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Bozzola E, Ciarlitto C, Guolo S, Brusco C, Cerone G, Antilici L, Schettini L, Piscitelli AL, Chiara Vittucci A, Cutrera R, Raponi M, Villani A. Respiratory Syncytial Virus Bronchiolitis in Infancy: The Acute Hospitalization Cost. Front Pediatr 2021; 8:594898. [PMID: 33537260 PMCID: PMC7848214 DOI: 10.3389/fped.2020.594898] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 12/14/2020] [Indexed: 01/09/2023] Open
Abstract
Introduction: Respiratory syncytial virus (RSV) bronchiolitis is among the leading causes of hospitalization in infants. Prophylaxis with palivizumab may reduce RSV infection, but its prescription is restricted to high-risk groups. The aim of the study is to retrospectively determine acute hospitalization costs of bronchiolitis. Materials and methods: Infants aged 1 month-1 year, admitted to Bambino Gesù Children Hospital, Rome, Italy, with a diagnosis of bronchiolitis from January 1 till December 31, 2017, were included in the study. Results: A total of 531 patients were enrolled in the study, and the mean age was 78.75 days. The main etiologic agent causing bronchiolitis was RSV, accounting for 58.38% of infections. The total cost of bronchiolitis hospitalization was 2,958,786 euros. The mean cost per patient was significantly higher in the case of RSV (5,753.43 ± 2,041.62 euros) compared to other etiology (5,395.15 ± 2,040.87 euros) (p = 0.04). Discussion: The study confirms the high hospitalization cost associated with bronchiolitis. In detail, in the case of RSV etiology, the cost was higher compared to other etiology, which is likely due to the longer hospitalization and the more frequent admission to the intensive cure department. Conclusion: This study highlights that bronchiolitis is an important cost item even in a tertiary hospital and that cost-effective interventions targeting RSV are increasingly urgent.
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Affiliation(s)
- Elena Bozzola
- Pediatric and Infectious Diseases Unit, Bambino Gesù Children Hospital, Rome, Italy
| | - Claudia Ciarlitto
- Pediatric and Infectious Diseases Unit, Bambino Gesù Children Hospital, Rome, Italy
| | - Stefano Guolo
- Sanitary Direction, Bambino Gesù Children Hospital, Rome, Italy
| | - Carla Brusco
- Sanitary Direction, Bambino Gesù Children Hospital, Rome, Italy
| | - Gennaro Cerone
- Sanitary Direction, Bambino Gesù Children Hospital, Rome, Italy
| | - Livia Antilici
- Pediatric and Infectious Diseases Unit, Bambino Gesù Children Hospital, Rome, Italy
| | - Livia Schettini
- Pediatric and Infectious Diseases Unit, Bambino Gesù Children Hospital, Rome, Italy
| | | | - Anna Chiara Vittucci
- Pediatric and Infectious Diseases Unit, Bambino Gesù Children Hospital, Rome, Italy
| | - Renato Cutrera
- Pneumology Unit, Bambino Gesù Children Hospital, Rome, Italy
| | | | - Alberto Villani
- Pediatric and Infectious Diseases Unit, Bambino Gesù Children Hospital, Rome, Italy
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Zamor R, Byczkowski T, Zhang Y, Vaughn L, Mahabee-Gittens EM. Language Barriers and the Management of Bronchiolitis in a Pediatric Emergency Department. Acad Pediatr 2020; 20:356-363. [PMID: 31981655 PMCID: PMC7102638 DOI: 10.1016/j.acap.2020.01.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/14/2020] [Accepted: 01/18/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Language barriers may influence the management of pediatric emergency department (PED) patients who may not align with evidence-based guidelines from the American Academy of Pediatrics. Our objective was to determine if a family's preferred language of Spanish versus English was associated with differences in management of bronchiolitis in the PED. METHODS We conducted a retrospective study of children ≤2 years old diagnosed with bronchiolitis in a PED over a 7-year period. Rates of PED testing, interventions, and disposition among children whose families' preferred language was Spanish were compared to children whose families' preferred language was English. Primary outcomes were frequencies of chest x-ray and bronchodilator orders. Secondary outcomes were diagnostic testing, medication orders, and disposition. Logistic regression was used to calculate adjusted odds ratios after controlling for age, emergency severity index, prior visit, and nesting within attending physicians. RESULTS A total of 13,612 encounters were included. Spanish-speaking families were more likely to have chest x-rays (35.8% vs 26.7%, P < .0001; adjusted odds ratio [aOR] 1.5; 95% confidence interval [CI] 1.2-1.9), complete blood counts (8.2% vs 4.9%, P < .005; aOR 1.7; 95% CI 1.2-2.5), and blood cultures ordered (8.1% vs 5.0%, P < .05; aOR 1.7; 95% CI 1.2-2.4). No other differences in bronchodilators, medication orders, or disposition were found between the 2 groups. CONCLUSIONS Among children diagnosed with bronchiolitis, Spanish-speaking families were more likely to have chest x-rays, complete blood counts, and blood cultures ordered compared to English-speaking families. Further research on how clinical practice guidelines and equity-focused guidelines can impact disparities in diagnostic testing within the PED is warranted.
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Affiliation(s)
- Ronine Zamor
- Department of Emergency Medicine, Cincinnati Children's Hospital and Medical Center (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio.
| | - Terri Byczkowski
- Department of Emergency Medicine, Cincinnati Children's Hospital and Medical Center (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio
| | - Yin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center (Y Zhang), Cincinnati, Ohio
| | - Lisa Vaughn
- Department of Emergency Medicine, Cincinnati Children's Hospital and Medical Center (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio
| | - E Melinda Mahabee-Gittens
- Department of Emergency Medicine, Cincinnati Children's Hospital and Medical Center (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine (R Zamor, T Byczkowski, L Vaughn, and EM Mahabee-Gittens), Cincinnati, Ohio
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Affiliation(s)
- Alyssa H Silver
- Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY
| | - Joanne M Nazif
- Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY
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Increased Use of Noninvasive Ventilation Associated With Decreased Use of Invasive Devices in Children With Bronchiolitis. Crit Care Explor 2019; 1:e0026. [PMID: 32166268 PMCID: PMC7063953 DOI: 10.1097/cce.0000000000000026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To assess how a change in practice to more frequent use of high-flow nasal cannula for the treatment of bronchiolitis would affect the use of invasive devices in children.
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Condella A, Mansbach JM, Hasegawa K, Dayan PS, Sullivan AF, Espinola JA, Camargo CA. Multicenter Study of Albuterol Use Among Infants Hospitalized with Bronchiolitis. West J Emerg Med 2018; 19:475-483. [PMID: 29760843 PMCID: PMC5942012 DOI: 10.5811/westjem.2018.3.35837] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 02/14/2018] [Accepted: 03/05/2018] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Although bronchiolitis is a common reason for infant hospitalization, significant heterogeneity persists in its management. The American Academy of Pediatrics currently recommends that inhaled albuterol not be used in routine care of children with bronchiolitis. Our objective was to identify factors associated with pre-admission (e.g., emergency department or primary care) use of albuterol among infants hospitalized for bronchiolitis. METHODS We analyzed data from a 17-center observational study of 1,016 infants (age <1 year) hospitalized with bronchiolitis between 2011-2014. Pre-admission albuterol use was ascertained by chart review, and data were available for 1,008 (99%) infants. We used multivariable logistic regression to identify infant characteristics independently associated with pre-admission albuterol use. RESULTS Half of the infants (n=508) received at least one albuterol treatment before admission. Across the 17 hospitals, pre-admission albuterol use ranged from 23-84%. In adjusted analysis, independent predictors of albuterol use were the following: age ≥2 months (age 2.0-5.9 months [odds ratio (OR) 2.09, 95% confidence interval (CI) {1.45-3.01}] and age 6.0-11.9 months [OR 2.89, 95% CI {1.99-4.19}]); prior use of a bronchodilator (OR 1.89, 95% CI [1.24-2.90]); and presence of wheezing documented in pre-admission chart (OR 3.94, 95% CI [2.61-5.93]). By contrast, albuterol use was less likely among those with ≥7 days since the start of breathing problem (OR 0.66, 95% CI [0.44-1.00]) and parent-reported fever (OR 0.75, 95% CI [0.58-0.96]). CONCLUSION Variation in pre-admission albuterol use suggests that local practice had a strong influence on use, but that patient characteristics also influenced the decision. While we agree with current guidelines in recommending against albuterol for all infants with bronchiolitis, our understanding of possible subgroups of responders may improve through investigation of infants with the identified characteristics.
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Affiliation(s)
- Anna Condella
- Columbia University College of Physicians and Surgeons, Division of Pediatric Emergency Medicine, Department of Pediatrics, New York, New York
| | - Jonathan M. Mansbach
- Harvard Medical School, Boston Children’s Hospital, Department of Medicine, Boston, Massachusetts
| | - Kohei Hasegawa
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Peter S. Dayan
- Columbia University College of Physicians and Surgeons, Division of Pediatric Emergency Medicine, Department of Pediatrics, New York, New York
| | - Ashley F. Sullivan
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Janice A. Espinola
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Carlos A. Camargo
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
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Mahant S, Wahi G, Giglia L, Pound C, Kanani R, Bayliss A, Roy M, Sakran M, Kozlowski N, Breen-Reid K, Lavigne M, Premji L, Moretti ME, Willan AR, Schuh S, Parkin PC. Intermittent versus continuous oxygen saturation monitoring for infants hospitalised with bronchiolitis: study protocol for a pragmatic randomised controlled trial. BMJ Open 2018; 8:e022707. [PMID: 29678995 PMCID: PMC5914772 DOI: 10.1136/bmjopen-2018-022707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 03/15/2018] [Accepted: 03/19/2018] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Bronchiolitis is the most common reason for hospitalisation in infants in developed countries. The main focus of hospital care is on supportive care, such as monitoring for hypoxia and supplemental oxygen administration, as active therapies lack effectiveness. Pulse oximetry is used to monitor hypoxia in hospitalised infants and is used either intermittently or continuously. Observational studies have suggested that continuous pulse oximetry use leads to a longer length of hospital stay in stable infants. The use of continuous pulse oximetry may lead to unnecessary clinical intervention due to readings that are of little clinical significance, false-positive readings and less reliance on the clinical status. There is a lack of high-quality evidence to guide which pulse oximetry monitoring strategy, intermittent or continuous, is superior in infants hospitalised with bronchiolitis with respect to patient and policy-relevant outcomes. METHODS AND ANALYSIS This is a multicentre, pragmatic randomised controlled trial comparing two strategies for pulse oximetry monitoring in infants hospitalised for bronchiolitis. Infants aged 1 month to 2 years presenting to Canadian tertiary and community hospitals will be randomised after stabilisation to receive either intermittent or continuous oxygen saturation monitoring on the inpatient unit until discharge. The primary outcome is length of hospital stay. Secondary outcomes include additional measures of effectiveness, acceptability, safety and cost. We will need to enrol 210 infants in order to detect a 12-hour difference in length of stay with a type 1 error rate of 5% and a power of 90%. ETHICS AND DISSEMINATION Research ethics approval has been obtained for this trial. This trial will provide data to guide hospitals and clinicians on the optimal pulse oximetry monitoring strategy in infants hospitalised with bronchiolitis. We will disseminate the findings of this study through peer-reviewed publication, professional societies and meetings. TRIAL REGISTRATION NUMBER NCT02947204.
