Posts Tagged ‘PICU’
Every fall I write about bronchiolitis because it is one of the most common respiratory ailments affecting infants and children under about two years of age. It is the most common reason infants end up in the hospital during the winter and early spring months. Every year we get severe cases in the PICU. Pediatricians have struggled for decades to figure out how to treat bronchiolitis but we don’t have any specific therapies that work very well. (We have some promising treatments on the horizon, though, as I wrote about here.) Recognizing this, the American Academy of Pediatrics has significantly revised its recommendations of what we should and should not do for children with bronchiolitis. Before I describe these new recommendations, however, I should review what bronchiolitis is and why it can make small children, particularly infants, so sick.
Bronchiolitis is caused by a viral infection of the small airways, the bronchioles. By far the most common virus to do this is one we call respiratory syncytial virus, or RSV. To scientists, RSV is a fascinating virus with several unique properties. One of these is its behavior in the population. When it’s present, RSV is everywhere. Then it suddenly vanishes. There are exceptions to everything in medicine — I have seen sporadic cases during the off-months — but generally RSV arrives with a bang in mid-winter and then leaves suddenly in the spring. It’s the only virus that consistently and reliably causes an epidemic every year, although it often alternates more severe with milder visitations. RSV epidemics often have some regional variability. For example, often one city will have a much more severe epidemic than do others in other regions of the country.
Another aspect of RSV that interests medical scientists is how poor a job our immune systems do in fighting it off. Virtually all children are infected with RSV during the first few years of life. Not only that, all of us are reinfected multiple times during our lives. Attempts at devising a vaccine for RSV have all been unsuccessful. In fact, early versions of an experimental vaccine seemed to make the disease worse in some infants, raising the possibility that some aspect of our immune response to the virus actually contributes to the symptoms.
RSV has a high attack rate — the term scientists use for the chances that a susceptible person will get the infection if exposed to it. That, plus our generally poor defenses against it, explain the frequent epidemics. Every year a new crop of susceptible infants enters the population.
So what is bronchiolitis? What does it look like? In medical terminology, adding the ending “itis” to a word means that whatever comes before is inflamed. Thus tonsillitis is an inflammation of the tonsils and appendicitis means an inflamed appendix. So bronchiolitis is an inflammation of the bronchioles, the final part of the system of air-conducting tubes that connect the lungs with the outside world. Beyond the bronchioles are the aveoli, the grape-like clusters of air sacs where the business of the lungs — getting oxygen into our bodies and carbon dioxide out — takes place.
Bronchiolitis is a disorder of blocked small airways. This prevents air from getting in and out normally, primarily out. The principal source of the blockage is that the bronchiole tubes are blocked from swelling of the walls and from debris caused by the RSV infection — bits of broken airway cells and mucous plugs. This picture shows what it looks like:
Infants are the ones who have the most trouble breathing with bronchiolitis. There are several reasons for this, but a key one is the construction of an infant’s chest. When small airways get blocked, we use our chest muscles — tightening them — to force air in and out of our lungs. We are helped in doing this by the fact that our lungs are encased in a fairly rigid rib cage; when we use our muscles to squeeze or expand our chest the system works like a bellows. Infants can’t do this well because the ribs across the entire front half of their chest are not yet solid bone — they are still soft cartilage. So when a small infant tries to move air against anything that is restricting airflow, like clogged bronchioles, his chest tends to sink inwards, causing what we call retractions. These are easiest to see just below the last ribs. They especially have trouble forcing air out, so their chests become hyperexpanded with air, making it look as if their chests are puffed out a little. The other reason infants have so much trouble handling debris in their bronchioles is that these tubes are already much smaller to start with, so they get more easily clogged up than do the larger airways of older children.
How does a child with bronchiolitis look? Typically they are breathing faster than the normal respiratory rate of 25-35; often they are puffing along at 60-70 breaths per minute. They also will show those chest retractions and have a cough. Fever is uncommon. They may look a bit dusky from not having enough oxygen in the blood. They often have trouble feeding because they are breathing so fast. The fast breathing, along with the poor feeding, often makes them become dehydrated. Our breath is completely humidified, so when we breathe fast we lose more water.
