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Cunningham S, Rodriguez A, Boyd KA, McIntosh E, Lewis SC. Bronchiolitis of Infancy Discharge Study (BIDS): a multicentre, parallel-group, double-blind, randomised controlled, equivalence trial with economic evaluation. Health Technol Assess 2016; 19:i-xxiii, 1-172. [PMID: 26364905 DOI: 10.3310/hta19710] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There are no randomised trials of peripheral capillary oxygen saturation (SpO2) targets in acute respiratory infection. Two national guidelines recommended different targets for the management of acute viral bronchiolitis. OBJECTIVES To compare the American Academy of Pediatrics guideline target of SpO2 ≥ 90% with the Scottish Intercollegiate Guidelines Network target of SpO2 ≥ 94%. DESIGN A multicentre, parallel-group, double-blind, randomised controlled, equivalence trial with economic evaluation. SETTING Eight paediatric hospital departments in the UK. PARTICIPANTS Infants > 6 weeks and ≤ 12 months of age (corrected for prematurity) with physician-diagnosed bronchiolitis admitted to hospital from a paediatric emergency assessment area. Follow-up for 6 months by standardised telephone contacts. INTERVENTION Infants were randomised to a target oxygen saturation of ≥ 94% (standard care) or ≥ 90% (modified care) displayed by a pulse saturation oximeter (Masimo Corporation Limited, CA, USA). ROUTINE CARE All infants received routine care in addition to the study intervention. Infants were eligible for discharge when they exhibited a SpO2 of ≥ 94% in room air for 4 hours including a period of sleep and were also feeding adequately (≥ 75% usual volume). PRIMARY OUTCOME A total of 615 infants were recruited, of whom 308 were allocated to the standard care group and 307 to the modified care group. The primary outcome was time to cough resolution. There was equivalence at the prespecified variance of ± 2 days [time to cough resolution: standard care group, 15 days; modified care group, 15 days; median difference 1 day (benefit modified), 95% confidence interval (CI) -1 to 2 days]. SECONDARY RESULTS Return to adequate feeding occurred sooner in infants in the modified care group than in those in the standard care group (19.5 vs. 24.1 hours). This difference was non-equivalent [median difference 2.7 hours (95% CI -0.3 to 7.0 hours) versus prespecified ± 4 hours; post-hoc hazard ratio 1.22 (95% CI 1.04 to 1.44 (p-value = 0.015)]. Parent perspective of the time taken to return to normal was not equivalent, being 12 days in the standard care group compared with 11 days in the modified care group [median difference 1.0 day (95% CI 0.0 to 3.0 days) versus prespecified ± 2 days; post-hoc hazard ratio 1.19 (95% CI 1.00 to 1.41); p-value = 0.043]. At 28 days, SpO2 was equivalent [mean difference 0.11% (95% CI -0.35% to 0.57%), within the 1% prespecified]. The modified care group (55.6%) required oxygen less than the standard care group (73.1%), and for a shorter period (5.7 hours vs. 27.6 hours). Infants in the modified care group were fit for discharge (30.2 hours vs. 44.2 hours, hazard ratio 1.46, 95% CI 1.23 to 1.73; p-value < 0.001) and were discharged (40.9 hours vs. 50.9 hours; hazard ratio 1.28, 95% CI 1.06 to 1.50; p-value < 0.003) sooner than those in the standard care group. There were 35 serious adverse events in the standard care group, compared with 25 in the modified care group. Eight infants in the standard care group and 12 in the modified care group were admitted to a high-dependency unit. By 28 days, 23 infants had been readmitted to hospital in the standard care group and 12 infants in the modified care group. Parents of infants in the modified care group did not experience higher levels of anxiety and, by 14 days, had lost 28% fewer hours to usual activities. NHS costs were £290 lower in the modified care group than in the standard care group, with additional societal costs also being lower in the modified care group. CONCLUSIONS Management of infants to a SpO2 target of ≥ 90% is as clinically effective as ≥ 94%, gives rise to no additional safety concerns, and appears to be cost-effective. Future work could focus on the safety and effectiveness of using intermittent oxygen saturation monitoring in secondary care, and to consider what are safe and effective oxygen saturation targets for children with bronchiolitis managed in primary care. TRIAL REGISTRATION This trial is registered as ISRCTN28405428. FUNDING This project was funded by the NIHR Health Technology Assessment programme. Masimo Corporation Limited, CA, USA, kindly provided oxygen saturation monitors with standard and altered algorithms.
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Affiliation(s)
- Steve Cunningham
- Department of Respiratory and Sleep Medicine, Royal Hospital for Sick Children, Edinburgh, UK
| | - Aryelly Rodriguez
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Kathleen A Boyd
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Emma McIntosh
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Steff C Lewis
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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Berents T, Lødrup Carlsen K, Mowinckel P, Sandvik L, Skjerven H, Rolfsjord L, Kvenshagen B, Hunderi J, Bradley M, Lieden A, Carlsen K, Thorsby P, Gjersvik P. Vitamin D levels and atopic eczema in infancy and early childhood in Norway: a cohort study. Br J Dermatol 2016; 175:95-101. [DOI: 10.1111/bjd.14537] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2016] [Indexed: 12/19/2022]
Affiliation(s)
- T.L. Berents
- Institute of Clinical Medicine University of Oslo Oslo Norway
- Department of Dermatology Oslo University Hospital Oslo Norway
| | - K.C. Lødrup Carlsen
- Institute of Clinical Medicine University of Oslo Oslo Norway
- Department of Pediatrics Oslo University Hospital Oslo Norway
| | - P. Mowinckel
- Department of Pediatrics Oslo University Hospital Oslo Norway
| | - L. Sandvik
- Institute of Clinical Medicine University of Oslo Oslo Norway
- Department of Biostatistics and Epidemiology Oslo University Hospital Oslo Norway
- University of Oslo Oslo Norway
| | - H.O. Skjerven
- Institute of Clinical Medicine University of Oslo Oslo Norway
- Department of Pediatrics Oslo University Hospital Oslo Norway
| | - L.B. Rolfsjord
- Institute of Clinical Medicine University of Oslo Oslo Norway
- Department of Pediatrics Elverum Hospital Elverum Norway
| | - B. Kvenshagen
- Department of Pediatrics Østfold Hospital Fredrikstad Norway
| | - J.O.G. Hunderi
- Institute of Clinical Medicine University of Oslo Oslo Norway
- Department of Pediatrics Oslo University Hospital Oslo Norway
- Department of Pediatrics Østfold Hospital Fredrikstad Norway
| | - M. Bradley
- Department of Molecular Medicine Karolinska Institute at Karolinska Hospital Stockholm Sweden
| | - A. Lieden
- Department of Molecular Medicine Karolinska Institute at Karolinska Hospital Stockholm Sweden
| | - K.‐H. Carlsen
- Institute of Clinical Medicine University of Oslo Oslo Norway
- Department of Pediatrics Oslo University Hospital Oslo Norway
| | - P.M. Thorsby
- Institute of Clinical Medicine University of Oslo Oslo Norway
- Hormone Laboratory Department of Medical Biochemistry Oslo University Hospital Oslo Norway
| | - P. Gjersvik
- Institute of Clinical Medicine University of Oslo Oslo Norway
- Department of Dermatology Oslo University Hospital Oslo Norway
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Carroll CL, Faustino EVS, Pinto MG, Sala KA, Canarie MF, Li S, Giuliano JS, The Northeast Pediatric Critical Care Research Consortium. A regional cohort study of the treatment of critically ill children with bronchiolitis. J Asthma 2016; 53:1006-11. [PMID: 27177013 DOI: 10.1080/02770903.2016.1180697] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To describe the treatment practices in critically ill children with RSV bronchiolitis across four regional PICUs in the northeastern United States, and to determine the factors associated with increased ICU length of stay in this population. METHODS We conducted a retrospective cohort study of children who were admitted with RSV bronchiolitis between July 2009 and July 2011 to the PICUs of Connecticut Children's Medical Center, Yale-New Haven Children's Hospital, Maria Fareri Children's Hospital, and Baystate Children's Hospital. Data were collected regarding clinical characteristics and intensive care course among these hospitals. RESULTS During the study period, 323 children were admitted to one of the four ICUs with RSV bronchiolitis. Despite similar mortality risk scores among ICUs, there was considerable variation in the use of therapies, particularly intubation and mechanical ventilation, in which there was greater than a 3.5-fold increased risk of intubation between sites with the highest and lowest frequency of intubation (odds ratio: 3.8; 95% confidence interval: 2.2-6.4). Albuterol was the most commonly used respiratory treatment, followed by chest physiotherapy, high-flow nasal cannula, and hypertonic saline. Longer stays in the ICU were associated with more frequent use of therapies, specifically invasive mechanical ventilation, inhaled corticosteroids, intrapulmonary percussive ventilation, and chest physiotherapy. CONCLUSIONS Even within a close geographic region, there is significant variation in the treatment provided to critically ill children with RSV bronchiolitis. None of these treatments were associated with shorter durations of hospitalization in this population and some, such as mechanical ventilation, were associated with longer ICU lengths of stay.