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Affiliation(s)
- Sanjay Mahant
- Division of Paediatric Medicine, Paediatric Outcomes Research Team (PORT), Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Research Institute, Hospital for Sick Children, Hamilton, Ontario, Canada
| | - Gita Wahi
- Department of Pediatrics, Hamilton Health Sciences Centre, McMaster University, Hamilton, Ontario, Canada
| | - Lucy Giglia
- Department of Pediatrics, Hamilton Health Sciences Centre, McMaster University, Hamilton, Ontario, Canada
| | - Catherine Pound
- Department of Paediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Ronik Kanani
- Department of Paediatrics, North York General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ann Bayliss
- Trillium Health Partners, Department of Paediatrics, University of Toronto, Mississauga, Ontario, Canada
| | - Madan Roy
- Department of Pediatrics, Hamilton Health Sciences Centre, McMaster University, Hamilton, Ontario, Canada
| | - Mahmoud Sakran
- Department of Paediatrics, Queens University, Lakeridge Health, Oshawa, Ontario, Canada
| | | | - Karen Breen-Reid
- Interprofessional Education, Learning Institute, Hospital for Sick Children, Toronto, Ontario, Canada
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Mollie Lavigne
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Laila Premji
- Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Myla E Moretti
- Clinical Trials Unit-Ontario Child Health Support Unit, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Andrew R Willan
- Dalla Lana School of Public Health, Ontario Child Health Support Unit, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Suzanne Schuh
- Division of Emergency Medicine, Department of Paediatrics, University of Toronto Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Patricia C Parkin
- Division of Paediatric Medicine, Paediatric Outcomes Research Team (PORT), Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Research Institute, Hospital for Sick Children, Hamilton, Ontario, Canada
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Improving Prehospital Management of Children With Respiratory Distress. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Reducing unnecessary chest X-rays, antibiotics and bronchodilators through implementation of the NICE bronchiolitis guideline. Eur J Pediatr 2018; 177:47-51. [PMID: 29080051 DOI: 10.1007/s00431-017-3034-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 10/09/2017] [Accepted: 10/17/2017] [Indexed: 10/18/2022]
Abstract
UNLABELLED Chest X-rays (CXR), antibiotics and inhaled/nebulized therapy are overused in bronchiolitis, despite evidence-based guidelines suggesting supportive management only. This study investigates the effect of the implementation of the NICE bronchiolitis guideline in a secondary paediatric unit in England. We present a quality improvement project with a completed audit cycle (winter 2014-2015 and 2015-2016) pre- and post-implementation of the NICE bronchiolitis guideline. The educational intervention included sessions for raising awareness of appropriate and inappropriate management of bronchiolitis for both clinicians and nursing staff. As a result, the number of chest radiographs reduced fivefold (from 20 to 4% of patients, absolute reduction 16%), antibiotics reduced more than threefold (from 22 to 6% of patients, absolute reduction 16%) and inhaled/nebulised treatment up to twofold (from 30 to 16%, absolute reduction 14%). Overall NICE guideline compliance rose from 28 to 63%. CONCLUSION Implementation of the NICE bronchiolitis guideline supported by a simple educational intervention can effectively reduce the number of inappropriate chest radiographs and antibiotic prescribing in bronchiolitis, and enhance compliance with the NICE guideline. What is Known: • Bronchiolitis management in paediatric units in the UK is variable, with poor evidence for existing guidance. Best available evidence was compiled into the NICE guideline, aiming to standardize care. • Some evidence exists for the effectiveness of quality improvement approaches to improve the management of bronchiolitis. What is New: • NICE guidance can be effectively applied to a department using simple educational tools. • Effective NICE implementation reduces the rates of unnecessary chest radiograph and antibiotic administration for patients admitted with bronchiolitis in District General Hospitals.
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Flores-González JC, Matamala-Morillo MA, Rodríguez-Campoy P, Pérez-Guerrero JJ, Serrano-Moyano B, Comino-Vazquez P, Palma-Zambrano E, Bulo-Concellón R, Santos-Sánchez V, Lechuga-Sancho AM. Epinephrine Improves the Efficacy of Nebulized Hypertonic Saline in Moderate Bronchiolitis: A Randomised Clinical Trial. PLoS One 2015; 10:e0142847. [PMID: 26575036 PMCID: PMC4648584 DOI: 10.1371/journal.pone.0142847] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Accepted: 10/07/2015] [Indexed: 11/23/2022] Open
Abstract
Background and Aims There is no evidence that the epinephrine-3% hypertonic saline combination is more effective than 3% hypertonic saline alone for treating infants hospitalized with acute bronchiolitis. We evaluated the efficacy of nebulized epinephrine in 3% hypertonic saline. Patients and Methods We performed a randomized, double-blind, placebo-controlled clinical trial in 208 infants hospitalized with acute moderate bronchiolitis. Infants were randomly assigned to receive nebulized 3% hypertonic saline with either 3 mL of epinephrine or 3 mL of placebo, administered every four hours. The primary outcome measure was the length of hospital stay. Results A total of 185 infants were analyzed: 94 in the epinephrine plus 3% hypertonic saline group and 91 in the placebo plus 3% hypertonic saline group. Baseline demographic and clinical characteristics were similar in both groups. Length of hospital stay was significantly reduced in the epinephrine group as compared with the placebo group (3.94 ±1.88 days vs. 4.82 ±2.30 days, P = 0.011). Disease severity also decreased significantly earlier in the epinephrine group (P = 0.029 and P = 0.036 on days 3 and 5, respectively). Conclusions In our setting, nebulized epinephrine in 3% hypertonic saline significantly shortens hospital stay in hospitalized infants with acute moderate bronchiolitis compared to 3% hypertonic saline alone, and improves the clinical scores of severity from the third day of treatment, but not before. Trial Registration EudraCT 2009-016042-57
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Affiliation(s)
| | | | | | | | - Belén Serrano-Moyano
- Department of Clinical Pediatrics, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - Paloma Comino-Vazquez
- Department of Clinical Pediatrics, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | | | | | | | - Alfonso M. Lechuga-Sancho
- Department of Clinical Pediatrics, Hospital Universitario Puerta del Mar, Cádiz, Spain
- Department of Maternal and Child Health Care and Radiology, University of Cádiz, Cádiz, Spain
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Ozdogan S, Tabakci B, Demirel AS, Atli B, Besli GE, Kose G. The evaluation of risk factors for recurrent hospitalizations resulting from wheezing attacks in preschool children. Ital J Pediatr 2015; 41:91. [PMID: 26577276 PMCID: PMC4650256 DOI: 10.1186/s13052-015-0201-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 11/11/2015] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND We aimed to evaluate the risk factors in preschool children admitted to inpatient services with a diagnosis of recurrent attacks of wheezing. METHOD The medical files of 44 preschool children with 2 or more recurrent hospitalizations resulting from wheezing between November 2011 and January 2012 were retrospectively investigated. RESULTS There were 28 males (64 %) and 16 females. The median age was 14 months (2.0-50). The median numbers of previous wheezing attacks and hospitalizations were 4 (2-10) and 2 (2-8), respectively. Fourteen patients (32 %) had been treated for gastroesophageal reflux (GER). The previous and recent hospital evaluations were investigated. Bronchopulmonary dysplasia and anemia were significantly more common in patients with 3 or more hospitalizations for wheezing than in those with 2 hospitalizations (p = 0.010 and p < 0.001, respectively). A review of the cases with 3 or more hospitalizations revealed that a history of GER and anemia were significant risk factors. CONCLUSION Anemia and GER are risk factors for recurrent hospitalizations resulting from wheezing and should be treated. If the history and physical examination suggest asthma, inhaler therapy treatment should be administered, with other investigations planned for patients who do not respond to treatment as expected.
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Affiliation(s)
- Sebnem Ozdogan
- Sisli Hamidiye Etfal Research and Training Hospital, Istanbul, Turkey.
- Sinan Ercan Sok, Isiklar 1 Apt. No 34, Da: 23, 34742, Kozyataği, Istanbul, Turkey.
| | - Burcu Tabakci
- Sisli Hamidiye Etfal Research and Training Hospital, Istanbul, Turkey.
| | | | - Bilge Atli
- Sisli Hamidiye Etfal Research and Training Hospital, Istanbul, Turkey.
| | - Gulser Esen Besli
- Istanbul Medeniyet University, Faculty of Medicine, Goztepe, Turkey.
| | - Gulsen Kose
- Sisli Hamidiye Etfal Research and Training Hospital, Istanbul, Turkey.
