her, your mom brought in a recording of the child and said, yeah, he catches his breath when he's sleeping, you might refer that child to an ENT physician or something like that. But you would tolerate periodic desaturations at night in this child for months out of time until he follows up with his ENT doctor. Likewise, you can probably tolerate some transient desaturation in infants too. The kids don't have atheroscalotic plaques in their hearts. Unlike old people, they can tolerate a fair amount of hypoxemia. Even in this current COVID outbreak, we're seeing patients with pretty significant hypoxemia and we're sort of learning to tolerate that as a symptom out of respect to their need to ventilate. That's really where it gets to. The emergency isn't so much getting the oxygen in. The emergency is actually getting the carbon dioxide out. There have been a couple of interesting studies that kind of think are fun. There was one study where they took children from, I believe it was the coast of Greece, up Mount Everest. And they made it as high as the first base camp. And what they did is they had these children, this is not a lie, where a pulse ox while they were sleeping. And they noted that the average pulse ox desaturation for these children who lived at sea level while at 1700 meters, which was the first stay overnight, was 86%. The reason why that's relevant is Colorado is 1700 meters. If I go on a trip to Colorado with my child, I don't put them on a pulse ox and I don't give a oxygen and they are desaturating to 86%, which is actually the same number you gave me. So I should be willing to tolerate a certain amount of risk around oxygen. The other thing is children and adults can't sense hypoxemia. So the reason why that's important is that giving this child oxygen will not make this child more comfortable. The concept of oxygen for comfort is a complete myth across all age groups. This was figured out by Henderson, sorry, Hasselbach, not Henderson, in 1911 in Germany, where he had these little mice and he made them hypoxemic. And he was the first person to figure out that mammals do not have the ability to sense hypoxemia. You can go online and look at YouTube videos at people and hypoxemia chambers and they desaturate and they're perfectly happy until they get really low and then they become sort of dumb and can't put the correct shape block in the box slot. But basically, they don't feel short of breath. So we have to remember that the 86% of this child is probably the least concerning thing that I'm going to do and sure I'll give a oxygen, but that's not the emergency. The emergency in this child is looking at his respiratory stats. And so you mentioned things like respiratory rate, which is important work of breathing, which is reflected by retractions. We have to remember that retractions are a result of non-compliant lung. And so if this child is non-compliant lung, he clearly has some eukus in there that's preventing it from expanding and contracting the way it's supposed to. And that can lead to decline of this child's respiratory status through exhaustion of the respiratory musculature. From a boots on the ground standpoint, I think most experienced pediatric ER doctors and hospitalists and even intensivists also will tell you there's something about the appearance of a child, which maybe isn't measurable in respiratory rate and retractions flaring or grunting that gives you a hunch about whether the child is in distress. A child who's lying there and just tolerates the IB without flinching is concerning. A child who's looking around the room and playful, even if their respiratory rate is high or have a little bit of retractions, is probably not as concerning to me. So to recap, it sounds like the hypoxia, we're okay with the hypoxemia is not the biggest red flag. We can tolerate some desaturations, especially in this population, but really the tachypnea and work of breathing is really the big red flag that we want to keep an eye on for these patients. Yeah, one of our intensivists at our hospital gave me a great line, which I really like and I use, which is 90 to 100 isn't a 80 to 90 is a B and 70, 80 is C, but you're still passing. Once you drop below 70, maybe you need to worry about a little bit. That's great. It was a great hit. The rules of thumb. Yeah, this is great. So let's say we have this patient in front of us and you know, the idiotinean ass who are your resident, your student, they say, what do you want to do for this patient? How would you approach the the workup? Should be beginning lab, should we be getting imaging, should we be getting a VBG or ABG? Should we be swabbing them doing an RPP? What kind of what kind of workup or diagnostic approach should we be taking in this patient in front of us? Yeah. So Justin, I think that's a really great question. And I think it relates again to that statement I made earlier about holding off for a little bit regarding your differential diagnosis. I would get no tests at all. And let me explain why I would do that because I think a lot of people are tempted to get things like CBCs, blood gases, chest X-rays, things like that. The first thing I would look at is say the CBC. And I think there's a lot of people out there who like to use the white count as a proxy for bacterial versus viral illness. There was a very good study in thorax where they looked at the white count and showed whether it was likely to be a viral or bacterial pathogen causing illness in respiratory patients under the age of five. And they showed that the white count was almost exactly 50% sensitive