Saturday, 28 March 2020

COVID Questions No 4 - What PPE should I wear at the moment and when should I wear it? (Updated 2 April 2020)

This post was originally written on 28th March 2020 and then significantly updated on 2 April 2020 in line with new PHE UK guidance published on that day.

Understandably, there is a lot of confusion and anxiety about the Personal Protective Equipment (PPE) that is needed to minimise the risk of COVID-19 infection being acquired by healthcare professionals.  Guidance is continually changing and the need to to protect ourselves as healthcare professionals in very real.

Different PPE is available for different circumstances and this post will explain what we are advised we should use and when according to the latest Public Health England (PHE) guidance.  Please note that this advice is continually being reviewed and updated.  I will also explore some of the pragmatic ways that we can reduce our infection risk and explain some of the complexities of the PHE guidance.  I will do my best to keep this post up to date but it is essential to look at the most recent guidance from your relevant organisation since decisions about PPE use are also made locally depending on the known prevalence of COVID-19 in specific areas.

There are two main things to understand when using PPE.  The first is what level of risk there is and the other is what level of precaution is advised for that level of risk.

What is the level of risk?

Working in a health care organisation already confers a certain level of risk.  In a time when we are asking people to undertake "social distancing," healthcare workers are going into environments which are probably the most densely populated public buildings at the moment.  These buildings contain the patients and staff in our area most likely to transmit COVID-19 infection.  As such, just turning up to work means that we come into an area where it is difficult to avoid people who put us at some risk.  Every door handle, computer keyboard and telephone is a potential way of catching the infection.

For this reason, most public health organisations have advised staff who are high risk should remove themselves from the workplace altogether.

Those who are physically at work can do a lot to protect themselves and their co-workers.  We should be minimising the number of meetings and restricting the number of people at these meetings as much as possible.  We should be vigilant about hand hygiene at all times, especially when we have used a phone, touched a door handle or other surface such as a computer keyboard.  Any way that we can find to avoid hand contact with surfaces should be adopted.  I now have continuous right shoulder pain and a bruise over my greater trochanter from barging doors open that I would previously have pushed with my hand.

Contact with asymptomatic patients (no fever or cough) is relaitively low-risk but still has the potential for infection.  Not enough is known about COVID-19 to be able to say how possible it is that a completely asymptomatic person might infect another person.  What is known is that in the absence of symptoms, the risk of infection comes primarily from direct contact or high risk procedures.  Someone who is not spreading droplets can transfer infection via surfaces or by having physical contact.

Healthcare workers who are seeing asymptomatic patients can reduce their risk in several ways.  Increasingly patient contacts are being avoided, for the benefit of staff and the public.  Clinic visits are becoming telephone or video consultations.  We are finding that there are opportunities to reduce follow-up and we are getting better at safety-netting rather than arranging a "routine" appointment for a review.

The risk of face-to-face clinical examination is being reduced, for example by avoiding throat examination unless it is necessary, rather than including oropharyngeal examination as a routine part of the assessment.

For face-to-face clinical contact that cannot be avoided, the risk of direct transmission of infection should be removed by good hand hygiene and avoidance of high risk procedures.
Now for the most significant change in the new guidance.  When it is determined that you are dealing with a high level of COVID-19, PHE recommend using mask, gown and gloves for all patient contact or close proximity, whether symptomatic or not.  That decision is made by individual health care providers based on the prevalence of COVID-19 in their patient population.
If a person is working in an area with symptomatic patients but has no direct patient contact and is not within 2 metres (about 6 feet) of patients, PHE recommends that a fluid resistant surgical mask is worn.
Contact and close proximity with symptomatic patients carries the further risk of infection transmission by droplets.  These patients are referred to as hot, but the "hot" patient includes children with a cough as well as febrile patients for this reason.  When having face-to-face contact with a symptomatic child, additional PPE is recommended in the form of:
  • Disposable gloves
  • Disposable moisture resistant apron
  • Moisture resistant mask (surgical mask)
  • Eye protection if there is a risk of splashing of secretions (e.g. from oropharyngeal examination)
The gloves and apron should be put on before approaching the patient and removed after leaving the patient.  PHE now recommends that the surgical mask can continue to be used afterwards.  It is imprtant to avoid contaminating the mask be touching it.

Droplets are small but large enough so that they will not bypass a surgical mask.  Essentially they are a projectile, not a vapour and so the risk of infection comes from the droplet travelling in a line from the patient to the clinician, not from the air breathed around the mask.  The size of a droplet causes it to be deposited in the upper airway rather than entering the bronchial tree, which is thought to further reduce its infective risk.  For this reason, filtered masks (FFP) as not required when the level of risk is droplet spread.
Contact with contaminated aerosol carries the additional risk that the infection could be breathed in.  The definition of an aerosol is a small droplet (smaller than 10µm) that is capable of being suspended in the room air and breathed in as far as the lower airways.