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Affiliation(s)
| | | | - Matthew G Pinto
- c Maria Fareri Children's Hospital at Westchester Medical Center , Valhalla , NY , USA
| | - Kathleen A Sala
- a Connecticut Children's Medical Center , Hartford , CT , USA
| | | | - Simon Li
- c Maria Fareri Children's Hospital at Westchester Medical Center , Valhalla , NY , USA
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Baron J, El-Chaar G. Hypertonic Saline for the Treatment of Bronchiolitis in Infants and Young Children: A Critical Review of the Literature. J Pediatr Pharmacol Ther 2016; 21:7-26. [PMID: 26997926 DOI: 10.5863/1551-6776-21.1.7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Bronchiolitis, an infection of the lower respiratory tract, is the leading cause of infant and child hospitalization in the United States. Therapeutic options for management of bronchiolitis are limited. Hypertonic saline inhalation therapy has been studied in numerous clinical trials with mixed results. In 2014, the American Academy of Pediatrics (AAP) published updated guidelines on the diagnosis and management of bronchiolitis, which include new recommendations on the use of hypertonic saline. We reviewed all published clinical trials mentioned in the 2014 AAP guidelines, as well as additional trials published since the guidelines, and critically evaluated each trial to determine efficacy, safety, and expectations of hypertonic saline inhalation therapy. A total of 2682 infants were studied over the course of 22 clinical trials. Nine trials were carried out in the outpatient/clinic/emergency department and 13 in the inpatient setting. We agree with the AAP guidelines regarding the recommendation to use nebulized hypertonic saline for infants hospitalized with bronchiolitis, with the expectation of reducing bronchiolitis scores and length of stay when it is expected to last more than 72 hours. However, we also believe there might be an advantage for hypertonic saline in reducing admission rates from the emergency department, based on close examination of the results of recent trials. This review also highlights important gaps in the available literature that need to be addressed in order to define the role of inhaled hypertonic saline therapy.
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Affiliation(s)
- Jeffrey Baron
- Pharmacy Department, Roswell Park Cancer Institute, Buffalo, New York
| | - Gladys El-Chaar
- Pharmacy Department, Roswell Park Cancer Institute, Buffalo, New York ; Department of Pharmacy, Winthrop-University Hospital, Mineola, New York ; Department of Clinical Pharmacy Practice, St John's University College of Pharmacy and Health Sciences, Jamaica, New York
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Vandini S, Faldella G, Lanari M. Latest options for treatment of bronchiolitis in infants. Expert Rev Respir Med 2016; 10:453-461. [PMID: 26901672 DOI: 10.1586/17476348.2016.1157473] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Bronchiolitis is the most frequent pathology associated with lower respiratory tract infection in newborns and young infants. The treatment of bronchiolitis is essentially supportive therapy for respiratory distress, hypoxia and dehydration. To date, no specific antiviral drug is used on a routine basis for the treatment of RSV infections. Currently, the only antiviral drug approved for the infection is ribavirin; however, its use is limited due to adverse side effects and the risks it poses to healthcare providers. Moreover, several drugs have been routinely administered for years in infants with acute RSV bronchiolitis, even if their efficacy is often not confirmed by clinical evidence, and studies on emerging antiviral drugs are still ongoing. In the present paper we review the recent literature about the drugs used during acute bronchiolitis and we summarize the main recommendations of national and international guidelines and the latest options for the treatment of bronchiolitis.
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Affiliation(s)
- Silvia Vandini
- a Neonatology and Neonatal Intensive Care Unit, S.Orsola-Malpighi Hospital, University of Bologna , Bologna , Italy
| | - Giacomo Faldella
- a Neonatology and Neonatal Intensive Care Unit, S.Orsola-Malpighi Hospital, University of Bologna , Bologna , Italy
| | - Marcello Lanari
- b Pediatrics and Neonatology Unit , Imola Hospital , Imola , Italy
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Management of Bronchiolitis in Community Hospitals in Ontario: a Multicentre Cohort Study. CAN J EMERG MED 2016; 18:443-452. [PMID: 26906352 DOI: 10.1017/cem.2016.7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Bronchiolitis is the leading cause of hospital admission for infants, but few studies have examined management of this condition in community hospital settings. We reviewed the management of children with bronchiolitis presenting to community hospitals in Ontario. METHODS We retrospectively reviewed a consecutive cohort of infants less than 12 months old with bronchiolitis who presented to 28 Ontario community hospitals over a two-year period. Bronchiolitis was defined as first episode of wheezing associated with signs of an upper respiratory tract infection during respiratory syncytial virus season. RESULTS Of 543 eligible children, 161 (29.7%, 95% Confidence Interval (CI) 22.3 to 37.0%) were admitted to hospital. Hospital admission rates varied widely (Interquartile Range 0%-40.3%). Bronchodilator use was widespread in the emergency department (ED) (79.7% of patients, 95% CI 75.0 to 84.5%) and on the inpatient wards (94.4% of patients, 95% CI 90.2 to 98.6%). Salbutamol was the most commonly used bronchodilator. At ED discharge 44.7% (95% CI 37.5 to 51.9%) of patients were prescribed a bronchodilator medication. Approximately one-third of ED patients (30.8%, 95% CI 22.7 to 38.8%), 50.3% (95% CI 37.7 to 63.0%) of inpatients, and 23.5% (95% CI 14.4 to 32.7) of patients discharged from the ED were treated with corticosteroids. The most common investigation obtained was a chest x-ray (60.2% of all children; 95% CI 51.9 to 68.5%). CONCLUSIONS Infants with bronchiolitis receive medications and investigations for which there is little evidence of benefit. This suggests a need for knowledge translation strategies directed to community hospitals.
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Jackson DJ, Lemanske RF, Gern JE. Infections and Asthma. PEDIATRIC ALLERGY: PRINCIPLES AND PRACTICE 2016. [PMCID: PMC7173469 DOI: 10.1016/b978-0-323-29875-9.00031-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Wheezing viral respiratory illnesses are the most common initial presentation of childhood asthma. Once asthma is established, viral infections, most notably rhinovirus (RV), are the most frequent trigger of severe asthma exacerbations. RV-C appears to be a particularly pathogenic virus in children with asthma. Evidence has recently emerged to suggest that bacterial pathogens in the lower airway may contribute to the expression of asthma. Ongoing studies are critical to our understanding of the role of the airway microbiome in asthma inception and exacerbation. Synergistic interactions between underlying allergy and virus infections play an important mechanistic role in asthma inception and exacerbation, and are an important therapeutic target. Novel therapies are needed to prevent and treat virus-induced wheezing and asthma exacerbations.