and 50% specific for bacterial versus viral conditions in patients where they knew what the cause was. So we know the white count is notoriously horrible really for all bacterial infections in children. In adults works great in kids terrible lab and probably a lot of the reason relates to the fact that several viruses in particular adenovirus can cause a very high white count. I read one study in children adenovirus average white count is 24. So I wouldn't go for the CBC. In terms of the chem seven I think you can assess this child's need for hydration and say look he had three wet diapers let's give him something to drink. If you're really worried about it significant dehydration I don't think it's unreasonable to get a sodium but certainly you should do that in the minority of cases. In terms of a blood culture I think after two months of age the utility of the blood culture starts to really get low and the reason is the false positive rate is actually almost double the true positive rate in terms of bacteremia. Also by two months of age I would suggest that the risk of E. coli and other pathogens that come from the birth process are starting to get very low. One possible exception is if a baby is septic I would certainly get a blood culture if they're looking very ill I would think about a blood culture. Certainly in this child who's next 35 weaker you might have a delayed diagnosis of group e-strap but unless this could were super sick I probably would avoid that for fear of a false positive driving unnecessary care down the road. In terms of the chest X-ray there is really been quite an abundance of data showing that they can cause harm and let me explain why that is. As we know antibiotics are associated with a bunch of problems down the road. Antibiotic use and childhood can cause an increase in it's a type 1 diabetes. It caused resistant antibiotics in the future because of a variety of problems of course antibiotic associated diarrhea though that's probably my least concerning of the of the bunch. Now if we were to just give antibiotics to everyone we would quickly end up in a bit of a quagmire in our country in terms of resistant rates and things like that so we would like to avoid antibiotics. What we found is in children who present with viral symptoms and this is based out of a couple of different studies that chest X-rays increase use of antibiotics but do not actually improve outcomes. So there was a notable study that was done I believe if I recall correctly in India this was a sort of famous study of over 500 children who presented just like this and what they did is they actually randomized them to whether they got a chest X-ray or not. What they found was when you got a chest X-ray you did not get better any faster but you did get increased unnecessary antibiotic use. So the act of getting a chest X-ray will not improve the child's outcome. This was replicated in the US and I believe Driscoll Texas where they had a really interesting study where they took kids who came into the hospital and they basically made the doctor decide whether he was giving antibiotics or not and then they were allowed to get a chest X-ray. The ER doctor would then read the X-ray and then decide whether the antibiotics but because of the way their hospital system was set up the radiologist didn't review the X-ray until the next day. So this set up a really good opportunity for us to take a look at what happens real time and what happened was is that all of the kids who got antibiotics the radiologist read the chest X-ray as normal in the ones where they elected to get a chest X-ray that increased the use of antibiotics and the only child who was actually reviewed as having pneumonia actually didn't end up getting antibiotics and that child tested positive for RSV and did fine and it was probably just RSV pneumonia. The caveat being I'm not saying no chest X-rays at all. I'm suggesting that we should minimize their use and if you're using them more than maybe 10% of the 20% of the time you're probably overusing them and you're going to be increasing your antibiotic use for no particular benefit. Certainly if a kid looks profoundly sick if the child requires innovation if you're going to the ICU I think those are all fine indications for chest X-rays. I think the one we really should avoid is the child who's relatively well appearing or is going to the general awards for a little bit of something. Those kids I would avoid them and then get an X-ray if they deteriorate or things change and then you could expand your differential right down there. So I have one question. So this is a little off our outline here but are there any types of other testing that you think may be useful in the future that are being investigated right now? I know one like especially in the adult world where we're looking at you know procausatone and things like that at looking at antibiotic use for adults is there anything like that or even procaus self that you foresee in the future that might be promising? Yeah that's a really good question. The data really are in the pneumonia literature and there is a very good argument that both C-reactive protein and procausatone are far and vastly superior to white count for determining a distinguishing bacteria on viral illness. However there is a reasonable cost to those labs and the receiver operator curve isn't stellar. What I mean by that is if you if you look at both the sensitivity and the specificity of the test and set different values you can't really find a point where you set what is quote unquote normal for pneumonia and