What can we do to treat bronchiolitis? You read above that we have no specific medicine that will kill the virus. What we have to offer is what we call supportive care: treating the symptoms until the infection clears. Some of that supportive care has been based on how we treat asthma, another condition where air has trouble getting into and out of the lungs. Some years ago we learned that these asthma treatments, such as albuterol breathing treatments and steroids, helped very few children. Even though we knew that fact, a common thing was to try the asthma drugs and see if they helped an individual child, then continue them if it appeared they did.
The new recommendations come down strongly on the side of not even trying these asthma drugs because compelling research argues against it. More than that, the new recommendations say not to take a chest x-ray because it doesn’t help the child and may cause more risk; taking a chest x-ray often leads to physicians over-diagnosing pneumonia and giving antibiotics when they aren’t called for. The new recommendations even suggest we stop testing for the RSV virus, which has been commonly done, because it doesn’t affect anything we do. One thing the recommendations continue from the past is providing good hydration, as well as oxygen if the child needs it — some do, but many do not.
One important point to make, especially for me as a pediatric intensivist, is that these recommendations only apply to children with milder disease. Some children with bronchiolitis become extremely ill and require help with their breathing, either with soft plastic prongs in their nose that deliver oxygen and air pressure or with a mechanical breathing machine. For those children we do what it takes to keep their blood oxygen levels in the safe range.
Old ways die hard, and it will be interesting to see if physicians follow these new recommendations. My guess is that, over time, we will. More and more we are learning that therapies that add risk and cost, without adding any benefit, are not the way to go.
Respiratory syncytial virus infection, aka RSV, is a common infection in children. A key aspect of RSV is how poor a job our immune systems do in fighting it off. Virtually all children are infected with RSV during the first few years of life. Not only that, all of us are reinfected multiple times during our lives. Attempts at devising a vaccine for RSV have all been unsuccessful. In fact, early versions of an experimental vaccine seemed to make the disease worse in some infants, raising the possibility that some aspect of our immune response to the virus actually contributes to the symptoms.
RSV has a high attack rate — the term scientists use for the chances that a susceptible person will get the infection if exposed to it. That, plus our generally poor defenses against it, explain the frequent epidemics. Every year a new crop of susceptible infants enters the population.
The most common form of RSV infection is called bronchiolitis. In medical terminology, adding the ending “itis” to a word means that whatever comes before is inflamed. Thus tonsillitis is an inflammation of the tonsils and appendicitis means an inflamed appendix. So bronchiolitis is an inflammation of the bronchioles, the final part of the system of air-conducting tubes that connect the lungs with the outside world. Beyond the bronchioles are the aveoli, the grape-like clusters of air sacs where the business of the lungs — getting oxygen into our bodies and carbon dioxide out — takes place.
Bronchiolitis is a disorder of blocked small airways. This prevents air from getting in and out normally, primarily out. In bronchiolitis, the main problem is that the bronchiole tubes are blocked from swelling of the walls and from debris caused by the RSV infection — bits of broken airway cells and mucous plugs. It looks like this, with the arrows showing air movement.
Infants are the ones who have the most trouble breathing with bronchiolitis. There are several reasons for this, but a key one is the construction of an infant’s chest. When small airways get blocked, we use our chest muscles — tightening them — to force air in and out of our lungs. We are helped in doing this by the fact that our lungs are encased in a fairly rigid rib cage; when we use our muscles to squeeze or expand our chest the system works like a bellows. Infants can’t do this well because the ribs across the entire front half of their chest are not yet solid bone — they are still soft cartilage. So when a small infant tries to suck air in against anything that is restricting airflow, like clogged bronchioles, his chest tends to sink inwards, causing what we call retractions. These are easiest to see just below the last ribs. They also have trouble forcing air out, so their chests become hyperexpanded with air, making it look as if their chests are puffed out a little. The other reason infants have so much trouble handling debris in their bronchioles is that these tubes are already much smaller to start with, so they get more easily clogged up than do the larger airways of older children.
