Thoracic & Respiratory I (September 2015)
Review: Jat KR. Ketamine for acute pedi asthma. Cochrane 2012
Review: Cornia PB et al. Does this coughing adolescent or adult patient have pertussis. JAMA. 2010
AIR: Respiratory
Review: Jat KR. Ketamine for acute pedi asthma. Cochrane 2012
Review: Cornia PB et al. Does this coughing adolescent or adult patient have pertussis. JAMA. 2010
AIR: Respiratory
13 comments
Ketamine for management in pediatric asthma
– How will this article change my practice?
Its unlikely to change my practice at this point. The only study wasn’t sufficiently powered did not reveal a significant benefit in using ketamine for non-intubated asthmatic kids
– What information that I previously believed was debunked by reading this article?
While it has not “debunked” my belief in Magnesium as an effective second line therapy following failure of initial treatments, this article has suggested that there is limited evidence for the effectiveness of second line therapies like magnesium.
– What new information did I learn?
I was unaware of the mechanism of action of the bronchodilator effect of keatmine. I also wondered after reading this article what caused the dramatic increase in prevalence in asthma hospitalization in the US from the 1980s—>2000s. Is it because everyone is using antibacterial soap now and we are less freqwuently exposed to desensitizing allergens on a daily basis.
– What current uncertainties exist or potential areas for research?
The effect of ketamine in ventilated children could be assessed to see if there is any difference in days spent on the vent, hospital stay, etc.
Does this coughing adolescent or adult patient have pertussis?
– How will this article change my practice?
I will keep keep pertussis on my differential if no other cause for chronic cough in adults can be dientified. I find it interesting that approximately half of reported cases of pertussis in the US today are in adults and that prior to vaccination 90 percent of infections were seen in children less than ten years.
– What information that I previously believed was debunked by reading this article?
I didn’t know that up to 32% of chronic cough in adults is attributable to pertussis.
– What new information did I learn?
I did not know about the relatively long incubation period of bortadella pertussis (7-10 days) whereas viral URIs typically have 1-3 day incubation period. I also was not aware that pertussis swabs should be taken with dacron swabs as cotton swabs toxic to the bacteria.
– What current uncertainties exist or potential areas for research?
It would be intereting to know if someone has looked into the different resistence between macrolide antibiotics: erythromycin vs. clarithromycin vs. azithromycin
– How has reading the article changed your practice? I don’t think it has changed my actual practice, since I didn’t view ketamine as a natural next step in refractory asthmatic peds cases. From a larger perspective, it reminded me that some of the anecdotal treatments that get tossed around are not based in very strong evidence.
– What information had you believed in previously that were debunked by reading this article? I thought there was stronger evidence supporting the use of ketamine in this population. Though it isn’t something I have seen in my (albeit limited) practice, I have heard about using ketamine for precisely the reasons outlined in this review, and I assumed that there was a more robust basis for its use.
– What new information did you learn from reading this article? There is only one relatively small RCT on the use of ketamine in the asthmatic peds patient; the other evidence supporting this practice is inferred or is coming from less secure methodology. So, I learned that there’s not much you can hang your hat on if you want to argue for this use of ketamine. That said, there doesn’t seem to be that much to lose, either, based on this limited data.
– What are current areas of uncertainty on this topic that can be potential areas for research? Pretty much all of it. There is clearly space for more RCTs evaluating ketamine use in refractory peds asthma cases, and within that same topic, it would be important to learn more about dosing and about success in different age brackets (there’s theoretically a fairly big difference between using it in a four year old versus in a seventeen year old, for example).
Does this coughing adolescent or adult patient have pertussis?
– How has reading the article changed your practice?
I will start to put pertussis higher up on my differential.
– What information had you believed in previously that were debunked by reading this article?
I definitely thought the inspiratory whoop was more sensitive than it is.
– What new information did you learn from reading this article?
I had heard about the surge in pertussis in recent years, but, like Liam, I was pretty surprised that it accounts for 32% of chronic cough in adults.