The current evidence for what creates a risk of aerosol transmitted infection is the basis for the current PHE guidance on when to use the appropriate PPE for this risk.  The current list is as follows:

Procedures included in the current PHE guidance list of areosol generating procedures (AGP)
  • Intubation, extubation and related procedures e.g. manual ventilation and open suctioning of the respiratory tract (including the upper respiratory tract)*
  • Tracheotomy/tracheostomy procedures (insertion/open suctioning/removal)
  • Bronchoscopy and upper ENT airway procedures that involve suctioning
  • Upper Gastro-intestinal Endoscopy where there is open suctioning of the upper respiratory tract
  • Surgery and post mortem procedures involving high-speed devices
  • Some dental procedures (e.g. high-speed drilling)
  • Non-invasive ventilation (NIV) e.g. Bi-level Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP)
  • High Frequency Oscillatory Ventilation (HFOV)
  • Induction of sputum
  • High flow nasal oxygen (HFNO)
Note that the wording of some of the list has changed, presumably in an attempt to be more correct.  I think that it is important to point out that one of the most commonly persormed AGPs could be lost in here.  "Non-invasive ventilation (NIV) e.g. Bi-level Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP)" includes use of bag-valve-mask ventilation.  In the current pandemic, if a child has a respiratory arrest you should put on aerosol PPE before providing CPR.

Rather than get caught up in the science of why things are on or off this list, I would say that the list is possibly better named "very high risk procedures."  The list is compiled by experts who have looked at both the available evidence and the hypothetical risk of each.  My personal opinion is that the list is a valid way of determining when best to use each level of PPE.

Any contact with patients who are undergoing such procedures requires aerosol PPE.
  • Filtering face piece (FFP) mask, which should have been fit tested to the clinician previously
  • Eye protection
  • Disposable gown (with full length arms)
  • Disposable gloves
Avoidance of aerosol generating procedures is also recommended where possible.  For example, it has been recommended that HFOT is not used in COVID-19 babies.

Stay safe.  Avoid unnecessary risk.  Clean everything.  Touch nothing you don't have to. Use the appropriate PPE and don't overuse PPE that is in limited supply and will be much needed for the high risk scenarios over the next few weeks.

Edward Snelson

Disclaimer: In the interests of the infographics not being awful, I did none of the drawings myself.  Full credit for the drawings goes to my vey talented daughter Naomi Snelson.  Thanks for the great pictures.

Thursday, 26 March 2020

COVID Questions No 3 - Should I stop examining children's throats?

As increasing evidence comes out of the countries hit worst by the COVID-19 pandemic, there is growing concern about the number of healthcare workers being affected.  A large number of COVID-19 positive tests in Italy (currently about 10%) have been healthcare workers.

It is important to emphasise that these statistics will inevitably have at least some bias.  Healthcare workers are much more likely to be tested for COVID-19.  It is a concerning figure nevertheless and it is well known that healthcare environments are inherently risky when it comes to acquiring infection.

There are three main ways to avoid getting infection as a healthcare worker.  The first is to avoid patient contact where possible.  The second is to use appropriate personal protective equipment as per guidance.  The third is to minimise the risk of the clinical encounter.

Over the past few days, there has been a growing discussion amongst frontline clinicians about a radical cultural change in clinical practice.  We have been asking his question:

Should I stop examining children's throats?

Like any such suggestion, the first time the question was asked out loud was probably in a one-to-one conversation in a closed room after checking that the GMC hadn't bugged the place.  Then, as the question was asked more and more, it became quickly apparent that there was a large proportion of frontline clinicians who felt that this was a sensible move in the current situation.

On 25th March 2020 the RCPCH published guidance stating that in the current situation "the oropharynx of children should only be examined if essential."  Never before in my career have I seen such a change in practice go from whispers between colleagues to official college guidance in such a short period of time.  Well done RCPCH!  For the first time since the introduction of FAOMed, you're ahead of us!

While this move is entirely intended to reduce the risk of clinical contact during the COVID-19 pandemic, clinicians will at the very least have questions.  When something is part of our routine and then taken away from us it will cause anxieties.  As acute clinicians, our intuitive thinking relies on a reasonably consistent approach and in most paediatric encounters, we are used to looking in the throat.  So the question is, is it OK to stop doing that routinely?

Here are a few common questions in response to this radical change.

What if I need to know what the focus of infection is?
Good question.  This has always been a hugely subjective issue.  Even before this pandemic, the majority of clinicians and organisations have been trying to encourage self-care for uncomplicated febrile illness in children.  If a clinical confirmation of infection focus was essential, health care organisations would be getting the message out.  "Never give your child fever medicines without seeing a doctor to check what the problem is."  That's not a thing.
A snotty febrile child has an URTI.  URTI does not exclude other infections nor does it exclude sepsis so the redness of the throat should not reassure us if we think a child has another probable diagnosis such as UTI, LRTI or sepsis.
The important question has always been, "does this child have signs of serious bacterial infection or sepsis?"  If the answer is no then the throat exam won't really change things (see below).  If the answer is yes, you're looking for a source and it probably isn't in the throat.