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Tapiainen T, Aittoniemi J, Immonen J, Jylkkä H, Meinander T, Nuolivirta K, Peltola V, Salo E, Seuri R, Walle SM, Korppi M. Finnish guidelines for the treatment of laryngitis, wheezing bronchitis and bronchiolitis in children. Acta Paediatr 2016; 105:44-9. [PMID: 26295564 DOI: 10.1111/apa.13162] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 06/22/2015] [Accepted: 08/17/2015] [Indexed: 01/04/2023]
Abstract
UNLABELLED Evidence-based guidelines are needed to harmonise and improve the diagnostics and treatment of children's lower respiratory tract infections. Following a professional literature search, an interdisciplinary working group evaluated and graded the available evidence and constructed guidelines for treating laryngitis, bronchitis, wheezing bronchitis and bronchiolitis. CONCLUSION Currently available drugs were not effective in relieving cough symptoms. Salbutamol inhalations could relieve the symptoms of wheezing bronchitis and should be administered via a holding chamber. Nebulised adrenaline or inhaled or oral glucocorticoids did not reduce hospitalisation rates or relieve symptoms in infants with bronchiolitis and should not be routinely used.
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Affiliation(s)
- Terhi Tapiainen
- Department of Pediatrics and Adolescence; Oulu University Hospital; Oulu Finland
- PEDEGO Research Unit - Research Unit for Pediatrics; Dermatology; Clinical Genetics; Obstetrics and Gynecology; and Medical Research Center; University of Oulu; Oulu Finland
| | | | | | - Heli Jylkkä
- Department of Pediatrics; University of Tampere; Tampere Finland
| | - Tuula Meinander
- Department of Internal Medicine; Tampere University Hospital and the Finnish Medical Society Duodecim; Tampere Finland
| | | | - Ville Peltola
- Department of Pediatrics; Turku University Hospital and University of Turku; Turku Finland
| | - Eeva Salo
- Department of Pediatrics; Helsinki University Hospital; Helsinki Finland
| | - Raija Seuri
- HUS Imaging; Children′s Hospital; Helsinki University Hospital; Helsinki Finland
| | | | - Matti Korppi
- Department of Pediatrics; Tampere University Hospital and University of Tampere; Tampere Finland
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Affiliation(s)
- Matti Korppi
- Tampere Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
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Silver AH, Esteban-Cruciani N, Azzarone G, Douglas LC, Lee DS, Liewehr S, Nazif JM, Agalliu I, Villegas S, Rhim HJH, Rinke ML, O'Connor K. 3% Hypertonic Saline Versus Normal Saline in Inpatient Bronchiolitis: A Randomized Controlled Trial. Pediatrics 2015; 136:1036-43. [PMID: 26553190 DOI: 10.1542/peds.2015-1037] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Bronchiolitis, the most common reason for hospitalization in children younger than 1 year in the United States, has no proven therapies effective beyond supportive care. We aimed to investigate the effect of nebulized 3% hypertonic saline (HS) compared with nebulized normal saline (NS) on length of stay (LOS) in infants hospitalized with bronchiolitis. METHODS We conducted a prospective, randomized, double-blind, controlled trial in an urban tertiary care children's hospital in 227 infants younger than 12 months old admitted with a diagnosis of bronchiolitis (190 completed the study); 113 infants were randomized to HS (93 completed the study), and 114 to NS (97 completed the study). Subjects received 4 mL nebulized 3% HS or 4 mL 0.9% NS every 4 hours from enrollment until hospital discharge. The primary outcome was median LOS. Secondary outcomes were total adverse events, subdivided as clinical worsening and readmissions. RESULTS Patient characteristics were similar in groups. In intention-to-treat analysis, median LOS (interquartile range) of HS and NS groups was 2.1 (1.2-4.6) vs 2.1 days (1.2-3.8), respectively, P = .73. We confirmed findings with per-protocol analysis, HS and NS groups with 2.0 (1.3-3.3) and 2.0 days (1.2-3.0), respectively, P = .96. Seven-day readmission rate for HS and NS groups were 4.3% and 3.1%, respectively, P = .77. Clinical worsening events were similar between groups (9% vs 8%, P = .97). CONCLUSIONS Among infants admitted to the hospital with bronchiolitis, treatment with nebulized 3% HS compared with NS had no difference in LOS or 7-day readmission rates.
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Affiliation(s)
- Alyssa H Silver
- Division of Pediatric Hospital Medicine, Department of Pediatrics,
| | | | | | | | - Diana S Lee
- Division of Pediatric Hospital Medicine, Department of Pediatrics
| | - Sheila Liewehr
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Department of Pediatrics, Steven and Alexandra Cohen Children's Medical Center at North Shore-LIJ Health System, New Hyde Park, New York; and
| | - Joanne M Nazif
- Division of Pediatric Hospital Medicine, Department of Pediatrics
| | - Ilir Agalliu
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Susan Villegas
- Department of Pharmacy, Arnold and Marie Schwartz College of Pharmacy, Long Island University, Brooklyn, New York Department of Pharmacy, The Children's Hospital at Montefiore, and
| | - Hai Jung H Rhim
- Division of Pediatric Hospital Medicine, Department of Pediatrics
| | - Michael L Rinke
- Division of Pediatric Hospital Medicine, Department of Pediatrics
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Korppi M. Is refraining from all invasive interventions the best treatment for infant bronchiolitis? Pediatr Pulmonol 2015; 50:1137-8. [PMID: 25470135 DOI: 10.1002/ppul.23143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 09/26/2014] [Accepted: 10/13/2014] [Indexed: 11/09/2022]
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Skjerven HO, Megremis S, Papadopoulos NG, Mowinckel P, Carlsen KH, Lødrup Carlsen KC. Virus Type and Genomic Load in Acute Bronchiolitis: Severity and Treatment Response With Inhaled Adrenaline. J Infect Dis 2015; 213:915-21. [PMID: 26508124 PMCID: PMC7107341 DOI: 10.1093/infdis/jiv513] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 10/19/2015] [Indexed: 02/06/2023] Open
Abstract
Background. Acute bronchiolitis frequently causes infant hospitalization. Studies on different viruses or viral genomic load and disease severity or treatment effect have had conflicting results. We aimed to investigate whether the presence or concentration of individual or multiple viruses were associated with disease severity in acute bronchiolitis and to evaluate whether detected viruses modified the response to inhaled racemic adrenaline. Methods. Nasopharyngeal aspirates were collected from 363 infants with acute bronchiolitis in a randomized, controlled trial that compared inhaled racemic adrenaline versus saline. Virus genome was identified and quantified by polymerase chain reaction analyses. Severity was assessed on the basis of the length of stay and the use of supportive care. Results. Respiratory syncytial virus (83%) and human rhinovirus (34%) were most commonly detected. Seven other viruses were present in 8%–15% of the patients. Two or more viruses (maximum, 7) were detected in 61% of the infants. Virus type or coinfection was not associated with disease severity. A high genomic load of respiratory syncytial virus was associated with a longer length of stay and with an increased frequency of oxygen and ventilatory support use. Treatment effect of inhaled adrenaline was not modified by virus type, load or coinfection. Discussion. In infants hospitalized with acute bronchiolitis, disease severity was not associated with specific viruses or the total number of viruses detected. A high RSV genomic load was associated with more-severe disease. Clinical Trials Registration. NCT00817466 and EudraCT 2009-012667-34.