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Everard ML, Hind D, Ugonna K, Freeman J, Bradburn M, Dixon S, Maguire C, Cantrill H, Alexander J, Lenney W, McNamara P, Elphick H, Chetcuti PA, Moya EF, Powell C, Garside JP, Chadha LK, Kurian M, Lehal RS, MacFarlane PI, Cooper CL, Cross E. Saline in acute bronchiolitis RCT and economic evaluation: hypertonic saline in acute bronchiolitis - randomised controlled trial and systematic review. Health Technol Assess 2015; 19:1-130. [PMID: 26295732 PMCID: PMC4781529 DOI: 10.3310/hta19660] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Acute bronchiolitis is the most common cause of hospitalisation in infancy. Supportive care and oxygen are the cornerstones of management. A Cochrane review concluded that the use of nebulised 3% hypertonic saline (HS) may significantly reduce the duration of hospitalisation. OBJECTIVE To test the hypothesis that HS reduces the time to when infants were assessed as being fit for discharge, defined as in air with saturations of > 92% for 6 hours, by 25%. DESIGN Parallel-group, pragmatic randomised controlled trial, cost-utility analysis and systematic review. SETTING Ten UK hospitals. PARTICIPANTS Infants with acute bronchiolitis requiring oxygen therapy were allocated within 4 hours of admission. INTERVENTIONS Supportive care with oxygen as required, minimal handling and fluid administration as appropriate to the severity of the disease, 3% nebulised HS every ± 6 hours. MAIN OUTCOME MEASURES The trial primary outcome was time until the infant met objective discharge criteria. Secondary end points included time to discharge and adverse events. The costs analysed related to length of stay (LoS), readmissions, nebulised saline and other NHS resource use. Quality-adjusted life-years (QALYs) were estimated using an existing utility decrement derived for hospitalisation in children, together with the time spent in hospital in the trial. DATA SOURCES We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and other databases from inception or from 2010 onwards, searched ClinicalTrials.gov and other registries and hand-searched Chest, Paediatrics and Journal of Paediatrics to January 2015. REVIEW METHODS We included randomised/quasi-randomised trials which compared HS versus saline (± adjunct treatment) or no treatment. We used a fixed-effects model to combine mean differences for LoS and assessed statistical heterogeneity using the I (2) statistic. RESULTS The trial randomised 158 infants to HS (n = 141 analysed) and 159 to standard care (n = 149 analysed). There was no difference between the two arms in the time to being declared fit for discharge [median 76.6 vs. 75.9 hours, hazard ratio (HR) 0.95, 95% confidence interval (CI) 0.75 to 1.20] or to actual discharge (median 88.5 vs. 88.7 hours, HR 0.97, 95% CI 0.76 to 1.23). There was no difference in adverse events. One infant developed bradycardia with desaturation associated with HS. Mean hospital costs were £2595 and £2727 for the control and intervention groups, respectively (p = 0.657). Incremental QALYs were 0.0000175 (p = 0.757). An incremental cost-effectiveness ratio of £7.6M per QALY gained was not appreciably altered by sensitivity analyses. The systematic review comprised 15 trials (n = 1922) including our own. HS reduced the mean LoS by -0.36 days (95% CI -0.50 to -0.22 days). High levels of heterogeneity (I (2) = 78%) indicate that the result should be treated cautiously. CONCLUSIONS In this trial, HS had no clinical benefit on LoS or readiness for discharge and was not a cost-effective treatment for acute bronchiolitis. Claims that HS achieves small reductions in LoS must be treated with scepticism. FUTURE WORK Well-powered randomised controlled trials of high-flow oxygen are needed. STUDY REGISTRATION This study is registered as NCT01469845 and CRD42014007569. FUNDING DETAILS This project was funded by the NIHR Health Technology Assessment (HTA) programme and will be published in full in Health Technology Assessment; Vol. 19, No. 66. See the HTA programme website for further project information.
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Affiliation(s)
- Mark L Everard
- School of Paediatrics and Child Health (SPACH), University of Western Australia, Perth, WA, Australia
| | - Daniel Hind
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Kelechi Ugonna
- Department of Respiratory Medicine, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Jennifer Freeman
- Division of Epidemiology & Biostatistics, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Mike Bradburn
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Simon Dixon
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Chin Maguire
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Hannah Cantrill
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John Alexander
- Children's Centre, Hospital of North Staffordshire NHS Trust, Stoke-on-Trent, UK
| | - Warren Lenney
- Institute for Science & Technology in Medicine, Keele University, Stoke-on-Trent, UK
| | - Paul McNamara
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Heather Elphick
- Department of Respiratory Medicine, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Philip Aj Chetcuti
- Children's Respiratory Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Eduardo F Moya
- Department of Paediatrics, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Colin Powell
- Department of Child Health, University Hospital of Wales, Cardiff, UK
| | - Jonathan P Garside
- Children's Outpatients, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, UK
| | - Lavleen Kumar Chadha
- Paediatrics, Doncaster and Bassetlaw Hospitals NHS Foundation Trust, Doncaster, UK
| | - Matthew Kurian
- Paediatrics, Doncaster and Bassetlaw Hospitals NHS Foundation Trust, Doncaster, UK
| | | | | | - Cindy L Cooper
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Cross
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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12
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Affiliation(s)
- Giovanni Piedimonte
- Cleveland Clinic Pediatric Institute, Cleveland, OH. Cleveland Clinic Children's Hospital for Rehabilitation, The Cleveland Clinic, Cleveland, OH
| | - Miriam K Perez
- Cleveland Clinic Pediatric Institute, Cleveland, OH. Department of Community Pediatrics, Independence Family Health Center, Independence, OH
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13
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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: 8] [Impact Index Per Article: 0.8] [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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14
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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: 112] [Impact Index Per Article: 11.2] [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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15
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Blanco-Reina E, Vega-Jiménez MA, Ocaña-Riola R, Márquez-Romero EI, Bellido-Estévez I. [Drug prescriptions study in the outpatient setting: assessment of off-label uses in children]. Aten Primaria 2014; 47:344-50. [PMID: 25443768 PMCID: PMC6983703 DOI: 10.1016/j.aprim.2014.07.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 07/28/2014] [Accepted: 07/30/2014] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVE to evaluate the prescription profile and to assess the off-label and unlicensed uses of medicines among non-hospitalised pediatric patients. DESIGN cross-sectional study. SETTING pediatric units in two urban health centers and general emergency room (Hospital Materno-Infantil, Málaga). MAIN MEASUREMENTS sociodemographics variables, reasons for consultation and information about therapeutic medications. The classification of prescriptions was established according to information requirements contained in the Summary of Products Characteristics (SPC). RESULTS A total of 388 children were included (a subsample of 105 treated in the emergency room). Four hundred sixty-two prescriptions (involving 74 different active ingredients) were evaluated. Each infant received and average of 1,7 drugs (95% CI: 1,6-1,9). The most prescribed medicines were ibuprofen, paracetamol, amoxicillin-clavulanate and budesonide. The therapeutic group with the greatest variety of drugs was the respiratory group. 27,4% (95% CI: 23,5-31) of prescriptions were off-label and the main cause was different age (60%; 95% CI: 54,1-63), followed by different dose (21,5%; 95% CI: 18-25), different indication (12%; 95% CI: 9,2-15) and different route of administration (7%; 95% CI: 5,4-10). CONCLUSIONS The rate of off-label uses presents intermediate figures. Around one third of the paediatric outpatients in our sample are exposed to at least one off-label or unlicensed prescription. We should, however, point out that such usage is based on scant official, quality information, although it is not necessarily incorrect. Evidence-based medicine should be encouraged to improve drug therapy in children, as well as following the rules on drugs in special situations.
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Affiliation(s)
- Encarnación Blanco-Reina
- Departamento de Farmacología y Pediatría, Facultad de Medicina, Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, España.
| | | | | | - Elisa Isabel Márquez-Romero
- Dispositivo de Cuidados Críticos y Urgencias, Distrito Sanitario de Málaga, Departamento de Farmacología y Pediatría, Facultad de Medicina, Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, España
| | - Inmaculada Bellido-Estévez
- Departamento de Farmacología y Pediatría, Facultad de Medicina, Universidad de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, España
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16
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Florin TA, Byczkowski T, Ruddy RM, Zorc JJ, Test M, Shah SS. Variation in the management of infants hospitalized for bronchiolitis persists after the 2006 American Academy of Pediatrics bronchiolitis guidelines. J Pediatr 2014; 165:786-92.e1. [PMID: 25015578 PMCID: PMC4177351 DOI: 10.1016/j.jpeds.2014.05.057] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 04/15/2014] [Accepted: 05/30/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe variation across US pediatric hospitals in the utilization of resources not recommended for routine use by the American Academy of Pediatrics guideline for infants hospitalized with bronchiolitis and to examine the association between resource utilization and disposition outcomes. STUDY DESIGN We conducted a cross-sectional study of infants ≤12 months hospitalized for bronchiolitis from 2007-2012 at 42 hospitals contributing data to the Pediatric Health Information System. Patients with asthma were excluded. The primary outcome was hospital-level variation in utilization of 5 resources not recommended for routine use: albuterol, racemic epinephrine, corticosteroids, chest radiography, and antibiotics. We also examined the association of resource utilization with length of stay (LOS) and readmission. RESULTS In total, 64,994 hospitalizations were analyzed. After adjustment for patient characteristics, albuterol (median, 52.4%; range, 3.5%-81%), racemic epinephrine (20.1%; 0.6%-78.8%), and chest radiography (54.9%; 24.1%-76.7%) had the greatest variation across hospitals. Utilization of albuterol, racemic epinephrine, and antibiotics did not change significantly over time compared with small decreases in corticosteroid (3.3%) and chest radiography (8.6%) use over the study period. Utilization of each resource was significantly associated with increased LOS without concomitant decreased odds of readmission. CONCLUSIONS Substantial use and variation in 5 resources not recommended for routine use by the American Academy of Pediatrics bronchiolitis guideline persists with increased utilization associated with increased LOS without the benefit of decreased readmission. Future work should focus on developing processes that can be widely disseminated and easily implemented to minimize unwarranted practice variation when evidence and guidelines exist.
