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Roqué-Figuls M, Giné-Garriga M, Granados Rugeles C, Perrotta C, Vilaró J. Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. Cochrane Database Syst Rev 2023; 4:CD004873. [PMID: 37010196 PMCID: PMC10070603 DOI: 10.1002/14651858.cd004873.pub6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
BACKGROUND Acute bronchiolitis is the leading cause of medical emergencies during winter months in infants younger than 24 months old. Chest physiotherapy is sometimes used to assist infants in the clearance of secretions in order to decrease ventilatory effort. This is an update of a Cochrane Review first published in 2005 and updated in 2006, 2012, and 2016. OBJECTIVES To determine the efficacy of chest physiotherapy in infants younger than 24 months old with acute bronchiolitis. A secondary objective was to determine the efficacy of different techniques of chest physiotherapy (vibration and percussion, passive exhalation, or instrumental). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, Web of Science, PEDro (October 2011 to 20 April 2022), and two trials registers (5 April 2022). SELECTION CRITERIA Randomised controlled trials (RCTs) in which chest physiotherapy was compared to control (conventional medical care with no physiotherapy intervention) or other respiratory physiotherapy techniques in infants younger than 24 months old with bronchiolitis. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS Our update of the searches dated 20 April 2022 identified five new RCTs with 430 participants. We included a total of 17 RCTs (1679 participants) comparing chest physiotherapy with no intervention or comparing different types of physiotherapy. Five trials (246 participants) assessed percussion and vibration techniques plus postural drainage (conventional chest physiotherapy), and 12 trials (1433 participants) assessed different passive flow-oriented expiratory techniques, of which three trials (628 participants) assessed forced expiratory techniques, and nine trials (805 participants) assessed slow expiratory techniques. In the slow expiratory subgroup, two trials (78 participants) compared the technique with instrumental physiotherapy techniques, and two recent trials (116 participants) combined slow expiratory techniques with rhinopharyngeal retrograde technique (RRT). One trial used RRT alone as the main component of the physiotherapy intervention. Clinical severity was mild in one trial, severe in four trials, moderate in six trials, and mild to moderate in five trials. One study did not report clinical severity. Two trials were performed on non-hospitalised participants. Overall risk of bias was high in six trials, unclear in five, and low in six trials. The analyses showed no effects of conventional techniques on change in bronchiolitis severity status, respiratory parameters, hours with oxygen supplementation, or length of hospital stay (5 trials, 246 participants). Regarding instrumental techniques (2 trials, 80 participants), one trial observed similar results in bronchiolitis severity status when comparing slow expiration to instrumental techniques (mean difference 0.10, 95% confidence interval (C) -0.17 to 0.37). Forced passive expiratory techniques failed to show an effect on bronchiolitis severity in time to recovery (2 trials, 509 participants; high-certainty evidence) and time to clinical stability (1 trial, 99 participants; high-certainty evidence) in infants with severe bronchiolitis. Important adverse effects were reported with the use of forced expiratory techniques. Regarding slow expiratory techniques, a mild to moderate improvement was observed in bronchiolitis severity score (standardised mean difference -0.43, 95% CI -0.73 to -0.13; I2 = 55%; 7 trials, 434 participants; low-certainty evidence). Also, in one trial an improvement in time to recovery was observed with the use of slow expiratory techniques. No benefit was observed in length of hospital stay, except for one trial which showed a one-day reduction. No effects were shown or reported for other clinical outcomes such as duration on oxygen supplementation, use of bronchodilators, or parents' impression of physiotherapy benefit. AUTHORS' CONCLUSIONS We found low-certainty evidence that passive slow expiratory technique may result in a mild to moderate improvement in bronchiolitis severity when compared to control. This evidence comes mostly from infants with moderately acute bronchiolitis treated in hospital. The evidence was limited with regard to infants with severe bronchiolitis and those with moderately severe bronchiolitis treated in ambulatory settings. We found high-certainty evidence that conventional techniques and forced expiratory techniques result in no difference in bronchiolitis severity or any other outcome. We found high-certainty evidence that forced expiratory techniques in infants with severe bronchiolitis do not improve their health status and can lead to severe adverse effects. Currently, the evidence regarding new physiotherapy techniques such as RRT or instrumental physiotherapy is scarce, and further trials are needed to determine their effects and potential for use in infants with moderate bronchiolitis, as well as the potential additional effect of RRT when combined with slow passive expiratory techniques. Finally, the effectiveness of combining chest physiotherapy with hypertonic saline should also be investigated.
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Affiliation(s)
- Marta Roqué-Figuls
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Maria Giné-Garriga
- Department of Physical Activity and Sport Sciences, Faculty of Psychology, Education and Sport Sciences (FPCEE) Blanquerna, Universitat Ramon Llull, Barcelona, Spain
| | - Claudia Granados Rugeles
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Carla Perrotta
- School of Public Health, University College Dublin, Dublin, Ireland
| | - Jordi Vilaró
- Blanquerna Faculty of Health Sciences. GRoW, Global Research on Wellbeing, Ramon Llull University, Barcelona, Spain
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Hon KL, Leung AKC, Wong AHC, Dudi A, Leung KKY. Respiratory Syncytial Virus is the Most Common Causative Agent of Viral Bronchiolitis in Young Children: An Updated Review. Curr Pediatr Rev 2023; 19:139-149. [PMID: 35950255 DOI: 10.2174/1573396318666220810161945] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/28/2022] [Accepted: 05/09/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Viral bronchiolitis is a common condition and a leading cause of hospitalization in young children. OBJECTIVE This article provides readers with an update on the evaluation, diagnosis, and treatment of viral bronchiolitis, primarily due to RSV. METHODS A PubMed search was conducted in December 2021 in Clinical Queries using the key terms "acute bronchiolitis" OR "respiratory syncytial virus infection". The search included clinical trials, randomized controlled trials, case control studies, cohort studies, meta-analyses, observational studies, clinical guidelines, case reports, case series, and reviews. The search was restricted to children and English literature. The information retrieved from the above search was used in the compilation of this article. RESULTS Respiratory syncytial virus (RSV) is the most common viral bronchiolitis in young children. Other viruses such as human rhinovirus and coronavirus could be etiological agents. Diagnosis is based on clinical manifestation. Viral testing is useful only for cohort and quarantine purposes. Cochrane evidence-based reviews have been performed on most treatment modalities for RSV and viral bronchiolitis. Treatment for viral bronchiolitis is mainly symptomatic support. Beta-agonists are frequently used despite the lack of evidence that they reduce hospital admissions or length of stay. Nebulized racemic epinephrine, hypertonic saline and corticosteroids are generally not effective. Passive immunoprophylaxis with a monoclonal antibody against RSV, when given intramuscularly and monthly during winter, is effective in preventing severe RSV bronchiolitis in high-risk children who are born prematurely and in children under 2 years with chronic lung disease or hemodynamically significant congenital heart disease. Vaccines for RSV bronchiolitis are being developed. Children with viral bronchiolitis in early life are at increased risk of developing asthma later in childhood. CONCLUSION Viral bronchiolitis is common. No current pharmacologic treatment or novel therapy has been proven to improve outcomes compared to supportive treatment. Viral bronchiolitis in early life predisposes asthma development later in childhood.