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Affiliation(s)
- Håvard O Skjerven
- Institute of Clinical Medicine, University of Oslo Department of Pediatrics, Oslo University Hospital, Norway
| | - Spyridon Megremis
- Department of Allergy, 2nd Pediatric Clinic, University of Athens, Greece Centre for Pediatrics and Child Health, Institute of Human Development, University of Manchester, United Kingdom
| | - Nikolaos G Papadopoulos
- Department of Allergy, 2nd Pediatric Clinic, University of Athens, Greece Centre for Pediatrics and Child Health, Institute of Human Development, University of Manchester, United Kingdom
| | | | - Kai-Håkon Carlsen
- Institute of Clinical Medicine, University of Oslo Department of Pediatrics, Oslo University Hospital, Norway
| | - Karin C Lødrup Carlsen
- Institute of Clinical Medicine, University of Oslo Department of Pediatrics, Oslo University Hospital, Norway
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Abstract
BACKGROUND Bronchiolitis is the leading cause of hospitalisation among infants in high-income countries. Acute viral bronchiolitis is associated with airway obstruction and turbulent gas flow. Heliox, a mixture of oxygen and the inert gas helium, may improve gas flow through high-resistance airways and decrease the work of breathing. In this review, we selected trials that objectively assessed the effect of the addition of heliox to standard medical care for acute bronchiolitis. OBJECTIVES To assess heliox inhalation therapy in addition to standard medical care for acute bronchiolitis in infants with respiratory distress, as measured by clinical endpoints (in particular the rate of endotracheal intubation, the rate of emergency department discharge, the length of treatment for respiratory distress) and pulmonary function testing (mainly clinical respiratory scores). SEARCH METHODS We searched CENTRAL (2015, Issue 2), MEDLINE (1966 to March week 3, 2015), EMBASE (1974 to March 2015), LILACS (1982 to March 2015) and the National Institutes of Health (NIH) website (May 2009). SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs of heliox in infants with acute bronchiolitis. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed trial quality. MAIN RESULTS We included seven trials involving 447 infants younger than two years with respiratory distress secondary to viral bronchiolitis. All children were recruited from a paediatric intensive care unit (PICU; 378 infants), except in one trial (emergency department; 69 infants). All children were younger than two (under nine months in two trials and under three months in one trial). Positive tests for respiratory syncytial virus (RSV) were required for inclusion in five trials. The two other trials were carried out in the bronchiolitis seasons. Seven different protocols were used for inhalation therapy with heliox.When heliox was used in the PICU, we observed no significant reduction in the rate of intubation: risk ratio (RR) 2.73 (95% confidence interval (CI) 0.96 to 7.75, four trials, 408 infants, low quality evidence). When heliox inhalation was used in the emergency department, we observed no increase in the rate of discharge: RR 0.51 (95% CI 0.17 to 1.55, one trial, 69 infants, moderate quality evidence).There was no decrease in the length of treatment for respiratory distress: mean difference (MD) -0.19 days (95% CI -0.56 to 0.19, two trials, 320 infants, moderate quality evidence). However, in the subgroup of infants who were started on nasal continuous positive airway pressure (nCPAP) right from the start, because of severe respiratory distress, heliox therapy reduced the length of treatment: MD -0.76 days (95% CI -1.45 to -0.08, one trial, 21 infants, low quality evidence). No adverse events related to heliox inhalation were reported.We found that infants treated with heliox inhalation had a significantly lower mean clinical respiratory score in the first hour after starting treatment when compared to those treated with air or oxygen inhalation: MD -1.04 (95% CI -1.60 to -0.48, four trials, 138 infants, moderate quality evidence). This outcome had statistical heterogeneity, which remained even after removing the study using a standard high-concentration reservoir mask. Several factors may explain this heterogeneity, including first the limited number of patients in each trial, and the wide differences in the baseline severity of disease between studies, with the modified Wood Clinical Asthma Score (m-WCAS) in infants treated with heliox ranging from less than two to more than seven. AUTHORS' CONCLUSIONS Current evidence suggests that the addition of heliox therapy may significantly reduce a clinical score evaluating respiratory distress in the first hour after starting treatment in infants with acute RSV bronchiolitis. We noticed this beneficial effect regardless of which heliox inhalation protocol was used. Nevertheless, there was no reduction in the rate of intubation, in the rate of emergency department discharge, or in the length of treatment for respiratory distress. Heliox could reduce the length of treatment in infants requiring CPAP for severe respiratory distress. Further studies with homogeneous logistics in their heliox application are needed. Inclusion criteria must include a clinical severity score that reflects severe respiratory distress to avoid inclusion of children with mild bronchiolitis who may not benefit from heliox inhalation. Such studies would provide the necessary information as to the appropriate place for heliox in the therapeutic schedule for severe bronchiolitis.
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Affiliation(s)
- Jean‐Michel Liet
- Hôpital Mère‐Enfant, CHU de NantesPediatric Intensive Care Unit38 Boulevard Jean‐MonnetFaïencerieNantesFrance44093
| | | | - Vineet Gupta
- Moses Cone HospitalPediatric Critical Care Medicine1200 N. Elm StreetGreensboroNCUSA27401
| | - Gilles Cambonie
- Hôpital Arnaud de VilleneuveService de Réanimation Pédiatrique et Néonatale, Pédiatrie II371 av du Doyen Gaston GiraudMontpellier CEDEX 5France34295
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Cunningham S, Rodriguez A, Adams T, Boyd KA, Butcher I, Enderby B, MacLean M, McCormick J, Paton JY, Wee F, Thomas H, Riding K, Turner SW, Williams C, McIntosh E, Lewis SC. Oxygen saturation targets in infants with bronchiolitis (BIDS): a double-blind, randomised, equivalence trial. Lancet 2015; 386:1041-8. [PMID: 26382998 PMCID: PMC4673090 DOI: 10.1016/s0140-6736(15)00163-4] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The American Academy of Pediatrics recommends a permissive hypoxaemic target for an oxygen saturation of 90% for children with bronchiolitis, which is consistent with the WHO recommendations for targets in children with lower respiratory tract infections. No evidence exists to support this threshold. We aimed to assess whether the 90% or higher target for management of oxygen supplementation was equivalent to a normoxic 94% or higher target for infants admitted to hospital with viral bronchiolitis. METHODS We did a parallel-group, randomised, controlled, equivalence trial of infants aged 6 weeks to 12 months of age with physician-diagnosed bronchiolitis newly admitted into eight paediatric hospital units in the UK (the Bronchiolitis of Infancy Discharge Study [BIDS]). A central computer randomly allocated (1:1) infants, in varying length blocks of four and six and without stratification, to be clipped to standard oximeters (patients treated with oxygen if pulse oxygen saturation [SpO2] <94%) or modified oximeters (displayed a measured value of 90% as 94%, therefore oxygen not given until SpO2 <90%). All parents, clinical staff, and outcome assessors were masked to allocation. The primary outcome was time to resolution of cough (prespecified equivalence limits of plus or minus 2 days) in the intention-to-treat population. This trial is registered with ISRCTN, number ISRCTN28405428. FINDINGS Between Oct 3, and March 30, 2012, and Oct 1, and March 29, 2013, we randomly assigned 308 infants to standard oximeters and 307 infants to modified oximeters. Cough resolved by 15·0 days (median) in both groups (95% CI for difference -1 to 2) and so oxygen thresholds were equivalent. We recorded 35 serious adverse events in 32 infants in the standard care group and 25 serious adverse events in 24 infants in the modified care group. In the standard care group, eight infants transferred to a high-dependency unit, 23 were readmitted, and one had a prolonged hospital stay. In the modified care group, 12 infants were transferred to a high-dependency unit and 12 were readmitted to hospital. Recorded adverse events did not differ significantly. INTERPRETATION Management of infants with bronchiolitis to an oxygen saturation target of 90% or higher is as safe and clinically effective as one of 94% or higher. Future research should assess the benefits and risks of different oxygen saturation targets in acute respiratory infection in older children, particularly in developing nations where resources are scarce. FUNDING National Institute for Health Research, Health Technology Assessment programme.