have a great sensitivity and specificity for either procausatone or CRP. So I think they're adjunctively perhaps helpful in a minority of cases. I would certainly use either one of those before I would look at a white count but for the majority patients there's probably no role for that because the majority of these kids are gonna be just fine and if they're deteriorating then there's time to start antibiotics. In a two month old with the fever if this clinically bronchiolitis patient were one month old or 26 days old or 19 days old what are your thoughts about the fever? What we're asking really is what is your risk tolerance for missing a bacterial infection and how long will you tolerate missing that? Certainly in an infant under one month of age my inclination personally is to still do what we call the full rule out sepsis which is your own blood and CSF and the reason is is that 0.4% of infants under one month of age with fever have meningitis and that's sort of a risk tolerance that I guess I'm not willing to make. Now there is one study that tried to look at does an RSV positive test reduce the likelihood of it being meningitis and the irony is they recruited thousands of patients that study and they were still not able to achieve statistical significance and that's because you need just an enormous study to figure out what the likelihood of having meningitis is in an infant number under one year's one month of age and I don't think we're ever going to see that study. So there's a little bit of it gets back to sort of your gestalt looking at the child. Is he really that sick? Was that a hundred point five or was it one or two? Is this child profoundly irritable or not? It becomes a complex algorithm which I don't think will ever have the answer. It's actually interesting. The AAP right now is trying to put together a guideline for the management of febrile infants and they are stuck on that very issue which is whether or not to do an LP in all children under one month of age and there's some disagreement I guess in the group so that guideline has yet to come out and it's been installed for maybe 15 years because they can't solve that simple problem. So I don't know if we'll ever have that answer. Now as you get older from one to two months I think it becomes a judgment call and ideally one where the hospitalist and the ER doctor work together and decide is this a child where we can put off the LP. I'm really fine with checking urins. I think the risk is relatively low and reasonably high number of these children have urinary tract infections. I know there are some doctors out there in fact a good friend of mine who is a national leader in the field of bronchulitis who believes that most infants with bronchulitis should not get a urinalysis and I can see that point certainly in kids over two but under one month of age I would pretty much get a urinal in everybody. The blood culture I think by the age of two months I think there's really no role for it. Unless you think this child has sepsis. Hey Crips at his listeners whether this is your first episode or you've been with us since day one you know our goal has always been to share real wisdom up our practicing medicine. So let's talk about something that actually changed my day today as a hospitalist. That's fake scrubs. I can't walk into a clinic or hospital without seeing people in fake scrubs and I get it. I wear them too. They're incredibly soft form fitting and durable and it's not just us. If you've been watching a certain popular ER drama TV yep they're in fakes too. These scrubs get it. That's what drew me in and what keeps me coming back. And because we work with kids and kids come with messes I love that fakes are endimicrobial. When stuff gets on your scrubs and it will you just wash them and they come out wrinkle free. I've washed mine well over 50 times and they still look brand new. All that and so much more is why we've teamed up with fakes. Now Crips at his listeners can get 15% off. Just go to wearfakes.com and use code FigsRx. that's w-e-a-r-f-i-g-s.com and use code bigs-r-x for 15% off. - What types of things are we doing in terms of general management? I know we talked a little bit about oxygen. Like if we do start oxygen, are there goals that we do for our sats? Like other medications that we're trying, including like steroids, is there a bit of useful? Can you talk about that a little bit? - Absolutely. So in terms of oxygen, I don't really have much of a goal 'cause I know this sounds crazy, but I just don't care that much. Now, I'm very aware that the National Guidelines for Bronchiolitis says that you should use a cutoff of 90%. As the author of that section of the National Guidelines, I can say I was full of crud. So I said that because that's where the data seemed to go, but the data are not based on clinical outcomes. They're based on the oxygen, evolution theme of an association curve. And really aren't a relevant clinical outcome. The reality is the vast majority of these kids do fine. I'm just waiting for the study where they use 85%. We have to recognize the limitation of our measurement. Paul Sox simulators are notoriously horrid. They are off by upwards of four or five points either way. There was a great study out of Canada where they artificially, without the doctor knowing lowered the readout of the Paul Sox by three points. And there was no difference in outcome in children, but the doctors were much more likely to admit that the hospital, so this is fear of hypoxemia, which I don't think necessarily has to be there. That side, what else can we do? 