We have never had any specific treatment that works for RSV bronchiolitis. All we can do is what we call supportive care — oxygen, some breathing treatments (which usually don’t help much), IV fluids if the child is too sick to eat, and a few things we can do to help with mucus clearance. But now that may be changing. A recent study looked at a new drug to kill the RSV virus directly, something we’ve never had before.
The drug, which can be given orally, was tested on adults, not children — yet. The results were very encouraging. One of the issues with other anti-viral drugs has been that they only work well if they are given very early in the course of the illness or even before symptoms start. This new anti-RSV drug works even after people are sick with the virus. It greatly reduced the amount of virus in respiratory mucus, where we usually find the virus. Perhaps more importantly for sick infants, it also caused rapid improvement in symptoms.
Dr. Peter Wright, an RSV expert, is excited about the possibilities of the drug. Dr. Wright has worked on RSV for many, many years — so many that he was one of my teachers at Vanderbilt Hospital way back in 1978. I can recall that he does not get excited easily. I’m excited, too, because severe RSV bronchiolitis is a real scourge we see frequently in the PICU. Some infants even die from it. I was also pleased to read that Dr. Wright is still on the RSV case after all these years.
Below is a guest post by Dr. David Tilstra. Dr. Tilstra is President of CentraCare Clinic and on the Board of Directors of CentraCare Health, a large health system (6 hospitals, more than 400 physicians) in central Minnesota. He is also a practicing geneticist, so he is not one of those medical executives entirely detached from clinical practice. Recently he wrote about navigating the tensions that can develop between keeping patients satisfied and still providing them good medical care. Here is what he had to say. As a PICU practitioner, his points make a lot of sense in my practice.
I hear providers groan when we talk about the patient experience and some even tell me that they have no impact on the patient experience, that’s an administration problem. Nothing further from the truth! If you interact with patients, you influence the patient experience. Some providers think a full waiting room is a measure of patient satisfaction. Actually, it’s a measure of how long patients will tolerate a long waiting process before they go elsewhere. These days the patient impatience is growing short and they will go elsewhere.
Patient experience is not to be confused with patient happiness. We are not Disney World; we are a health care delivery system. Everything we do will not make people happy, but they still can be satisfied and can have a good experience with their health care. The customer is always right isn’t even followed in the business world anymore and we in healthcare shouldn’t have that attitude either. We need to deliver the best care for the patient. That is a core piece of what we do. Sometimes that is getting patients out of bed when they hurt. It probably won’t make them happy, but it’s necessary for getting the patient on the road to recovery. Sometimes we have to deliver bad news. It won’t make the patient happy, but how we deliver the news has a huge impact on their experience. Imagine a doctor walking in the room, telling the patient they have cancer and walking out (this has happened in our system). Now imagine a doctor walking in the room, sitting down, and telling the patient they have cancer and staying to listen and deal with the emotions (this also happens in our system everyday). The experience of the patient is very different. Are they happy? Probably not. Which had the better experience?
The patient experience starts with delivering safe care – no patient injured by medical care has had a good experience. Safety is priority number one. The next level of patient experience is high quality care – harder to define, but critical to delivering the best experience to the patient. As the mission statement says, we are here to improve the health of every patient, every day. Quality is critical to improving the patient’s health. Third, we have to focus on how we deliver the care. Patients are looking for caring, competence and professionalism in their health care provider. That is the provider’s responsibility in improving the patient experience. The administration’s duty is to get the frustration out of the process – get the phones answered quickly, smooth the registration process, etc.
Last why is this important? You could say it’s a business issue – patients are more willing than ever to go elsewhere for their care if they don’t have a good experience. We won’t be in the healthcare business if we don’t pay attention to the patient experience. More important, these are our friends and neighbors. It’s the right thing to do. It’s how we become the leader in Minnesota for quality, safety, service and value.
