Antibiotics for bronchiolitis in children

High-flow nasal cannula therapy for infants with bronchiolitis

BACKGROUND

Bronchiolitis is a common lower respiratory tract illness, usually of viral aetiology, affecting infants younger than 24 months of age and is the most common cause of hospitalisation of infants. It causes airway inflammation, mucus production and mucous plugging, resulting in airway obstruction. Effective pharmacotherapy is lacking and bronchiolitis is a major cause of morbidity and mortality. Conventional treatment consists of supportive therapy in the form of fluids, supplemental oxygen, and respiratory support. Traditionally, oxygen delivery is as a dry gas at 100% concentration via low-flow nasal prongs. However, the use of heated, humidified, high-flow nasal cannula (HFNC) therapy enables delivery of higher inspired gas flows of an air/oxygen blend, at 2 to 3 L/kg per minute up to 60 L/min in children. It can provide some level of continuous positive airway pressure (CPAP) to improve ventilation in a minimally invasive manner. This may reduce the need for invasive respiratory support, thus potentially lowering costs, with clinical advantages and fewer adverse effects.

OBJECTIVES

To assess the effects of HFNC therapy compared with conventional respiratory support in the treatment of infants with bronchiolitis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, and Web of Science (from June 2013 to December 2022). In addition, we consulted ongoing trial registers and experts in the field to identify ongoing studies, checked reference lists of relevant articles, and searched for conference abstracts. Date restrictions were imposed such that we only searched for studies published after the original version of this review.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs that assessed the effects of HFNC (delivering oxygen or oxygen/room air blend at flow rates greater than 4 L/minute) compared to conventional treatment in infants (< 24 months) with a clinical diagnosis of bronchiolitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently used a standard template to assess trials for inclusion and extract data on study characteristics, risk of bias elements, and outcomes. We contacted trial authors to request missing data. Outcome measures included the need for invasive respiratory support and time until discharge, clinical severity measures, oxygen saturation, duration of oxygen therapy, and adverse events.

MAIN RESULTS

In this update we included 15 new RCTs (2794 participants), bringing the total number of RCTs to 16 (2813 participants). Of the 16 studies, 11 compared high-flow to low-flow, and five compared high-flow to CPAP. These studies included infants less than 24 months of age as stated in our selection criteria. There were no significant differences in sex. We found that when comparing high-flow to low-flow oxygen therapy for infants with bronchiolitis there may be a reduction in the total length of hospital stay (mean difference (MD) -0.65 days, 95% confidence interval (CI) -1.23 to -0.06; P < 0.00001, I2 = 89%; 7 studies, 1951 participants; low-certainty evidence). There may also be a reduction in the duration of oxygen therapy (MD -0.59 days, 95% CI -1 to -0.18; P < 0.00001, I2 = 86%; 7 studies, 2132 participants; low-certainty evidence). We also found that there was probably an improvement in respiratory rate at one and 24 hours, and heart rate at one, four to six, and 24 hours in those receiving high-flow oxygen therapy when compared to pre-intervention baselines. There was also probably a reduced risk of treatment escalation in those receiving high-flow when compared to low-flow oxygen therapy (risk ratio (RR) 0.55, 95% CI 0.39 to 0.79; P = 0.001, I2 = 43%; 8 studies, 2215 participants; moderate-certainty evidence). We found no difference in the incidence of adverse events (RR 1.2, 95% CI 0.38 to 3.74; P = 0.76, I2 = 26%; 4 studies, 1789 participants; low-certainty evidence) between the two groups. The lack of comparable outcomes in studies comparing high-flow and CPAP, as well as the small numbers of participants, limited our ability to perform meta-analysis on this group.

AUTHORS' CONCLUSIONS

High-flow nasal cannula therapy may have some benefits over low-flow oxygen for infants with bronchiolitis in terms of a greater improvement in respiratory and heart rates, as well as a modest reduction in the length of hospital stay and duration of oxygen therapy, with a reduced incidence of treatment escalation. There does not appear to be a difference in the number of adverse events. Further studies comparing high-flow nasal cannula therapy and CPAP are required to demonstrate the efficacy of one modality over the other. A standardised clinical definition of bronchiolitis, as well as the use of a validated clinical severity score, would allow for greater and more accurate comparison between studies.