'Cause the oxygen isn't gonna really help or hurt. There's a lot of interest historically in albuterol. And I guess I kind of want to take first, if we can, the big picture of therapy and how we measure whether therapy is beneficial. Is that okay? And then we can talk about individual therapies. 'Cause we have to be a little bit suspicious about the things we do in bronchiolitis. The reason is this. My favorite study in bronchiolitis was a study where they went into a room, evaluated patients that did a respiratory score. And there's a number of different respiratory disorders. In this case, it was the RDAI, which is the respiratory distress assessment index, which is combination of respiratory symptoms and air entry and we use things like that. And they did a respiratory score and then they waited a half hour and did another respiratory score. There was literally no intervention in this study. They just did two respiratory scores. And I, this was published and I was like, why didn't I think of doing this, these guys are geniuses? Because what they showed was that while the majority of patients had no significant change in their respiratory stress, there were several patients who got dramatically better and several patients who got dramatically worse. I think a little bit of how we respond to patient experience at our interventions on a personal basis as physicians. And I'm reminded of an article that came out in one of those weekly city newspapers, I think it was the Phoenix or something. And it was by this guy in the 80s named Cecil Adams who wrote this article called The Straight Dope. And somebody wrote in and they said, you know, it's funny every time I walk under a street lamp, the street lamp goes off. I think I'm causing the street lamp to go off. And I think there are a lot of people who out here who had this experience where you're walking or street lamp and it goes off and you say, wow, what did I do? Now, of course, street lamps are designed to go off periodically when they overheated something about the mechanism and Cecil Adams explains this. The point is is that we are designed as people to look for associations in our personal experience and our personal experience may be a more profound driver of what we do than reading an article with a randomized controlled trial. The reason why that's important is we have to recognize that all of us will have an experience where we give a child albuterol and they look dramatically better afterwards. And it doesn't take many patients to do that. It takes about 20 patients before you see a dramatic improvement. But the thing is if you'd measured their respiratory distress before and after doing nothing, one in 20 patients would get better doing nothing. So the problem is, is we sit there and we give these children albuterol and we say, well, that kid worked. I'm gonna keep trying this therapy and see how things go. Well, the way to really look at this and see whether a therapy is effective, given bronchiolitis is such a waxing and weaning condition kid has a booger, he cops it up, he's better, grows a new booger, he's worse. The way to fix this and look at it is through rigorous study, and essentially, where you have a control group, you have one group that gets the albuterol and the other group that doesn't. That's been done over and over and over and over again. So when we were looking at all the albuterol studies that have ever been written about bronchiolitis and there were hundreds, they're ended up only being about 26 or 29, I forget the exact number that were actually albuterol versus placebo. A lot of them were like albuterol versus racemic epi and I'm not sure how useful that is because there was a tacit assumption that inhaled therapy works and they both have a similar mechanism. So of those studies where albuterol versus placebo is done, what was really interesting is in the inpatient setting, there was no difference in any outcome whatsoever. There was no difference in length of stay, there was no difference in hospitalization rate, there was no difference in respiratory status. In the outpatient setting, there was a very, very mild reduction in the severity of illness symptoms, but no difference in hospitalization. The problem is, is that all of these studies, there's a suspicion about your ability to truly see if the placebo was blinded. And the reason for that is it's really obvious when you listen to a child before and after albuterol that their heart rate has gone up dramatically. And so the concern as people review these papers is, this very mild improvement of albuterol or placebo in the outpatient setting, without any other hard thing to look at, other than just respiratory symptoms, may have been related to a lack of blinding all by itself. So the recommendation of the panel who wrote the guidelines was, you really should not use albuterol in any setting. Now, they said should not, but they did not say must not. And the reason for that is, there's a recognition that every now and then you might feel differently. And I myself, I confess, I am a nihilist with albuterol. I virtually never use it, but last year, I had an 18 month old who's under two, and I always am suspicious that they don't have asthma under two. This kid was covered with asthma. He'd gotten albuterol in the ER. They swore up down inside of ways that it was helping. So I said, okay, I'll continue. So I don't think it's bad to occasionally use albuterol, but again, we're getting back to that idea of deferring your differential diagnosis. Don't guess it's asthma. Don't use albuterol. If the child's