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Affiliation(s)
- Kam L Hon
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Kowloon Bay, Hong Kong
| | - Alexander K C Leung
- Department of Pediatrics, The University of Calgary, and The Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Alex H C Wong
- Department of Family Medicine, The University of Calgary, Calgary, Alberta, Canada
| | - Amrita Dudi
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Kowloon Bay, Hong Kong
| | - Karen K Y Leung
- Department of Paediatrics and Adolescent Medicine, The Hong Kong Children's Hospital, Kowloon Bay, Hong Kong
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Alharbi AS, Alqwaiee M, Al-Hindi MY, Mosalli R, Al-Shamrani A, Alharbi S, Yousef A, Al Aidaroos A, Alahmadi T, Alshammary A, Miqdad A, Said Y, Alnemri A. Bronchiolitis in children: The Saudi initiative of bronchiolitis diagnosis, management, and prevention (SIBRO). Ann Thorac Med 2018; 13:127-143. [PMID: 30123331 PMCID: PMC6073791 DOI: 10.4103/atm.atm_60_18] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 05/09/2018] [Indexed: 12/19/2022] Open
Abstract
Bronchiolitis is the leading cause of admissions in children less than two years of age. It has been recognized as highly debated for many decades. Despite the abundance of literature and the well-recognized importance of palivizumab in the high risk groups, and despite the existence of numerous, high-quality, recent guidelines on bronchiolitis, the number of admissions continues to increase. Only supportive therapy and few therapeutic interventions are evidence based and proved to be effective. Since Respiratory Syncytial Virus (RSV) is the major cause of bronchiolitis, we will focus on this virus mostly in high risk groups like the premature babies and children with chronic lung disease and cardiac abnormalities. Further, the prevention of RSV with palivizumab in the high risk groups is effective and well known since 1998; we will discuss the updated criteria for allocating infants to this treatment, as this medication is expensive and should be utilized in the best condition. Usually, diagnosis of bronchiolitis is not challenging, however there has been historically no universally accepted and validated scoring system to assess the severity of the condition. Severe RSV, especially in high risk children, is unique because it can cause serious respiratory sequelae. Currently there is no effective curative treatment for bronchiolitis. The utility of different therapeutic interventions is worth a discussion.
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Affiliation(s)
- Adel S. Alharbi
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defense, Riyadh, Saudi Arabia
| | - Mansour Alqwaiee
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defense, Riyadh, Saudi Arabia
| | - Mohammed Y Al-Hindi
- King Abdullah International Medical Research Center/King Saud bin Abdulaziz University for Health Sciences, Department of Pediatric, Ministry of National Guard, Jeddah, Saudi Arabia
| | - Rafat Mosalli
- Department of Pediatrics, Umm Al Qura university, Makkah, Saudi Arabia
| | - Abdullah Al-Shamrani
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defense, Riyadh, Saudi Arabia
| | - Saleh Alharbi
- Department of Pediatrics, Umm Al Qura university, Makkah, Saudi Arabia
| | - Abdullah Yousef
- Department of Pediatrics, College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia
| | - Amal Al Aidaroos
- Department of Pediatrics, Prince Sultan Military City, Ministry of Defense, Riyadh, Saudi Arabia
| | - Turki Alahmadi
- King Abdulaziz University, College of Medicine, Department of Pediatrics, Jeddah, Saudi Arabia
| | | | - Abeer Miqdad
- Department of Pediatrics, Security forces hospital, Riyadh, Saudi Arabia
| | - Yazan Said
- King Fahad Specialist Hospital, Ministry of Health, Dammam, Saudi Arabia
| | - Abdulrahman Alnemri
- College of Medicine, Peadiatric Department, King Saud University, Riyadh, Saudi Arabia
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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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Roqué i Figuls M, Giné‐Garriga M, Granados Rugeles C, Perrotta C, Vilaró J. Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. Cochrane Database Syst Rev 2016; 2:CD004873. [PMID: 26833493 PMCID: PMC6458017 DOI: 10.1002/14651858.cd004873.pub5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND This Cochrane review was first published in 2005 and updated in 2007, 2012 and now 2015. Acute bronchiolitis is the leading cause of medical emergencies during winter in children younger than two years of age. Chest physiotherapy is sometimes used to assist infants in the clearance of secretions in order to decrease ventilatory effort. OBJECTIVES To determine the efficacy of chest physiotherapy in infants aged less than 24 months old with acute bronchiolitis. A secondary objective was to determine the efficacy of different techniques of chest physiotherapy (for example, vibration and percussion and passive forced exhalation). SEARCH METHODS We searched CENTRAL (2015, Issue 9) (accessed 8 July 2015), MEDLINE (1966 to July 2015), MEDLINE in-process and other non-indexed citations (July 2015), EMBASE (1990 to July 2015), CINAHL (1982 to July 2015), LILACS (1985 to July 2015), Web of Science (1985 to July 2015) and Pedro (1929 to July 2015). SELECTION CRITERIA Randomised controlled trials (RCTs) in which chest physiotherapy was compared against no intervention or against another type of physiotherapy in bronchiolitis patients younger than 24 months of age. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data. Primary outcomes were change in the severity status of bronchiolitis and time to recovery. Secondary outcomes were respiratory parameters, duration of oxygen supplementation, length of hospital stay, use of bronchodilators and steroids, adverse events and parents' impression of physiotherapy benefit. No pooling of data was possible. MAIN RESULTS We included 12 RCTs (1249 participants), three more than the previous Cochrane review, comparing physiotherapy with no intervention. Five trials (246 participants) evaluated conventional techniques (vibration and percussion plus postural drainage), and seven trials (1003 participants) evaluated passive flow-oriented expiratory techniques: slow passive expiratory techniques in four trials, and forced passive expiratory techniques in three trials.Conventional techniques failed to show a benefit in the primary outcome of change in severity status of bronchiolitis measured by means of clinical scores (five trials, 241 participants analysed). Safety of conventional techniques has been studied only anecdotally, with one case of atelectasis, the collapse or closure of the lung resulting in reduced or absent gas exchange, reported in the control arm of one trial.Slow passive expiratory techniques failed to show a benefit in the primary outcomes of severity status of bronchiolitis and in time to recovery (low quality of evidence). Three trials analysing 286 participants measured severity of bronchiolitis through clinical scores, with no significant differences between groups in any of these trials, conducted in patients with moderate and severe disease. Only one trial observed a transient significant small improvement in the Wang clinical score immediately after the intervention in patients with moderate severity of disease. There is very low quality evidence that slow passive expiratory techniques seem to be safe, as two studies (256 participants) reported that no adverse effects were observed.Forced passive expiratory techniques failed to show an effect on severity of bronchiolitis in terms of time to recovery (two trials, 509 participants) and time to clinical stability (one trial, 99 participants analysed). This evidence is of high quality and corresponds to patients with severe bronchiolitis. Furthermore, there is also high quality evidence that these techniques are related to an increased risk of transient respiratory destabilisation (risk ratio (RR) 10.2, 95% confidence interval (CI) 1.3 to 78.8, one trial) and vomiting during the procedure (RR 5.4, 95% CI 1.6 to 18.4, one trial). Results are inconclusive for bradycardia with desaturation (RR 1.0, 95% CI 0.2 to 5.0, one trial) and bradycardia without desaturation (RR 3.6, 95% CI 0.7 to 16.9, one trial), due to the limited precision of estimators. However, in mild to moderate bronchiolitis patients, forced expiration combined with conventional techniques produced an immediate relief of disease severity (one trial, 13 participants). AUTHORS' CONCLUSIONS None of the chest physiotherapy techniques analysed in this review (conventional, slow passive expiratory techniques or forced expiratory techniques) have demonstrated a reduction in the severity of disease. For these reasons, these techniques cannot be used as standard clinical practice for hospitalised patients with severe bronchiolitis. There is high quality evidence that forced expiratory techniques in severe patients do not improve their health status and can lead to severe adverse events. Slow passive expiratory techniques provide an immediate and transient relief in moderate patients without impact on duration. Future studies should test the potential effect of slow passive expiratory techniques in mild to moderate non-hospitalised patients and patients who are respiratory syncytial virus (RSV) positive. Also, they could explore the combination of chest physiotherapy with salbutamol or hypertonic saline.
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Affiliation(s)
- Marta Roqué i Figuls
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre ‐ Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 171Edifici Casa de ConvalescènciaBarcelonaCatalunyaSpain08041
| | - Maria Giné‐Garriga
- Universitat Ramon LlullFPCEE Blanquerna. Department of Physical Activity and Sport SciencesCíster 34BarcelonaSpain08022
| | - Claudia Granados Rugeles
- Pontificia Universidad JaverianaDepartment of Clinical Epidemiology and Biostatistics, Faculty of MedicineCr. 7 #40‐62, 2nd FloorBogotáDCColombia
| | - Carla Perrotta
- Hospital Italiano de Buenos AiresFamily MedicineCiudad Autonoma de Buenos AiresArgentina
| | - Jordi Vilaró
- Ramon Lull UniversityDepartment of Health SciencesPadilla, 326‐332BarcelonaSpain08025
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Goldstein H, Tagg A, Lawton B, Davis T. Easing the wheeze. Emerg Med Australas 2015; 27:384-6. [PMID: 26289296 DOI: 10.1111/1742-6723.12463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2015] [Indexed: 12/01/2022]
Affiliation(s)
- Henry Goldstein
- Emergency Department, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Andrew Tagg
- Emergency Department, Footscray Hospital, Melbourne, Victoria, Australia
| | - Ben Lawton
- Emergency Department, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Emergency Department, Logan Hospital, Logan City, Queensland, Australia
| | - Tessa Davis
- Emergency Department, Sydney Children's Hospital, Sydney, New South Wales, Australia
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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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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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Turner TL, Kopp BT, Paul G, Landgrave LC, Hayes D, Thompson R. Respiratory syncytial virus: current and emerging treatment options. CLINICOECONOMICS AND OUTCOMES RESEARCH 2014; 6:217-25. [PMID: 24812523 PMCID: PMC4008286 DOI: 10.2147/ceor.s60710] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Respiratory syncytial virus (RSV) is an important respiratory pathogen in infants and children worldwide. Although RSV typically causes mild upper respiratory infections, it frequently causes severe morbidity and mortality, especially in premature infants and children with other chronic diseases. Treatment of RSV is limited by a lack of effective antiviral treatments; however, ribavirin has been used in complicated cases, along with the addition of intravenous immune globulin in specific patients. Vaccination strategies for RSV prevention are heavily studied, but only palivizumab (Synagis®) has been approved for use in the United States in very select patient populations. Research is ongoing in developing additional vaccines, along with alternative therapies that may help prevent or decrease the severity of RSV infections in infants and children. To date, we have not seen a decrement in RSV morbidity and mortality with our current options; therefore, there is a clear need for novel RSV preventative and therapeutic strategies. In this review, we discuss the current and evolving trends in RSV treatment for infants and children.
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Affiliation(s)
- Tiffany L Turner
- Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, USA
| | - Benjamin T Kopp
- Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, USA
| | - Grace Paul
- Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, USA
| | | | - Don Hayes
- Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, USA
| | - Rohan Thompson
- Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, USA
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Piñero Fernández JA, Alfayate Migueléz S, Menasalvas Ruiz A, Salvador García C, Moreno Docón A, Sánchez-Solís de Querol M. [Epidemiology, clinical features and medical interventions in children hospitalized for bronchiolitis]. An Pediatr (Barc) 2012; 77:391-6. [PMID: 22726299 PMCID: PMC7105076 DOI: 10.1016/j.anpedi.2012.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 11/07/2011] [Accepted: 05/09/2012] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To describe the epidemiology, clinical characteristics and treatments prescribed in children with bronchiolitis admitted to our hospital. MATERIAL AND METHODS Observational, descriptive and prospective study of children younger than 18 months, admitted to Hospital Virgen de la Arrixaca of Murcia (Spain), with the diagnosis of bronchiolitis, during the season of maximum incidence (December 2008-April 2009). RESULTS A total of 235 infants were admitted, of whom 78.7% of them were aged 5 months or less. We found a positive correlation between the number of cigarettes smoked by their mothers during pregnancy and the number of hospitalization and oxygen therapy days. Children whose mothers were smokers at the time of their admission needed a greater number of oxygen therapy days. Also infants who were not breastfed needed oxygen therapy during more days. Just under one quarter (23.8%) of them had underlying diseases, with prematurity being the most frequent and a risk factor for the ongoing of oxygen therapy and hospital stay. The use of diagnostic tests, bronchodilators, corticosteroids and antibiotics was high. The onset of high temperature was associated with an increased use of antibiotics in outside and inside the hospital setting. An abnormal chest X-ray or a raised C-reactive protein was associated with a higher use of antibiotics. Respiratory Syncytial virus (RSV) was the main aetiological agent, followed by Rhinovirus, Bocavirus, Adenovirus and Metapneumovirus CONCLUSIONS The majority of hospital admissions due to bronchiolitis took place during the first months of life. Infants whose mothers smoked during pregnancy had a worse clinical outcome. Despite the availability of clinical practice guidelines in our area, the use of diagnostic tests and pharmacological treatment was high.