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Affiliation(s)
- Todd A. Florin
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Terri Byczkowski
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Richard M. Ruddy
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Joseph J. Zorc
- Division of Emergency Medicine, the Children’s Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Matthew Test
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Samir S. Shah
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH,Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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17
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Schmiedl S, Fischer R, Ibáñez L, Fortuny J, Klungel OH, Reynolds R, Gerlach R, Tauscher M, Thürmann P, Hasford J, Rottenkolber M. Utilisation and off-label prescriptions of respiratory drugs in children. PLoS One 2014; 9:e105110. [PMID: 25180704 PMCID: PMC4152124 DOI: 10.1371/journal.pone.0105110] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 07/21/2014] [Indexed: 12/05/2022] Open
Abstract
Respiratory drugs are widely used in children to treat labeled and non-labeled indications but only some data are available quantifying comprehensively off-label usage. Thus, we aim to analyse drug utilisation and off-label prescribing of respiratory drugs focusing on age- and indication-related off-label use. Patients aged ≤18 years documented in the Bavarian Association of Statutory Health Insurance Physicians database (approx. 2 million children) between 2004 and 2008 were included in our study. Annual period prevalence rates (PPRs) per 10,000 children and the proportion of age- and indication-related off-label prescriptions were calculated and stratified by age and gender. Within the study period, highest PPRs were found for the fixed combination of clenbuterol/ambroxol (between 374–575 per 10,000 children) and the inhaled short acting beta-2-agonist salbutamol (between 378–527 per 10,000 children). Highest relative PPR increase was found for oral salbutamol (approx. 39-fold) whereas the most distinct decrease was found for oral long-acting beta-2-agonist clenbuterol (−97%). Compound classes most frequently involved in off-label prescribing were inhaled bronchodilative compounds (91,402; 37.3%) and oral beta-2-agonists (26,850; 22.5%). The highest absolute number of off-label prescriptions were found for inhaled salbutamol (n = 67,084; 42.0%) and oral clenbuterol/ambroxol (fixed combination, n = 18,897; 20.7%). Off-label prescribing due to indication was of much greater relevance than age-related off-label use. Most frequently, bronchodilative compounds were used off-label to treat respiratory tract infections. Highest off-label prescription rates were found in the youngest patients without relevant gender-related differences. Off-label prescribing of respiratory drugs is common especially in young children. Bronchodilative drugs were most frequently used off-label for treating acute bronchitis or upper respiratory tract infections underlining the essential need for a more rational prescribing in this area.
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Affiliation(s)
- Sven Schmiedl
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
- Philipp Klee-Institute for Clinical Pharmacology, HELIOS Clinic Wuppertal, Wuppertal, Germany
- * E-mail:
| | | | - Luisa Ibáñez
- Fundació Institut Català de Farmacologia, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Departament de Farmacologia, Terapèutica i Toxicologia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Olaf H. Klungel
- Utrecht Institute for Pharmaceutical Sciences, Division Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands
| | - Robert Reynolds
- Epidemiology, Pfizer, New York, New York, United States of America
| | - Roman Gerlach
- National Association of Statutory Health Insurance Physicians of Bavaria, Munich, Germany
| | - Martin Tauscher
- National Association of Statutory Health Insurance Physicians of Bavaria, Munich, Germany
| | - Petra Thürmann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
- Philipp Klee-Institute for Clinical Pharmacology, HELIOS Clinic Wuppertal, Wuppertal, Germany
| | - Joerg Hasford
- Institute for Medical Information Sciences, Biometry, and Epidemiology, Ludwig-Maximilians-Universitaet, Munich, Germany
| | - Marietta Rottenkolber
- Institute for Medical Information Sciences, Biometry, and Epidemiology, Ludwig-Maximilians-Universitaet, Munich, Germany
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18
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Kose M, Ozturk MA, Poyrazoğlu H, Elmas T, Ekinci D, Tubas F, Kurt T, Goktas MA. The efficacy of nebulized salbutamol, magnesium sulfate, and salbutamol/magnesium sulfate combination in moderate bronchiolitis. Eur J Pediatr 2014; 173:1157-60. [PMID: 24687251 DOI: 10.1007/s00431-014-2309-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 03/24/2014] [Accepted: 03/24/2014] [Indexed: 11/28/2022]
Abstract
UNLABELLED The aim of this paper is to compare the effect of nebulized magnesium sulfate to nebulized salbutamol and salbutamol/magnesium sulfate on successful discharge from the emergency department. A total of 56 infants were included in this double-blinded, prospective study. Infants were grouped according to the nebulized treatment they received: group 1-salbutamol/normal saline, group 2-magnesium sulfate and normal saline, and group 3-salbutamol plus magnesium sulfate. Heart beat, bronchiolitis, clinical severity scores (CSS), and oxygen saturation of the patients were determined before and after nebulization (0, 1, 4 h). The patients were monitored for adverse reactions. Post-treatment mean CSS results were significantly lower than pre-treatment scores in all groups at 4 h with no significant difference within groups. CSS scores were lower in the salbutamol/magnesium sulfate group when compared with the magnesium sulfate and salbutamol groups (3.4 (2.4-4.3), 4.7 (3.8-5.7), 4.0 (3.2-4.3)). CSS were significantly lower than those from the magnesium sulfate group. CONCLUSION Nebulized magnesium sulfate plus salbutamol may have additive effects for improving the short-term CSS.
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Affiliation(s)
- Mehmet Kose
- Department of Pediatric Pulmonology, Erciyes University Faculty of Medicine, Pediatric Pulmonology Unit, Kayseri, 38000, Turkey,
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19
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Abstract
Background Bronchiolitis is one of the major causes for hospital admissions in infants. Managing bronchiolitis, both in the outpatient and inpatient setting remains a challenge to the treating pediatrician. The effectiveness of various interventions used for infants with bronchiolitis remains unclear. Need and purpose To evaluate the evidence supporting the use of currently available treatment and preventive strategies for infants with bronchiolitis and to provide practical guidelines to the practitioners managing children with bronchiolitis. Methods A search of articles published on bronchiolitis was performed using PubMed. The areas of focus were diagnosis, treatment and prevention of bronchiolitis in children. Relevant information was extracted from English language studies published over the last 20 years. In addition, the Cochrane Database of Systematic Reviews was searched. Results and Conclusions Supportive care, comprising of taking care of oxygenation and hydration, remains the corner-stone of therapy in bronchiolitis. Pulse oximetry helps in guiding the need for oxygen administration. Several recent evidence-based reviews have suggested that bronchodilators or corticosteroids lack efficacy in bronchiolitis and should not be routinely used. A number of other novel therapies (such as nebulized hypertonic saline, heliox, CPAP, montelukast, surfactant, and inhaled furosemide) have been evaluated in clinical trials, and although most of them did not show any beneficial results, some like hypertonic saline, surfactant, CPAP have shown promising results.
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20
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Abstract
BACKGROUND Bronchiolitis is an acute, viral lower respiratory tract infection affecting infants and is sometimes treated with bronchodilators. OBJECTIVES To assess the effects of bronchodilators on clinical outcomes in infants (0 to 12 months) with acute bronchiolitis. SEARCH METHODS We searched CENTRAL 2013, Issue 12, MEDLINE (1966 to January Week 2, 2014) and EMBASE (1998 to January 2014). SELECTION CRITERIA Randomized controlled trials (RCTs) comparing bronchodilators (other than epinephrine) with placebo for bronchiolitis. DATA COLLECTION AND ANALYSIS Two authors assessed trial quality and extracted data. We obtained unpublished data from trial authors. MAIN RESULTS We included 30 trials (35 data sets) representing 1992 infants with bronchiolitis. In 11 inpatient and 10 outpatient studies, oxygen saturation did not improve with bronchodilators (mean difference (MD) -0.43, 95% confidence interval (CI) -0.92 to 0.06, n = 1242). Outpatient bronchodilator treatment did not reduce the rate of hospitalization (11.9% in bronchodilator group versus 15.9% in placebo group, odds ratio (OR) 0.75, 95% CI 0.46 to 1.21, n = 710). Inpatient bronchodilator treatment did not reduce the duration of hospitalization (MD 0.06, 95% CI -0.27 to 0.39, n = 349).Effect estimates for inpatients (MD -0.62, 95% CI -1.40 to 0.16) were slightly larger than for outpatients (MD -0.25, 95% CI -0.61 to 0.11) for oximetry. Oximetry outcomes showed significant heterogeneity (I(2) statistic = 81%). Including only studies with low risk of bias had little impact on the overall effect size of oximetry (MD -0.38, 95% CI -0.75 to 0.00) but results were close to statistical significance.In eight inpatient studies, there was no change in average clinical score (standardized MD (SMD) -0.14, 95% CI -0.41 to 0.12) with bronchodilators. In nine outpatient studies, the average clinical score decreased slightly with bronchodilators (SMD -0.42, 95% CI -0.79 to -0.06), a statistically significant finding of questionable clinical importance. The clinical score outcome showed significant heterogeneity (I(2) statistic = 73%). Including only studies with low risk of bias reduced the heterogeneity but had little impact on the overall effect size of average clinical score (SMD -0.22, 95% CI -0.41 to -0.03).Sub-analyses limited to nebulized albuterol or salbutamol among outpatients (nine studies) showed no effect on oxygen saturation (MD -0.19, 95% CI -0.59 to 0.21, n = 572), average clinical score (SMD -0.36, 95% CI -0.83 to 0.11, n = 532) or hospital admission after treatment (OR 0.77, 95% CI 0.44 to 1.33, n = 404).Adverse effects included tachycardia, oxygen desaturation and tremors. AUTHORS' CONCLUSIONS Bronchodilators such as albuterol or salbutamol do not improve oxygen saturation, do not reduce hospital admission after outpatient treatment, do not shorten the duration of hospitalization and do not reduce the time to resolution of illness at home. Given the adverse side effects and the expense associated with these treatments, bronchodilators are not effective in the routine management of bronchiolitis. This meta-analysis continues to be limited by the small sample sizes and the lack of standardized study design and validated outcomes across the studies. Future trials with large sample sizes, standardized methodology across clinical sites and consistent assessment methods are needed to answer completely the question of efficacy.
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Affiliation(s)
- Anne M Gadomski
- Bassett Medical CenterResearch Institute1 Atwell RoadCooperstownNew YorkUSA13326
| | - Melissa B Scribani
- Bassett Medical CenterComputing Center1 Atwell RoadCooperstownNew YorkUSA13326
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21
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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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22
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Beigelman A, Bacharier LB. Infection-induced wheezing in young children. J Allergy Clin Immunol 2014; 133:603-4. [PMID: 24636478 DOI: 10.1016/j.jaci.2013.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 11/26/2013] [Accepted: 12/04/2013] [Indexed: 11/17/2022]
Affiliation(s)
- Avraham Beigelman
- Department of Pediatrics, Washington University and St Louis Children's Hospital, St Louis, Mo
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University and St Louis Children's Hospital, St Louis, Mo.