getting worse or not improving the way they should, sure, try some albuterol, see if it helps. But if we launch albuterol to everybody, we're gonna create some very irritable babies. Now, a lot of people might say, well, what's the harm of albuterol? Well, the harm of albuterol isn't much. But it feels awful. If anybody out there has asthma, and they take six puffs up there, albuterol inhaler, they'll tell you, I feel terrible when I do that. It's awful. And we have to recognize that for maybe one in 500 babies who's getting a little bit of benefit from albuterol, that means we're making 499 babies feel completely crappy while they're short of respiratory, you're having this respiratory stress. So I would advocate for less albuterol in general. In terms of steroids, I feel like there's a little bit more data emphasizing the complete lack of benefit. In this case, the forest plot, which is sort of a meta-analysis of all the papers, is incredibly confident that children are to have no response whatsoever to steroids. And steroids do have some harm. They can harm growth. I have seen one patient who was getting repeated steroids or repeated viral infections, and he was actually falling off his growth curve. So there's some harm there. And I wouldn't use steroids at all, really, in anybody. I don't see any benefit child under two getting steroids. Certainly, there's really never been a study showing benefit. That's not true. There was one study by Alan Sari in the Middle East. He's a really prolific bronchiolitis researcher. He gave children a remarkably high dose of steroids. He gave them 0.6 milligrams per kilo of dexamethasone, every day for five days. And children hospitalized with bronchiolitis, and they went home an average of nine hours sooner. And that was statistically significant. However, and this was a small study and all the rest of the study showed no benefit. And even in that study, the readmission rate was the same in the two groups. And nine hours, it's not really clear to me that's worth such a colossal dosing of steroids. So it's awesome. So I think a couple of things that, as far as recapping for treatment, the hypoxia we're not super worried about. And it's one of my favorites says, as an early hospitalist, I don't have that many pearls to share. But one of the ones I really like, there's a study that I think was just very designed, funny, where they sent these kiddos home with a pulsox, but the parents couldn't see it. So they just recorded them. And they show that the kids had these persistent desats overnight and were clinically stable. There was no association with the admission rates. And then steroids also not a lot of good evidence. profound evidence that it's bad. I don't think there's really any excuse for steroids. That was the only thing in the bronchialitis guidelines that we said, level of recommendation strong and grade A level of evidence. So the Guidelines Committee was universal in agreement that the evidence behind steroids was that it could only be harmful. So what if this kid is looking like he's just getting worse on the floor? You're like, you go on every hour or two, seems to be looking worse and worse. What are the things that we can do on the floor to help try to prevent this kid from needing to go to the ICU or to a higher level care? - Yeah. - So that's a really good question. And I think I want to back up and look at sort of like the 10,000 foot view for a second. And if you look at it, we have to recognize that mortality is exceptionally rare. There are occasionally infants who die of bronchialitis. There was one study using the kids' database, I believe it was, which showed 50 deaths per year from in RSV, from RSV in children who do not have complex chronic health conditions. So 50 sounds like a lot, and that's a huge database. This is the largest one we have, but we have to recognize that 10 million children get RSV every year, which works out to be one in 200,000. One in 200,000 sounds like something I'm not willing to tolerate, but we then have to back up and say, well, an infant's risk of death in a car in one year is one in 10,000. So you're 20 times more likely to die driving in a car than you are to die of bronchialitis, and yet we're willing to put kids in cars. So we have to at some point tolerate risk. So clearly bronchialitis is a low risk condition. And I know there are people out there say, I once saw a child who died of RSV, maybe. I've never seen that, and I've been at this for 20 years, but it's certainly I've heard it. And those children, it's unclear that we could have done something more to help them. And they're already on ventilators and doing everything. So we need to be a little bit more calm about things and keep an eye on children, but not get too worried. Now that aside, checking our nervousness at the door, we go in and we see a child who's sitting there working to breathe, retractions, flaring, grunting. And we're like, this needs to be escalated somehow. There's no medication that will make this child do better. Certainly if a child's getting really sick, I will open up my differential diagnosis and maybe get a chest x-ray or a blood gas to see where we stand. Although I don't often use blood gases over my hunch about a child's physical appearance, but some like to do that, you might get a blood culture g's, what if it's sepsis. I don't think anybody would blame you for the child who's really sick and looking like they need to be in intensive care. Certainly a chest x-ray isn't unreasonable also because very rarely I've seen it once, you can get spontaneous pneumothorax