When might I need to examine the throat?
The necessity for this is probably going to be mainly to look for evidence of a significant pathology such as peri-tonsillar abscess.  I would suggest that such a possibility can be all but excluded clinically if a child is well analgesed and is able to eat or drink.
If you do feel that examining the throat is important to do, you must wear eye protection.

Don’t I need to determine if the child has tonsillitis?
Tonsillitis in children can always be treated symptomatically.  The NICE guidance for treating sore throats attempts to direct the clinician toward cases where a symptom benefit from antibiotics is more likely but does not mandate the use of antibiotic in any uncomplicated URTI/ tonsillitis.  The reason there is no mandate is that there is no evidence that in this era in the UK, antibiotics prevent the rare complications of URTI/tonsillitis.
Regardless of clinical findings, the symptom benefit from antibiotics is poor.  The lack of evidence for significant benefit has led the Children's Hospital Melbourne to recommend no prescription of antibiotics in any case apart from high risk children or signs of complicated URTI.
So if the child is low risk (99.9% of children) and has no signs of complications from the infection, the visualisation of the tonsils is non-essential.

Should I therefore prescribe antibiotics empirically?
In the interests of openness and honesty, I need to say first that the RCPCH does advocate this.  There is a reminder that under the age of three years old, FeverPAIN should not be used.  Over the age of three, it is proposed that in the current climate we prescribe antibiotics as follows.
"If using the feverpain scoring system to decide if antibiotics are indicated (validated in children 3 years and older), we suggest that a pragmatic approach is adopted, and automatically starting with a score of 2 in lieu of an examination seems reasonable. 
Children with a total feverpain score or 4 or 5 should be prescribed antibiotics (we suggest children with a score of 3 or less receive safety netting advice alone)"

I'm going to stick my neck out and suggest that this approach is wrong, for the following reasons:

  1. First and foremost, it contradicts the public health approach to containing the COVID-19 pandemic.  People are being told that if they have a fever without signs of something that looks like a serious illness (difficulty breathing, poorly responsive etc.) they should stay at home, self-medicate and not seek a face to face clinical contact.  This is for their benefit, to protect the health service and to reduce the spread of COVID-19.  Lowering a threshold for prescribing antibiotics for sore throat at this time goes against that move.
  2. Secondly, the RCPCH has misquoted the NICE guidance.  In their speediness to protect clinicians from unnecessary risk, they have missed a word.  Just the one but it the word from the guidance that frequently goes unnoticed.  That word is consider.  It doesn't say give antibiotics for a FeverPAIN score above 4.  It says consider.  I consider that question every time and in most cases the answer is "The likelihood of benefit from antibiotics does not justify the risks."  

I feel (personal opinion) that since there is no mandate to treat low risk children who have no signs of complications of their URTI/tonsillitis, we should default to not prescribing antibiotics in these cases.  To lower our threshold for prescribing instead of raising it at this time of such a high risk clinical environment feels wrong.  It seems contrary to the need to protect children and their carers from the risks of a visit to a GP or hospital and it feels contrary to the drive to reduce the number of people bringing COVID-19 with them to those places.

Again, huge respect to the RCPCH for cutting through the red tape and rapidly producing guidance to protect healthcare workers.  Whenever something is done in that sort of timeframe, it is likely that detail gets missed.  That's where we come in.  We notice the typos and consider the implications.  We ask questions that deserve answers after the fact in lieu of the consultation period that couldn't happen due to the timescale needed.

Edward Snelosn

Wednesday, 25 March 2020

COVID questions No 2 - What PPE do I need to give a nebuliser to a child?

Healthcare workers are rightly concerned about their own health and want to avoid catching COVID-19.  Wearing the right personal protective equipment (PPE) for each patient and procedure is part of how we are going to minimise our risk of infection.

At the same time, many places have experienced shortages of PPE, especially the availability of filtering face piece protection (FFP) masks.  It is therefore important that we don't overuse PPE during this COVID-19 pandemic.  I will cover the issue of what the recommended level of PPE is and why in a post in the near future.  In this post I'm going to explore the answer to a very specific issue that has caused a great deal of discussion in the past few days.

Should I be wearing an FFP mask when giving a nebuliser to a child?

In order to answer that question, I'll need to answer a few other questions first.  The issue of level of PPE recommended by Public Health England (PHE) is said to be related to whether the patient contact involves an aerosol generating procedure, droplets or neither.

What is the difference between a droplet or an aerosol?