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Affiliation(s)
- Steve Cunningham
- Department of Child Life and Health, University of Edinburgh, Edinburgh, UK.
| | - Aryelly Rodriguez
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Tim Adams
- Department of Paediatrics, Crosshouse Hospital, Kilmarnock, UK
| | - Kathleen A Boyd
- Health Economics & Health Technology Assessment, Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Isabella Butcher
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Morag MacLean
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Jonathan McCormick
- Department of Paediatrics, Ninewells Hospital and Medical School, Dundee, UK
| | - James Y Paton
- School of Medicine, University of Glasgow, Glasgow, UK
| | - Fiona Wee
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Huw Thomas
- Department of Respiratory Medicine, Bristol Children's Hospital, Bristol, UK
| | - Kay Riding
- Department of Child Life and Health, University of Edinburgh, Edinburgh, UK
| | | | | | - Emma McIntosh
- Health Economics & Health Technology Assessment, Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Steff C Lewis
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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Skjerven HO, Rolfsjord LB, Berents TL, Engen H, Dizdarevic E, Midgaard C, Kvenshagen B, Aas MH, Hunderi JOG, Stensby Bains KE, Mowinckel P, Carlsen KH, Lødrup Carlsen KC. Allergic diseases and the effect of inhaled epinephrine in children with acute bronchiolitis: follow-up from the randomised, controlled, double-blind, Bronchiolitis ALL trial. THE LANCET RESPIRATORY MEDICINE 2015; 3:702-708. [PMID: 26321593 DOI: 10.1016/s2213-2600(15)00319-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 08/03/2015] [Accepted: 08/03/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Although use of inhaled bronchodilators in infants with acute bronchiolitis is not supported by evidence-based guidelines, it is often justified by the belief in a subgroup effect in individuals developing atopic disease. We aimed to assess if inhaled epinephrine during acute bronchiolitis in infancy would benefit patients with later recurrent bronchial obstruction, atopic eczema, or allergic sensitisation. METHODS In the randomised, double-blind, multicentre Bronchiolitis ALL trial, 404 infants with moderate-to-severe acute bronchiolitis were recruited from eight hospitals in Norway to receive either inhaled epinephrine or saline up to every second hour throughout the hospital stay. Randomisation was done centrally, and the two study medications (20 mg/mL racemic epinephrine or 0.9% saline) were prepared in identical bottles. The dose given depended on the infant's weight: 0.10 mL, less than 5 kg; 0.15 mL, 5-6.9 kg; 0.2 mL, 7-9.9 kg; and 0.25 mL, 10 kg or more; all dissolved in 2 mL of 0.9% saline before nebulisation. The primary outcome was the length of hospital stay. In this follow-up study, 294 children were reinvestigated at 2 years of age with an interview, a clinical examination, and a skin prick test for 17 allergens, determining bronchial obstruction, atopic eczema, and allergic sensitisation, on which subgroup analyses were done. Analyses were done by intention to treat. The trial has been completed and is registered at ClinicalTrials.gov (number NCT00817466) and EUDRACT (number 2009-012667-34). FINDINGS Length of stay did not differ between patients who received inhaled epinephrine versus saline in the subgroup of infants who developed recurrent bronchial obstruction by age 2 years (143 [48.6%] of 294 patients; p(interaction)=0.40). However, the presence of atopic eczema or allergic sensitisation by the age of 2 years (n=77) significantly interacted with the treatment effect of inhaled epinephrine (p(interaction)=0.02); the length of stay (mean 80.3 h, 95% CI 72.8-87.9) was significantly shorter in patients receiving inhaled epinephrine versus saline in patients without allergic sensitisation or atopic eczema by 2 years (-19.9 h, -33.1 to -6.3; p=0.003). No significant differences were found in length of hospital stay in response to epinephrine or saline in children with atopic eczema or allergic sensitisation by 2 years (+16.2 h, -11.0 to 43.3; p=0.24). INTERPRETATION Contrary to our hypothesis, hospital length of stay for bronchiolitis was not reduced by administration of inhaled epinephrine in infants who subsequently developed atopic eczema, allergic sensitisation, or recurrent bronchial obstruction. The present study does not support an individual trial of inhaled epinephrine in acute bronchiolitis in children with increased risk of allergic diseases. FUNDING Medicines for Children Network, Norway.
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Affiliation(s)
- Håvard Ove Skjerven
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Pediatrics, Oslo University Hospital, Oslo, Norway.
| | - Leif Bjarte Rolfsjord
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Pediatrics, Innlandet Hospital Trust, Elverum, Norway
| | - Teresa Løvold Berents
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Dermatology, Oslo University Hospital, Oslo, Norway
| | - Hanne Engen
- Department of Pediatrics, Telemark Hospital Trust, Skien, Norway
| | - Edin Dizdarevic
- Department of Pediatrics, Sørlandet Hospital Trust, Kristiansand, Norway
| | | | - Bente Kvenshagen
- Department of Pediatrics, Østfold Hospital Trust, Fredrikstad, Norway
| | | | - Jon Olav Gjengstø Hunderi
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Pediatrics, Oslo University Hospital, Oslo, Norway; Department of Pediatrics, Østfold Hospital Trust, Fredrikstad, Norway
| | - Karen Eline Stensby Bains
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Pediatrics, Oslo University Hospital, Oslo, Norway
| | - Petter Mowinckel
- Department of Pediatrics, Oslo University Hospital, Oslo, Norway
| | - Kai-Håkon Carlsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Pediatrics, Oslo University Hospital, Oslo, Norway
| | - Karin C Lødrup Carlsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Pediatrics, Oslo University Hospital, Oslo, Norway
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66
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Inhaled epinephrine does not shorten hospital stay for infants with bronchiolitis destined to develop repeated bronchospasm. THE LANCET RESPIRATORY MEDICINE 2015; 3:665-667. [PMID: 26321594 DOI: 10.1016/s2213-2600(15)00333-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 08/18/2015] [Indexed: 11/23/2022]
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Berents TL, Carlsen KCL, Mowinckel P, Skjerven HO, Kvenshagen B, Rolfsjord LB, Bradley M, Lieden A, Carlsen KH, Gaustad P, Gjersvik P. Skin Barrier Function and Staphylococcus aureus Colonization in Vestibulum Nasi and Fauces in Healthy Infants and Infants with Eczema: A Population-Based Cohort Study. PLoS One 2015; 10:e0130145. [PMID: 26070153 PMCID: PMC4466520 DOI: 10.1371/journal.pone.0130145] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 05/18/2015] [Indexed: 01/08/2023] Open
Abstract
Atopic eczema (AE) is associated with Staphylococcus aureus (S. aureus) colonization and skin barrier dysfunction, often measured by increased transepidermal water loss (TEWL). In the present study, the primary aim was to see whether S. aureus colonization in the vestibulum nasi and/or fauces was associated with increased TEWL in infants with healthy skin and infants with eczema. Secondarily, we aimed to investigate whether TEWL measurements on non-lesional skin on the lateral upper arm is equivalent to volar forearm in infants. In 167 of 240 infants, recruited from the general population, TEWL measurements on the lateral upper arm and volar forearm, using a DermaLab USB, fulfilled our environmental requirements. The mean of three TEWL measurements from each site was used for analysis. The infants were diagnosed with no eczema (n = 110), possible AE (n = 28) or AE (n = 29). DNA samples were analysed for mutations in the filaggrin gene (FLG). Bacterial cultures were reported positive with the identification of at least one culture with S. aureus from vestibulum nasi and/or fauces. S. aureus colonization, found in 89 infants (53%), was not associated with increased TEWL (i.e. TEWL in the upper quartile), neither on the lateral upper arm or volar forearm (p = 0.08 and p = 0.98, respectively), nor with AE (p = 0.10) or FLG mutation (p = 0.17). TEWL was significantly higher on both measuring sites in infants with AE compared to infants with possible AE and no eczema. FLG mutation was significantly associated with increased TEWL, with a 47% difference in TEWL. We conclude that S. aureus in vestibulum nasi and/or fauces was not associated with TEWL, whereas TEWL measurements on the lateral upper arm and volar forearm appear equally appropriate in infants.