with bronculitis in addition to the pneumonia thing. But all that aside, the first thing I think a lot of people do are thinking about giving positive pressure. And the first therapy, which is sort of swept the country in the last five years is high flones of cannula, which is really just a heated and warmed application of air to be clear, not oxygen, but air that's blown in the nose. And the idea behind the mechanism proposed behind this therapy, which was first started after people sort of lifted it from the NICU is that it would allow one of four possible mechanisms that have been written in the literature. The two most popular ones are that it will provide some peep, although the amount of peep is probably fairly minimal. There was a study of infants in newborn nurseries where they literally to volunteer infants, they taped their mouths shut and put a monometer in their mouth and then blew high flow at them. And a high flow of six liters per minute, which isn't all that much, provided a peep of five, which isn't a huge amount of peep, but it's some. So that's what their mouths taped shut, though, with their mouths open. It's not really clear how much peep there is, though, probably is some 'cause they are obligate nose breeders. So whatever the case may be, you provide some peep. The other argument, and there's caps of thought, and I don't really care what the mechanism is, I just care for works and we'll get to that in a second. The other provisioned mechanism is that infants when they breathe have very rapid shallow breathing, and they stack up CO2 in their airway dead space and are actually re-inhaling their CO2, creating a respiratory acidosis. And as we know, acid, not oxygen, is the cause of an infant's desire to breathe harder. So the idea is you're sort of blowing out the airway dead space like one might with a leaf bow, blower in a barrel of leaves, you blow out the leaves, you blow out the CO2, and they don't re-inhale it. Whatever the mechanism, the proposal is that this causes children to breathe better. Back to our assessment of whether therapies work. So if we look really carefully at the literature as opposed to our personal experience, and we have to recognize that in our personal experience, there are some kids who just get better and some kids who just get worse and some kids most kids just stay the same. We've all seen a kid, and I have absolutely seen a kid where I put him on the high floor and I said, "That made a difference." And I turned it off, and he got better, I turned it on and got worse, I mean the other way around. And I was like, "Okay, this is working. I'm going to give High Flown his kid." But when we look at this rigorously from a perspective randomized controlled trial perspective, we're not really seeing a huge amount of benefit. The first thing I would mention is dosing of High Flow, and the next thing I would talk about is whether it's therapeutic. So the first is dosing. Right now in America, we have two schools of thought. The schools of thought are tightly applied to which hospital you're in, as opposed to which individual you are, which into itself is fascinating. But there are some hospitals where they give two liters per minute per kilogram, up to a max of 30, and there's other hospitals where they give six or eight, but they won't really go above eight. Which is really interesting, right? So at my hospital right now, there's probably a child with bronchialitis who's on six liters of High Flow, and literally a hundred miles away in Springfield, Massachusetts, there's a child on 30 liters of High Flow. And the doctors in my hospital think the other doctors are crazy, the doctors in the other hospital think my hospital is crazy, and literally nobody's crazy. That said, the majority of the world uses two liters per minute. So then we can look at what studies are out there, and the biggest one by far is the one that was published in the New England Journal last year in out of Australia, where they looked at multiple sites of rural sort of community hospitals, using High Flow in his account in infants with bronchialitis. And they randomized them to either not being on High Flow, but having High Flow available if they got really sick, and putting them on High Flow. And what they showed is nothing. In other words, the infants have the same length of stay, the same readmission rate. There was literally no difference in any outcome with the exception of one, which was touted, so they did get it published in the New England Journal. And that was infants who weren't on High Flow were more likely to be started on High Flow, which is logical because infants who are already on High Flow can't be started on High Flow because they're already on it. So it was really a study about physician behavior may be more so than anything else, but what was glaringly obvious was there was no length of stay difference. In our own hospital, one of my colleagues conducted a study of 2,000 patients in our hospital before and after the incidence, the application of High Flow as a cannibal children on the wards. And what he showed was there was no difference in length of stay, but there was a little bit of a difference in cost because kids on High Flow were less likely to be sent to the ICU. You could make the argument that those kids maybe just shouldn't have been sent to the ICU, but that High Flow was a way we could sort of influence our own behavior and feel like we'd done something until the child's spontaneous is recovered. So it really wasn't showing much benefit of High Flow. So I guess what I'm saying is High