Essentially the difference is size.  An aerosol is defined as a droplet <10µm in diameter.  The significance of this is that it is large enough to carry a virus but small enough to bypass a standard droplet resistant mask (surgical mask) and enter the respiratory tract.

Is a nebuliser an aerosol generating procedure?

A nebuliser is not an AGP within the definition that is pertinent to this issue.  A nebuliser mask does create aerosol but the aerosol is water and drug only. (unless you are doing it very wrong indeed!  Don't get the child to spit in the chamber before you turn it on.)  The mist that you see coming out the side is not contaminated with virus.

The science of what happens next is that any aerosol from the nebuliser that comes in contact with the respiratory tract sticks where it lands.  If the child coughs, what comes out is droplets, for which a standard surgical mask is protective.

There is good evidence that nebulisers do not create a high risk of infection to health care workers.

Why is high flow oxygen therapy (HFOT) on the list of aerosol generating procedures then?

That is an excellent question and one that I asked when I saw the list.  The answer is that the list is probably badly named.  In reality the list is made up of a combination of AGPs, high risk procedures and procedures that may be high risk but this is as yet uncertain.  HFOT is much closer to nebulised therapy than it is to bag-valve-mask ventilation or CPAP so it may be low risk.  As a relatively new therapy, it is a sensible precaution to treat it as high risk procedure.  However it is probably misleading to call HFOT an AGP.

So here's the bottom line:

As a final note, metered dose via spacer is at least as effective and often preferable.

Keep sending your COVID-19 questions.

Edward Snelson

Monday, 23 March 2020

COVID Questions: No 1 - Should clinicians recommend the use of ibuprofen in a child with suspected COVID-19 infection?

As the COVID-19 pandemic gains momentum, we're all going to find ourselves either much busier or stuck at home.  Over the next few weeks I intend to publish a series of short articles for the FOAMed community, to provide some coffee break sized learning for clinicians on the front line.  If you have any COVID questions of your own, please send them to me.

These posts will not be heavily referenced, if at all.  We are in the very early stages of gathering evidence and the risk with early evidence is that it can be very misleading for various reasons.  Much of what is coming out from this crisis is a renaissance of pragmatism.  That pragmatism is born out of necessity but is based in the common sense and experience of the clinicians who look after children.  Together we can figure out what's truly important and cut through the evidence, without ignoring it.

The first question is: Should we recommend the use of ibuprofen for symptomatic relief in a child with a respiratory tract infection?

France's health minister, Olivier Véran created a great deal of anxiety for both clinicians and the public when he said that people should avoid using ibuprofen because it may make COVID-19 infection worse.  This prompted a variety of responses from organisations around the world.  Some recommended against using ibuprofen and some stating that there was no evidence that it made COVID-19 infection worse.

Why was there such a disparity of recommendations?  The answer is that your view will depend on your perspective.

Is there a possibility that ibuprofen could make COVID-19 infection worse?  Yes.  There is a hypothetical risk because the anti-inflammatory properties of ibuprofen include some elements of the immune response.

Is there any evidence that this biochemical effect has any clinical effect?  No.  There is no clinical evidence that ibuprofen actually makes COVID-19 infection worse.

So with a hypothetical harm and no evidence that it is real, what should you recommend?  That depends on whether you think that being able to take ibuprofen is important.  If not, then you may as well avoid it.  I would argue that there are plenty of reasons to think that avoiding the use of ibuprofen is harmful in children with respiratory tract infection.

It is arguable that the single greatest risk of avoiding Ibuprofen is the unnecessary exposure to infection.

Children with uncomplicated respiratory tract infections are best managed symptomatically.  Although parents often seek a clinical assessment, this rarely adds anything other than reassurance in the child who has no respiratory distress, signs of sepsis or dehydration.  In normal circumstances, the clinical assessment itself is low risk.  These times are not normal circumstances.  Any healthcare setting is currently extremely high risk for acquiring COVID-19 infection, so anything that brings you to the doors of a hospital or community clinical environment is itself dangerous.

It therefore follows that anything that avoids this attendance is protective.  Analgesia is a good way of helping a child with a respiratory tract infection to feel well and behave in a way that lets the parent know that they are not dangerously unwell.  It is also a good way to give the child the best possible chance of hydrating orally, by resolving their sore throat, sore ear or general malaise.

It is interesting that the initial flurry of recommendations against the use of ibuprofen was followed by a steady stream of statements that there was no evidence for such avoidance and a series of retractions and clarifications.  I think that the about turn was brought about by an alliance of evidence based medicine purists and front-line pragmatists who recognised that symptomatic relief is under-rated and has a genuinely important role in these times.

Even if you have genuine anxieties about the use of ibuprofen in children with potential COVID-19 infection, I would suggest the following principle:
While avoiding ibuprofen may feel safe, my opinion is that ibuprofen may be useful as a way to keep children and the adults who care for them safe by avoiding uneccessary clinical contact.