– What are current areas of uncertainty on this topic that can be potential areas for research?
Would be great to have more clinically helpful testing.
Ketamine in pediatric asthma:
It is very interesting stuff. This demonstrate exactly why we need double blinded RCT’s. As in the pathophys and previous case reports and series, ketamine seemed to be a slam dunk.
However, this Allen study and the Cochrane review, failed to show any difference in outcomes.
I don’t think this kills ketamine because the numbers in this RCT is very small. I think we need more, especially in adults.
Interestingly: They quoted the adult study: (Howton 1996) that also showed no significant different in outcomes. But they had to lower the dose of ketamine in the intervention group because the patients were having dysphoric reactions, which we know is more likely to happen in adults. The pediatric studies didn’t show any increase in side effects. So we know it’s safe to use in children at least.
Good stuff.
Pertussis:
The frequency to which I see patients come to urgent care complaining about > 2 or 3 weeks of cough is astounding. Their CXR is almost always clear.
I’ve been frequently treating with z-pack if they live in close quarters with children. But as the article says, usually it does not actually improve the patient’s symptoms after the catarrhal stage, only their contagiousness.
This article reminds us that Pertussis should be on the back of our minds. I think having those classic symptoms helps, but lack of those symptoms makes it very difficult to diagnose. Especially in light of the difficulties with the confirmatory tests such as PCR or culture. I doubt we get those back during the ED visit either.
Does this coughing adolescent or adult patient have pertussis?
– How will this article change my practice?
I rarely thought about Pertussis in older individuals and assumed that if kids were already vaccinated they could not get it again.
– What information that I previously believed was debunked by reading this article?
I did not know vaccination strength waned over 12 years. I also thought a paroxysmal cough was a slam dunk dx of Pertussis (though I have yet to hear one in clinical practice)
– What new information did I learn?
A lot! Alex, as you said, we see a lot of chronic cough and I will now consider Pertussis (and have a slightly lower threshold to give AZT if they live with kids). I also did not know how hard it is to diagnose it via laboratory methods.
– What current uncertainties exist or potential areas for research?
I think there is still more to be done re: the clinical exam considering this paper could only find 3 papers that met their criteria, and only one of those had level 1 evidence.
Ketamine for management of acute asthma exacerbations in children
– How will this article change my practice?
This article is slightly disappointing because it won’t be able to change my practice. We have all heard about ketamine reducing bronchospasm in asthma cases and about its theoretical ability to stave off intubation, but this article argues that there is no evidence to support these claims.
– What information that I previously believed was debunked by reading this article?
I thought that there was more data to support these claims than this article demonstrates. While there is obviously more in the adult literature, it is still not as robust as I had previously believed.
– What new information did I learn?
I learned that the emergence reactions, hallucinations and behavioral changes are actually found to be less prevalent in children younger than 10 years, which is in contrast to what I would have intuitively thought.
– What current uncertainties exist or potential areas for research?
The entire topic is an area for future research, since the entire Cochrane group was only able to find one study to analyze. Specifically, this study had a lower dose of ketamine that what is often used, so maybe studies looking at higher doses may be able to find a benefit.
Does this coughing adolescent or adult patient have pertussis?
– How will this article change my practice?
This article will definitely change my practice. We see so many patients in the ED complaining of a cough, and pertussis has never been high on my differential. I will be much more inclined to treat them from now on, especially if they have young children at home.
– What information that I previously believed was debunked by reading this article?
As has been already said, the number that really jumped out to me was the 32% of chronic cough in adults being due to pertussis.
– What new information did I learn?
I did not know that there is such poor testing for pertussis. With such high false negative rates of serologic testing and poor specificity of clinical signs and symptoms, it makes for a really difficult diagnosis. It also calls into question the validity of the study data.
– What current uncertainties exist or potential areas for research?
I had always thought that you needed to prescribe erythromycin for at least 2 weeks, so I would be interested to know the effective duration of treatment.