Flow is out there. It's extremely commonly used. It's yet to be proven that it's beneficial, which is an amazing thing to say. Many of us have hunches that there's some patients who seem to respond to it. It's pretty harmless. I've been on High Flow myself to see how it feels. And I turned it up to 30 and I will say, I felt like I was stacking here. I felt a little bit like an asthmatic 'cause I was literally blowing full at 30. It definitely made me feel weird, but I wasn't in distress and it wasn't horribly uncomfortable. So I would say that judicious use of High Flow is probably not bad. It may stave things off for a bit, but the jury's really out there. And I think many would argue, people are starting to argue anyway, that maybe it's just our next version of albuterol. And we've done this so many times. We did this with hypertonic, saline nips. If you remember 10 years ago, and then after tons of people saying, "Oh, anecdotally, it's working great." And a bunch of small studies, Susan Wu out of LA, children's show they had made no different turns of like to stay in the hospital. And that was replicated in another study in Virginia that I saw. And so people basically started realizing, "Yeah, this isn't doing anything." And it went by the wayside. And I wouldn't be surprised. different five years, we stop using high flow and we're on to the next thing, I have no idea. So if the evidence for high flow doesn't seem to work and I admit, you know, that's a lot of what we're doing for the patients. What are we doing for these patients? You know, if I'm in clinical and I have a patient who is borderline respiratory distress, distressed with clear bronchialitis, when should we admit these kids? What can we do for them and what can be helpful in the hospital? Yeah, so to a certain degree, the decision to admit is based on the judgment of the primary care physician or whoever's seeing the patient in the outpatient setting. And it takes into account whether the child is in respiratory distress, which clearly is an admission criteria, how you define that is a little bit of a judgment call. But if you're nervous, probably err on the side of sending them in because in countries where they don't have developed healthcare systems, bronchialitis is a cause of workout. So if you're worried send them in, the other thing which you clearly have to assess is hydration status and is the child drinking adequately and maintaining adequate urine output. And if the child is making good wet diapers, you're probably okay. Now in terms of what you can do and how you can counsel families because I think a lot of practitioners are stuck, well, I used to sell them, use our view to all and it was a way to sort of help them. What do I tell families? And I've relied more and more on nasal suctioning as a very harmless way of improving outcomes. The evidence isn't awesome, but there is some argument that infants which have frequent nasal suctioning do better in the hospital, whereas infants who have frequent deep suctioning actually maybe do worse. So nasal suction is probably good idea and this new device is out there. There's actually several different ones, which I would say is a parent activated nasal suctioning device, I don't want to use a trade name, but any of them will work and it's really kind of disgusting, but you put one out of the tube in your mouth and the other one at the child's nose, you apply some saline to loosen up the boogers and you suck. The mucus doesn't go into the parent's mouth, the mucus gets usually caught in a little collection chamber and there's usually a filter, but that inhalational power of a parent is far more effective than a little blue bulb. On a whim, I did a study of four patients where I had two patients get, at that time, I used the nose-free to device, which is a device like I just described, and then the other parents used the blue bulb and actually weighed the mucus. This is not a publishable study, but I will say vastly more than twice as much mucus was liberated using the nose-free to end. I was fairly convinced it was an effective thing to do. So what I think we do is we give the parents get this device and suck out your child's nose at least every few hours and certainly before feeds, and that's something that families can focus on and can really help them feel empowered to get their kid better. And I think it is probably effective. Great. Let's maybe kind of wind down with a few rapid-fire questions. That sound okay? Sure. So, rapid-fire, hydration in G-Tube or IV fluids, what do we do? I think that I prefer NG-Tubes, but in older kids who are able to rip them out probably IV. I think either is fine. I think the parents should have some involvement in that decision. Sometimes parents feel strongly one way or another, and I don't really care all that much. Great. Re-admission rates. How do we counsel patients about when they're going home, what to look for, what their likelihood of coming back to the hospital is? The only thing we know about re-admission rates is that the distance you live from a hospital determines your re-admission. And as far as we can tell, nothing in the hospital makes a difference. This was well studied by Jeff Reese. So if you live a long way, you're less likely to be a remit because you don't want to drive back. All right, my kid has bronchialitis. Is he going to have asthma later on in life? Maybe. There are some studies arguing that RSV infection and infancy increases your risk of asthma. It's not clear to me that that's truly a risk. It could be there some underlying perencomal thing that means