Edward Snelson

Wednesday, 8 January 2020

Something or nothing - why topical antibiotics are not for neonates with eye and umbilical infections

Newborn babies cause clinicians a lot of anxiety.  The worry about infections can lead to the use of antibiotics "just to be safe."  This is usually not the best approach.  Most of the time, the symptoms are nothing, and when they are something more significant, sending the baby home with topical antibiotics is not the solution.

Let's look at two common scenarios.

Scenario 1 - The baby with a sticky eye

A one week old presents with a unilateral sticky eye.  The baby is otherwise well, feeding and growing.   The left eye has a yellow discharge around the margin of the eyelid.  The baby's examination is otherwise normal.

What's the problem?  Something or nothing.

The nothing problem is the more common scenario.  Many babies are born with a non-patent nasolacrimal duct.  The inability to drain tears from the eye to the nose leads to the sticky eye.  Tears are made up mainly of water and lipid (for lubrication).  The water mostly evaporates leading to a thick secretion which accumulates.  This is not a sign of an infection.

Most blocked tear ducts will self-resolve over weeks or months.  It is unusual for them to persist until the infant's first birthday.  If it does, an ophthalmologist can unblock the duct with a probe.

Rarely, there will be a cystic collection in the tear duct.  This presents with the same sticky eye but with a swelling visible at the inner canthus of the eye.  There are some good pictures of what that looks like here.  Although these do sometimes self resolve, dacrocystoceles can be problematic and should be referred to an ophthalmologist.

The something problem is infective conjunctivitis, but not as you know it in older children.  Babies have all those lovely maternal antibodies to protect them from common viral infections, so viral conjunctivitis is relatively rare in newborns.  In addition to the increased likelihood of bacterial infections, there are two other factors that make topical antibiotics a bad idea for newborn eye infections.

Firstly, the infection may be congenitally acquired.  Chlamydia and gonorrhoea are two organisms that cause bacterial eye infections in neonates.

Secondly, the baby's immune system is heavily reliant on the aforementioned maternal antibodies.  Their own immune system is immature and relatively unresponsive.  That is one reason why newborns have vague symptoms during serious bacterial infections, while a one year old has a temperature of 39C and can look really unwell with an uncomplicated viral illness.

If this baby does have a bacterial eye infection, it is high risk both for the eye and the baby.
Opthalmia Neonatorum - from the Centers for Disease Control and Prevention's Public Health Image Library #3766

As a result of all of these factors, eye infections in newborns (ophthalmia neonatorum) should be taken seriously and referred for acute assessement and management by paediatrics or ophthalmology depending on your local pathways.

How do I tell the difference between the something and the nothing?

It's actually quite simple.  There are a few quick things to check:
The answers to these questions give you the answer to what you should do next.
While it might feel like the safe option to just give topical antibiotics to every baby with a sticky eye, this is not the case.  If the problem is a blocked tear duct, the eye drops may cause a chemical conjunctivitis and make things worse.  If the problem is an infection, it is higher risk for the eye and the baby and so needs careful assessment and management.

Scenario 2 - The baby with red skin around the umbilical stump

A three day old baby is brought to you by one of their parents.  There is some redness around the umbilical stump.

What is the problem?  Something or nothing.

The nothing option if the umbilical stump is still attached is non-infective inflammation.  From the moment of birth, the umbilical stump is devitalised tissue.  In the absence of a blood supply, it goes through a process that leads to separation, usually about a week or two after birth.  During this time it can either just become dry and shrivelled or it can become a bit sticky and smelly.  Often, the skin around the base has been repeatedly cleaned to remove any stickiness.  This itself can cause a small halo of red skin.
Image taken from the Stanford Newborn Nursery site and used with permission. This material was compiled by Janelle Aby, MD for educational purposes only.  Reproduction for commercial purposes is prohibited.  Utilisation of the materials for educating those who care for newborns is permitted with proper citation of source.
The nothing option if the umbilical stump has separated is an umbilical granuloma.  These benign growths are quite common and will self resolve.  They have a tendency to produce some exudate.  Again, repeated cleaning can cause a bit of inflammation to the surrounding skin.

The something scenario is omphalitis.  Infection of the umbilical stump carries a high risk of invasive infection.  This of course is partly due to the immunology of a newborn (see above).  It is also because the umbilicus retains its connection to the circulation.  The external part may be dead but the vessels inside are still patent and may help to seed the infection systemically.
Image taken from the Stanford Newborn Nursery site and used with permission. This material was compiled by Janelle Aby, MD for educational purposes only.  Reproduction for commercial purposes is prohibited.  Utilisation of the materials for educating those who care for newborns is permitted with proper citation of source.
Omphalitis is now a rare occurrence in the UK and other similar counties.  It remains a more frequent presentation in countries with limited healthcare resources, especially where it is common to give birth in unclean environments.
Since most of these neonates will be cared for in a hospital setting, babies that present to GP or ED are likely to be low risk.

