In K. Kim

Helium/oxygen-driven albuterol nebulization in the treatment of children with moderate to severe asthma exacerbations: a randomized, controlled trial.

Background. Helium and oxygen mixtures (heliox) increase both pulmonary aerosol delivery and gas delivery relative to oxygen. We aimed to compare the effectiveness of a 70%:30% helium/oxygen (heliox)–driven continuous aerosol delivery versus 100% oxygen-driven delivery in the treatment of asthmatic children with moderate to severe exacerbations. Methods. We enrolled 30 children aged 2 to 18 years who presented to an urban, pediatric emergency department (ED) with moderate to severe asthma as defined by a pulmonary index (PI) score of ≥8. PI scores can range from 0 to 15. In this randomized, controlled, single-blind trial conducted in a convenience sample of children, all patients in the trial received an initial nebulized albuterol (5 mg) treatment driven by 100% oxygen and a dose of oral prednisone or prednisolone. Subsequently, patients were randomly assigned to receive continuously nebulized albuterol (15 mg/hour) delivered by either heliox or oxygen using a nonrebreathing face mask. The primary outcome measure was degree of improvement as assessed in blinded video-recorded PI scores over 240 minutes (at 30-minute intervals for the first 3 hours) or until ED discharge (if <240 minutes). Results. The mean change in PI score from baseline to 240 minutes or ED discharge was 6.67 for the heliox group compared with 3.33 for the oxygen group. Eleven (73%) patients in the heliox group were discharged from the hospital in <12 hours compared with 5 (33%) patients in the conventional group. Conclusion. Continuously nebulized albuterol delivered by heliox was associated with a greater degree of clinical improvement compared with that delivered by oxygen among children with moderate to severe asthma exacerbations.

The Anatomic Relationship of Femoral Vein to Femoral Artery in Euvolemic Pediatric Patients by Ultrasonography: Implications for Pediatric Femoral Central Venous Access

BACKGROUND Knowledge of the femoral vein (FV) anatomy in pediatric patients is important in the selection of appropriate size central line catheters as well as the approach to central venous access. This knowledge may avoid potential complications during central line access. OBJECTIVES To describe the relationship of the FV to the femoral artery (FA). To measure FV diameter and FV depth using ultrasonography (US) in newborns, infants, and children up to 9 years of age. METHODS This study was a prospective descriptive study at a tertiary care childrens hospital. A convenience sample of euvolemic children was enrolled aged 0-9 years presenting to an urban pediatric emergency department. All patients underwent a standardized US evaluation using a Sonosite Titan bedside machine by a single emergency physician. The FA and FV were identified by four criteria: relative positions, FV compressibility, FV enlargement by Valsalva maneuver, and absence of FV pulsatility. The position of the FV relative to the FA was described as being completely overlapped by the FA, having partial (<50%) overlap by the FA, and having no overlap by the FA. The FV depth was measured from the skin to the superior border of the vein using the US machines caliper function. RESULTS A total of 84 patients were studied. The FV was found to be completely overlapped by the FA in 8% of subjects and partially overlapped by the FA in 4% of subjects. The mean FV diameter ranged from 4.5 mm in young infants to 10.8 mm in patients 9 years of age. The mean FV depth ranged from 6.5 mm in neonates to 11.2 mm in patients 9 years of age. CONCLUSIONS External landmarks were not always predictive of internal anatomy. The FV was completely or partially overlapped by the FA in 12% of cases. Thus, visualization of femoral vessels should be recommended prior to attempting pediatric femoral central venous access.

The Anatomic Relationship Between the Common Femoral Artery and Common Femoral Vein in Frog Leg Position Versus Straight Leg Position in Pediatric Patients

BACKGROUND Overlap of the femoral artery (FA) on the femoral vein (FV) has been shown to occur in pediatric patients. This overlap may increase complications such as arterial puncture and failed insertions of central venous lines (CVLs). Knowledge of the anatomic relationship between the FV and FA may be important in avoiding these complications. OBJECTIVES The objective was to evaluate the anatomic relationship of the FA and FV in straight leg position and frog leg position. METHODS This was a prospective, descriptive study of a convenience sample of 80 total subjects (16 subjects from each of five predetermined stratified age groups). Each subject underwent a standardized ultrasound examination in both the straight and the frog leg positions. The location of the FA in relation to the FV was measured at three locations: immediately distal, 1 cm distal, and 3 cm distal to the inguinal ligament. Overlap of the FA on the FV and the diameter of the FV was noted at each location. Measurements were repeated in both the straight leg and the frog leg positions. RESULTS For the left leg, immediately distal to the inguinal ligament, the FV was overlapped by the FA in 36% of patients in straight leg position and by 45% of patients in frog leg position. At 1 cm distal to the ligament, overlap was observed in 75% of patients in straight leg position and 88% of patients in the frog leg position. At 3 cm distal to the ligament, overlap was observed in 93% of patients in straight leg position and 86% of patients in the frog leg position. The percentage of vessels with overlap was similar in the right leg at each location for both the straight and the frog leg positions. Pooled mean (+/-SD) FV diameters for the left leg immediately distal to the inguinal ligament were 0.64 (+/-0.23) cm in the straight leg position and 0.76 (+/-0.28) cm in the frog leg position; at 1 cm distal to the ligament, 0.66 (+/-0.23) and 0.78 (+/-0.29) cm; and at 3 cm distal to the ligament, 0.65 (+/-0.27) and 0.69 (+/-0.29) cm. FV diameters for the right leg were similar to the left. CONCLUSIONS A significant percentage of children have FAs that overlap their FVs. This overlap may be responsible for complications such as FA puncture with CVL placement. Ultrasound-guided techniques may decrease these risks. Placing children in the frog leg position increases the diameter of the FV visualized on ultrasound.