It seems lately that questions of medical ethics are coming up more and more in the news, things like the rights of patients to make decisions, definitions of futile care, and end of life care. The way to look at these things is not in a vacuum. All of us may have our own opinions about right and wrong, but the field of medical ethics is actually one that has a body of research and accepted practice. It certainly is something we deal with frequently in the PICU. It may sound esoteric, but generally it isn’t. Even so, it can be complicated. But complicated or not, it’s also something all of us should know a little about. This is because, in fact, many of us will encounter these issues quite suddenly and unexpectedly with our loved ones, or even ourselves. It is good to be prepared and knowledgeable. The cartoon above suggests it’s all about the law and medical tradition. Really, it’s more complicated than that — and more interesting.
So what are the accepted principles of medical ethics? There are four main principles, which on the surface are quite simple. They are these:
1. Beneficence (or, only do good things)
2. Nonmaleficence (or, don’t do bad things)
3. Autonomy (or, the patient decides important things)
4. Justice (or, be fair to everyone)
The first of these principles, beneficence, is the straightforward imperative that whatever we do should, before all else, benefit the patient. At first glance this seems an obvious statement. Why would we do anything that does not help the patient? In reality, we in the PICU, for example, are frequently tempted to do (or asked to do by families or other physicians) things that are of marginal or even no benefit to the patient. Common examples include a treatment or a test we think is unlikely to help, but just might. Should we do it just because somebody wants it?
There is a long tradition in medicine, one encapsulated in the Latin phrase primum non nocere (“first do no harm”), which admonishes physicians to avoid harming our patients. This is the principle of nonmaleficence. Again, this seems obvious. Why would we do anything to harm our patients? But let’s consider the example of tests or treatments we consider long shots — those which probably won’t help, but possibly could. It is one thing when someone asks us to mix an innocuous herbal remedy into a child’s feeding formula. It is quite another when we’re considering giving a child with advanced cancer a highly toxic drug that may or may not treat the cancer, but will certainly cause the child pain and suffering. Should we do it?
Our daily discussions in the PICU about the proper action to take, and particularly about who should decide, often lead us directly to the third key principle of medical ethics, which is autonomy. Autonomy means physicians should respect a patient’s wishes regarding what medical care he or she wants to receive. Years ago patients tended to believe, along with their physicians, that the doctor always knew best. The world has changed since that time, and today patients and their families have become much more involved in decisions regarding their care. This is a good thing. Recent legal decisions have emphasized the principle that patients who are fully competent mentally may choose to ignore medical advice and do (or not do) to their own bodies as they wish.
The issue of autonomy becomes much more complicated for children, or in the situation of an adult who is not able to decide things for himself. Who decides what to do? In the PICU, the principle of autonomy generally applies to the wishes of the family for their child. But what if they want something the doctors believe is wrong or dangerous? What if the family cannot decide what they want for their child? Finally, what if the child does not want what his or her parents want — at what age and to what extent should we honor the child’s wishes? (I’ve written about that issue here.) As you can see, the simple issue of autonomy is often not simple at all.
The fourth key principle of medical ethics, justice, stands somewhat apart from the other three. Justice means physicians are obligated to treat every patient the same, irrespective of age, race, sex, personality, income, or insurance status.
You can see how these ethical principles, at first glance so seemingly straightforward, can weave themselves together into a tangled knot of conflicting opinions and desires. The devil is often in the details. For example, as a practical matter, we often encounter a sort of tug-of-war between the ethical principles of beneficence and nonmaleficence — the imperative to do only helpful things and not do unhelpful ones. This is because everything we do carries some risk. We have different ways of describing the interaction between them, but we often speak of the “risk benefit ratio.” Simply put: Is the expected or potential benefit to the child worth the risk the contemplated test, treatment, or procedure will carry?
The difficult situations, of course, are those painted in shades of grey, and this includes a good number of them. In spite of that, thinking about how these four principles relate to each other is an excellent way of framing your thought process.
If you are interested in medical ethics, there are many good sites where you can read more. Here is a good site from the University of Washington, here is a link to the President’s Council on Bioethics (which discusses many specific issues), and here is an excellent blog specifically about the issues of end of life care maintained by Thaddeus Pope, a law professor who is expert in the legal ramifications. If you want a really detailed discussion, an excellent standard book is Principles of Biomedical Ethics, by Beauchamp and Childress.