Decreasing Unnecessary Antibiotic Usage in Patients Admitted With Bronchiolitis

BACKGROUND AND OBJECTIVES

Bronchiolitis is a viral syndrome that occurs in children aged <2 years and is a common reason for admission to children's hospitals. The American Academy of Pediatrics bronchiolitis guideline discourages routine antibiotic therapy for bronchiolitis. Despite this, there is high use of antibiotics in this patient population.

METHODS

We performed a retrospective chart review of all patients aged ≤2 years admitted to our tertiary care center with bronchiolitis during 2 subsequent respiratory seasons. Between the 2 seasons, we provided an intervention to our hospital medicine group, which included a didactic review of American Academy of Pediatrics bronchiolitis guideline followed by subsequent, ongoing reinforcement from antibiotic stewardship weekday rounds.

RESULTS

We were able to achieve a 40% decrease in overall antibiotic use between the 2 study periods (25% vs 15%, P < .001).

CONCLUSIONS

Provider education, along with focused antibiotic stewardship audits with real-time feedback, resulted in decreased use of antibiotics in patients admitted with bronchiolitis.

Antibiotic use and prescription and its effects on Enterobacteriaceae in the gut in children with mild respiratory infections in Ho Chi Minh City, Vietnam. A prospective observational outpatient study

BACKGROUND AND OBJECTIVES

Treatment guidelines do not recommend antibiotic use for acute respiratory infections (ARI), except for streptococcal pharyngitis/tonsillitis and pneumonia. However, antibiotics are prescribed frequently for children with ARI, often in absence of evidence for bacterial infection. The objectives of this study were 1) to assess the appropriateness of antibiotic prescriptions for mild ARI in paediatric outpatients in relation to available guidelines and detected pathogens, 2) to assess antibiotic use on presentation using questionnaires and detection in urine 3) to assess the carriage rates and proportions of resistant intestinal Enterobacteriaceae before, during and after consultation.

MATERIALS AND METHODS

Patients were prospectively enrolled in Children's Hospital 1, Ho Chi Minh City, Vietnam and diagnoses, prescribed therapy and outcome were recorded on first visit and on follow-up after 7 days. Respiratory bacterial and viral pathogens were detected using molecular assays. Antibiotic use before presentation was assessed using questionnaires and urine HPLC. The impact of antibiotic usage on intestinal Enterobacteriaceae was assessed with semi-quantitative culture on agar with and without antibiotics on presentation and after 7 and 28 days.

RESULTS

A total of 563 patients were enrolled between February 2009 and February 2010. Antibiotics were prescribed for all except 2 of 563 patients. The majority were 2nd and 3rd generation oral cephalosporins and amoxicillin with or without clavulanic acid. Respiratory viruses were detected in respiratory specimens of 72.5% of patients. Antibiotic use was considered inappropriate in 90.1% and 67.5%, based on guidelines and detected pathogens, respectively. On presentation parents reported antibiotic use for 22% of patients, 41% of parents did not know and 37% denied antibiotic use. Among these three groups, six commonly used antibiotics were detected with HPLC in patients' urine in 49%, 40% and 14%, respectively. Temporary selection of 3rd generation cephalosporin resistant intestinal Enterobacteriaceae during antibiotic use was observed, with co-selection of resistance to aminoglycosides and fluoroquinolones.

CONCLUSIONS

We report overuse and overprescription of antibiotics for uncomplicated ARI with selection of resistant intestinal Enterobacteriaceae, posing a risk for community transmission and persistence in a setting of a highly granular healthcare system and unrestricted access to antibiotics through private pharmacies.

REGISTRATION

This study was registered at the International Standard Randomised Controlled Trials Number registry under number ISRCTN32862422: http://www.isrctn.com/ISRCTN32862422.

Associations Between Quality Measures and Outcomes for Children Hospitalized With Bronchiolitis

OBJECTIVES

To use adherence to the Pediatric Respiratory Illness Measurement System (PRIMES) indicators to evaluate the strength of associations for individual indicators with length of stay (LOS) and cost for bronchiolitis.