Psychiatric patients in the pediatric emergency department undergoing routine urine toxicology screens for medical clearance: Results and use

Objective: We sought to determine the use and results of urine toxicology screens (UTS) in psychiatric patients undergoing a UTS test for medical clearance in a pediatric emergency department. Methods: A structured retrospective study was conducted over a 6-month period. All emergency department (ED) charts were reviewed of patients 8 to 17 years who had a UTS. Urine toxicology screens were identified as medically indicated or routine-driven. Medically indicated UTS were patients who presented with seizures, syncope, headache, altered mental status, ingestion, chest pain/palpitation, shortness of breath, sexual assault, or those who were brought in for motor vehicle accident (MVA). Routine-driven UTS were uncomplicated psychiatric patients who presented with aggressive or out of control behavior, intentional self-inflicted wounds, or symptoms of depression, all of whom presented without any evidence of drug or alcohol ingestion or altered mental status. Routine-driven UTS were quantified for positive tests. In addition, we determined the change in management and disposition of those patients. We also determined the concordance of provided drug use history with UTS result. Results: Of the 652 charts reviewed, 267 UTS were medically indicated; 385 were routine-driven. Of the routine-driven UTS group, 254/267 (95%) patients with negative screens and 115/118 (97%) with positive screens were referred for psychiatric treatment after psychiatric evaluation. Fisher exact test of the comparison of the disposition after psychiatric assessment with the UTS result was nonsignificant. The UTS result also had no effect on the type of psychiatric disposition (ie, outpatient therapy, partial hospitalization, inpatient hospitalization). Concordance with provided history of illicit drug use was significant. Conclusions: Routine-driven UTS in uncomplicated pediatric psychiatric patients being evaluated in the ED offered little additional information, did not influence management, and potentially increased both ED cost and time. Patients with straightforward psychiatric complaints may be medically cleared without a UTS.

Aerosol drug delivery using heliox and nebulizer reservoirs: results from an MRI-based pediatric model.

An MRI-based model of the mouth, throat, and upper airways of a 5-year-old boy is used to evaluate methods for increasing the nebulized drug dose delivered to the lungs. Four methods are considered: (1) standard nebulizer delivery with air, (2) delivery with 70/30 helium-oxygen (heliox), (3) delivery with air and an aerosol-conserving reservoir, and (4) delivery with heliox and a reservoir. When comparing air and heliox, delivery flowrates were adjusted so that the aerosols produced were of similar size. The reservoir utilized was the Medicator Aerosol Maximizer (Healthline Medical, Baldwin Park, CA). It conserves the aerosol generated by the nebulizer during exhalation and makes it available for the next inhalation. Technetium-DTPA was utilized. The standard nebulizer driven by air delivered 2.2% of the dose loaded into the nebulizer to the lungs as fine droplets, versus 3.3% for the nebulizer with heliox (50% increase; p = 0.002 vs. air), 2.9% for the nebulizer plus reservoir driven by air (32% increase; p = 0.02 vs. no reservoir), and 4.0% for the nebulizer plus reservoir driven by heliox (82% increase; p = 0.002 vs. air without reservoir). The increased pulmonary dose when heliox was utilized occurred because of decreased deposition within the nebulizer and other delivery equipment. The increased pulmonary dose when the reservoirs were utilized occurred due to a decrease in the dose expelled from the nebulizer by exhalation.

Helium-Oxygen Therapy for Infants With Bronchiolitis: A Randomized Controlled Trial