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Affiliation(s)
- Teresa Løvold Berents
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Dermatology, Oslo University Hospital, Oslo, Norway
- * E-mail:
| | - Karin Cecilie Lødrup Carlsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pediatrics, Oslo University Hospital, Oslo, Norway
| | - Petter Mowinckel
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pediatrics, Oslo University Hospital, Oslo, Norway
| | - Håvard Ove Skjerven
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pediatrics, Oslo University Hospital, Oslo, Norway
| | | | - Leif Bjarte Rolfsjord
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pediatrics, Innlandet Hospital Trust, Elverum, Norway
| | - Maria Bradley
- Department of Molecular Medicine, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
- Department of Dermatology, Karolinska University Hospital, Stockholm, Sweden
| | - Agne Lieden
- Department of Molecular Medicine, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
| | - Kai-Håkon Carlsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pediatrics, Oslo University Hospital, Oslo, Norway
| | - Peter Gaustad
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Microbiology, Oslo University Hospital, Oslo, Norway
| | - Petter Gjersvik
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Dermatology, Oslo University Hospital, Oslo, Norway
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68
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Quinonez RA, Schroeder AR. Safely doing less and the new AAP bronchiolitis guideline. Pediatrics 2015; 135:793-5. [PMID: 25847807 DOI: 10.1542/peds.2014-3703] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2014] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ricardo A Quinonez
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Children's Hospital of San Antonio, San Antonio, Texas; and
| | - Alan R Schroeder
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, California
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Abstract
Infections caused by viruses are universal during childhood and adolescence. Clinicians will regularly care for children and adolescents who present with infections caused by a wide number of viral pathogens. These infections have varied presentations. Many infections may have clinical presentations that are specific to the infecting virus but present differently, based on the age and immunocompetence of the patient. Some children are directly impacted early in their lives when maternal disease results in an in utero infection (cytomegalovirus, rubella virus, or parvovirus B19). Other viruses may infect children in a predictable pattern as they grow older (rhinovirus or influenza virus). Fortunately, many viral infections frequently encountered in the past are no longer extant due to widespread immunization efforts. Recognition of these vaccine-preventable infections is important because outbreaks of some of these diseases (mumps or measles) continue to occur in the United States. Vigilance in vaccine programs against these viral agents can prevent their re-emergence. In addition, an increasing number of viral infections (herpes simplex virus, influenza virus, varicella zoster virus, or cytomegalovirus) can now be successfully treated with antiviral medications. Most viral infections in children result in self-limited illness and are treated symptomatically and infected children experience full recovery. This review will address the epidemiology, clinical presentation, diagnosis, treatment, and prevention of viral infections commonly encountered by the clinician.
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70
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Rolfsjord LB, Skjerven HO, Bakkeheim E, Carlsen K, Hunderi JOG, Kvenshagen BK, Mowinckel P, Lødrup Carlsen KC. Children hospitalised with bronchiolitis in the first year of life have a lower quality of life nine months later. Acta Paediatr 2015; 104:53-8. [PMID: 25169812 DOI: 10.1111/apa.12792] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 06/20/2014] [Accepted: 08/25/2014] [Indexed: 11/30/2022]
Abstract
AIM Acute bronchiolitis increases the risk of asthma, and reduced quality of life (QoL) is reported in children with asthma and allergy. However, the impact of asthma risk factors on QoL is unclear. This study investigated whether bronchiolitis and common asthma risk factors in infancy had an influence on later QoL. METHODS The parents of 209 infants recruited during hospitalisation for bronchiolitis at a mean age of 4 months, and 206 controls responded to the generic Infant Toddler Quality of Life Questionnaire 9 months later. We used robust regression analyses to assess the association between four asthma risk factors, atopic eczema, parental asthma, parental allergic rhinoconjunctivitis and second-hand smoke and QoL in the two groups. RESULTS QoL was lower among children with previous bronchiolitis in the overall health and general health domains and lower in six of 13 domains in children with atopic eczema. Compared with no risk factors, children with previous bronchiolitis and three risk factors had lower scores in four domains, and control children with three risk factors had lower scores in three domains. CONCLUSION Having acute bronchiolitis, atopic eczema and three asthma risk factors were negatively associated with later QoL in early childhood.
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Affiliation(s)
- Leif Bjarte Rolfsjord
- Department of Paediatrics Innlandet Hospital Trust Elverum Norway
- Department of Paediatrics Oslo University Hospital Oslo Norway
- Faculty of Medicine Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Håvard Ove Skjerven
- Department of Paediatrics Oslo University Hospital Oslo Norway
- Faculty of Medicine Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Egil Bakkeheim
- Department of Paediatrics Oslo University Hospital Oslo Norway
| | - Kai‐Håkon Carlsen
- Department of Paediatrics Oslo University Hospital Oslo Norway
- Faculty of Medicine Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Jon Olav Gjengstø Hunderi
- Department of Paediatrics Oslo University Hospital Oslo Norway
- Faculty of Medicine Institute of Clinical Medicine University of Oslo Oslo Norway
| | | | | | - Karin C. Lødrup Carlsen
- Department of Paediatrics Oslo University Hospital Oslo Norway
- Faculty of Medicine Institute of Clinical Medicine University of Oslo Oslo Norway
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Chen YJ, Lee WL, Wang CM, Chou HH. Nebulized hypertonic saline treatment reduces both rate and duration of hospitalization for acute bronchiolitis in infants: an updated meta-analysis. Pediatr Neonatol 2014; 55:431-8. [PMID: 24461195 DOI: 10.1016/j.pedneo.2013.09.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 08/19/2013] [Accepted: 09/03/2013] [Indexed: 11/18/2022] Open
Abstract
Nebulized hypertonic saline (HS) treatment reduced the length of hospitalization in infants with acute bronchiolitis in a previous meta-analysis. However, there was no reduction in the admission rate. We hypothesized that nebulized HS treatment might significantly decrease both the duration and the rate of hospitalization if more randomized controlled trials (RCTs) were included. We searched MEDLINE, PubMed, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL) without a language restriction. A meta-analysis was performed based on the efficacy of nebulized HS treatment in infants with acute bronchiolitis. We used weighted mean difference (WMD) and risk ratio as effect size metrics. Eleven studies were identified that enrolled 1070 infants. Nebulized HS treatment significantly decreased the duration and rate of hospitalization compared with nebulized normal saline (NS) [duration of hospitalization: WMD = -0.96, 95% confidence interval (CI) = -1.38 to -0.54, p < 0.001; rate of hospitalization: risk ratio = 0.59, 95% CI = 0.37-0.93, p = 0.02]. Furthermore, nebulized HS treatment had a beneficial effect in reducing the clinical severity (CS) score of acute bronchiolitis infants post-treatment (Day 1: WMD = -0.77, 95% CI = -1.30 to -0.24, p = 0.005; Day 2: WMD = -0.85, 95% CI = -1.30 to -0.39, p < 0.001; Day 3: WMD = -1.14, 95% CI = -1.69 to -0.58, p < 0.001). There was no decrease in the rate of readmission (risk ratio = 1.08, 95% CI = 0.68-1.73, p = 0.74). Nebulized HS treatment significantly decreased both the rate and the duration of hospitalization. Due to the efficacy and cost-effectiveness, HS should be considered for the treatment of acute bronchiolitis in infants.