Ketamine for management in pediatric asthma
– How will this article change my practice?
Because this was a single study with insufficient power, my practice won’t change. However, it does sound like Ketamine (in theory) could have some benefits for non-intubated asthma patients in the future (if more research can be done to help prove its benefit).
– What information that I previously believed was debunked by reading this article?
No debunking of anything in this particular article. However, I was interested to see reference to the use of Mg and how there is limited evidence of its effectiveness. I’ve heard that from several sources, but I notice that we still tend to give it.
– What new information did I learn?
To be honest, I didn’t really know much about the proposed use of Ketamine for acute asthma in pedi patients, so the background on pathophys/mechanism was new info.
– What current uncertainties exist or potential areas for research?
The takeaway point from this is that we need some RCTs for the use of Ketamine in this population/condition. Again, as I said earlier, the concept seems very promising!
Pertussis article
– Practice change: I think after reading this article I will be far more likely to have pertussis high on the differential for adults with cough > 3 weeks w/out another obvious cause. And have a lower threshold to treat.
– debunk: the incidence of pertussis in adults was higher than I realized.
– new info: incidence, the extent to which it is quite difficult to diagnose pertussis through pcr/culture
– potential areas of research: beyond improving laboratory diagnostic tools, I’d say it’d be interesting to design studies that would help to better identify the clinical features of pertussis and improve out ability to diagnose clinically.
Ketamine for acute pedi asthma
How has reading the article changed your practice?
o It hasn’t. Prior to this article I’ve never heard of ketamine used in the management of asthma in pediatric patients. And the one study that it highlights, although small, shows no advantages to using ketamine in this context.
What information had you believed in previously that were debunked by reading this article?
o I had thought that hospitalization 2/2 to asthma exacerabations had been decreasing (not increasing) while the prevlance had hit a plateau. Apparently not. Secondly, I thought the evidence was more robust in favor of inhaled streroids but the author counts it as a 2nd line therapy with “limited evidence.”
What new information did you learn from reading this article?
o I learned that ketamine is PCP-derived! And that in addition to it’s anxiolytic/amnesic properties, it has a significant analgesia property. I also learned that ketamine increases pulmonary compliance, bronchial relaxation, and can inhibit catecholamine re-uptake.
What are current areas of uncertainty on this topic that can be potential areas for research?
o I think the literature in peds asthma is always difficult to sort out because of the etiologic complexity of airway disease in children. Aside from that, it would be interesting to know at what time and frequency the interventions were conducted – which I think may have potentially played a role in admission or not (eg, there’s been some evidence to suggest starting steroids at triage may decrease admission rates). I’d also like to see a similar study done but with different doses of ketamine (loading and infusion). While it could very well be that ketamine is a potent bronchodilator, perhaps the threshold was never met (or perhaps reaching certain levels may cause a level of toxicity).
Pertusis
-How has reading the article changed your practice?
o I will be more inclined to put pertussis in the differential, particularly in cases where exposure to infants is present and with those who have a prolonged cough history. Additionally, I will try to get a better “cough history” in the HPI – not just productive or not, but more along the lines of cough variation, inclusion of inspiratory whoop, post tussive emesis, paroxysms, vaccine hx.
-What information had you believed in previously that were debunked by reading this article?
o Not really seen in adults – but I learned that several months ago when my partner’s father was diagnosed with it! Apparently 50% are in adolescents/adults.
-What new information did you learn from reading this article?
o I learned quite a few things: only the presence of posttussive emesis and inspiratory whoop modestly increase likelihood of infection (and not paroxysmal cough); long incubation hx of pertussis (which can guide the way one phrases sick contact questions in HPI); about 50% of cases are in adolescents/adults!
-What are current areas of uncertainty on this topic that can be potential areas for research?
o There were 4 studies referenced suggesting that claritho/azithro were better than erythromycin which requires frequent dosing and has many adverse effects. I’d like to know why erythromycin is still so commonly used. It is just because it’s inexpensive?