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What's the best way (in a patient with wheezing), to determine if this is likely due to reactive airway disease or asthma exacerbation, vs a viral illness?
Reactive airway disease/asthma exacerbation vs viral illness?
- Thread starter Hemichordate
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Have a fancy lab with a respiratory viral panel and see if something comes up positive.
Or look for other symptoms (nasal congestion, rhinorrhea, fevers, conjunctivitis, sick contacts, etc), recognizing that some overlap with seasonal allergies, so you'll need to know if they have those and if they were exposed to any of their allergens.
Or look for other symptoms (nasal congestion, rhinorrhea, fevers, conjunctivitis, sick contacts, etc), recognizing that some overlap with seasonal allergies, so you'll need to know if they have those and if they were exposed to any of their allergens.
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These two things aren't mutually exclusive. Viral respiratory infections are a very common trigger for asthma exacerbations. You can also have viral-induced wheezing associated with LRTIs caused by crud in the smaller airways (i.e bronchiolitis), but this doesn't mean the patient necessarily has asthma.
In the midst of an acute illness, your best bet is probably the history: Previous diagnosis of asthma? History of wheezing outside of illnesses (exercise, etc.)? Bronchodilator responsiveness? Family history of atopy that would suggest an increased risk for asthma?
Remember that the diagnosis of asthma requires multiple episodes of reversible bronchoconstriction and airway inflammation (it's recurrent), so you can't make a definitive diagnosis if this is the patient's first episode of wheezing. When the patient is well again and if they are old enough to cooperate, you can consider pulmonary function testing to look for reversible airway obstruction.
In the midst of an acute illness, your best bet is probably the history: Previous diagnosis of asthma? History of wheezing outside of illnesses (exercise, etc.)? Bronchodilator responsiveness? Family history of atopy that would suggest an increased risk for asthma?
Remember that the diagnosis of asthma requires multiple episodes of reversible bronchoconstriction and airway inflammation (it's recurrent), so you can't make a definitive diagnosis if this is the patient's first episode of wheezing. When the patient is well again and if they are old enough to cooperate, you can consider pulmonary function testing to look for reversible airway obstruction.
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Aren't rvps like $1500? Wouldn't it be better to just trial a bronchodilator?
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There isn't a great way to do it, and as mentioned above the two can come together. History of wheezing is important, but I generally say treat the physiology you are seeing/hearing instead of anchoring to and treating a certain diagnosis. If you hear wheezing try some albuterol and see what happens, especially if they have a history of wheezing. Know that if the kid is febrile and showing other signs of infection, it's more likely to be viral. You won't always be able to tell, and that's ok.
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We keep being told different things about the cost, and there's words going around that it's required for bed placement, which is very frustrating.
But, as mentioned above, you can have both. And some bronchiolitis does respond to albuterol, though it's not very often. So that can only really be a rough gauge. So, you can prove they do or do not have a viral illness with an RVP, but can't necessarily diagnose them with asthma based on responsiveness to albuterol.
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I think people are getting cost and charge mixed together. Cost is the money the hospital uses to run a test, provide a room, etc. Charge is the money the hospital bills for the service. For instance, hospitals charge $100+ for a dose of Tylenol, but the cost is much less.
As for the RVP question, in a kid who is febrile and wheezing, I personally think it is reasonable. 1) if gives the provider and family a specific answer if positive 2) is more accurate than rapid serology based testing 3) tests for more viruses 4) prevents exploring additional avenues when positive. Also take it in the context of a hospitalization for bronchiolitis. Just the bed space alone is going to be an approximate $4000 to $5000 per day. This doesn't include provider service fees, medications, other diagnostic tests, etc. So a 4 day hospital stay is going to be about a $25000+ charge. However the actual cost, is lower.
As for the RVP question, in a kid who is febrile and wheezing, I personally think it is reasonable. 1) if gives the provider and family a specific answer if positive 2) is more accurate than rapid serology based testing 3) tests for more viruses 4) prevents exploring additional avenues when positive. Also take it in the context of a hospitalization for bronchiolitis. Just the bed space alone is going to be an approximate $4000 to $5000 per day. This doesn't include provider service fees, medications, other diagnostic tests, etc. So a 4 day hospital stay is going to be about a $25000+ charge. However the actual cost, is lower.