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Affiliation(s)
- Yen-Ju Chen
- Department of Pediatrics, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Wen-Li Lee
- Department of Pediatrics, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Chuang-Ming Wang
- Department of Pediatrics, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Hsin-Hsu Chou
- Department of Pediatrics, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan.
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Ravaglia C, Poletti V. Recent advances in the management of acute bronchiolitis. F1000PRIME REPORTS 2014; 6:103. [PMID: 25580257 PMCID: PMC4229723 DOI: 10.12703/p6-103] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute bronchiolitis is characterized by acute wheezing in infants or children and is associated with signs or symptoms of respiratory infection; it is rarely symptomatic in adults and the most common etiologic agent is respiratory syncytial virus (RSV). Usually it does not require investigation, treatment is merely supportive and a conservative approach seems adequate in the majority of children, especially for the youngest ones (<3 months); however, clinical scoring systems have been proposed and admission in hospital should be arranged in case of severe disease or a very young age or important comorbidities. Apnea is a very important aspect of the management of young infants with bronchiolitis. This review focuses on the clinical, radiographic, and pathologic characteristics, as well as the recent advances in management of acute bronchiolitis.
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Affiliation(s)
- Claudia Ravaglia
- Pulmonology Unit, Department of Thoracic DiseasesGB Pierantoni - L Morgagni Hospital, via C. Forlanini 34, 47100 ForlìItaly
| | - Venerino Poletti
- Pulmonology Unit, Department of Thoracic DiseasesGB Pierantoni - L Morgagni Hospital, via C. Forlanini 34, 47100 ForlìItaly
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Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM, Johnson DW, Light MJ, Maraqa NF, Mendonca EA, Phelan KJ, Zorc JJ, Stanko-Lopp D, Brown MA, Nathanson I, Rosenblum E, Sayles S, Hernandez-Cancio S. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics 2014; 134:e1474-502. [PMID: 25349312 DOI: 10.1542/peds.2014-2742] [Citation(s) in RCA: 1076] [Impact Index Per Article: 107.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
This guideline is a revision of the clinical practice guideline, "Diagnosis and Management of Bronchiolitis," published by the American Academy of Pediatrics in 2006. The guideline applies to children from 1 through 23 months of age. Other exclusions are noted. Each key action statement indicates level of evidence, benefit-harm relationship, and level of recommendation. Key action statements are as follows:
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74
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Baraldi E, Lanari M, Manzoni P, Rossi GA, Vandini S, Rimini A, Romagnoli C, Colonna P, Biondi A, Biban P, Chiamenti G, Bernardini R, Picca M, Cappa M, Magazzù G, Catassi C, Urbino AF, Memo L, Donzelli G, Minetti C, Paravati F, Di Mauro G, Festini F, Esposito S, Corsello G. Inter-society consensus document on treatment and prevention of bronchiolitis in newborns and infants. Ital J Pediatr 2014; 40:65. [PMID: 25344148 PMCID: PMC4364570 DOI: 10.1186/1824-7288-40-65] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 04/18/2014] [Indexed: 01/14/2023] Open
Abstract
Acute bronchiolitis is the leading cause of lower respiratory tract infection and hospitalization in children less than 1 year of age worldwide. It is usually a mild disease, but some children may develop severe symptoms, requiring hospital admission and ventilatory support in the ICU. Infants with pre-existing risk factors (prematurity, bronchopulmonary dysplasia, congenital heart diseases and immunodeficiency) may be predisposed to a severe form of the disease. Clinical diagnosis of bronchiolitis is manly based on medical history and physical examination (rhinorrhea, cough, crackles, wheezing and signs of respiratory distress). Etiological diagnosis, with antigen or genome detection to identify viruses involved, may have a role in reducing hospital transmission of the infection. Criteria for hospitalization include low oxygen saturation (<90-92%), moderate-to-severe respiratory distress, dehydration and presence of apnea. Children with pre-existing risk factors should be carefully assessed.To date, there is no specific treatment for viral bronchiolitis, and the mainstay of therapy is supportive care. This consists of nasal suctioning and nebulized 3% hypertonic saline, assisted feeding and hydration, humidified O2 delivery. The possible role of any pharmacological approach is still debated, and till now there is no evidence to support the use of bronchodilators, corticosteroids, chest physiotherapy, antibiotics or antivirals. Nebulized adrenaline may be sometimes useful in the emergency room. Nebulized adrenaline can be useful in the hospital setting for treatment as needed. Lacking a specific etiological treatment, prophylaxis and prevention, especially in children at high risk of severe infection, have a fundamental role. Environmental preventive measures minimize viral transmission in hospital, in the outpatient setting and at home. Pharmacological prophylaxis with palivizumab for RSV bronchiolitis is indicated in specific categories of children at risk during the epidemic period. Viral bronchiolitis, especially in the case of severe form, may correlate with an increased incidence of recurrent wheezing in pre-schooled children and with asthma at school age.The aim of this document is to provide a multidisciplinary update on the current recommendations for the management and prevention of bronchiolitis, in order to share useful indications, identify gaps in knowledge and drive future research.
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Affiliation(s)
- Eugenio Baraldi
- />SIMRI-Società Italiana per le Malattie Respiratorie Infantili, Kragujevac, Italy
- />Women’s and Children’s Health Department, Unit of Pediatric Respiratory Medicine and Allergy, University of Padova, Via Giustiniani 3, 35128 Padova, Italy
| | | | - Paolo Manzoni
- />SIN-Società Italiana di Neonatologia, Kragujevac, Italy
| | - Giovanni A Rossi
- />SIMRI-Società Italiana per le Malattie Respiratorie Infantili, Kragujevac, Italy
| | - Silvia Vandini
- />SIN-Società Italiana di Neonatologia, Kragujevac, Italy
| | - Alessandro Rimini
- />SICP-Società Italiana di Cardiologia Pediatrica, Kragujevac, Italy
| | | | - Pierluigi Colonna
- />SICP-Società Italiana di Cardiologia Pediatrica, Kragujevac, Italy
| | - Andrea Biondi
- />AIEOP - Società Italiana di Ematologia e Oncologia Pediatrica, Kragujevac, Italy
| | - Paolo Biban
- />AMIETIP - Accademia Medica Infermieristica di Emergenza e Terapia Intensiva Pediatrica, Kragujevac, Italy
| | | | - Roberto Bernardini
- />SIAIP - Società Italiana di Allergologia e Immunologia Pediatrica, Kragujevac, Italy
| | - Marina Picca
- />SICuPP - Società Italiana delle Cure Primarie Pediatriche, Kragujevac, Italy
| | - Marco Cappa
- />SIEDP - Società Italiana di Endocrinologia e Diabetologia Pediatrica, Kragujevac, Italy
| | - Giuseppe Magazzù
- />SIFC - Società Italiana per lo studio della Fibrosi Cistica, Kragujevac, Italy
| | - Carlo Catassi
- />SIGENP - Società Italiana Gastroenterologia Epatologia e Nutrizione Pediatrica, Kragujevac, Italy
| | | | - Luigi Memo
- />SIMGePeD - Società Italiana Malattie Genetiche Pediatriche e Disabilità Congenite, Kragujevac, Italy
| | | | - Carlo Minetti
- />SINP - Società Italiana di Neurologia Pediatrica, Kragujevac, Italy
| | | | - Giuseppe Di Mauro
- />SIPPS - Società Italiana di Pediatria Preventiva e Sociale, Kragujevac, Italy
| | - Filippo Festini
- />SISIP - Società Italiana di Scienze Infermieristiche Pediatriche, Kragujevac, Italy
| | - Susanna Esposito
- />SITIP - Società Italiana di Infettivologia Pediatrica, Kragujevac, Italy