Offhand you would not think a child with severe viral pneumonia and one with a major head injury are much alike, but they are. Together they illustrate a great truth of pediatric intensive care medicine, which is much of what we do is not specific treatment for the child’s problem; rather, it is what we term “supportive care,” because it supports the continued functioning of the child’s vital organs and systems while the problem runs its course and the child heals.
Both of these children often require very sophisticated technology to provide that organ support, things like mechanical ventilators and devices for measuring pressures inside the brain, but that technology doesn’t actually cure anything. But if it doesn’t cure anything, what does it do?
One of the most important principles of supportive care in the pediatric intensive care unit is that we make sure what we are doing does not make the problem worse. A good example of that is the child with a severe head injury. Although there are a few things we do to help the situation, a key aspect of what we do is the maneuvers we go through to make sure the brain is given a chance to heal without further stresses. For the child with severe pneumonia, the sort of child who is often on a mechanical ventilator machine, we do a similar thing — we use the machinery in such a way to minimize the chances that the ventilator itself does no harm, although this is not always possible.
This kind of watchful waiting at a sick child’s bedside is something parents have done for millennia. What the PICU often offers is simply an updated version of that time-honored vigil. I find that both comforting and reassuring. Deep down, essential things have not really changed much.
I’ve written about this before, but it’s well worth doing it again. It’s once more cold season, bringing up the question parents commonly face: Should they buy one of those rows and rows of cough, sneeze, and runny nose medicines one finds in every drug store and supermarket? In a nushell, no — none of the preparations sold over-the-counter to treat upper respiratory infections in children work, and all could be dangerous. That’s the conclusion of a report some years ago by the Food and Drug Administration, one still worth reading. You can read about the details, as well as the history of how and why these cold remedies were regulated in the past, here.
There is a huge market for these products. Ninety-five million packages of them are sold each year, and drug companies spend millions of dollars marketing them in various ways. The implication of the advertising is that these preparations (most are mixtures of several things) are safe.
In fact, they are not. Poison control centers receive thousands of calls about them every year, and The Centers for Disease Control found that many are seen in emergency departments owing to their side-effects. The FDA even found 123 deaths linked to their use. Possible side-effects can include hallucinations, dangerous over-sedation, and serious heart rhythm disturbances. Over the years I myself have cared for several children in the PICU who had serious side-effects from them.
The problem isn’t just over-dosing errors. The problem is we don’t know the correct dose for children, and estimating how much to give from adult doses is misleading and dangerous. The fundamental problem, though, is that they just don’t work. In fact, a total of six carefully randomized studies testing these agents in children under twelve all showed they worked no better than placebo — in other words, a sugar pill worked just as well. So using them puts a child at some risk with no benefit.
The Food and Drug Administration has issued a public health advisory that they not be used at all in children less then two years of age. They left use in children older than two alone, but I wouldn’t use them for those children, either. They don’t help, and may harm.
If you have questions about cold preparations, by all means talk to your child’s doctor about it. But the growing consensus among physicians is simple — don’t use them in small children.
So what can you use for a child with a bad cough? Some recent research, a good quality study, suggests that Grandma’s old folk remedy of honey actually helps. It not only can sooth the cough, but may have a specific cough-supressant effect.
Another thing to keep in mind is that persistent cough may actually represent a variant of bronchospasm or wheezing, particularly if your child has had wheezing troubles in the past. So it’s worth checking with your doctor if your child has a persistent cough because anti-wheezing medications, such as albuterol, can help that situation.
Asthma is a common problem in children — nearly 10% now have it — and the number is increasing. Researchers are not sure of the reasons for this steady increase (more here), but decreased air quality, lower activity levels among children, and an increase childhood obesity have all been implicated. Whatever the cause, it means that millions of American children take medicine for asthma. A significant number of these children end up in the PICU for a severe asthma attack. As I speak to their parents, it is clear that more than a few parents have only vague ideas of how the different types of asthma medicines we use work in their child’s body. This is an important subject, since using the medicines correctly is the best way to keep your child out of breathing trouble, and to use them correctly it very much helps to understand how they work.
