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ما هي الممارسات المثلى في تدبير التهاب القصيبات الحاد عند الأطفال؟


ما هي الممارسات المثلى في تدبير التهاب القصيبات الحاد عند الأطفال؟

المعلومة

عدد أهم 3 خطوات في الممارسة المثلى لمقاربة طفل عمره 4 أشهر لديه التهاب قصيبات حاد؟

List the three major steps involved in the best practice management of a 4 months old infant with acute bronchiolitis
by

The best evidence supports using nebulized hypertonic saline (3%) alone as the best practice in this field.

Nebulized beta agonists is a regular medical practice. Nebulized epinephrine or steroids is the last resort and not commonly used, no evidence supports its superior clinical usefulness.

Frequent suctioning for the upper respiratory tract is essential in this age group.

Diagnostic workup usually contains: CBC, CRP, CXR, nasal wash for RSV and influenza A&B detection. BUT the main daignostic method is clinical.

Nebulized Hypertonic Saline Without Adjunctive Bronchodilators for Children With Bronchiolitis

Shawn Ralston, MDa,b, Vanessa Hill, MDa,b, Marissa Martinez, MDb

a Department of Pediatrics, University of Texas Health Science Center at San Antonio, San Antonio, Texas; and
b Christus Santa Rosa Children's Hospital, San Antonio, Texas

OBJECTIVE The goal was to determine an adverse event rate for nebulized hypertonic saline solution administered without adjunctive bronchodilators for infants with bronchiolitis.

METHODS This was a retrospective cohort study of the use of nebulized 3% saline for children <2 years of age who were hospitalized with the primary diagnosis of bronchiolitis at a single academic medical center. The medical records of study participants were analyzed for the use of nebulized 3% saline solution and any documented adverse events related to this therapy. Other clinical outcomes evaluated included respiratory distress scores, timing of the use of bronchodilators in relation to 3% saline solution, transfer to a higher level of care, and readmission within 72 hours after discharge.

RESULTS A total of 444 total doses of 3% saline solution were administered, with 377 doses (85%) being administered without adjunctive bronchodilators. Four adverse events occurred with these 377 doses, for a 1.0% adverse event rate (95% confidence interval: 0.3%–2.8%). Adverse events were generally mild. One episode of bronchospasm was documented, for a rate of 0.3% (95% confidence interval: <0.01%–1.6%).

CONCLUSIONS The use of 3% saline solution without adjunctive bronchodilators for inpatients with bronchiolitis had a low rate of adverse events in our center. Additional clinical trials of 3% saline solution in bronchiolitis should evaluate its effectiveness in the absence of adjunctive bronchodilators.

Cost-effectiveness of Epinephrine and Dexamethasone in Children With Bronchiolitis

Amanda Sumner, MSca, Douglas Coyle, PhDb, Craig Mitton, PhDc, David W. Johnson, MDd, Hema Patel, MD, MSce, Terry P. Klassen, MD, MScf, Rhonda Correll, HBScNa, Serge Gouin, MDg, Maala Bhatt, MD, MSce, Gary Joubert, MDh, Karen J. L. Black, MD, MSci, Troy Turner, MDf, Sandra Whitehouse, MD, MALSj, Amy C. Plint, MD, MSck, for Pediatric Emergency Research Canada

a Clinical Research Unit, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada;
Departments of b Epidemiology and Community Medicine and
k Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada;
c Health Studies, University of British Columbia, Okanagan, British Columbia, Canada;
Departments of d Pediatrics and Pharmacology and Therapeutics, University of Calgary, Calgary, Alberta, Canada;
e Department of Pediatrics, McGill University, Montreal, Quebec, Canada;
f Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada;
g Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada;
h Department of Pediatrics, University of Western Ontario, London, Ontario, Canada;
Departments of i Emergency Medicine and Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada; and
j Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada

OBJECTIVE Using data from the Canadian Bronchiolitis Epinephrine Steroid Trial we assessed the cost-effectiveness of treatments with epinephrine and dexamethasone for infants between 6 weeks and 12 months of age with bronchiolitis.

METHODS An economic evaluation was conducted from both the societal and health care system perspectives including all costs during 22 days after enrollment. The effectiveness of therapy was measured by the duration of symptoms of feeding problems, sleeping problems, coughing, and noisy breathing. Comparators were nebulized epinephrine plus oral dexamethasone, nebulized epinephrine alone, oral dexamethasone alone, and no active treatment. Uncertainty around estimates was assessed through nonparametric bootstrapping.

RESULTS The combination of nebulized epinephrine plus oral dexamethasone was dominant over the other 3 comparators in that it was both the most effective and least costly. Average societal costs were $1115 (95% credible interval [CI]: 919–1325) for the combination therapy, $1210 (95% CI: 1004–1441) for no active treatment, $1322 (95% CI: 1093–1571) for epinephrine alone, and $1360 (95% CI: 1124–1624) for dexamethasone alone. The average time to curtailment of all symptoms was 12.1 days (95% CI: 11–13) for the combination therapy, 12.7 days (95% CI: 12–13) for no active treatment, 13.0 days (95% CI: 12–14) for epinephrine alone, and 12.6 days (95% CI: 12–13) for dexamethasone alone.

CONCLUSION Treating infants with bronchiolitis with a combination of nebulized epinephrine plus oral dexamethasone is the most cost-effective treatment option, because it is the most effective in controlling symptoms and is associated with the least costs.

KMG's picture
KMG
طبيب مقيم


شكراً لك دكتور خالد. Surprised
تبقى الخطوات الأولى للتدبير هي حسب ترتيب الأهمية لامتحانات ال OSCE
1- minimal handling
أي تجنب تحريك الطفل قدر المستطاع
2- hydration
بحسب وزن الطفل، حالته الشارديةو الحالة العامة.

و قد أضاف الدكتور خالد مشكوراً البحوث التي تتناول الكورتيزونات مشابهات بيتا، و الأدوية الاستنشاقية الأخرى (كبخار المحلول الملحي مثلاً).

يوصى بتقليل تحريك الطفل (لاسباب كثيرة منها تقليل خطر الاستنشاق)، لدرجة أنه يكتب في اضبارته ملاحظة بأن تجرى له كل الإجراءات التمريضية سوية قدر المستطاع لتجنب تحريكه بشكل متكرر.

المرجع موجود في الأعلى.

Ahmed.AlHalabi's picture
Ahmed.AlHalabi
معيد


شكراً لكما.. Surprised

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Dr_Hero
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