OBJECTIVE To compare nebulized racemic epinephrine delivered by 70% helium and 30% oxygen or 100% oxygen followed by helium-oxygen inhalation therapy via high-flow nasal cannula (HFNC) vs oxygen inhalation via HFNC in the treatment of bronchiolitis. DESIGN Prospective, randomized, controlled, single-blind trial. SETTING This study was conducted from October 1, 2004, through May 31, 2008, in the emergency department of an urban, tertiary care childrens hospital. Patients Infants aged 2 to 12 months with a Modified Woods Clinical Asthma Score (M-WCAS) of 3 or higher. INTERVENTIONS Patients initially received nebulized albuterol treatment driven by 100% oxygen. Patients were randomized to the helium-oxygen or oxygen group and received nebulized racemic epinephrine via a face mask. After nebulization, humidified helium-oxygen or oxygen was delivered by HFNC. After 60 minutes of inhalation therapy, patients with an M-WCAS of 2 or higher received a second delivery of nebulized racemic epinephrine followed by helium-oxygen or oxygen delivered by HFNC. Main Outcome Measure Degree of improvement of M-WCAS for 240 minutes or until emergency department discharge. RESULTS Of 69 infants enrolled, 34 were randomized to the helium-oxygen group and 35 to the oxygen group. The mean change in M-WCAS from baseline to 240 minutes or emergency department discharge was 1.84 for the helium-oxygen group compared with 0.31 for the oxygen group (P < .001). The mean M-WCAS was significantly improved for the helium-oxygen group compared with the oxygen group at 60 minutes (P = .005), 120 minutes (P < .001), 180 minutes (P < .001), and 240 minutes (P < .001). CONCLUSION Nebulized racemic epinephrine delivered by helium-oxygen followed by helium-oxygen inhalation therapy delivered by HFNC was associated with a greater degree of clinical improvement compared with that delivered by oxygen among infants with bronchiolitis. Trial Registration clinicaltrials.gov Identifier: NCT00116584.

Evaluating the length of stay and value of time in a pediatric emergency department with two models by comparing two different albuterol delivery systems

Abstract Objective: Asthma is one of the most common childhood illnesses and accounts for a substantial amount of pediatric emergency department visits. Historically, acute exacerbations are treated with a beta agonist via nebulizer therapy (NEB). However, with the advent of the spacer, the medication can be delivered via a metered dose inhaler (MDI + S) with the same efficacy for mild-to-moderate asthma exacerbations. To date, no study has been done to evaluate emergency department (ED) length of stay (LOS) and opportunity cost between nebulized vs MDI + S. The objective of this study was to compare ED LOS and associated opportunity cost among children who present with a mild asthma exacerbation according to the delivery mode of albuterol: MDI + S vs NEB. Methods: A structured, retrospective cross-sectional study was conducted. Medical records were reviewed from children aged 1–18 years treated at an urban pediatric ED from July 2007 to June 2008 with a discharge diagnosis International Classification of Disease-9 of asthma. Length of stay was defined: time from initial triage until the time of the guardian signature on the discharge instructions. An operational definition was used to define a mild asthma exacerbation; those patients requiring only one standard weight based albuterol treatment. Emergency department throughput time points, demographic data, treatment course, and delivery method of albuterol were recorded. Results: Three hundred and four patients were analyzed: 94 in the MDI + S group and 209 in the NEB group. Mean age in years for the MDI + S group was 9.57 vs 5.07 for the NEB group (p < 0.001). The percentage of patients that received oral corticosteroids was 39.4% in the MDI + S group vs 61.7% in the NEB group (p < 0.001). There was no difference between groups in: race, insurance status, gender, or chest radiographs. The mean ED LOS for patients in the MDI + S group was 170 minutes compared to 205 minutes in the NEB group. On average, there was a 25.1 minute time savings per patient in ED treatment time (p < 0.001; 95% CI = 3.8–31.7). Significant predictors of outcome for treatment time were chest radiograph, steroids, and treatment mode. Opportunity cost analysis estimated a potential cost savings of

Improving Pediatric Education for Emergency Medical Services Providers: A Qualitative Study.

213,532 annually using MDI + S vs NEB. Conclusion: In mild asthma exacerbations, administering albuterol via MDI + S decreases ED treatment time when compared to administering nebulized albuterol. A metered dose inhaler with spacer utilization may enhance opportunity cost savings and decrease the left without being seen population with improved throughput. Limitations: The key limitations of this study include its retrospective design, the proxy non-standard definition of mild asthma exacerbation, and the opportunity cost calculation, which may over-estimate the value of ED time saved based on ED volume.

The History and Physics of Heliox

OBJECTIVES Previous studies have illustrated pediatric knowledge deficits among Emergency Medical Services (EMS) providers. The purpose of this study was to identify perspectives of a diverse group of EMS providers regarding pediatric prehospital care educational deficits and proposed methods of training improvements. METHODS Purposive sampling was used to recruit EMS providers in diverse settings for study participation. Two separate focus groups of EMS providers (administrative and non-administrative personnel) were held in three locations (urban, suburban, and rural). A professional moderator facilitated focus group discussion using a guide developed by the study team. A grounded theory approach was used to analyze data. RESULTS Forty-two participants provided data. Four major themes were identified: (1) suboptimal previous pediatric training and training gaps in continuing pediatric education; (2) opportunities for improved interactions with emergency department (ED) staff, including case-based feedback on patient care; (3) barriers to optimal pediatric prehospital care; and (4) proposed pediatric training improvements. CONCLUSION Focus groups identified four themes surrounding preparation of EMS personnel for providing care to pediatric patients. These themes can guide future educational interventions for EMS to improve pediatric prehospital care. Brown SA , Hayden TC , Randell KA , Rappaport L , Stevenson MD , Kim IK . Improving pediatric education for Emergency Medical Services providers: a qualitative study. Prehosp Disaster Med. 2017;32(1):20-26.