In a low risk baby, the decision about what to do is fairly straightforward.
While it might feel like the safe option to just give topical antibiotics to every baby with a sticky umbilicus, this is not the case.  If the problem is non-infective inflamed skin, applying chemicals is only likely to make that worse.  Inflamed and broken skin does not make a good barrier to infection.  If the problem is an infection, it is a high risk situation best managed in a secondary care setting.

So if it's nothing, leave it alone.  This of course always requires good safetynetting advice.  If it is something significant, this is usually best managed in a secondary care setting.  There's no real role for the practice of doing something to make us feel like we've done something.

Edward Snelson
Cautious binarian

Sunday, 24 November 2019

Paediatric Warning Scores - why they are always right but never the answer

This decade has seen a massive rise in the use of early warning scores.  For many clinicians early warning scores are a thing with which they are well familiar.  For those who were in practice before early warning scores became commonplace, they can confusing. For those wondering what the place of these scores is, it is important to be clear about what they are and what they do.
What is a Paediatric Early Warning Score and which is the best?

Paediatric early warning scores are ways of flagging patients up for further assessment and guiding the urgency of that assessment.

The original paediatric early warning score is called PEWS and exists in many forms.  It tends to be chart based and was designed for monitoring of inpatients.  The idea behind it was to take a traditional observation chart and give thresholds for concern and action to the numbers being measured.  The reason for doing this was an awareness that sometimes observations were recorded but that deterioration or severity of illness was not acted upon.

PEWS charts have colours to show how deranged the numbers are.  Anything not in the green is used either as a threshold in its own right (i.e. a red parameter for one physiological variable has a required action) or is part of a score (i.e. added to the values of other parameters) or both.
Because children have differing physiology* at different ages and because each clinical environment is different, it is essential to use a PEWS chart that is appropriate to the child and for the actions to be appropriate to the place where it is used.

Although PEWS was designed for ongoing inpatient monitoring, it has been used in other environments including primary care community settings such as out-of-hours care providers.
A relatively new kid on the block is the Paediatric Observation Priority (POPS) score.  This scoring system includes a score for nurse/clinician gut feeling and a somewhat subjective score for breathing, making it an interesting blend of measured parameters and clinical judgement.
The other big difference with POPS is that it was designed for use in the front end of an Emergency Department.  Essentially, it was crafted to identify those patients who were more likely to need early senior decision making and early investigation or treatment.

Because it is not an ongoing observation chart, it can all cleverly fit on one page which has the numerical values* for each age.  For all of these reasons, POPS is increasingly used in community settings as a front door assessment tool.

*Note the careful avoidance of the word normal when referring to physiological parameters in children.  There is no normal, just numbers.

I wouldn't say that any one is better than another.  They have different usability and different emphasis.  What works best will vary by people and place of use.

Where a snapshot assessment is needed for high volumes of patients, I find that POPS works well.

What does the score mean?

The obtuse answer to that is, "A warning score in itself is not an answer."  The score was never designed to be an answer.  Instead it is part of a process that asks questions.  A score is simply a way of assigning a numerical value to a set number of variables.  It standardises a snapshot but in no way replaces appropriate clinical judgement.

The questions that are being asked are:
  • Is this child seriously unwell?
  • Who should be assessing this child?
  • Is the assessment time critical?
Of course these are questions that have always existed before scores were invented.  So if the score just asks the obvious questions, what is the point in them?

If the score is high but I am happy with the patient, does the score prove I am wrong?

No.  Let's prove that with an example.

Scenario 1 -
You go to see a child who has a POPS score of 5...
When you look at the breakdown of how they got  that score, they are a wheezy 3 year old with slight increased work of breathing (+1), a heart rate of 160 (+1), respiratory rate of 24 (+1), and Temp of 38 (+1). They were born prematurely at 32 weeks (+1) but have no ongoing complications of this.
When you go to see them, they run past you shouting, "I'm Spiderman!"
You complete your assessment and conclude that they have an uncomplicated viral URTI with a moderate viral wheeze.  It responds really well to salbutamol.
Four hour later they are tucked in bed at home with no respiratory distress.

Scenario 2 -
You go to see a child who has a POPS score of 5...
When you look at the breakdown of how this unwell 6 month old got  that score, they have a temperature of 37.9, heart rate is 176 (+1), a respiratory rate of 40 and they are grunting (+1).  They are subdued but if someone makes a noise the child produces a weak cry (+1).  They look seriously ill and the person completing the initial POPS score gave them 2 points for gut feel (+2).
Completing you assessment you decide that they are probably septic and act accordingly. Within 4 hours they are on a paediatric critical care unit, ventilated and on inotropes.  Two weeks later they leave hospital and make a full recovery.