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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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Abstract
Respiratory syncytial virus is a highly infectious virus that commonly causes bronchiolitis and leads to high morbidity and a low, but important, incidence of mortality. Supportive therapy is the foundation of management. Hydration/nutrition and respiratory support are important evidence-based interventions. For children with severe disease, continuous positive airway pressure or mechanical ventilation may be necessary. Ribavirin may be used for treatment of patients with severe disease. Palivizumab provides important ongoing immunoprophylaxis during epidemic months for high-risk infants. Caregiver education and incorporating an explanation of all therapies and anticipatory guidance, including strategies for reducing the risk of infection, are vital.
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Graeber SY, Zhou-Suckow Z, Schatterny J, Hirtz S, Boucher RC, Mall MA. Hypertonic saline is effective in the prevention and treatment of mucus obstruction, but not airway inflammation, in mice with chronic obstructive lung disease. Am J Respir Cell Mol Biol 2013; 49:410-7. [PMID: 23590312 DOI: 10.1165/rcmb.2013-0050oc] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Recent evidence suggests that inadequate hydration of airway surfaces is a common mechanism in the pathogenesis of airway mucus obstruction. Inhaled hypertonic saline (HS) induces osmotic water flux, improving hydration of airway surfaces. However, trials in patients with obstructive lung diseases are limited. The aim of this study was to investigate effects of HS on mucus obstruction and airway inflammation in the prevention and treatment of obstructive lung disease in vivo. We, therefore, used the β-epithelial Na(+) channel (βENaC)-overexpressing mouse as a model of chronic obstructive lung disease and determined effects of preventive and late therapy with 3% HS and 7% HS on pulmonary mortality, airway mucus obstruction, and inflammation. We found that preventive treatment with 3% HS and 7% HS improved growth, reduced mortality, and reduced mucus obstruction in neonatal βENaC-overexpressing mice. In adult βENaC-overexpressing mice with chronic lung disease, mucus obstruction was significantly reduced by 7% HS, but not by 3% HS. Treatment with HS triggered airway inflammation with elevated keratinocyte chemoattractant levels and neutrophils in airways from wild-type mice, but reduced keratinocyte chemoattractant in chronic neutrophilic inflammation in adult βENaC-overexpressing mice. Our data demonstrate that airway surface rehydration with HS provides an effective preventive and late therapy of mucus obstruction with no consistent effects on inflammation in chronic lung disease. These results suggest that, through mucokinetic effects, HS may be beneficial for patients with a spectrum of obstructive lung diseases, and that additional strategies are required for effective treatment of associated airway inflammation.
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Affiliation(s)
- Simon Y Graeber
- Department of Translational Pulmonology, Translational Lung Research Center, University of Heidelberg, Im Neuenheimer Feld 350, Heidelberg, Germany
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Nicolai A, Ferrara M, Schiavariello C, Gentile F, Grande M, Alessandroni C, Midulla F. Viral bronchiolitis in children: a common condition with few therapeutic options. Early Hum Dev 2013; 89 Suppl 3:S7-11. [PMID: 23972293 PMCID: PMC7130661 DOI: 10.1016/j.earlhumdev.2013.07.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Even though bronchiolitis is a disease that has been recognized for many years, there are still few therapeutic strategies beyond supportive therapies. Bronchiolitis is the most frequent cause of hospital admission in children less than 1 year of age. The incidence is estimated to be about 150° million cases a year worldwide, and 2-3% of these cases require hospitalization. It is acknowledged that viruses cause bronchiolitis, but most of the studies focus on RSV. The RSV causes a more severe form of bronchiolitis in children with risk factors including prematurity, cardiovascular disease and immunodeficiency. Other viruses involved in causing bronchiolitis include RV, hMPV, hBoV and co-infections. The RV seems to be associated with a less severe acute disease, but there is a correlation between the early infection and subsequent wheezing bronchitis and asthma in later childhood and adulthood. The supportive therapies used are intravenous fluids and oxygen supplement administered by nasal cannula or CPAP in most complicated patients. Additional pharmacological therapies include epinephrine, 3% hypertonic saline and corticosteroids. The Epinephrine seems to have the greatest short-term benefits and reduces the need of hospital admission, whereas hypertonic saline and corticosteroids seem to reduce the length of hospital stay. As bronchiolitis is such a prevalent disease in children and RV seems to play an important role, perhaps more studies should center around the RV's contribution to the initial disease and following pathology.
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Affiliation(s)
| | | | | | | | | | | | - F. Midulla
- Corresponding author at: Viale Regina Elena 324, 00161 Roma, Paediatric Department, Sapienza University of Rome, Italy. Tel.: + 39 0649979363.
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Hartling L, Chisholm A, Thomson D, Dryden DM. A descriptive analysis of overviews of reviews published between 2000 and 2011. PLoS One 2012; 7:e49667. [PMID: 23166744 PMCID: PMC3499476 DOI: 10.1371/journal.pone.0049667] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 10/12/2012] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Overviews of systematic reviews compile data from multiple systematic reviews (SRs) and are a new method of evidence synthesis. OBJECTIVES To describe the methodological approaches in overviews of interventions. DESIGN Descriptive study. METHODS We searched 4 databases from 2000 to July 2011; we handsearched Evidence-based Child Health: A Cochrane Review Journal. We defined an overview as a study that: stated a clear objective; examined an intervention; used explicit methods to identify SRs; collected and synthesized outcome data from the SRs; and intended to include only SRs. We did not restrict inclusion by population characteristics (e.g., adult or children only). Two researchers independently screened studies and applied eligibility criteria. One researcher extracted data with verification by a second. We conducted a descriptive analysis. RESULTS From 2,245 citations, 75 overviews were included. The number of overviews increased from 1 in 2000 to 14 in 2010. The interventions were pharmacological (n = 20, 26.7%), non-pharmacological (n = 26, 34.7%), or both (n = 29, 38.7%). Inclusion criteria were clearly stated in 65 overviews. Thirty-three (44%) overviews searched at least 2 databases. The majority reported the years and databases searched (n = 46, 61%), and provided key words (n = 58, 77%). Thirty-nine (52%) overviews included Cochrane SRs only. Two reviewers independently screened and completed full text review in 29 overviews (39%). Methods of data extraction were reported in 45 (60%). Information on quality of individual studies was extracted from the original SRs in 27 (36%) overviews. Quality assessment of the SRs was performed in 28 (37%) overviews; at least 9 different tools were used. Quality of the body of evidence was assessed in 13 (17%) overviews. Most overviews provided a narrative or descriptive analysis of the included SRs. One overview conducted indirect analyses and the other conducted mixed treatment comparisons. Publication bias was discussed in 18 (24%) overviews. CONCLUSIONS This study shows considerable variation in the methods used for overviews. There is a need for methodological rigor and consistency in overviews, as well as empirical evidence to support the methods employed.
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Affiliation(s)
- Lisa Hartling
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
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Enriquez A, Chu I, Mellis C, Lin W. Nebulised deoxyribonuclease for viral bronchiolitis in children younger than 24 months. Cochrane Database Syst Rev 2012; 11:CD008395. [PMID: 23152257 PMCID: PMC7388903 DOI: 10.1002/14651858.cd008395.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Bronchiolitis is one of the most common respiratory problems in the first year of life. The sputum of infants with bronchiolitis has increased deoxyribonucleic acid (DNA) content, leading to mucous plugging and airway obstruction. Recombinant human deoxyribonuclease (rhDNase), an enzyme that digests extracellular DNA, might aid the clearance of mucus and relieve peripheral airway obstruction. OBJECTIVES To determine the effect of nebulised rhDNase on the severity and duration of viral bronchiolitis in children younger than 24 months of age in the hospital setting. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2012, Issue 7 which includes the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to July Week 4, 2012), EMBASE (1974 to August 2012) and LILACS (1982 to August 2012). SELECTION CRITERIA Randomised controlled trials (RCTs) using nebulised rhDNase alone or with concomitant therapy in children younger than 24 months of age hospitalised with acute bronchiolitis. DATA COLLECTION AND ANALYSIS Two review authors independently performed literature searches, assessed trial quality and extracted data. We obtained unpublished data from trial authors. We used Review Manager 5.1 to pool treatment effects expressed as the mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI). MAIN RESULTS Three RCTs (333 participants) were identified, two of which were multicentre trials comprising only participants positive for respiratory syncytial virus (RSV). The other trial enrolled participants clinically diagnosed with bronchiolitis from a hospital in Italy. All studies used 2.5 mL (1 mg/mL) of nebulised rhDNase compared with placebo either as a daily or a twice daily dose. Adjunctive therapy included nebulised salbutamol, steroids, supplemental oxygen, intravenous fluids or tube feeding, nasal washing, nasal decongestants and antibiotics.Overall, nebulised rhDNase showed no benefit in clinically meaningful outcomes. Meta-analysis favoured the control group with a shorter duration of hospital stay (MD 0.50; 95% CI 0.10 to 0.90, P = 0.01) and better clinical score improvement (SMD -0.24; 95% CI -0.50 to 0.01, P = 0.06). The largest trial showed no difference in supplemental oxygen use or intensive care unit (ICU) admission.In one RCT, four out of 11 patients in the treatment group had atelectasis. Two of these patients showed distinctive clinical improvement after nebulised rhDNase.There was no significant difference in adverse events. These included temporary desaturation, temporary coughing, increased coughing, facial rash, hoarseness, dyspnoea and bad taste, reported in a total of 11 patients from both treatment groups. AUTHORS' CONCLUSIONS The results based on the three included studies in this review did not support the use of nebulised rhDNase in children under 24 months of age hospitalised with acute bronchiolitis. In these patients, treatment did not shorten the length of hospitalisation or improve clinical outcomes. It might have a role in severe bronchiolitis complicated by atelectasis, but further clinical studies would need to be performed.