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Affiliation(s)
- J A Piñero Fernández
- Sección de Enfermedades Infecciosas Pediátricas, Hospital Virgen de la Arrixaca, Murcia, España.
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11
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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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12
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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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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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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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Commentary. Ann Emerg Med 2012; 59:230-2. [DOI: 10.1016/j.annemergmed.2011.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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18
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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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20
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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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21
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Wright M, Mullett CJ, Piedimonte G. Pharmacological management of acute bronchiolitis. Ther Clin Risk Manag 2011; 4:895-903. [PMID: 19209271 PMCID: PMC2621418 DOI: 10.2147/tcrm.s1556] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This article reviews the current knowledge base related to the pharmacological treatments for acute bronchiolitis. Bronchiolitis is a common lower respiratory illness affecting infants worldwide. The mainstays of therapy include airway support, supplemental oxygen, and support of fluids and nutrition. Frequently tried pharmacological interventions, such as ribavirin, nebulized bronchodilators, and systemic corticosteroids, have not been proven to benefit patients with bronchiolitis. Antibiotics do not improve the clinical course of patients with bronchiolitis, and should be used only in those patients with proven concurrent bacterial infection. Exogenous surfactant and heliox therapy also cannot be recommended for routine use, but surfactant replacement holds promise and should be further studied.
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Affiliation(s)
- Melvin Wright
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, WV, USA
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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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Hartling L, Fernandes RM, Bialy L, Milne A, Johnson D, Plint A, Klassen TP, Vandermeer B. Steroids and bronchodilators for acute bronchiolitis in the first two years of life: systematic review and meta-analysis. BMJ 2011; 342:d1714. [PMID: 21471175 PMCID: PMC3071611 DOI: 10.1136/bmj.d1714] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate and compare the efficacy and safety of bronchodilators and steroids, alone or combined, for the acute management of bronchiolitis in children aged less than 2 years. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline, Embase, Central, Scopus, PubMed, LILACS, IranMedEx, conference proceedings, and trial registers. Inclusion criteria Randomised controlled trials of children aged 24 months or less with a first episode of bronchiolitis with wheezing comparing any bronchodilator or steroid, alone or combined, with placebo or another intervention (other bronchodilator, other steroid, standard care). REVIEW METHODS Two reviewers assessed studies for inclusion and risk of bias and extracted data. Primary outcomes were selected by clinicians a priori based on clinical relevance: rate of admission for outpatients (day 1 and up to day 7) and length of stay for inpatients. Direct meta-analyses were carried out using random effects models. A mixed treatment comparison using a Bayesian network model was used to compare all interventions simultaneously. RESULTS 48 trials (4897 patients, 13 comparisons) were included. Risk of bias was low in 17% (n = 8), unclear in 52% (n = 25), and high in 31% (n = 15). Only adrenaline (epinephrine) reduced admissions on day 1 (compared with placebo: pooled risk ratio 0.67, 95% confidence interval 0.50 to 0.89; number needed to treat 15, 95% confidence interval 10 to 45 for a baseline risk of 20%; 920 patients). Unadjusted results from a single large trial with low risk of bias showed that combined dexamethasone and adrenaline reduced admissions on day 7 (risk ratio 0.65, 0.44 to 0.95; number needed to treat 11, 7 to 76 for a baseline risk of 26%; 400 patients). A mixed treatment comparison supported adrenaline alone or combined with steroids as the preferred treatments for outpatients (probability of being the best treatment based on admissions at day 1 were 45% and 39%, respectively). The incidence of reported harms did not differ. None of the interventions examined showed clear efficacy for length of stay among inpatients. CONCLUSIONS Evidence shows the effectiveness and superiority of adrenaline for outcomes of most clinical relevance among outpatients with acute bronchiolitis, and evidence from a single precise trial for combined adrenaline and dexamethasone.
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Affiliation(s)
- Lisa Hartling
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, 11402 University Avenue, Edmonton, AB, 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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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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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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Abstract
BACKGROUND Bronchiolitis is an acute, viral lower respiratory tract infection affecting infants and often treated with bronchodilators. OBJECTIVES To assess the effects of bronchodilators on clinical outcomes in infants with acute bronchiolitis. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 1) which contains the Acute Respiratory Infections Group's Specialized Register, MEDLINE (1966 to March week 2 2010) and EMBASE (2003 to March 2010). 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. Unpublished data were obtained from trial authors. MAIN RESULTS We included 28 trials (1912 infants) with bronchiolitis. In 10 inpatient and 10 outpatient studies, oxygen saturation did not improve with bronchodilators (mean difference (MD) -0.45, 95% confidence interval (CI) -0.96 to 0.05, n = 1182). Outpatient bronchodilator treatment did not reduce the rate of hospitalization (12% in bronchodilator group versus 16% in placebo, odds ratio (OR) 0.78, 95% CI 0.47 to 1.29, n = 650). Inpatient bronchodilator treatment did not reduce the duration of hospitalization (MD 0.06, 95% CI -0.27 to 0.39, n = 349). In seven inpatient and eight outpatient studies, average clinical score decreased slightly with bronchodilators (standardized mean difference (SMD) -0.37, 95% CI -0.62 to -0.13, n = 1006).Oximetry and clinical score outcomes showed significant heterogeneity. Including only studies at low risk of bias significantly reduced heterogeneity measures for oximetry (I(2) statistic = 17%) and average clinical score (I(2) statistic = 26%), while having little impact on the overall effect size of oximetry (MD -0.38, 95% CI -0.75 to 0.00, P = 0.05) and average clinical score (SMD -0.26, 95% CI -0.44 to -0.08, P = 0.005).Effect estimates for outpatients were slightly larger than for inpatients for oximetry (outpatients MD -0.57, 95% CI -1.13 to 0.00 versus inpatients MD -0.29, 95% CI -1.10 to 0.51) and average clinical score (outpatients SMD -0.49, 95% CI -0.86 to -0.11 versus inpatients SMD -0.20, 95% CI -0.43 to 0.03). Adverse effects included tachycardia and tremors. AUTHORS' CONCLUSIONS Bronchodilators 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. The small improvements in clinical scores for outpatients must be weighed against the costs and adverse effects of bronchodilators.