METHODS

We prospectively enrolled children with bronchiolitis at 5 children's hospitals between July 1, 2014, and June 30, 2016. We examined associations between adherence to each individual PRIMES indicator for bronchiolitis and LOS and cost. Sixteen indicators were included, 9 "overuse" indicators for care that should not occur and 7 "underuse" indicators for care that should occur. We performed mixed effects linear regression to examine the association between adherence to each individual indicator and LOS (hours) and cost (dollars). All models controlled for patient demographics, patient complexity, and hospital.

RESULTS

We enrolled 699 participants. The mean age was 8 months; 56% were male, 38% were white, and 63% had public insurance. Three indicators were significantly associated with shorter LOS and lower cost. All 3 indicators were overuse indicators and related to laboratory testing: no blood cultures (adjusted mean difference in LOS: -24.3 hours; adjusted mean cost difference: -$731, P < .001), no complete blood cell counts (LOS: -17.8 hours; cost: -$399, P < .05), and no respiratory syncytial virus testing (LOS: -16.6 hours; cost: -$272, P < .05). Two underuse indicators were associated with higher cost: documentation of oral intake at discharge ($671, P < .01) and documentation of hospital follow-up ($538, P < .05).

CONCLUSIONS

A subset of PRIMES quality indicators for bronchiolitis are strongly associated with improved outcomes and can serve as important measures for future quality improvement efforts.

Lung ultrasound in infants with bronchiolitis

Lung ultrasound (LUS) is nowadays a fast-growing field of study since the technique has been widely acknowledged as a cost-effective, radiation free, and ready available alternative to standard X-ray imaging. However, despite extensive acoustic characterization studies and documented medical evidences, a lot is still unknown about how ultrasounds interact with lung tissue. One of the most discussed lung artifacts are the B-lines [in all ages] and the subpleural consolidations (in young infants). Recently, LUS has been claimed to be able to detect pneumonia in infants with bronchiolitis, although this can be an overestimation due to the peculiar physiology of small peripheral airways of the pediatric lung (particularly in neonate/infants). Distinguishing consolidations from atelectasis in young infants with bronchiolitis can be challenging and those criteria well defined for adults and older children (size and bronchogram) cannot easily translated in this specific subset. Therefore, if decades of studies clearly defined the low risk of SBI in bronchiolitis, we need to be careful before stating that LUS may confirm pneumonia in such a high number of cases and, importantly, new and promising techniques such as LUS should give us new insights bringing us to improvements and not back to overuse of antibiotics. More studies are surely need on this topic.

Impact of antibiotics for children presenting to general practice with cough on adverse outcomes: secondary analysis from a multicentre prospective cohort study

Background

Clinicians commonly prescribe antibiotics to prevent major adverse outcomes in children presenting in primary care with cough and respiratory symptoms, despite limited meaningful evidence of impact on these outcomes.

Aim

To estimate the effect of children’s antibiotic prescribing on adverse outcomes within 30 days of initial consultation.

Design and setting

Secondary analysis of 8320 children in a multicentre prospective cohort study, aged 3 months to <16 years, presenting in primary care across England with acute cough and other respiratory symptoms.

Method

Baseline clinical characteristics and antibiotic prescribing data were collected, and generalised linear models were used to estimate the effect of antibiotic prescribing on adverse outcomes within 30 days (subsequent hospitalisations and reconsultation for deterioration), controlling for clustering and clinicians’ propensity to prescribe antibiotics.

Results

Sixty-five (0.8%) children were hospitalised and 350 (4%) reconsulted for deterioration. Clinicians prescribed immediate and delayed antibiotics to 2313 (28%) and 771 (9%), respectively. Compared with no antibiotics, there was no clear evidence that antibiotics reduced hospitalisations (immediate antibiotic risk ratio [RR] 0.83, 95% confidence interval [CI] = 0.47 to 1.45; delayed RR 0.70, 95% CI = 0.26 to 1.90, overall P = 0.44). There was evidence that delayed (rather than immediate) antibiotics reduced reconsultations for deterioration (immediate RR 0.82, 95% CI = 0.65 to 1.07; delayed RR 0.55, 95% CI = 0.34 to 0.88, overall P = 0.024).

