If you’re looking to bring your clinical game to the next level, look no further than this next episode where we’ll discuss three huge areas of medical overuse. By the end of the episode, you’ll know not to give antibiotics in an asthma exacerbation, why it may be okay to discharge a well-appearing infant undergoing sepsis rule-out at 24 hours, and how to expertly use metered-dose inhalers in the inpatient setting. We welcome Drs. Leonard Feldman (@DocLennyF) and Carrie Herzke, both @TWDFNR authors, to explore and educate us on these topics. Listen along here, and follow us @TheCribsiders on #MedTwitter!
Keywords: high value care, pediatrics, asthma, febrile infant, sepsis rule out, 48 hour, asthmonia, pneumonia, TWDFNR, things we do for no reason
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Started in 2012 at Society of Hospital Medicine Annual Meeting, “Things We Do For No Reason™” was a talk that covered 3 – 4 new topics each year – “the low hanging fruit of high value care.” Topics include practices that have no evidence behind them, don’t help patients, and are things we should, for the most part, get rid of. These topics have now become a regular series in the Journal of Hospital Medicine. The goal is for learners to become more skeptical and question norms rather than accept practices without evidence.
A nebulizer works by taking a solution and aerosolizing it for the patient to inhale. Oftentimes, this is administered by a respiratory therapist (RT) in the hospital. A metered dose inhaler sprays a pre-specified dose either directly into the patient’s mouth or into a spacer to be inhaled by the patient. (Fun fact: there used to be a syrup form of beta-agonists that Dr. Feldman and Herzke remember taking when there were children; sadly, this formulation is no longer available.)
In terms of efficacy, there are several reviews that demonstrate that the efficacy of these therapies are similar (Dolovich 2005; Cates 2013). MDIs are associated with decreased levels of tachycardia and tremulousness (Cates 2013; Kerem 1993; Schuh 1999), and they are also associated with decreased time spent in the Emergency Department compared to nebulizers (Cates 2013). Both therapies are likely efficacious in the in-patient setting.
While both therapies are efficacious, patients will eventually be discharged from the hospital and be dependent on a MDI for control of mild symptoms. The literature has demonstrated that oftentimes children and adults do not know how to properly and effectively use their MDIs once they are not supervised, even if they state that they are confident in how to use it (Alexander 2016). This, unsurprisingly, leads to patients having worse control of their asthma as an out-patient. Switching to MDIs while inpatient allows for significant instruction on how to appropriately use their inhaler.
In nebulizers, you are delivering a higher dose than an MDI typically. If you want them to be equivalent, a rule of thumb is that 2.5 / 5mg of nebulizer is equal to 4 / 8 puffs of MDI.
Critically ill patients, such as patients in status asthmaticus, were excluded from all the above analyses, so the commentary regarding MDIs does not apply to this patient population.
At UCSF there was a successful study to use nebulizers for the first 24 hours if necessary then transition to MDI therapy for the remainder of the hospital stay (Moriates 2013).
The 48 hour rule-out is based on studies that were performed in the 1970s, and there are two main reasons why they are not necessarily relevant anymore. First, this was a time-period when culture plates were physically examined by a human to check for growth; therefore, they were only checked once a day (Rowley 1986), meaning that the time to positivity (TTP) was artificially long. (They could turn positive at 25 hours but not be read as positive until 48 hours.) Now, we have specific machines that can detect growth of bacteria in blood cultures (mainly through CO2) and notify staff to be checked for growth at that time. Second, these studies were overly broad and do not include our typical 48-hour rule-out patient, which is a previously healthy infant that has been discharged from the hospital. Their studies included NICU infants and ICU admissions that often grow atypical organisms, such as fungi, that need longer to grow out, which inflated the time to positivity of their cultures (Rowley 1986; La Scolea 1981; Pichichero 1979).
Recent studies of healthy febrile infants with new culture monitoring systems report that TTP for 97% of bacteria treated as true pathogens is ≤36 hours (Evans 2013). Additionally, after 36 hours, the rate of identifying a contaminant increases by 8-fold. No difference was found in infants ≤ 28 days versus those aged 0-90 days. Overall, the mean TTP in infants aged 0-90 days was 15.4 hours, and only 4% of possible pathogens were identified after 36 hours. In other words, you would have to monitor 1,250-2,778 infants past 36 hours in order to catch one bacteremic infant.
There are well documented clinical criteria via the Rochester (Jaskiewicz 1994), Boston (Baskin 1992), and Philadelphia (Baker 1993) studies that can be used to formally decide (Herzke 2018). Dr. Herzke considers monitoring an infant for longer than 36 hours if there is a clinical suspicion for HSV, abnormalities on CSF/urine studies, and/or if the child is not well-appearing.
Overall, there is data that asthma and pneumonia are co-diagnosed per records review, but the true question is whether they actually co-exist. From 2007-2012, out of 42 hospitals, 43% of patients with a community acquired pneumonia (CAP) diagnosis were also diagnosed with an asthma exacerbation (Wilson 2015). The evidence, especially in small children, that these are bacterial CAP triggering asthma flares is quite slim. First, bacteria are a rare etiology of pneumonia, especially in children < 5 years old with viruses causing up to 80% of pneumonia (Jain 2015). This suggests that it is unlikely that bacteria are causing pneumonia in young children – let alone causing a pneumonia that is inciting an asthma exacerbation.
In children and adults, there are studies that compare the bacterial populations of patients with asthma exacerbations versus controls. There was no significant difference in S. pneumoniae; the only difference between the two groups was in the rates of Mycoplasma, which were more present in the group with asthma exacerbations (Lieberman 2003).
Not quite. First, children that test positive for Mycoplasma often test positive for other viruses that are much more likely to trigger an asthma exacerbation (Duenas Meza 2016). Additionally, it is, again, quite uncommon for young children to have a pathogenic Mycoplasma infection, and there are meta-analyses that demonstrate that treating Mycoplasma does not necessarily improve clinical outcomes (Biondi 2014). Expert opinion: Dr. Feldman states that the one population that he considers treatment in are adolescents that have a clinical history consistent with a walking pneumonia.
Antibiotics may improve peak-flow and symptoms (Stokholm 2016). Per Dr. Feldman, it’s “kind of like taking hydroxychloroquine for COVID.” Dr. Herzke also points out that you are going to give a steroid burst anyway that should resolve the inflammation quite well.
Listeners will explain three clinical scenarios of low-value care and be able to more effectively manage these scenarios in the future.
After listening to this episode listeners will…
Dr. Feldman and Herzke report no relevant financial disclosures. The Cribsiders report no relevant financial disclosures.
Herzke C, Feldman L, Lee N, Chui C, Berk J. “Things We Do For No Reason in Pediatrics”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ August 5, 2020.
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