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Affiliation(s)
- A M Gadomski
- Mary Imogene Bassett Hospital, Research Institute, 1 Atwell Road, Cooperstown, NY 13326, USA.
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Fernandes RM, Bialy LM, Vandermeer B, Tjosvold L, Plint AC, Patel H, Johnson DW, Klassen TP, Hartling L. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev 2010:CD004878. [PMID: 20927740 DOI: 10.1002/14651858.cd004878.pub3] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Previous systematic reviews have not shown clear benefit of glucocorticoids for acute viral bronchiolitis, but their use remains considerable. Recent large trials add substantially to current evidence and suggest novel glucocorticoid-including treatment approaches. OBJECTIVES To review the efficacy and safety of systemic and inhaled glucocorticoids in children with acute viral bronchiolitis. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, issue 4); MEDLINE (1950 to November 2009); EMBASE (1980 to Week 47 2009); LILACS (1982 to November 2009); Scopus® (1823 to November 2009); and IRAN MedEx (1998 to November 2009). SELECTION CRITERIA Randomised controlled trials (RCTs) comparing short-term systemic or inhaled glucocorticoids versus placebo or another intervention in children < 24 months with acute bronchiolitis (first episode with wheezing). Our primary outcomes were: admissions by days 1 and 7 for outpatient studies; and length of stay (LOS) for inpatient studies. Secondary outcomes included clinical severity parameters, healthcare use, pulmonary function, symptoms, quality of life and harms. DATA COLLECTION AND ANALYSIS Two authors independently extracted data on study and participant characteristics, interventions and outcomes. We assessed risk of bias and graded strength of evidence. Inpatient and outpatient results were meta-analysed separately using random-effects models. We pre-specified subgroup analyses, including the combined use of protocolised bronchodilators. MAIN RESULTS We included 17 trials (2596 participants); only two had low overall risk of bias. Baseline severity, glucocorticoid schemes, comparators and outcomes were heterogeneous. Glucocorticoids did not significantly reduce outpatient admissions by days 1 and 7 when compared to placebo (pooled risk ratios (RRs) 0.92; 95% CI 0.78 to 1.08; and 0.86; 95% CI 0.7 to 1.06, respectively). There was no benefit in LOS for inpatients (mean difference -0.18 days; 95% CI -0.39 to 0.04). Unadjusted results from a large factorial low risk of bias RCT found combined high-dose systemic dexamethasone and inhaled epinephrine reduced admissions by day 7 (baseline risk of admission 26%; RR 0.65, 95% CI 0.44 to 0.95; number needed to treat 11, 95% CI 7 to 76), with no differences in short-term adverse effects. No other comparisons showed relevant differences in primary outcomes. AUTHORS' CONCLUSIONS Current evidence does not support a clinically relevant effect of systemic or inhaled glucocorticoids on admissions or length of hospitalization. Combined dexamethasone and epinephrine may reduce outpatient admissions, but results are exploratory and safety data limited. Future research should further assess the efficacy, harms and applicability of combined therapy.
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Affiliation(s)
- Ricardo M Fernandes
- Gulbenkian Programme for Advanced Medical Education and, Departamento da Criança e da Família, and Farmacologia Clínica e Terapêutica, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte EPE and Faculdade de Medicina, Instituto de Medicina Molecular, Universidade de Lisboa, Avenida Professor Egas Moniz, Lisboa, Portugal, 1649-028
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Chu IW, Mellis C, Lin WY, Enriquez A. Nebulised deoxyribonuclease for viral bronchiolitis in infants. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd008395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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González de Dios J, Ochoa Sangrador C. Conferencia de Consenso sobre bronquiolitis aguda (I): metodología y recomendaciones. An Pediatr (Barc) 2010; 72:221.e1-221.e33. [DOI: 10.1016/j.anpedi.2009.11.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2009] [Accepted: 11/30/2009] [Indexed: 01/17/2023] Open
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Abstract
Acute viral bronchiolitis remains a cause of substantial morbidity and health care costs in young infants. It is the most common lower respiratory tract condition and most common reason for admission to hospital in infants. Many respiratory viruses have been associated with acute viral bronchiolitis although respiratory syncytial virus (RSV) remains the most frequently identified virus. Most infants have a mild self limiting illness while others have more severe illness and require hospital admission and some will need ventilatory support. Differences in innate immune function in response to the respiratory viral insult as well as differences in the geometry of the airways may explain some of the variability in clinical pattern. Young age and history of prematurity remain the most important risk factors although male gender, indigenous status, exposure to tobacco smoke, poor socioeconomic factors and associated co-morbidities such as chronic lung disease and congenital heart disease increase the risks of more severe illness. Supportive therapy remains the major treatment option as no specific treatments to date have been shown to provide clinically important benefits except for inhaled hypertonic saline. Prophylaxis of high risk infants with palivizumab should be considered although the cost effectiveness is still unclear. Many questions remain regarding optimal management approaches for infants requiring hospitalisation with bronchiolitis including use of nasogastric feeding, the optimal role of supplemental oxygen, optimal use of hypertonic saline and the role of combinations of therapies, the use of heliox or modern physiotherapy approaches.
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Affiliation(s)
- Claire Wainwright
- Department of Paediatrics and Child Health, Queensland Children's Respiratory Centre, Royal Children's Hospital, University of Queensland, Herston Rd, Herston, Queensland, Australia 4029.