Conclusion

Most children presenting with acute cough and respiratory symptoms in primary care are not at risk of hospitalisation, and antibiotics may not reduce the risk. If an antibiotic is considered, a delayed antibiotic prescription may be preferable as it is likely to reduce reconsultation for deterioration.

Bronchiolitis in children: The Saudi initiative of bronchiolitis diagnosis, management, and prevention (SIBRO)

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.

Intermittent versus continuous oxygen saturation monitoring for infants hospitalised with bronchiolitis: study protocol for a pragmatic randomised controlled trial

INTRODUCTION

Bronchiolitis is the most common reason for hospitalisation in infants in developed countries. The main focus of hospital care is on supportive care, such as monitoring for hypoxia and supplemental oxygen administration, as active therapies lack effectiveness. Pulse oximetry is used to monitor hypoxia in hospitalised infants and is used either intermittently or continuously. Observational studies have suggested that continuous pulse oximetry use leads to a longer length of hospital stay in stable infants. The use of continuous pulse oximetry may lead to unnecessary clinical intervention due to readings that are of little clinical significance, false-positive readings and less reliance on the clinical status. There is a lack of high-quality evidence to guide which pulse oximetry monitoring strategy, intermittent or continuous, is superior in infants hospitalised with bronchiolitis with respect to patient and policy-relevant outcomes.

METHODS AND ANALYSIS

This is a multicentre, pragmatic randomised controlled trial comparing two strategies for pulse oximetry monitoring in infants hospitalised for bronchiolitis. Infants aged 1 month to 2 years presenting to Canadian tertiary and community hospitals will be randomised after stabilisation to receive either intermittent or continuous oxygen saturation monitoring on the inpatient unit until discharge. The primary outcome is length of hospital stay. Secondary outcomes include additional measures of effectiveness, acceptability, safety and cost. We will need to enrol 210 infants in order to detect a 12-hour difference in length of stay with a type 1 error rate of 5% and a power of 90%.

ETHICS AND DISSEMINATION

Research ethics approval has been obtained for this trial. This trial will provide data to guide hospitals and clinicians on the optimal pulse oximetry monitoring strategy in infants hospitalised with bronchiolitis. We will disseminate the findings of this study through peer-reviewed publication, professional societies and meetings.

TRIAL REGISTRATION NUMBER

NCT02947204.

Antibiotics for persistent cough or wheeze following acute bronchiolitis in children

BACKGROUND

Bronchiolitis is a common acute respiratory condition with high prevalence worldwide. This clinically diagnosed syndrome is manifested by tachypnoea (rapid breathing), with crackles or wheeze in young children. In the acute phase of bronchiolitis (≤ 14 days), antibiotics are not routinely prescribed unless the illness is severe or a secondary bacterial infection is suspected. Although bronchiolitis is usually self-limiting, some young children continue to have protracted symptoms (e.g. cough and wheezing) beyond the acute phase and often re-present to secondary care.

OBJECTIVES

To compare the effectiveness of antibiotics versus controls (placebo or no treatment) for reducing or treating persistent respiratory symptoms following acute bronchiolitis within six months of acute illness.

SEARCH METHODS

We searched the following databases: the Cochrane Airways Group Register of Trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), the World Health Organization (WHO) trial portal, the Australian and New Zealand Clinical Trials Registry, and ClinicalTrials.gov, up to 26 August 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing antibiotics versus controls (placebo or no treatment) given in the post-acute phase of bronchiolitis (> 14 days) for children younger than two years with a diagnosis of bronchiolitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies against predefined criteria, and selected, extracted, and assessed data for inclusion. We contacted trial authors for further information.