The first thing to understand is what is taking place inside the lung during an asthma attack. Once you know that, you can see how the different asthma medicines relieve the symptoms. Here is a schematic drawing of what a normal lung looks like:
You can think of the lungs as being composed of two parts. The first is a system of conducting tubes that begin at the nose and mouth, move through the trachea (windpipe), split into ever smaller tubes, called bronchi, and end with tiny tubes called bronchioles. The job of this system is to get the air to the business portion of the lungs, which are the alveolar sacs. This second part of the lung brings the air right next to tiny blood vessels, or lung capillaries. Entering capillary blood is depleted in oxygen and loaded with carbon dioxide, one of the waste products of the body’s metabolism. What happens next is gas exchange: as the blood moves through the capillaries, oxygen from the air we breathe in goes into the blood, and carbon dioxide leaves the blood and goes into the air we breathe out. The newly recharged blood then leaves the lungs in an ever enlarging system of pulmonary veins and then goes out to the body.
The main problem in asthma is that the conducting airway system gets blocked in several ways, so the oxygen can’t get in and the carbon dioxide can’t leave. Although both are a problem in a severe asthma attack, getting the air out is usually a bigger issue than getting it in because it is easier for us to generate more force sucking in air than blowing it out. So the hallmark of asthma is not getting the air out — called air trapping. Why does this happen? There are two principal reasons: for one, the small airways, the bronchioles, constrict, get smaller; for another, the walls of the airways swell and the airways themselves fill with excess mucous, blocking air flow. Here’s another schematic drawing of what that looks like.
Thus during an asthma attack these things happen, all of which act together to narrow the airways and reduce air flow:
- The smooth muscle bands around the tiny airways tighten
- The linings of the airways get inflamed and swell
- The mucous glands in the airways release too much mucous, filling the airways
The medicines that we use to treat asthma work by reducing (or even preventing) one or more of these things. But before we get to them, an obvious question is why are our lungs are constructed in this way, especially if it can cause trouble? Why are those smooth muscle bands there? Why does there need to be mucous in our airways?
The smooth muscle bands are there for a good reason. The lungs need a way to direct the air we breathe in to the best spots, which are those regions of the lung with the best blood flow, and that changes from minute to minute from such things as changes in our position — lying down to standing up, for example. Those muscle bands function like the head gates of an irrigation system, opening and closing to direct air to the best places. The mucous is important because it is one of the chief defenses our lungs have against harmful or irritating things we breathe in. The mucous traps debris and steadily moves it up and out of our lungs. In asthma, both of these natural systems become deranged. The so-called triggers for this derangement vary from person to person, but the results are similar. The medicines we use are similar, too, no matter what started the asthma attack.
One of the mainstays of asthma treatment is a member of a class of medicines we call selective beta agonists. The generic name for the one we use most commonly is albuterol. Common brand names for albuterol are Ventolin and Proventil. Albuterol comes as a liquid, which we blow into a mist either with a device called a nebulizer or with what’s called a metered dose inhaler (“puffer”). The second of these is more convenient to carry around, but it can be more difficult to use with small children, although adding a special chamber to the device can help. The patient inhales the mist of albuterol. It works by soaking into the smooth muscle bands, making them relax, and in that way making the airway tubes bigger to allow more air flow. (There is also an oral form of albuterol, but for a variety of reasons it is not a good choice for children with asthma.) For many patients with asthma, inhaled albuterol alone is adequate treatment for their symptoms. A key thing to know about albuterol is that it goes to work right away, generally within minutes, so it is a good medicine for an acute asthma attack.
Another class of medicines long used in the treatment of asthma is corticosteroids, or steroids for short. These medicines work by being powerful blockers of inflammation. If you have ever had a poison ivy rash, for example, you are familiar with inflammation: redness, swelling, and seepage of fluid from the tissue (we can use steroids to treat poison ivy, too). A similar inflammation around the small airways is characteristic of asthma. It makes the linings of the airways swell, weep fluid, and increase mucous production. For a severe attack, we give steroids by mouth or intravenously (IV, directly into the bloodstream). They are very effective when given that way. But they do not go to work right away — several hours are needed at least. So although we may start them during an acute attack, we don’t expect them to help for a while.