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Affiliation(s)
| | - I‐Wen Chu
- Chang Gung Memorial HospitalDepartment of Medical Research and Academic‐Industrial Collaboration OfficeNo.5, Fusing St.Gueishan TownshipTaoyuanTaiwan333
| | - Craig Mellis
- The University of SydneyFaculty of Medicine, Room 406, Blackburn Building, D06SydneyNSWAustralia2006
| | - Wan‐Yu Lin
- Taichung General Veteran HospitalDepartment of Nuclear Medicine160 Sec. 3, Chung‐Gang RdTaichung CityTaiwan407
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Abstract
Respiratory Syncytial Virus (RSV) is a common virus that infects children and adults; however, children younger than two years of age tend to develop more serious respiratory symptoms. RSV is responsible for thousands of outpatient visits (e.g., emergency room/primary care physician), hospitalizations and can result in death. Treatment is primarily supportive care and the illness resolves without complications in most children. RSV prophylaxis with palivizumab is an option for high-risk infants and children, which can decrease hospitalization and length of stay. Immunocompromised patients are a special population of which ribavirin and palivizumab may be used for treatment. Currently, no medication or vaccine available has been able to show a reduction in mortality from RSV. Future vaccines are in the developmental stage and will hopefully decrease the symptomatic and economic burden of this disease.
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Affiliation(s)
- Lea S Eiland
- Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, Huntsville, Alabama
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Advanced nursing directives: integrating validated clinical scoring systems into nursing care in the pediatric emergency department. Nurs Res Pract 2012; 2012:596393. [PMID: 22778944 PMCID: PMC3384969 DOI: 10.1155/2012/596393] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 02/06/2012] [Accepted: 02/20/2012] [Indexed: 11/24/2022] Open
Abstract
In an effort to improve the quality and flow of care provided to children presenting to the emergency department the implementation of nurse-initiated protocols is on the rise. We review the current literature on nurse-initiated protocols, validated emergency department clinical scoring systems, and the merging of the two to create Advanced Nursing Directives (ANDs). The process of developing a clinical pathway for children presenting to our pediatric emergency department (PED) with suspected appendicitis will be used to demonstrate the successful integration of validated clinical scoring systems into practice through the use of Advanced Nursing Directives. Finally, examples of 2 other Advanced Nursing Directives for common clinical PED presentations will be provided.
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Sakellaropoulou A, Emporiadou M, Aivazis V, Mauromixalis J, Hatzistilianou M. Acute bronchiolitis in a paediatric emergency department of Northern Greece. Comparisons between two decades. Arch Med Sci 2012; 8:509-14. [PMID: 22852008 PMCID: PMC3400904 DOI: 10.5114/aoms.2012.29279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2011] [Revised: 10/21/2011] [Accepted: 01/02/2012] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Acute bronchiolitis is the most common lower respiratory tract infection in infants and toddlers concerning small bronchi or bronchioli. This retrospective study aimed to evaluate the incidence of acute bronchiolitis and the use of β(2)-agonists between two different decades. MATERIAL AND METHODS During 1990-1991 and 2001-2002, the files of the 2(nd) Paediatric Emergency Department of Aristotle University of Thessaloniki, AHEPA Hospital were reviewed and cases of acute bronchiolitis were recorded and analysed. RESULTS During 1990-1991, 14 538 children were identified with respiratory infections and bronchiolitis was diagnosed in 519/14 538 children (3.56%). Only 34 out of 519 patients received nebulised salbutamol (6.6%) and 221/519 were hospitalized (42.6%). During 2001-2002, 9001 children were found to have respiratory tract infections and acute bronchiolitis was diagnosed in 641/9001 of them (7.12%). In total, 411/641 children (64.1%) received salbutamol and ipratropium, and 89/641 patients (13.88%) were hospitalized. There was a predominance of male sex in both decades (p = 0.509). There was a statistically significant difference (p < 0.001) concerning the use of nebulised salbutamol with nebulised ipratropium between the two decades. Finally, during 2001-2002, the use of bronchodilators with or without corticosteroids was more frequent and it appears to be correlated with the reduced number of admissions to hospital (p < 0.05) compared with 1990-1991. CONCLUSIONS There was an increase in the incidence of acute bronchiolitis during the last decade. The admission rate decreased probably due to the use of nebulized salbutamol and ipratropium, but further multicentre comparative trials are required to define the role of bronchodilators in the treatment of acute bronchiolitis.
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Affiliation(s)
| | - Maria Emporiadou
- 2 Paediatric Department, Aristotle University of Thessaloniki, AHEPA Hospital, Greece
| | - Victor Aivazis
- 1 Paediatric Department, Aristotle University of Thessaloniki, AHEPA Hospital, Greece
| | - John Mauromixalis
- 2 Paediatric Department, Aristotle University of Thessaloniki, AHEPA Hospital, Greece
| | - Maria Hatzistilianou
- 2 Paediatric Department, Aristotle University of Thessaloniki, AHEPA Hospital, Greece
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32
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Sandweiss DR, Kadish HA, Campbell KA. Outpatient management of patients with bronchiolitis discharged home on oxygen: a survey of general pediatricians. Clin Pediatr (Phila) 2012; 51:442-6. [PMID: 22157426 DOI: 10.1177/0009922811430525] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To describe the experience of general pediatricians in weaning bronchiolitis patients, treated as outpatients, from oxygen. METHODS The authors surveyed members of the American Academy of Pediatrics' Council on Community Pediatrics regarding management of outpatient oxygen for bronchiolitis. RESULTS The survey had 214 (28.4%) responses from pediatricians, of whom 172 (80.3%) practiced outpatient pediatrics. Among those, 27 (15.7%) cared for bronchiolitis patients discharged on oxygen. Pediatricians managing home oxygen practiced at higher altitude (5000 vs 339 ft, P < .001). No clear weaning protocol was reported. Over half (61.5%) of the pediatricians managing home oxygen acknowledged difficulty in deciding when to stop oxygen. A median of 2 (interquartile range [IQR] = 2-2) outpatient visits and 6 (IQR = 4-7) outpatient days on home oxygen were needed prior to oxygen discontinuation. CONCLUSION Pediatricians are not routinely managing home oxygen for hypoxic bronchiolitis patients. Variable weaning process, difficulties in determining oxygen stoppage, multiple follow-up visits, and prolonged home oxygen usage highlight the need to evaluate the impact of this emerging practice.
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Abstract
Pediatric respiratory illnesses are a huge burden to emergency departments worldwide. This article reviews the latest evidence in the epidemiology, assessment, management, and disposition of children presenting to the emergency department with asthma, croup, bronchiolitis, and pneumonia.
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Affiliation(s)
- Joseph Choi
- McGill University FRCP Emergency Medicine Residency Program, Royal Victoria Hospital, 687 Pine Avenue West, Room A4.62, Montreal, Quebec, Canada H3A 1A1.
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Eber E. Treatment of acute viral bronchiolitis. Open Microbiol J 2011; 5:159-64. [PMID: 22262989 PMCID: PMC3258671 DOI: 10.2174/1874285801105010159] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Revised: 10/12/2011] [Accepted: 10/27/2011] [Indexed: 11/29/2022] Open
Abstract
Acute viral bronchiolitis represents the most common lower respiratory tract infection in infants and young children and is associated with substantial morbidity and mortality. Respiratory syncytial virus is the most frequently identified virus, but many other viruses may also cause acute bronchiolitis. There is no common definition of acute viral bronchiolitis used internationally, and this may explain part of the confusion in the literature. Most children with bronchiolitis have a self limiting mild disease and can be safely managed at home with careful attention to feeding and respiratory status. Criteria for referral and admission vary between hospitals as do clinical practice in the management of acute viral bronchiolitis, and there is confusion and lack of evidence over the best treatment for this condition. Supportive care, including administration of oxygen and fluids, is the cornerstone of current treatment. The majority of infants and children with bronchiolitis do not require specific measures. Bronchodilators should not be routinely used in the management of acute viral bronchiolitis, but may be effective in some patients. Most of the commonly used management modalities have not been shown to have a clear beneficial effect on the course of the disease. For example, inhaled and systemic corticosteroids, leukotriene receptor antagonists, immunoglobulins and monoclonal antibodies, antibiotics, antiviral therapy, and chest physiotherapy should not be used routinely in the management of bronchiolitis. The potential effect of hypertonic saline on the course of the acute disease is promising, but further studies are required. In critically ill children with bronchiolitis, today there is little justification for the use of surfactant and heliox. Nasal continuous positive airway pressure may be beneficial in children with severe bronchiolitis but a large trial is needed to determine its value. Finally, very little is known on the effect of the various interventions on the development of post-bronchiolitic wheeze.
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Affiliation(s)
- Ernst Eber
- Respiratory and Allergic Disease Division, Pediatric Department, Medical University of Graz, Austria
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Care of infants and children with bronchiolitis: a systematic review. J Pediatr Nurs 2011; 26:519-29. [PMID: 22055372 DOI: 10.1016/j.pedn.2010.07.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2010] [Revised: 07/09/2010] [Accepted: 07/19/2010] [Indexed: 11/23/2022]
Abstract
Bronchiolitis is the most frequent cause of hospitalization in the infant population. Management varies widely, and the efficacy of many routinely implemented therapies is not supported by evidence. The purpose of the systematic review was to identify the best evidence available regarding the care of infants and children with bronchiolitis. A two-phase literature search was performed, and 20 publications were appraised. An abundance of evidence regarding management of bronchiolitis was revealed resulting in numerous recommendations. Use of a clinical pathway is proposed as a possible solution for moving this evidence into practice.