MAIN RESULTS

In this review update, we added one study with 219 children. A total of two RCTs with 249 children (n = 240 completed) were eligible for inclusion in this review. Both studies contributed to our primary and secondary outcomes, but we assessed the quality of evidence for our three primary outcomes as low, owing to the small numbers of studies and participants; and high attrition in one of the studies. Data show no significant differences between treatment groups for our primary outcomes: proportion of children (n = 249) who had persistent symptoms at follow-up (odds ratio (OR) 0.69, 95% confidence interval (CI) 0.37 to 1.28; fixed-effect model); and number of children (n = 240) rehospitalised with respiratory illness within six months (OR 0.54, 95% CI 0.05 to 6.21; random-effects model). We were unable to analyse exacerbation rate because studies used different methods to report this information. Data showed no significant differences between treatment groups for our secondary outcome: proportion of children (n = 240) with wheeze at six months (OR 0.47, 95% CI 0.06 to 3.95; random-effects model). One study reported bacterial resistance, but only at 48 hours (thus with limited applicability for this review). Another study reported adverse events from which all children recovered and remained in the study.

AUTHORS' CONCLUSIONS

Current evidence is insufficient to inform whether antibiotics should be used to treat or prevent persistent respiratory symptoms in the post-acute bronchiolitis phase. Future RCTs are needed to evaluate the efficacy of antibiotics for reducing persistent respiratory symptoms. This is particularly important in populations with high acute and post-acute bronchiolitis morbidity (e.g. indigenous populations in Australia, New Zealand, and the USA).

The use of multiplex PCR for the diagnosis of viral severe acute respiratory infection in children: a high rate of co-detection during the winter season

Respiratory tract infection is a major cause of hospitalization in children. Although most such infections are viral in origin, it is difficult to differentiate bacterial and viral infections, as the clinical symptoms are similar. Multiplex polymerase chain reaction (PCR) methods allow testing for multiple pathogens simultaneously and are, therefore, gaining interest. This prospective case-control study was conducted from October 2013 to February 2014. Nasopharyngeal (NP) and oropharyngeal (throat) swabs were obtained from children admitted with severe acute respiratory infection (SARI) at a tertiary hospital. A control group of 40 asymptomatic children was included. Testing for 16 viruses was done by real-time multiplex PCR. Multiplex PCR detected a viral pathogen in 159/177 (89.9 %) patients admitted with SARI. There was a high rate of co-infection (46.9 %). Dual detections were observed in 64 (36.2 %), triple detections in 17 (9.6 %), and quadruple detections in 2 (1.1 %) of 177 samples. Seventy-eight patients required intensive care unit (ICU) admission, of whom 28 (35.8 %) had co-infection with multiple viruses. AdV, HBoV, HRV, HEV, and HCoV-OC43 were also detected among asymptomatic children. This study confirms the high rate of detection of viral nucleic acids by multiplex PCR among hospitalized children admitted with SARI, as well as the high rate of co-detection of multiple viruses. AdV, HBoV, HRV, HEV, and HCoV-OC43 were also detected in asymptomatic children, resulting in challenges in clinical interpretation. Studies are required to provide quantitative conclusions that will facilitate clinical interpretation and application of the results in the clinical setting.

Principal findings of systematic reviews for the management of acute bronchiolitis in children

Bronchiolitis is the most common cause of hospitalization among infants during the first 12 months of life, with high direct and indirect cost for health system and families. Different treatment approaches co-exist worldwide resulting in many drugs prescribed, without any proven benefit. Twenty systematic reviews of randomized clinical trials (SRCTs) on management of acute bronchiolitis in children were retrieved through 5 databases and their methodological quality was determined using an AMSTAR tool. Epinephrine showed impact only in short-term outcomes among outpatients (reduced admission at day 1 and improved the clinical score in the first 2 hours, compared to placebo) and inpatients (decreased length of stay (LOS) and improved saturation only in the first 2 hours, compared to nebulized salbutamol, but with high heterogeneity). Nebulized 3% saline among inpatients (but not in the emergency department setting) decreased hospital LOS. In small trials, exogenous surfactant among children may decrease the duration of mechanical ventilation and intensive care unit LOS and had favorable effects on oxygenation and CO2 elimination at 24 hrs. Although several SRCTs are currently available, only few treatments show clinically important improvements. Therefore, it is still difficult to prepare a well-established and accepted guideline for the treatment of acute bronchiolitis.