that you're more likely to respond badly to RSV and develop asthma later. So I can't say it's causal, but it's certainly associated. But I don't usually focus on that because the vast majority of kids who get bronchialitis do not develop asthma in the future. For bronchialitis, what's the typical age that we would see this condition in? Actually it's kids under two, although absolutely up to four. It's rare in the two to four group, but we've all seen it. Those kids tend to get a little bit more work up because you're more worried about other things. And that's not unreasonable. But under two, that's pretty much what it is. And I remember learning that it was in part because of intra-alviolar connections, like these pores of con and canals of Lambert, have you guys had a thing like why you have a round pneumonia? It certainly causes round pneumonia as in children you're completely correct. It can also probably cause a more diffuse picture because the virus can spread through the lung per ancoma. Although I can't blame the pores of con, I'm not really sure, but it is one theory. I think the pores of con, they're the worst. Well, that's all because you wrote a tutorial on bronchialitis that you use a great star trick. Con-giff for that. I'd remember. How makes perfect sense? That's how I remember the pores of con. Yeah. The pores of con. What about doing an RPP, should we be doing a respiratory viral panel on these patients? And as part of that, what viruses do cause bronchialitis? Is it only RSV? No, of course. There's other viruses. And they have different seasons. So, human metanumavirus tends to be a little bit more lingering on than there's a million. You know, rhinovirus can cause it. Ocovirus may be. One thing to know is that it's not always seasonal in Florida. They have 10 months of RSV a year, and nobody really knows why. But there's a wide variety of respiratory viruses, flu, periflu, et cetera. The RPP. I think it's okay to get it if you promise yourself that if it's positive, you're going to change your management. The fear I have is that a lot of people get it to just reassure themselves, and there is a cost. And if you think about it's 100 bucks for an RPP, you see 6,000 patients a year. That's 600 grand. You could have bought another doctor for that. So think about the use of these tests in terms of overall cost to the healthcare system. But if it's going to change your management, if it's going to help you nudge one way or the other, I'm not going to argue. You didn't pay 600 grand a year. That's an expensive doctor. No, but I figure maybe my health, my practice insurance, it bumps it way down there. Greena, do I shave my counter? It's a plastic surging. Well, are we seeing SARS-CoV-2 in this? Yeah, I think it'll be very reasonable right now to test for COVID. But at this point, in all hospitalizations. Because there's so much ramification in terms of the spread of the virus and the impact of it on grandma, I think that's a very different scenario. So I wouldn't mind getting a COVID test in these kids right now. Down the road, if we have a vaccine, obviously, I might not recommend that. Great. So I think let's wrap it up. So Brian, tell us a little bit about what are the main take home points for our listeners? For students, residents, and attendings who are seeing bronchialitis patients, what are the big pearls that we can leave them with? I think the biggest pearl is the differential diagnosis comes later. If I had to say one thing and that reflects decreased likelihood of getting testing and less therapies in general, I think that's really important. And the nose free day is a super help in terms of getting parents focused on something they can do. I think that's a good trick. That's awesome. I think this is really, really great. I learned a lot. Any other things that you would like to plug or give a shout out to? I have to pause and think, who do I want to give a shout out to Justin? I want to give a shout out to your podcast. Can I do that? Is that true? Yeah, we're happy to promote our own podcast on the podcast. Absolutely. I just think. So yeah, thanks, Justin. You know what? There's a lot going on in medicine. But I think one of the really exciting things that's going on is your podcast. So I'm on the plug, Crimson. So I think it's really cool that you're reaching out in a novel way to bring pediatric education to America, I think that's awesome stuff. I think it's a great plug for everyone who hasn't heard about it yet. Check out the crib ciders, available on all podcast mediums. If they haven't heard an episode by now, yeah, wait. This has been another episode of the crib ciders. It's for the kids. Get the show notes at the cribciders.com/podcast and sign up for our mailing list, knowledge gummies, to get our weekly show notes in your inbox. We're committed to providing you with high value, practice changing knowledge. To do that, we need your feedback. So please subscribe, rate, and review the show on Apple Podcasts or contact us at the [email protected]. Special thanks to our producer on this episode, Jess Kelly. I've been Justin Lee Burke. This is Jess Kelly. And this has been Chris, the Chew Man Chew. Thank you. All right. You've already listened to the entire episode, now claim CME credit. Continuing education credit is provided by the BCU Health Continuing Education. BCU Health is jointly accredited by the ACCME, ACPE, and ANCC to provide continuing education for the entire health care team. Check us out at ce.bcuhealth.org/cribciders for more information and to claim credit after listening to this episode.