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Kantharajah M, Zaman FD, Samra D, Gunturu MN, Del Mar CB, van Driel ML. Immunoglobulin treatment for respiratory syncytial virus infection. Hippokratia 2011. [DOI: 10.1002/14651858.cd009417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Myuri Kantharajah
- Bond University; Faculty of Health Sciences and Medicine; University Drive Robina Gold Coast Queensland Australia 4229
| | - Farah Diba Zaman
- Bond University; Faculty of Health Sciences and Medicine; University Drive Robina Gold Coast Queensland Australia 4229
| | - Danielle Samra
- Bond University; Faculty of Health Sciences and Medicine; University Drive Robina Gold Coast Queensland Australia 4229
| | - Monica N Gunturu
- Bond University; Faculty of Health Sciences and Medicine; University Drive Robina Gold Coast Queensland Australia 4229
| | - Chris B Del Mar
- Bond University; Faculty of Health Sciences and Medicine; University Drive Robina Gold Coast Queensland Australia 4229
| | - Mieke L van Driel
- Bond University; Faculty of Health Sciences and Medicine; University Drive Robina Gold Coast Queensland Australia 4229
- Ghent University; Department of General Practice and Primary Health Care; 1K3, De Pintelaan 185 Ghent Belgium 9000
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Approach to a child with lower airway obstruction and bronchiolitis. Indian J Pediatr 2011; 78:1396-400. [PMID: 21625831 DOI: 10.1007/s12098-011-0492-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2011] [Accepted: 05/16/2011] [Indexed: 02/05/2023]
Abstract
Lower airway obstruction can occur at the level of trachea, bronchi or bronchioles. It is characterized clinically by wheeze and hyperinflated chest, apart from other signs of respiratory distress. Common causes include bronchiolitis, asthma, pneumonia, laryngotracheo-bronchitis, congenital malformations and foreign body inhalation. Bronchiolitis usually occurs in children aged 2 months to 2 years. It is most commonly caused by respiratory syncytial virus infection. The diagnosis is mainly clinical, and investigations have a very limited role. Humidified oxygen and supportive therapy are the mainstays of treatment. A trial of inhaled epinephrine or parenteral steroids may be considered for non-responders. It is usually associated with good outcome.
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Bem RA, Domachowske JB, Rosenberg HF. Animal models of human respiratory syncytial virus disease. Am J Physiol Lung Cell Mol Physiol 2011; 301:L148-56. [PMID: 21571908 PMCID: PMC3154630 DOI: 10.1152/ajplung.00065.2011] [Citation(s) in RCA: 151] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 05/05/2011] [Indexed: 11/22/2022] Open
Abstract
Infection with the human pneumovirus pathogen, respiratory syncytial virus (hRSV), causes a wide spectrum of respiratory disease, notably among infants and the elderly. Laboratory animal studies permit detailed experimental modeling of hRSV disease and are therefore indispensable in the search for novel therapies and preventative strategies. Present animal models include several target species for hRSV, including chimpanzees, cattle, sheep, cotton rats, and mice, as well as alternative animal pneumovirus models, such as bovine RSV and pneumonia virus of mice. These diverse animal models reproduce different features of hRSV disease, and their utilization should therefore be based on the scientific hypothesis under investigation. The purpose of this review is to summarize the strengths and limitations of each of these animal models. Our intent is to provide a resource for investigators and an impetus for future research.
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Affiliation(s)
- Reinout A Bem
- Pediatric Intensive Care Unit, Emma Children’s Hospital, Academic Medical Center, Amsterdam, The Netherlands.
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Hartling L, Bialy LM, Vandermeer B, Tjosvold L, Johnson DW, Plint AC, Klassen TP, Patel H, Fernandes RM. Epinephrine for bronchiolitis. Cochrane Database Syst Rev 2011:CD003123. [PMID: 21678340 DOI: 10.1002/14651858.cd003123.pub3] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Bronchodilators are commonly used for acute bronchiolitis, despite uncertain effectiveness. OBJECTIVES To examine the efficacy and safety of epinephrine in children less than two with acute viral bronchiolitis. SEARCH STRATEGY We searched CENTRAL (2010, Issue 3) which contains the Acute Respiratory Infections Group's Specialized Register, MEDLINE (1950 to September Week 2, 2010), EMBASE (1980 to September 2010), Scopus (1823 to September 2010), PubMed (March 2010), LILACS (1985 to September 2010) and Iran MedEx (1998 to September 2010). SELECTION CRITERIA We included randomized controlled trials comparing epinephrine to placebo or another intervention involving children less than two years with acute viral bronchiolitis. Studies were included if the trials presented data for at least one quantitative outcome of interest.We selected primary outcomes a priori, based on clinical relevance: rate of admission by days one and seven of presentation for outpatients, and length of stay (LOS) for inpatients. Secondary outcomes included clinical severity scores, pulmonary function, symptoms, quality of life and adverse events. DATA COLLECTION AND ANALYSIS Two review authors independently screened the searches, applied inclusion criteria, assessed risk of bias and graded the evidence. We conducted separate analyses for different comparison groups (placebo, non-epinephrine bronchodilators, glucocorticoids) and for clinical setting (inpatient, outpatient). MAIN RESULTS We included 19 studies (2256 participants). Epinephrine versus placebo among outpatients showed a significant reduction in admissions at Day 1 (risk ratio (RR) 0.67; 95% confidence interval (CI) 0.50 to 0.89) but not at Day 7 post-emergency department visit. There was no difference in LOS for inpatients. Epinephrine versus salbutamol showed no differences among outpatients for admissions at Day 1 or 7. Inpatients receiving epinephrine had a significantly shorter LOS compared to salbutamol (mean difference -0.28; 95% CI -0.46 to -0.09). One large RCT showed a significantly shorter admission rate at Day 7 for epinephrine and steroid combined versus placebo (RR 0.65; 95% CI 0.44 to 0.95). There were no important differences in adverse events. AUTHORS' CONCLUSIONS This review demonstrates the superiority of epinephrine compared to placebo for short-term outcomes for outpatients, particularly in the first 24 hours of care. Exploratory evidence from a single study suggests benefits of epinephrine and steroid combined for later time points. More research is required to confirm the benefits of combined epinephrine and steroids among outpatients. There is no evidence of effectiveness for repeated dose or prolonged use of epinephrine or epinephrine and dexamethasone combined among inpatients.
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Affiliation(s)
- Lisa Hartling
- Department of Pediatrics, University of Alberta, Aberhart Centre One, Room 9424, 11402 University Avenue, Edmonton, Alberta, Canada, T6G 2J3
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Abstract
Viral bronchiolitis is common, and about 98-99% of infants are managed in the home. Because about 95% of infants < 2 years old are infected with respiratory syncytial virus, however, bronchiolitis is the commonest reason for admission to hospital in the first 6 months of life. It is usually a self-limiting condition lasting around a week in previously well children. About 1% of infants are admitted to hospital, and about 10% of hospitalised infants will require admission to the intensive care unit. Respiratory syncytial virus is isolated from about 70% of infants hospitalised with bronchiolitis. The emphasis of hospital treatment is to ensure adequate hydration and oxygenation. Other than supplemental oxygen, little in the way of pharmacological treatment has been demonstrated to alter the course of the illness or the risk of wheezing in the months following bronchiolitis.
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Affiliation(s)
- Dominic A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.
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Wright M, Piedimonte G. Respiratory syncytial virus prevention and therapy: past, present, and future. Pediatr Pulmonol 2011; 46:324-47. [PMID: 21438168 DOI: 10.1002/ppul.21377] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Revised: 08/24/2010] [Accepted: 08/29/2010] [Indexed: 11/06/2022]
Abstract
Respiratory syncytial virus (RSV) is the most common respiratory pathogen in infants and young children worldwide. More than 50 years after its discovery, and despite relentless attempts to identify pharmacological therapies to improve the clinical course and outcomes of this disease, the most effective therapy remains supportive care. Although the quest for a safe and effective vaccine remains unsuccessful, pediatricians practicing during the past decade have been able to protect at least the more vulnerable patients with safe and effective passive prophylaxis. This review summarizes the history, microbiology, epidemiology, pathophysiology, and clinical manifestations of this infection in order to provide the reader with the background information necessary to fully appreciate the many challenges presented by the clinical management of young children with bronchiolitis. The last part of this article attempts an evidence-based review of the pharmacologic strategies currently available and those being evaluated, intentionally omitting highly experimental approaches not yet tested in clinical trials and, therefore, not likely to become available in the foreseeable future.
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Affiliation(s)
- Melvin Wright
- Department of Pediatrics and Pediatric Research Institute, West Virginia University School of Medicine, Morgantown, West Virginia 26506-9214, USA
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43
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Abstract
Wheeze, a common symptom in pre-school children, is a continuous high-pitched sound, with a musical quality, emitting from the chest during expiration. A pragmatic clinical classification is episodic (viral) wheeze and multiple-trigger wheeze. Diagnostic difficulties include other conditions that give rise to noisy breathing which could be misinterpreted as wheeze. Most preschool children with wheeze do not need rigorous investigations. Primary prevention is not possible but avoidance of environmental tobacco smoke exposure should be strongly encouraged. Bronchodilators provide symptomatic relief in acute wheezy episodes but the evidence for using oral steroids is conflicting for children presenting to the Emergency Department [ED]. Parent initiated oral steroid courses cannot be recommended. High dose inhaled corticosteroids [ICS] used intermittently are effective in children with frequent episodes of moderately severe episodic (viral) wheeze or multiple-trigger wheeze, but this associated with short term effects on growth and cannot be recommended as a routine. Maintenance treatment with low to moderate continuous ICS in pure episodic (viral) wheeze is ineffective. Whilst low to moderate dose regular ICS work in multi-trigger wheeze, the medication does not modify the natural history of the condition. Even if there is a successful trial of treatment with ICS, a break in treatment should be given to see if the symptoms have resolved or continuous therapy is still required. Maintenance as well as intermittent Montelukast has a role in both episodic and multi trigger wheeze. Good multidisciplinary support and education is essential in managing this common condition.
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Affiliation(s)
- Jayesh M Bhatt
- Consultant in Respiratory Paediatrics, Nottingham University Hospitals NHS Trust (QMC campus), Nottingham, NG7 2UH.
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44
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Bialy L, Foisy M, Smith M, Fernandes RM. The Cochrane Library and the Treatment of Bronchiolitis in Children: An Overview of Reviews. ACTA ACUST UNITED AC 2011. [DOI: 10.1002/ebch.673] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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45
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Abstract
Understanding the role of ontogeny in the disposition and actions of medicines is the most fundamental prerequisite for safe and effective pharmacotherapeutics in the pediatric population. The maturational process represents a continuum of growth, differentiation, and development, which extends from the very small preterm newborn infant through childhood, adolescence, and to young adulthood. Developmental changes in physiology and, consequently, in pharmacology influence the efficacy, toxicity, and dosing regimen of medicines. Relevant periods of development are characterized by changes in body composition and proportion, developmental changes of physiology with pathophysiology, exposure to unique safety hazards, changes in drug disposition by major organs of metabolism and elimination, ontogeny of drug targets (e.g., enzymes, transporters, receptors, and channels), and environmental influences. These developmental components that result in critical windows of development of immature organ systems that may lead to permanent effects later in life interact in a complex, nonlinear fashion. The ontogeny of these physiologic processes provides the key to understanding the added dimension of development that defines the essential differences between children and adults. A basic understanding of the developmental dynamics in pediatric pharmacology is also essential to delineating the future directions and priority areas of pediatric drug research and development.