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Chidgey SM, Broadley KJ. Respiratory syncytial virus infections: characteristics and treatment. J Pharm Pharmacol 2010; 57:1371-81. [PMID: 16259768 DOI: 10.1211/jpp.57.11.0001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Abstract
In this review, we describe the history, epidemiology and clinical manifestations of infections attributed to respiratory syncytial virus (RSV) in children. At present, no cure exists for RSV infection but commonly employed palliative treatments include oxygen and inhaled β2-adrenoceptor agonists, such as salbutamol, to relieve the wheezing and increased bronchiolar smooth muscle constriction. Adrenaline (epinephrine) has been found to be superior to the selective β2-adrenoceptor agonists. Oral or inhaled corticosteroids should counteract the inflammatory response to RSV infection but their effectiveness is controversial. Inhaled ribavirin is the only licensed antiviral product approved for the treatment of RSV lower respiratory-tract infection in hospitalized children, although its use is now restricted to high-risk infants. Other treatments considered are nasopharyngeal suctioning, surfactant therapy, recombinant human deoxyribonuclease I, heliox (helium:oxygen) and inhaled nitric oxide. Prevention of infection by RSV antibodies is another strategy and, currently, palivizumab is the only safe, effective and convenient preventative treatment for RSV disease in high-risk populations of infants and young children. Its cost-effectiveness, however, has been questioned. Both live attenuated and subunit vaccines against RSV infection have been developed but so far there is no safe and effective vaccine available. Finding effective treatments and prophylactic measures remains a major challenge for the future.
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Affiliation(s)
- Sharon M Chidgey
- Department of Pharmacology, Welsh School of Pharmacy, Cardiff University, King Edward VII Avenue, Cardiff CF10 3XF, UK
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González de Dios J, Ochoa Sangrador C. Estudio de variabilidad en el abordaje de la bronquiolitis aguda en España en relación con la edad de los pacientes. An Pediatr (Barc) 2010; 72:4-18. [DOI: 10.1016/j.anpedi.2009.10.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Accepted: 10/26/2009] [Indexed: 10/20/2022] Open
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Abstract
Acute lower respiratory infections (ALRI) are the major cause of morbidity and mortality in young children worldwide. ALRIs are important indicators of the health disparities that persist between Indigenous and non-Indigenous children in developed countries. Bronchiolitis and pneumonia account for the majority of the ALRI burden. The epidemiology, diagnosis, and management of these diseases in Indigenous children are discussed. In comparison with non-Indigenous children in developing countries they have higher rates of disease, more complications, and their management is influenced by several unique factors including the epidemiology of disease and, in some remote regions, constraints on hospital referral and access to highly trained staff. The prevention of repeat infections and the early detection and management of chronic lung disease is critical to the long-term respiratory and overall health of these children.
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Affiliation(s)
- Anne B Chang
- Child Health Division, Menzies School of Health Research, Charles Darwin University Darwin, Rocklands Drive, Tiwi, NT 0811, Australia.
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Meyburg J, Bernhard M, Hoffmann GF, Motsch J. Principles of pediatric emergency care. DEUTSCHES ARZTEBLATT INTERNATIONAL 2009; 106:739-47; quiz 748. [PMID: 19997587 PMCID: PMC2788902 DOI: 10.3238/arztebl.2009.0739] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Accepted: 09/17/2009] [Indexed: 11/27/2022]
Abstract
BACKGROUND Children account for only a small percentage of pre-hospital emergency patients but are a special challenge for the treating physician. METHODS The Medline database was selectively searched for articles appearing up to June 2009. The authors added other important literature of which they were aware. RESULTS The broad spectrum of diseases, the wide age range with the physiological and anatomical changes that occur in it, and the special psychological, emotional, and communicative features of children make pediatric emergencies a special challenge for emergency physicians. CONCLUSIONS A mastery of basic emergency techniques including clinical evaluation of the child, establishment of venous access, airway management, resuscitation, and drug dosing is essential for the successful emergency treatment of children. We recommend classifying the common non-traumatic pediatric emergencies by four cardinal manifestations: respiratory distress, altered consciousness, seizure, and shock. Classifying these rare emergency situations in this way helps assure that their treatment will be goal-oriented and appropriate to the special needs of sick children.
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Affiliation(s)
- Jochen Meyburg
- Abteilung Allgemeine Pädiatrie, Zentrum für Kinder- und Jugendmedizin, Universitätsklinikum Heidelberg, Germany.
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Frohna JG, Frey U. Combination of epinephrine and dexamethasone may reduce hospitalization in children with bronchiolitis. J Pediatr 2009; 155:761-2. [PMID: 19840626 DOI: 10.1016/j.jpeds.2009.08.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- John G Frohna
- Department of Pediatrics, University of Wisconsin, Madison, Wisconsin, USA
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38
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Grammatikos AP, Mantadakis E, Falagas ME. Meta-analyses on Pediatric Infections and Vaccines. Infect Dis Clin North Am 2009; 23:431-57. [DOI: 10.1016/j.idc.2009.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Affiliation(s)
- Kam-Lun Hon
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.
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40
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Prospective population-based study of RSV-related intermediate care and intensive care unit admissions in Switzerland over a 4-year period (2001-2005). Infection 2008; 37:109-16. [PMID: 19412586 DOI: 10.1007/s15010-008-8130-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Accepted: 08/06/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Respiratory syncytial virus (RSV) infections are a leading cause of hospital admissions in small children. A substantial proportion of these patients require medical and nursing care, which can only be provided in intermediate (IMC) or intensive care units (ICU). This article reports on all children aged < 3 years who required admission to IMC and/or ICU between October 1, 2001 and September 30, 2005 in Switzerland. PATIENTS AND METHODS We prospectively collected data on all children aged < 3 years who were admitted to an IMC or ICU for an RSV-related illness. Using a detailed questionnaire, we collected information on risk factors, therapy requirements, length of stay in the IMC/ICU and hospital, and outcome. RESULTS Of the 577 cases reported during the study period, 90 were excluded because the patients did not fulfill the inclusion criteria; data were incomplete in another 25 cases (5%). Therefore, a total of 462 verified cases were eligible for analysis. At the time of hospital admission, only 31 patients (11%) were older than 12 months. Since RSV infection was not the main reason for IMC/ICU admission in 52% of these patients, we chose to exclude this subgroup from further analyses. Among the 431 infants aged < 12 months, the majority (77%) were former near term or full term (NT/FT) infants with a gestational age > or = 35 weeks without additional risk factors who were hospitalized at a median age of 1.5 months. Gestational age (GA) < 32 weeks, moderate to severe bronchopulmonary dysplasia (BPD), and congenital heart disease (CHD) were all associated with a significant risk increase for IMC/ICU admission (relative risk 14, 56, and 10, for GA < or = 32 weeks, BPD, and CHD, respectively). Compared with NT/FT infants, high-risk infants were hospitalized at an older age (except for infants with CHD), required more invasive and longer respiratory support, and had longer stays in the IMC/ICU and hospital. CONCLUSIONS In Switzerland, RSV infections lead to the IMC/ICU admission of approximately 1%-2% of each annual birth cohort. Although prematurity, BPD, and CHD are significant risk factors, non-pharmacological preventive strategies should not be restricted to these high-risk patients but also target young NT/FT infants since they constitute 77% of infants requiring IMC/ICU admission.