Continuous positive airway pressure (CPAP) for acute bronchiolitis in children

BACKGROUND

Acute bronchiolitis is one of the most frequent causes of emergency department visits and hospitalisation in infants. There is no specific treatment for bronchiolitis except for supportive therapy. Continuous positive airway pressure (CPAP) is supposed to widen the peripheral airways of the lung, allowing deflation of over-distended lungs in bronchiolitis. The increase in airway pressure also prevents the collapse of poorly supported peripheral small airways during expiration. In observational studies, CPAP is found to be beneficial in acute bronchiolitis.

OBJECTIVES

To assess the efficacy and safety of CPAP compared to no CPAP or sham CPAP in infants and children up to three years of age with acute bronchiolitis.

SEARCH METHODS

We searched CENTRAL (2014, Issue 3), MEDLINE (1946 to April week 2, 2014), EMBASE (1974 to April 2014), CINAHL (1981 to April 2014) and LILACS (1982 to April 2014).

SELECTION CRITERIA

We considered randomised controlled trials (RCTs), quasi-RCTS, cross-over RCTs and cluster-RCTs evaluating the effect of CPAP in children with acute bronchiolitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data using a structured proforma, analysed the data and performed meta-analyses.

MAIN RESULTS

We included two studies with a total of 50 participants under 12 months of age. In one study there was a high risk of bias for incomplete outcome data and selective reporting, and both studies had an unclear risk of bias for several domains including random sequence generation. The effect of CPAP on the need for mechanical ventilation in children with acute bronchiolitis was uncertain due to imprecision around the effect estimate (two RCTs, 50 participants; risk ratio (RR) 0.19, 95% CI 0.01 to 3.63; low quality evidence). Neither trial measured our other primary outcome of time to recovery. One trial found that CPAP significantly improved respiratory rate compared with no CPAP (one RCT, 19 participants; mean difference (MD) -5.70 breaths per minute, 95% CI -9.30 to -2.10), although the other study reported no difference between groups with no numerical data to pool. Change in arterial oxygen saturation was measured in only one trial and the results were imprecise (one RCT, 19 participants; MD -1.70%, 95% CI -3.76 to 0.36). The effect of CPAP on the change in partial pressure of carbon dioxide (pCO2) was also imprecise (two RCTs, 50 participants; MD -2.62 mmHg, 95% CI -5.29 to 0.05; low quality evidence). Duration of hospital stay was similar in both of the groups (two RCTs, 50 participants; MD 0.07 days, 95% CI -0.36 to 0.50; low quality evidence). Both trials reported no cases of pneumothorax and there were no deaths in either study. Change in partial pressure of oxygen (pO2), hospital admission rate (from emergency department to hospital), duration of emergency department stay, need for intensive care unit admission, local nasal effects and shock were not measured in either study.

AUTHORS' CONCLUSIONS

The effect of CPAP in children with acute bronchiolitis is uncertain due to the limited evidence available. Larger trials with adequate power are needed to evaluate the effect of CPAP in children with acute bronchiolitis.

Association between respiratory syncytial virus activity and pneumococcal disease in infants: a time series analysis of US hospitalization data

BACKGROUND

The importance of bacterial infections following respiratory syncytial virus (RSV) remains unclear. We evaluated whether variations in RSV epidemic timing and magnitude are associated with variations in pneumococcal disease epidemics and whether changes in pneumococcal disease following the introduction of seven-valent pneumococcal conjugate vaccine (PCV7) were associated with changes in the rate of hospitalizations coded as RSV.