The score indicated a need for an early and expert decision to be made.  In the case of scenario 1, the decision that the child was essentially well was entirely valid.  The score was valid also.

A score which is made up of these parameters cannot be wrong.  It is just a score.

Should I be using POPS scores in my clinical practice?

That depends on what you are using the score for.  If the score is to identify which of several children need to be put in front of a senior decision maker and how quickly that needs to happen, then that is a good use of a POPS score.  If the score is intended to identify a possible deterioration of a patient who is being monitored and observed, then this is what PEWS was designed for, though some will use POPS in that scenario.

If you have already made a clinical decision about the best course of action, then what do you want a score for?  After all, the score is simply a volume control for a question.  If you have already decided what the answer is, what is the score for?

Edward Snelson
Qualitative quantifier
Comment from Dr Damian Roland - Consultant in PEM at Leicester Royal Infirmary and one of the original developers of the POPS score:

Many thanks Edward - great piece and love the volume analogy! I use a very similar example of two different patients with the same score and what this means. It's an important example as children with higher scores (if admitted) have longer length of stay (based on the initial assessment POPS). A child with a score of 5 and above if admitted is likely to be in hospital for over 24 hours and also has a slightly higher risk of return if discharged (but the latter association actually quite weak). But lots of children with a POPS of 5 at presentation are safely and correctly discharged. So POPS helps highlight a patient who needs an intervention (which may be something as simple as senior review) but shouldn't tell you what to do.

I try to emphasise that the patients presenting to an Emergency Department are usually in a pre-treatment phase of their illness (they've not had medications) and therefore the range of possible acuities is very wide (which is why POPS is 0-16). This is different from an inpatient PEWS which is looking to identify children in a post treatment phase who are deteriorating. The bandwidth of PEWS (typically 0-7/8) is therefore smaller.

Finally POPS was designed to also help support decisions on 'wellness'. A POPS of 0 has a very high positive predictive value for being discharged without subsequent return and admission. It's the volume analogy in reverse. A POPS of 0 screams: why are you admitting me? And in some cases (DSH, Risk from specific past medical history, Social Concerns) you will do but it's the cognitive prompt that's the important thing.

Thanks Edward for shining a light on this important topic. I am happy to share copies of my paper explaining POPS "Scoring systems in paediatric emergency care: Panacea or paper exercise?" on request.

Thursday, 17 October 2019

The NYCE guideline for viral induced wheeze - Let's clear a few things up

If you’re unsure about how to manage viral wheeze in children, you’re not alone.  There is much confusion about this common paediatric presentation.  The uncertainty about best management exists for several reasons.
  • Research: The research on interventions is usually age based rather than specific to the condition being treated.
  • Guidelines: There are very few guidelines specifically for viral induced wheeze.  No national guidelines exist.  Some centres use asthma guidelines for acute treatment of viral wheeze while some develop  local guidelines which have significant variations.  
  • Front-line: There is often uncertainty about the diagnosis.  Telling the difference between bronchiolitis, vial induced wheeze and asthma/multi-trigger wheeze can be a challenge.

When you see a wheezy child, you want answers to all these questions.  So here we go, one at a time.

Question 1 – Does this child have viral induced wheeze?
If the child in front of you is snotty and between the ages of 12 months and 5 years then the answer is “almost certainly.”  Almost is somewhat unsatisfactory so here is the breakdown of that statement.

Wheezy children under the age of 12 months usually have bronchiolitis, a condition that is also induced by a virus but involves wetness of the small airways rather than bronchospasm of the larger airways.

Wheezy children over the age of 5 years might still have viral induced wheeze but asthma is a more significant possibility in this age group.  Children under the age of five may also get wheezy with other triggers but there is debate about what this should be called (e.g. multi-trigger wheeze) and when a diagnosis of asthma is given under the age of five it can easily turn out to be wrong.

The most certainty about the diagnosis of viral induced wheeze exists in those children between the age of 12 months and 5 years who
  • Only wheeze with a viral illness
  • Have a relatively rapid onset of wheeze
  • Have demonstrated response to beta-agonist treatment

It is worth knowing that there are wheezy presentations in this age group that can look a lot like viral wheeze.  These include bronchomalacia, acute allergy, and cardiac failure due to e.g. acute myocarditis.

Question 2 – What and how much treatment should I give to a child with viral induced wheeze?
Treatment of acute viral wheeze is often extrapolated from asthma guidelines.  Most, such as the BTS guidelines, stratify according to severity, mainly based on signs of increased work of breathing.

Other factors to consider include the child’s previous history of wheezy episodes.  It is reasonable to treat children who have progressed to needing a critical care level of treatment on previous occasions more aggressively in terms of treatment and more cautiously in terms of admission.