Steroids are powerful drugs. When you take them by mouth they affect your entire body, not just your asthma, and that can cause problems. This is why we only use systemic steroids — those by vein or by mouth — for as short a time as possible, typically five days or so. We have other forms of steroids that are inhaled. This allows them to work directly on the airways without affecting the entire body. Common brand names of inhaled steroids are Pulmicort and Flovent. The inhaled steroids, like the systemic ones, don’t go to work right away. So they are intended primarily as a medicine to maintain control of the asthma. It is a common mistake for parents to give their child multiple doses of inhaled steroids when they have worsening breathing troubles — steroids are not intended to be used that way. The proper so-called “rescue medication” for worsening symptoms is albuterol or drugs like it.
These days we have hybrid medications that combine a long-acting albuterol type drug with an inhaled steroid. This combination is intended as something to be taken for chronic control of patients with moderate or worse asthma, and these agents are quite effective at doing that. Common brand names are Advair and Symbicort.
So albuterol (and beta-agonists like it) and steroids are mainstay medicines for treating asthma. In combination they make a good team because they attack the asthma via two different modes of action. We have some other medications that work by still other mechanisms. Montelukast (brand name Singulair) blocks airway inflammation by another mechanism than do steroids. Unlike systemic steroids, the action of montelukast is more selective and this medication is safe to take for prolonged periods. For some patients, montelukast and an occasional puff of albuterol is sufficient to keep them out of trouble. Finally, an inhaled drug called ipratropium (brand name Atrovent) blocks excessive mucous production by another method than blocking inflammation; it is often helpful as an adjunct to the other medicines. A couple of medications (brand names Combivent and DuoNeb) combine ipratropium and albuterol together so they can be inhaled at the same time.
So how do doctors decide what asthma medicines to use? One obvious principle is that it makes little sense to use more than one medication of the same category: combinations ought to work in different ways so they can work together. But beyond that obvious principle, how do we decide? The usual approach is to classify patients with asthma according to their severity and then add medicines in a logical, step-wise way until we get control of the symptoms. There are guidelines to help us do this. A good, recent summary is here, published by the National Institutes of Health. If you or your child has asthma it is a good place to find information. It is also useful to look at the actual decision tree doctors use to decide what medicines to use and in what order. You can find it here. One key principle is that we divide medicines into maintenance medications — those the child takes every day — and “rescue” medications, ones the child takes for worsening symptoms.
Asthma is common and is getting more common every year. Certainly speak with your child’s doctor about doing some good detective work to figure out what your child’s asthma triggers are. Then take steps to modify exposure to them or avoid them. Common sense tells us that if we can reduce symptoms by reducing exposure to common triggers, such as tobacco smoke, we should do everything we can to reduce the need for asthma medications. But for many children, this will not be enough; their parents should understand how these medicines work in order to make the best use of them.
I’ve written about this before, but it’s always a good thing to remind ourselves of simple things in medicine. The severe-looking physician pictured above is Robert F. Loeb, long a professor at Columbia University Medical School. He reportedly could be a bit tyrannical to students and residents, but he is credited with formulating a simple way to cut through to the nub of things.
Sometimes we doctors are prone to do too much to our patients, especially in high-tech environments like the PICU. The bewildering array of all the tests and therapies we have can confuse us more than enlighten us. Dr. Loeb long ago offered a simple way to cut through all the confusion, offering what have come to be known as Loeb’s Laws. We all learned variants of them in medical school, but now and then we need to be reminded of them. Here is one formulation:
1. If what you are doing is doing good, keep doing it.
2. If what you are doing is not doing good, stop doing it.
3. If you do not know what to do, do nothing.
4. Never make the treatment worse than the disease.
Dr. Loeb was not a surgeon, so one occasionally hears a tongue-in-cheek substitution of his fourth law that goes something like this: “If at all possible, keep your patient out of the operating room.”
Seventy years later, Dr. Loeb’s wisdom is still often useful. All of us, doctors and patients, are tempted to do things just because we can do them, or because we’re curious. That’s never a good way to proceed.