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Walsh P, Caldwell J, McQuillan KK, Friese S, Robbins D, Rothenberg SJ. Comparison of nebulized epinephrine to albuterol in bronchiolitis. Acad Emerg Med 2008; 15:305-13. [PMID: 18370982 PMCID: PMC2613253 DOI: 10.1111/j.1553-2712.2008.00064.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare the effect of nebulized racemic epinephrine to nebulized racemic albuterol on successful discharge from the emergency department (ED). METHODS Children up to their 18th month of life presenting to two teaching hospital EDs with a clinical diagnosis of bronchiolitis who were ill enough to warrant treatment but did not need immediate intubation were eligible for this double-blind randomized controlled trial (RCT). Patients received either three doses of racemic albuterol or one dose of racemic epinephrine plus two saline nebulizers. Disposition was decided 2 hours after the first nebulizer. Successful discharge was defined as not requiring additional bronchodilators in the ED after study drug administration and not subsequently admitted within 72 hours. Adjusted relative risks (aRR) were estimated using the modified Poisson regression with successful discharge as the dependent variable and study drug and severity of illness as exposures. Secondary analysis was performed for patients aged less than 12 months and first presentation. RESULTS The authors analyzed 703 patients; 352 patients were given albuterol and 351 epinephrine. A total of 173 in the albuterol group and 160 in the epinephrine group were successfully discharged (crude RR = 1.08, 95% confidence interval [CI] = 0.92 to 1.26). When adjusted for severity of illness, patients who received albuterol were significantly more likely than patients receiving epinephrine to be successfully discharged (aRR = 1.18, 95% CI = 1.02 to 1.36). This was also true among those with first presentation and in those less than 12 months of age. CONCLUSIONS In children up to the 18th month of life, ED treatment of bronchiolitis with nebulized racemic albuterol led to more successful discharges than nebulized epinephrine.
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Affiliation(s)
- Paul Walsh
- Department of Emergency Medicine, Kern Medical Center, Bakersfield, CA, USA.
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43
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Kao B, Stewart de Ramirez SA, Belfort MB, Hansen A. Inhaled epinephrine for the treatment of transient tachypnea of the newborn. J Perinatol 2008; 28:205-10. [PMID: 18200024 DOI: 10.1038/sj.jp.7211917] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Infants with transient tachypnea of the newborn (TTN) have relatively low levels of epinephrine, which is known to mediate fetal lung fluid absorption. Providing exogenous epinephrine could be a valuable diagnostic and therapeutic intervention for this common condition. Our primary objective was to determine if inhaled racemic epinephrine is safe for the treatment of TTN. Our secondary objective was to determine its efficacy. STUDY DESIGN We conducted a randomized, blinded, placebo-controlled pilot trial. Inhaled racemic epinephrine or placebo was administered to 20 newborns with TTN. Physiologic variables of cardiopulmonary function were measured during and after treatment. RESULT No infant in either the treatment or control arm experienced an adverse event, including tachycardia or hypertension. We did not detect a difference between the two groups regarding rate of resolution of tachypnea. CONCLUSION We did not observe any adverse effects of inhaled racemic epinephrine when administered for the treatment of TTN. Larger studies are necessary to determine efficacy.
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Affiliation(s)
- B Kao
- Division of Newborn Medicine, Department of Medicine, Children's Hospital Boston, Boston, MA, USA
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Affiliation(s)
- Andrew Bush
- Imperial School of Medicine at National Heart and Lung Institute, London SW3 6NP.
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45
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Abstract
Respiratory syncytial virus (RSV), the recently identified human metapneumovirus (HMPV), and the human parainfluenza viruses (HPIVs), cause most cases of childhood croup, bronchiolitis, and pneumonia. Influenza virus also causes a significant burden of disease in young children, although its significance in children was not fully recognized until recently. This article discusses pathogens that have been studied for several decades, including RSV and HPIVs, and also explores the newly identified viral pathogens HMPV and human coronavirus NL63. The escalating rate of emergence of new infectious agents, fortunately meeting with equally rapid advancements in molecular methods of surveillance and pathogen discovery, means that new organisms will soon be added to the list. A section on therapies for bronchiolitis addresses the final common pathways that can result from infection with diverse pathogens, highlighting the mechanisms that may be amenable to therapeutic approaches. The article concludes with a discussion of the overarching impact of new diagnostic strategies.
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46
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Abstract
Bronchiolitis is a disorder most commonly caused in infants by viral lower respiratory tract infection. It is the most common lower respiratory infection in this age group. It is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, increased mucus production, and bronchospasm. The American Academy of Pediatrics convened a committee composed of primary care physicians and specialists in the fields of pulmonology, infectious disease, emergency medicine, epidemiology, and medical informatics. The committee partnered with the Agency for Healthcare Research and Quality and the RTI International-University of North Carolina Evidence-Based Practice Center to develop a comprehensive review of the evidence-based literature related to the diagnosis, management, and prevention of bronchiolitis. The resulting evidence report and other sources of data were used to formulate clinical practice guideline recommendations. This guideline addresses the diagnosis of bronchiolitis as well as various therapeutic interventions including bronchodilators, corticosteroids, antiviral and antibacterial agents, hydration, chest physiotherapy, and oxygen. Recommendations are made for prevention of respiratory syncytial virus infection with palivizumab and the control of nosocomial spread of infection. Decisions were made on the basis of a systematic grading of the quality of evidence and strength of recommendation. The clinical practice guideline underwent comprehensive peer review before it was approved by the American Academy of Pediatrics. This clinical practice guideline is not intended as a sole source of guidance in the management of children with bronchiolitis. Rather, it is intended to assist clinicians in decision-making. It is not intended to replace clinical judgment or establish a protocol for the care of all children with this condition. These recommendations may not provide the only appropriate approach to the management of children with bronchiolitis.
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47
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Abstract
Bronchiolitis is a distressing, potentially life-threatening respiratory condition that affects young babies. Around 2-3% of all infants younger than 1 year are admitted to hospital with bronchiolitis, usually during the seasonal epidemic. The majority of these infants are infected with respiratory syncytial virus and all have an intense inflammatory response in their airways. Although most infants recover, they have an increased risk of recurrent wheezing. Although bronchiolitis is common, little is known about what causes infants to be susceptible. Diagnostic interventions have little effect on clinical outcome, and apart from supportive measures, there is no specific treatment. Bronchiolitis therefore presents an intriguing clinical conundrum and a major challenge to researchers. High quality clinical studies are needed to clarify assessment of disease severity and criteria for hospital admission, particularly the use of pulse oximetry and chest radiography. Careful mapping of the inflammatory pathways in the pathogenesis of bronchiolitis should lead to development of new therapies to alleviate symptoms.