It is also well worth considering is whether the child has received effective treatment prior to presentation.  If the child has either been given no inhaled beta-agonists at home or the delivery has been ineffective, they are more likely to respond to a more conservative dose of inhaled treatment.  If they have been given substantial and effective treatment at home and are working hard to breate despite this, they are more likely to need a larger number of puffs to achieve an improvement.

Here is an example of how to treat an acute viral wheeze at presentation to primary care:

The use of oral steroids in children with viral wheeze is controversial.  Much of the available research looks at wheezing within an age group, not categorising children into phenotypes of underlying cause.  This has led to age based approaches by some and a selective approach to using steroids by others.

The best evidence (1) for the use of oral steroids for viral wheeze between the ages of 1 and 5 would suggest that the following group are most likely to have a small benefit:
  • Children with a diagnosis of asthma
  • Children who have required substantial amounts of inhaled beta-agonist prior to presentation
  • Children whose severity and lack of response to treatment with beta-agonists requires admission to hospital

One simplified application of this evidence is to say that if the child does not have asthma and does not require in-patient treatment, there is too little evidence to support the routine use of oral steroids.  Note that a family history of atopy, though often used in decision making here, is not an indicator that the child is likely to benefit from steroids.

Question 3 – Should this child be admitted?
The answer to that will depend on various factors including clinical setting and local infrastructure.  In an urban primary care/ secondary care model, admission should be the norm in the pre-hospital setting for children with a moderatel or severe episode who have required significant quantities of salbutal and are not responding well. 

Children whose severity is judged to be mild, and those who are moderate at presentation but respond well to their first dose on inhaled beta-agonist can usually be managed in the community.

Risk factors such as prematurity, comorbidities, pervious life-threatening episodes, parental confidence/competence and adverse social circumstances should all be involved in this important decision.

Question 4 – How much beta-agonist should the parents give if I am sending them home?
There is huge variation in practice here.  Experience tells us that paradoxically children tend to need larger doses of inhalers rather than standard or small doses.  This is likely to be due to a combination of delivery (getting all that is given to where it will count) and physics, since children’s airways have different flow dynamics to adult airways.
The majority of clinicians will recommend that the child receives 6-10 puffs of salbutamol 3-4 hourly.  Note that local guidelines vary in terms of dose and interval.  There is a certain amount of clinical judgement involved which will be influenced by the presentation and the circumstances (including the parental confidence and competence with delivery of inhalers and their ability to recognise markers of deterioration.)

What guidelines often fail to explain are the aims of treatment at home.
  • To get the child’s breathing looking normal or nearly normal
  • To maintain that improvement for at least a couple of hours and ideally four hours
  • To prevent the viral wheeze from affecting the child’s activity, ability to feed etc.

It is useful to tell parents that the inhalers will not treat the symptoms of the viral illness such as cough and runny nose.

Treatment failure is generally considered to be:
  • Significantly increased work of breathing despite inhaled beta-agonists
  • Worsening severity – progressively requiring more puffs or more puffs at shorter intervals
  • Parental global concern about the appearance or wellness of the child

A further variation in practice is how people manage the issue of reducing/ stopping the inhaled beta-agonist treatment.  Viral wheeze is by definition a time limited problem.  As the effect of the virus and the child’s immune response resolve, so does the bronchospasm.  There are two main approaches to the way that people advise how to move towards stopping the inhaler.
  • A set weaning regime – many centres have a planned weaning regime for inhalers that is given to parents.  This sets out a planned reduction of the number/ frequency of inhaler given to the child.  It is usually written down and given to the parents for them to follow.
  • A weaning plan that is not prescriptive – it is equally common to give parents a plan that puts them in the driving seat.  Often, it recommends a set dosing and interval for a set period (e.g. 6 puffs four hourly for two days) to be followed by a period of using the inhaler when it is apparent that the child would benefit (e.g. increased work of breathing or audible wheezing).

Each approach has pros and cons.  A set weaning regime carries a risk that the parents will follow it even when the child is not ready.  A weaning regime that requires parental judgement carries a risk that the inhalers will continue to be given when not needed (e.g. to treat a cough) or that the parents will simply stop after two days and not recognise the child’s need for further inhalers.

Whichever approach is used, the risks can be managed by careful explanation of what to do, how to do it and when to divert from the plan.

It's important to know the uncertainties and variations in practice.  It's also important to have a guideline.  Viral wheeze has always been a paradox in that regard.  There is a broad concensus that viral wheeze is not asthma, yet there has always been a tendency to shoe-horn the management of viral wheeze into asthma guidelines.  Perhaps it is time that viral wheeze had its own guideline.  Wouldn't that be NICE.

Edward Snelson
  1. Foster S et al, Oral prednisolone in preschool children with virus-associated wheeze: a prospective, randomised, double-blind, placebo-controlled trial, Lancet, Vol 6, Issue 2, P97-106, Feb 01, 2018