Many, myself included, have written about the overuse of head computed tomography (CT) scanning in children. This concern has become more focused now that we have some data on the radiation risk of those scans. The bottom line is not that we should stop doing head CTs in children, but that we should always balance the risk against the benefit, just as we should do with all medical testing. In the case of CT, the risk is tiny, but it is not zero. That risk is worth taking if the benefit is substantially more than the risk; that is, if getting the information that the CT yields is a good exchange for the risk. Put another way, is the risk of not getting the information the scan gives us greater than the risk of doing the scan itself? As a PICU doctor I order a lot of head CT scans, and I think about this trade-off with each one.
A very common reason doctors order a head CT is to evaluate a headache, even when they know the chances of finding a serious cause for the headache, such as a brain tumor, are very small. In many situations those chances of finding something bad are near zero. So how should we analyze the risk/benefit ratio between doing the CT or not? Various experts have formulated recommendations for when a head CT is indicated to help guide us in our decision-making. These include any items in the following list. The key thing to keep in mind is that serious brain problems, especially a tumor, only very rarely appear without some other abnormality accompanying the headache.
- Age less than 3 years
- Sudden, explosive and severe headaches
- Associated changes in mental status or performance
- Headaches that awaken a child from sleep
- Associated nausea and vomiting
- A steadily worsening pattern of headache
A recent study in Pediatrics, the journal of the American Academy of Pediatrics, assessed how well doctors (and families, too — parents often urge doctors to do CTs) are doing. The answer is not so well.
The authors of the study examined the claims records of over 15,000 children who had had at least two visits to a doctor with the complaint of headache — 25% of them received at least one head CT scan as part of the evaluation of their symptoms. Interestingly, children seen by a neurologist, a brain specialist, were only half as likely to get a CT scan. Children seen in an emergency department were four times more likely to get a CT scan than were children evaluated in a doctor’s office.
Some of these results are easily explained. It makes sense that a neurologist is more skilled in evaluating headaches and is therefore more comfortable not doing a CT than is a doctor who only occasionally treats headache. Children being seen in an emergency department are usually there because of some acute problem, so if they are there for a headache it is more likely to be new and sudden. Emergency department doctors rarely know the child, so they are probably more swayed to rule out a serious problem while they have the child there. Also, emergency room doctors order a lot of head CT scans anyway, probably too many, for minor head injuries. So they are already primed to order scans for headaches.
What is the ideal number of CT scans for headaches in children? Certainly we don’t want every scan to show an abnormality; if that were the case, it would mean we are not ordering enough of them. We want most of them to be negative to make sure we are catching all the serious problems. But the finding that a quarter of all children going to the doctor for a headache are getting a CT scan is disturbing — it’s too many.
Parents have a key role in this, especially since at least one study indicates that a major reason for doctors ordering all those scans is that parents are anxious enough not to trust either the doctor’s judgement or the standard list of indications for a scan, whether that’s for a headache or a bonk on the head. I have encountered that myself. Remember that the recommendations for head CT have been validated by research; if your child with a headache doesn’t fit any of them, it is best to wait and see how things go.
This is something that doesn’t seem, on the surface, to be directly related to critical care, but it really is. Doctor Mike Magee and his wife founded an organization called The Rocking Chair Project. The notion is simple. Parents (and grandparents) have known for generations, probably millennia, that rocking a baby is comforting to the child. But there’s more — now we know something as simple as gentle rocking of infants actually has a positive effect on their brain development.
The project began like this. Doctor Magee and his wife told their daughter, a family practice resident physician, to identify a needy mother who had just given birth, and they would donate a gliding rocker to her and her new baby if a family practice resident would deliver the chair to the home, assemble it as part of a home visit, and continue to give close follow-up to the family. The idea took off, and there is now a foundation to continue the project.
I’ve written in several places — this blog, my first book, an op-ed piece in the Denver Post — that disadvantaged kids have a disproportionately high chance of ending up in the PICU. James Heckman, a Noble Prize-winning economist, has shown that early intervention programs, besides giving kids better outcomes, even save money. So if a rocking chair can keep a child away from my PICU, we’ve saved that child from suffering and we’ve saved society some money. It’s win-win, and incredibly low-tech.