| | | | - on behalf of their respective Scientific Pediatric Societies
- />SIMRI-Società Italiana per le Malattie Respiratorie Infantili, Kragujevac, Italy
- />Women’s and Children’s Health Department, Unit of Pediatric Respiratory Medicine and Allergy, University of Padova, Via Giustiniani 3, 35128 Padova, Italy
- />SIN-Società Italiana di Neonatologia, Kragujevac, Italy
- />SICP-Società Italiana di Cardiologia Pediatrica, Kragujevac, Italy
- />AIEOP - Società Italiana di Ematologia e Oncologia Pediatrica, Kragujevac, Italy
- />AMIETIP - Accademia Medica Infermieristica di Emergenza e Terapia Intensiva Pediatrica, Kragujevac, Italy
- />FIMP - Federazione Italiana Medici Pediatri, Kragujevac, Italy
- />SIAIP - Società Italiana di Allergologia e Immunologia Pediatrica, Kragujevac, Italy
- />SICuPP - Società Italiana delle Cure Primarie Pediatriche, Kragujevac, Italy
- />SIEDP - Società Italiana di Endocrinologia e Diabetologia Pediatrica, Kragujevac, Italy
- />SIFC - Società Italiana per lo studio della Fibrosi Cistica, Kragujevac, Italy
- />SIGENP - Società Italiana Gastroenterologia Epatologia e Nutrizione Pediatrica, Kragujevac, Italy
- />SIMEUP - Società Italiana di Medicina di Emergenza ed Urgenza Pediatrica, Kragujevac, Italy
- />SIMGePeD - Società Italiana Malattie Genetiche Pediatriche e Disabilità Congenite, Kragujevac, Italy
- />SIMP - Società Italiana di Medicina Perinatale, Kragujevac, Italy
- />SINP - Società Italiana di Neurologia Pediatrica, Kragujevac, Italy
- />SIPO - Società Italiana Pediatria Ospedaliera, Kragujevac, Italy
- />SIPPS - Società Italiana di Pediatria Preventiva e Sociale, Kragujevac, Italy
- />SISIP - Società Italiana di Scienze Infermieristiche Pediatriche, Kragujevac, Italy
- />SITIP - Società Italiana di Infettivologia Pediatrica, Kragujevac, Italy
- />SIP-Società Italiana di Pediatria, Kragujevac, Italy
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Mecklin M, Hesselmar B, Qvist E, Wennergren G, Korppi M. Diagnosis and treatment of bronchiolitis in Finnish and Swedish children's hospitals. Acta Paediatr 2014; 103:946-50. [PMID: 24773444 DOI: 10.1111/apa.12671] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 04/08/2014] [Accepted: 04/24/2014] [Indexed: 11/28/2022]
Abstract
AIM There is no widely accepted consensus on the diagnosis and treatment of bronchiolitis. This study describes current practices in Finnish and Swedish hospitals. METHODS A questionnaire on the diagnosis and treatment of bronchiolitis in children below 2 years of age was sent to all Finnish and Swedish hospitals providing inpatient care for children. All 22 Finnish hospitals answered, covering 100% of the <12-month-old population and 21 of the 37 Swedish hospitals responded, covering 74%. RESULTS The mean upper age limit for bronchiolitis was 12.7 months in Finnish hospitals and 12.5 months in Swedish hospitals. In both, laboured breathing, chest retractions and fine crackles were highlighted as the main clinical findings, followed by prolonged expiration. The mean value for the lowest acceptable saturation in room air was 94% in Finnish hospitals and 93% in Swedish hospitals. The most important factors influencing hospitalisation were young age, desaturation and inability to take oral fluids. Finnish doctors preferred intravenous routes, and Swedish doctors preferred nasogastric tubes for supplementary feeding. The first-line drug therapy was inhaled racemic adrenaline in Finland and inhaled levo-adrenaline in Sweden. CONCLUSION The diagnosis and treatment of bronchiolitis is fairly similar in Finnish and Swedish hospitals.
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Affiliation(s)
- Minna Mecklin
- Tampere Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Bill Hesselmar
- Department of Paediatrics; Queen Silvia Children's Hospital; University of Gothenburg; Gothenburg Sweden
| | - Erik Qvist
- Helsinki Children's Hospital; Helsinki University and University Hospital; Helsinki Finland
| | - Göran Wennergren
- Department of Paediatrics; Queen Silvia Children's Hospital; University of Gothenburg; Gothenburg Sweden
| | - Matti Korppi
- Tampere Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
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Abstract
PURPOSE OF REVIEW Bronchiolitis is a common condition in children less than 2 years of age and is a leading cause of infant hospitalization. Although there is significant variability in testing and treatment of children with bronchiolitis, diagnostic testing rarely improves care, and no currently available pharmacologic options have been proven to provide meaningful benefits or improve outcomes. RECENT FINDINGS Beta-agonists continue to be used frequently despite evidence that they do not reduce hospital admissions or length of stay. In general, therapies initially considered promising were subsequently proven ineffective, a pattern seen in studies on corticosteroids, and more recently with nebulized racemic epinephrine and hypertonic saline. Recent research has improved our understanding of the viral epidemiology of bronchiolitis, with increasing recognition of viruses other than respiratory syncytial virus and better awareness of the role of viral coinfections. How these findings will translate into improved outcomes remains uncertain. SUMMARY Much of the emphasis of the last few decades of bronchiolitis clinical care and research has centered on the identification and testing of novel therapies. Future quality improvement efforts should focus more on the limitation of unnecessary testing and treatments. Future research should include identification of subgroups of children with bronchiolitis that may benefit from focused clinical interventions.
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Affiliation(s)
- Alan R. Schroeder
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, CA
| | - Jonathan M. Mansbach
- Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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77
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Bronchiolite aiguë du nourrisson Les traitements sont-ils vraiment nécessaires ? État actuel et perspectives. Arch Pediatr 2014. [DOI: 10.1016/s0929-693x(14)71546-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Øymar K, Skjerven HO, Mikalsen IB. Acute bronchiolitis in infants, a review. Scand J Trauma Resusc Emerg Med 2014; 22:23. [PMID: 24694087 PMCID: PMC4230018 DOI: 10.1186/1757-7241-22-23] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 03/28/2014] [Indexed: 12/26/2022] Open
Abstract
Acute viral bronchiolitis is one of the most common medical emergency situations in infancy, and physicians caring for acutely ill children will regularly be faced with this condition. In this article we present a summary of the epidemiology, pathophysiology and diagnosis, and focus on guidelines for the treatment of bronchiolitis in infants. The cornerstones of the management of viral bronchiolitis are the administration of oxygen and appropriate fluid therapy, and overall a “minimal handling approach” is recommended. Inhaled adrenaline is commonly used in some countries, but the evidences are sparse. Recently, inhalation with hypertonic saline has been suggested as an optional treatment. When medical treatment fails to stabilize the infants, non-invasive and invasive ventilation may be necessary to prevent and support respiratory failure. It is important that relevant treatment algorithms exist, applicable to all levels of the treatment chain and reflecting local considerations and circumstances.
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Affiliation(s)
- Knut Øymar
- Department of Paediatrics, Stavanger University Hospital, PO Box 8100, N-4068 Stavanger, Norway.
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Valeur HS. Ikke nødvendig med adrenalin ved akutt bronkiolitt. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2013. [DOI: 10.4045/tidsskr.13.0739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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