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Maybe I'm using the term wrong, but when I say RAD I guess I mean what I've heard called "transient wheeze of childhood/infancy"--what the adult medicine doctors in that article refer to as "not enough data in a young child" or someone who wheezes with viral illness as a toddler/until 3 y/o and then grows out of it
http://www.atsjournals.org/doi/full/10.1164/ajrccm.160.5.9811002
Edited because I got the age range wrong for transient wheeze
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I think the multiplex viral panels are useful only if they are going to change management*(cohort with other children with same disease process, forgo abx, forgo other testing to search for etiology of illness). They so sound very cool because we can say definitively "it's X" rather then "umm, probably a virus?". Ordered thoughtfully, they can be helpful.
However, I fear they will become an extension (a potentially much more expensive extension) of the RSV RADT. A test that tells you about exactly one virus and absolutely nothing about the child's hydration and respiratory status.
*Exceptions would include research and certain public health purposes.
However, I fear they will become an extension (a potentially much more expensive extension) of the RSV RADT. A test that tells you about exactly one virus and absolutely nothing about the child's hydration and respiratory status.
*Exceptions would include research and certain public health purposes.
That's a far more useful paper.
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I think it's partly where the "only 30% of teeny kids who wheeze get asthma" comes from
(Of the 16,333 children studied, 1,221 (7.5%) were classified as having had transient early wheezing, 671 (4.1%) as having had persistent wheezing, and 918 (5.6%) as having had late-onset wheezing, while 13,523 (82.8%) formed the control group.)
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Generally agree with this, but I will say that in the real world there is some additional value to these tests beyond "would it change management"
Example -- parent got angry at me once because I told them their child had viral bronchiolitis. Patient got worse, went to hospital where they had a positive rapid RSV test. Parent was mad because their child had "RSV instead of a virus." Even though the management didnt change, knowing the specific virus causing the illness was highly valuable to the parent.
I would also say that these viral panels can change management in ways that you don't initially consider.
Example -- kid comes in with 6 days of fevers, weakness/fatigue, joint pains, conjunctivitis, large lymph node in neck. I'm starting to think about Kawasaki and perhaps admit them for IVIG. However I first run a viral panel which comes back positive for adenovirus. That has happened at least twice in my career, and now before I diagnose Kawasaki I always check for adeno first since it's such a great mimicker of Kawasaki
Now there are a couple of companies that can do a rapid FA6 viral panel with results in 2 hours that are much less expensive -- I saw one that costs under $30 for PPO insurance plans.
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I find RVP's useful for giving a sense of how long things will last - especially in my ICU asthmatics. If they have a concurrent virus, I can tell the parents to expect a longer hospital stay, and I'm less concerned if they're stuck on high flow or continuous albuterol after 48 hours.
Also, our nurses in the PICU have gotten into a habit of not putting kids in isolation unless there is an RVP ordered or a result from an OSH. Probably not the best practice, but our infection control people haven't made a peep about it either. Now that I have a kid of my own at home, I'm a lot more cognizant about bringing viruses home with me and so it's a way to lower my risks of having my wife get mad at me for getting our daughter sick.
Also, our nurses in the PICU have gotten into a habit of not putting kids in isolation unless there is an RVP ordered or a result from an OSH. Probably not the best practice, but our infection control people haven't made a peep about it either. Now that I have a kid of my own at home, I'm a lot more cognizant about bringing viruses home with me and so it's a way to lower my risks of having my wife get mad at me for getting our daughter sick.
I second that. It's a huge problem. People do not understand that it is only a panel of the 30 or so viral pathogens (some bacterial too) and that there are thousands more that are not tested. The worst is when people would take them off isolation precautions because the panel came back negative. At my institution we are lucky to have a very rational epidemiology dept who was able to change the culture. We now place people on isolation precautions when we suspect a viral respiratory infection, regardless of whether we order a panel or if it comes back negative. The other major issue is that insurance companies are starting to deny paying for this (and to be honest they should). It is an exceedingly expensive test for the little clinical benefit that it provides. I don't need a $1000 test to tell me that someone has a virus.
It's more like a $150 test.
How is deciding on contact precautions not the responsibility of the physician?! This seems like a major infectious control liability for the hospital if you are risking spreading a virus to other patients.
D
da8s0859q
Had the same as an ED attending. Influenza B. Mom said prior to testing, "they told me yesterday this is a virus. My baby ain't got no virus."
Told her up front I agreed with it being viral. Then I ordered the swab to confirm. Talked all about influenza being a virus (in this child who at that time was fine, eating, drinking, watching TV, no need for IV, as benign as a kid with the flu can be).
Don't worry. Sometimes, they'll hate me AND you.