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MESH Headings
- Adolescent
- Body Composition/physiology
- Child
- Child, Preschool
- Drug-Related Side Effects and Adverse Reactions
- Female
- Human Development/physiology
- Humans
- Infant
- Infant, Newborn/physiology
- Infant, Newborn, Diseases/drug therapy
- Infant, Newborn, Diseases/physiopathology
- Infant, Premature/physiology
- Infant, Premature, Diseases/drug therapy
- Infant, Premature, Diseases/physiopathology
- Male
- Pediatrics
- Pharmaceutical Preparations/metabolism
- Pharmacokinetics
- Pharmacological Phenomena/physiology
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Affiliation(s)
- Hannsjörg W Seyberth
- Klinik fur Kinder- und Jugendmedizin, Philipps-Universität Marburg, Baldingerstraße, 35043 Marburg, Germany.
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46
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Chéron G, Patteau G, Nouyrigat V. Bronchiolite del lattante. EMC - URGENZE 2011. [PMCID: PMC7149004 DOI: 10.1016/s1286-9341(11)70664-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
La bronchiolite è un’infezione virale stagionale delle vie respiratorie basse del lattante. Il suo agente causale principale è il virus respiratorio sinciziale. La comparsa di un distress respiratorio è legata all’intensità della risposta infiammatoria delle vie aeree. Benché si tratti di una malattia frequente, le cause della suscettibilità dei lattanti a questa infezione non sono conosciute. La diagnosi è clinica. Il trattamento è sintomatico in assenza di misure specifiche. I rapporti a medio e a lungo termine di un primo episodio di bronchiolite con le recidive e con l’asma non sono spiegati. Essi potrebbero dipendere dalla natura del virus in causa al momento del primo episodio e da fattori genetici individuali.
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47
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Gadomski AM, Brower M. Bronchodilators for bronchiolitis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd001266.pub3] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Oakley E, Babl FE, Acworth J, Borland M, Kreiser D, Neutze J, Theophilos T, Donath S, South M, Davidson A. A prospective randomised trial comparing nasogastric with intravenous hydration in children with bronchiolitis (protocol): the comparative rehydration in bronchiolitis study (CRIB). BMC Pediatr 2010; 10:37. [PMID: 20515467 PMCID: PMC2903564 DOI: 10.1186/1471-2431-10-37] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2009] [Accepted: 06/01/2010] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Bronchiolitis is the most common reason for admission of infants to hospital in developed countries. Fluid replacement therapy is required in about 30% of children admitted with bronchiolitis. There are currently two techniques of fluid replacement therapy that are used with the same frequency-intravenous (IV) or nasogastric (NG).The evidence to determine the optimum route of hydration therapy for infants with bronchiolitis is inadequate. This randomised trial will be the first to provide good quality evidence of whether nasogastric rehydration (NGR) offers benefits over intravenous rehydration (IVR) using the clinically relevant continuous outcome measure of duration of hospital admission. METHODS/DESIGN A prospective randomised multi-centre trial in Australia and New Zealand where children between 2 and 12 months of age with bronchiolitis, needing non oral fluid replacement, are randomised to receive either intravenous (IV) or nasogastric (NG) rehydration.750 patients admitted to participating hospitals will be recruited, and will be followed daily during the admission and by telephone 1 week after discharge. Patients with chronic respiratory, cardiac, or neurological disease; choanal atresia; needing IV fluid resuscitation; needing an IV for other reasons, and those requiring CPAP or ventilation are excluded.The primary endpoint is duration of hospital admission. Secondary outcomes are complications, need for ICU admission, parental satisfaction, and an economic evaluation. Results will be analysed using t-test for continuous data, and chi squared for categorical data. Non parametric data will be log transformed. DISCUSSION This trial will define the role of NGR and IVR in bronchiolitis TRIAL REGISTRATION The trial is registered with the Australian and New Zealand Clinical Trials Registry--ACTRN12605000033640.
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Affiliation(s)
- Ed Oakley
- Department of Emergency Medicine Monash Medical Centre, Clayton Rd, Clayton Victoria 3168 Australia
- Murdoch Children's Research Institute Flemington Rd Parkville Victoria 3052 Australia
- Southern Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria 3800 Australia
| | - Franz E Babl
- Murdoch Children's Research Institute Flemington Rd Parkville Victoria 3052 Australia
- Department of Emergency Medicine Royal Children's Hospital, Flemington Rd, Parkville, Victoria 3052, Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria 3010 Australia
| | - Jason Acworth
- Department of Emergency Medicine Royal Children's Hospital Brisbane, Herston Rd, Herston Queensland 4006 Australia
| | - Meredith Borland
- Department of Emergency Medicine Princess Margaret Hospital Roberts Rd, Subiaco, Perth 6008 Western Australia
| | - David Kreiser
- Murdoch Children's Research Institute Flemington Rd Parkville Victoria 3052 Australia
- Department of Emergency Medicine, Sunshine Hospital 176 Furlong Rd, St Albans Victoria 3021 Australia
| | - Jocelyn Neutze
- Department of Emergency Medicine Kidz First Hospital, 100 Hospital Road, Papatoetoe, Auckland 2025, NZ
| | - Theane Theophilos
- Murdoch Children's Research Institute Flemington Rd Parkville Victoria 3052 Australia
- Department of Emergency Medicine Royal Children's Hospital, Flemington Rd, Parkville, Victoria 3052, Australia
| | - Susan Donath
- Murdoch Children's Research Institute Flemington Rd Parkville Victoria 3052 Australia
| | - Mike South
- Murdoch Children's Research Institute Flemington Rd Parkville Victoria 3052 Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria 3010 Australia
- Department of Medicine Royal Children's Hospital Flemington Rd, Parkville Victoria 3052 Australia
| | - Andrew Davidson
- Murdoch Children's Research Institute Flemington Rd Parkville Victoria 3052 Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria 3010 Australia
- Department of Anaesthesia, Royal Children's Hospital, Flemington Rd, Parkville, Victoria 3052 Australia
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49
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Norwood A, Mansbach JM, Clark S, Waseem M, Camargo CA. Prospective multicenter study of bronchiolitis: predictors of an unscheduled visit after discharge from the emergency department. Acad Emerg Med 2010; 17:376-82. [PMID: 20370776 DOI: 10.1111/j.1553-2712.2010.00699.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES There is little evidence about which children with bronchiolitis will have worsened disease after discharge from the emergency department (ED). The objective of this study was to determine predictors of post-ED unscheduled visits. METHODS The authors conducted a prospective cohort study of patients discharged from 2004 to 2006 at 30 EDs in 15 U.S. states. Inclusion criteria were diagnosis of bronchiolitis, age <2 years, and discharge home; the exclusion criterion was previous enrollment. Unscheduled visits were defined as urgent visits to an ED/clinic for worsened bronchiolitis within 2 weeks. RESULTS Of 722 patients eligible for the current analysis, 717 (99%) had unscheduled visit data, of whom 121 (17%; 95% confidence interval [CI] = 14% to 20%) had unscheduled visits. Unscheduled visits were more likely for children age <2 months (11% vs. 6%; p = 0.04), males (70% vs. 57%; p = 0.007), and those with history of hospitalization (27% vs. 18%; p = 0.01). The two groups were similar in other demographic and clinical factors (all p > 0.10). Using multivariable logistic regression, independent predictors of unscheduled visits were age <2 months, male, and history of hospitalization. CONCLUSIONS In this study of children age younger than 2 years with bronchiolitis, one of six children had unscheduled visits within 2 weeks of ED discharge. The three predictors of unscheduled visits were age under 2 months, male sex, and previous hospitalization.
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Affiliation(s)
- Agatha Norwood
- Department of Medicine, Children's Hospital Boston, Harvard Medical School, Boston, MA, USA
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50
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Turner TJ, Barnes H, Reid J, Garrubba M. Evidence for perinatal and child health care guidelines in crisis settings: can Cochrane help? BMC Public Health 2010; 10:170. [PMID: 20350326 PMCID: PMC3091544 DOI: 10.1186/1471-2458-10-170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Accepted: 03/29/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is important that healthcare provided in crisis settings is based on the best available research evidence. We reviewed guidelines for child and perinatal health care in crisis situations to determine whether they were based on research evidence, whether Cochrane systematic reviews were available in the clinical areas addressed by these guidelines and whether summaries of these reviews were provided in Evidence Aid. METHODS Broad internet searches were undertaken to identify relevant guidelines. Guidelines were appraised using AGREE and the clinical areas that were relevant to perinatal or child health were extracted. We searched The Cochrane Database of Systematic Reviews to identify potentially relevant reviews. For each review we determined how many trials were included, and how many were conducted in resource-limited settings. RESULTS Six guidelines met selection criteria. None of the included guidelines were clearly based on research evidence. 198 Cochrane reviews were potentially relevant to the guidelines. These reviews predominantly addressed nutrient supplementation, breastfeeding, malaria, maternal hypertension, premature labour and prevention of HIV transmission. Most reviews included studies from developing settings. However for large portions of the guidelines, particularly health services delivery, there were no relevant reviews. Only 18 (9.1%) reviews have summaries in Evidence Aid. CONCLUSIONS We did not identify any evidence-based guidelines for perinatal and child health care in disaster settings. We found many Cochrane reviews that could contribute to the evidence-base supporting future guidelines. However there are important issues to be addressed in terms of the relevance of the available reviews and increasing the number of reviews addressing health care delivery.
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Affiliation(s)
- Tari J Turner
- Monash Institute of Health Services Research, Monash University, Locked Bag 29, Clayton 3168 Australia
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
| | - Hayley Barnes
- previously of the Australasian Cochrane Centre, Monash University, Locked Bag 29, Clayton 3168 Australia
| | - Jane Reid
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
| | - Marie Garrubba
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
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