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Affiliation(s)
- Rosalind L Smyth
- Division of Child Health, School of Reproductive and Developmental Medicine, University of Liverpool, Alder Hey Children's Hospital, Liverpool L12 2AP, UK.
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48
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Abstract
Preparation for pediatric pulmonary emergencies in the office setting includes adequate training for all medical staff, properly sized and working equipment, and medications to help alleviate respiratory distress when indicated. Status asthmaticus, viral bronchiolitis, and croup account for the vast majority of respiratory emergencies encountered in the pediatric office setting. Timely application of proven approaches to assessment and treatment of these illnesses can prevent hospitalization, decrease length of hospitalizations, and save lives.
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Affiliation(s)
- André Fallot
- Division of Pediatric Pulmonology, San Antonio Military Pediatric Center, Lackland Air Force Base, TX 78236, USA.
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Langley JM, Smith MB, LeBlanc JC, Joudrey H, Ojah CR, Pianosi P. Racemic epinephrine compared to salbutamol in hospitalized young children with bronchiolitis; a randomized controlled clinical trial [ISRCTN46561076]. BMC Pediatr 2005; 5:7. [PMID: 15876347 PMCID: PMC1142326 DOI: 10.1186/1471-2431-5-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2004] [Accepted: 05/05/2005] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bronchiolitis is the most common cause of lower respiratory tract illness in infancy, and hospital admission rates appear to be increasing in Canada and the United States. Inhaled beta agonists offer only modest short-term improvement. Trials of racemic epinephrine have shown conflicting results. We sought to determine if administration of racemic epinephrine during hospital stay for bronchiolitis improved respiratory distress, was safe, and shortened length of stay. METHODS The study was a randomized, double-blind controlled trial of aerosolized racemic epinephrine compared to salbutamol every one to 4 hours in previously well children aged 6 weeks to < or = 2 years of age hospitalized with bronchiolitis. The primary outcome was symptom improvement as measured by the Respiratory Distress Assessment Instrument (RDAI); secondary outcomes were length of stay in hospital, adverse events, and report of symptoms by structured parental telephone interview one week after discharge. RESULTS 62 children with a mean age of 6.4 months were enrolled; 80% of children had Respiratory Syncytial Virus (RSV). Racemic epinephrine resulted in significant improvement in wheezing and the total RDAI score on day 2 and over the entire stay (p < 0.05). The mean LOS in the epinephrine arm was 2.6 days (95% CI 2, 3.2) v. 3.4 days in those in the salbutamol group (95% CI 2.6, 4.2) (p > 0.05). Adverse events were not significantly different in the two arms. At one week post-discharge, over half of parents reported that their child still had a respiratory symptom and 40% had less than normal feeding. CONCLUSION Racemic epinephrine relieves respiratory distress in hospitalized infants with bronchiolitis and is safe but does not abbreviate hospital stay. Morbidity associated with bronchiolitis as identified by parents persists for at least one week after hospital discharge in most infants.
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Affiliation(s)
- Joanne M Langley
- Clinical Trials Research Centre, Dalhousie University, Halifax, Canada
- Departments of Pediatrics, Dalhousie University, Halifax, Canada
- Departments of Community Health and Epidemiology, Dalhousie University, Halifax, Canada
| | - Michael B Smith
- Department of Pediatrics, Queen's University Belfast and Craigavon Area Hospital, Craigavon, Northern Ireland
| | - John C LeBlanc
- Departments of Pediatrics, Dalhousie University, Halifax, Canada
- Departments of Community Health and Epidemiology, Dalhousie University, Halifax, Canada
- Department of Psychiatry, Dalhousie University, Halifax, Canada
| | - Heather Joudrey
- Clinical Trials Research Centre, Dalhousie University, Halifax, Canada
| | - Cecil R Ojah
- Departments of Pediatrics, Dalhousie University, Halifax, Canada
- Saint John Regional Hospital, Atlantic Health Sciences Corporation, Saint John, Canada
| | - Paul Pianosi
- Division of Allergy, Immunology and Pulmonology, Department of Pediatric and Adolescent Medicine, Mayo Clinic Rochester, MN, USA
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Christakis DA, Cowan CA, Garrison MM, Molteni R, Marcuse E, Zerr DM. Variation in inpatient diagnostic testing and management of bronchiolitis. Pediatrics 2005; 115:878-84. [PMID: 15805359 DOI: 10.1542/peds.2004-1299] [Citation(s) in RCA: 172] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We know little about the variation in diagnosis and management of bronchiolitis. The objectives of this study were (1) to document variations in treatment and diagnostic approaches, lengths of stay (LOSs), and readmission rates and (2) to determine which potentially modifiable process of care measures are associated with longer LOSs and antibiotic usage. METHODS We used the Pediatric Health Information System, which includes demographic, diagnostic, and detailed patient-level data on 30 large children's hospitals. We examined infants who were younger than 1 year and hospitalized for bronchiolitis (October 2001-September 2003). Multivariate analysis of variance was used to determine whether the variance in the outcomes was hospital related after controlling for other covariates. Linear regression was used to model predictors of increased LOS. Logistic regression was used to model antibiotic usage. Analyses were stratified by age group (<3 months and 3-11 months). RESULTS A total of 17397 patients were included in the analysis. The mean LOS was 2.97 days; 72% of patients received chest radiographs, 45% received antibiotics, and 25% received systemic steroids. The mean LOS varied considerably across hospitals (range: 2.40-3.90 days), and hospital remained a significant contributor to LOS variation after controlling for our covariates. Variations in the use of diagnostic tests and medications as well as readmission rates also existed and also remained significant after controlling for covariates. The factors associated with the greatest increases in LOS in the regression analyses included higher severity scores and use of antibiotics, bronchodilators, and corticosteroids. The strongest predictors of antibiotic use in the logistic regression analyses were higher severity scores and receipt of a blood or cerebrospinal fluid culture. Receiving a chest radiograph was a significant predictor of antibiotic use in older but not younger infants. CONCLUSIONS Considerable, unexplained variation exists in the inpatient management of bronchiolitis. The development of national guidelines and controlled trials of new therapies and different management approaches are indicated.
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