METHODS AND FINDINGS

We used data from the State Inpatient Databases (Agency for Healthcare Research and Quality), including >700,000 RSV hospitalizations and >16,000 pneumococcal pneumonia hospitalizations in 36 states (1992/1993-2008/2009). Harmonic regression was used to estimate the timing of the average seasonal peak of RSV, pneumococcal pneumonia, and pneumococcal septicemia. We then estimated the association between the incidence of pneumococcal disease in children and the activity of RSV and influenza (where there is a well-established association) using Poisson regression models that controlled for shared seasonal variations. Finally, we estimated changes in the rate of hospitalizations coded as RSV following the introduction of PCV7. RSV and pneumococcal pneumonia shared a distinctive spatiotemporal pattern (correlation of peak timing: ρ = 0.70, 95% CI: 0.45, 0.84). RSV was associated with a significant increase in the incidence of pneumococcal pneumonia in children aged <1 y (attributable percent [AP]: 20.3%, 95% CI: 17.4%, 25.1%) and among children aged 1-2 y (AP: 10.1%, 95% CI: 7.6%, 13.9%). Influenza was also associated with an increase in pneumococcal pneumonia among children aged 1-2 y (AP: 3.2%, 95% CI: 1.7%, 4.7%). Finally, we observed a significant decline in RSV-coded hospitalizations in children aged <1 y following PCV7 introduction (-18.0%, 95% CI: -22.6%, -13.1%, for 2004/2005-2008/2009 versus 1997/1998-1999/2000). This study used aggregated hospitalization data, and studies with individual-level, laboratory-confirmed data could help to confirm these findings.

CONCLUSIONS

These analyses provide evidence for an interaction between RSV and pneumococcal pneumonia. Future work should evaluate whether treatment for secondary bacterial infections could be considered for pneumonia cases even if a child tests positive for RSV. Please see later in the article for the Editors' Summary.

Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age

Bronchiolitis is the most common reason for admission to hospital in the first year of life. There is tremendous variation in the clinical management of this condition across Canada and around the world, including significant use of unnecessary tests and ineffective therapies. This statement pertains to generally healthy children ≤2 years of age with bronchiolitis. The diagnosis of bronchiolitis is based primarily on the history of illness and physical examination findings. Laboratory investigations are generally unhelpful. Bronchiolitis is a self-limiting disease, usually managed with supportive care at home. Groups at high risk for severe disease are described and guidelines for admission to hospital are presented. Evidence for the efficacy of various therapies is discussed and recommendations are made for management. Monitoring requirements and discharge readiness from hospital are also discussed.

Recent advances in the management of acute bronchiolitis

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.

Inter-society consensus document on treatment and prevention of bronchiolitis in newborns and infants

Acute bronchiolitis is the leading cause of lower respiratory tract infection and hospitalization in children less than 1 year of age worldwide. It is usually a mild disease, but some children may develop severe symptoms, requiring hospital admission and ventilatory support in the ICU. Infants with pre-existing risk factors (prematurity, bronchopulmonary dysplasia, congenital heart diseases and immunodeficiency) may be predisposed to a severe form of the disease. Clinical diagnosis of bronchiolitis is manly based on medical history and physical examination (rhinorrhea, cough, crackles, wheezing and signs of respiratory distress). Etiological diagnosis, with antigen or genome detection to identify viruses involved, may have a role in reducing hospital transmission of the infection. Criteria for hospitalization include low oxygen saturation (<90-92%), moderate-to-severe respiratory distress, dehydration and presence of apnea. Children with pre-existing risk factors should be carefully assessed.To date, there is no specific treatment for viral bronchiolitis, and the mainstay of therapy is supportive care. This consists of nasal suctioning and nebulized 3% hypertonic saline, assisted feeding and hydration, humidified O2 delivery. The possible role of any pharmacological approach is still debated, and till now there is no evidence to support the use of bronchodilators, corticosteroids, chest physiotherapy, antibiotics or antivirals. Nebulized adrenaline may be sometimes useful in the emergency room. Nebulized adrenaline can be useful in the hospital setting for treatment as needed. Lacking a specific etiological treatment, prophylaxis and prevention, especially in children at high risk of severe infection, have a fundamental role. Environmental preventive measures minimize viral transmission in hospital, in the outpatient setting and at home. Pharmacological prophylaxis with palivizumab for RSV bronchiolitis is indicated in specific categories of children at risk during the epidemic period. Viral bronchiolitis, especially in the case of severe form, may correlate with an increased incidence of recurrent wheezing in pre-schooled children and with asthma at school age.The aim of this document is to provide a multidisciplinary update on the current recommendations for the management and prevention of bronchiolitis, in order to share useful indications, identify gaps in knowledge and drive future research.

Recent advances in management of bronchiolitis

Background

Bronchiolitis is one of the major causes for hospital admissions in infants. Managing bronchiolitis, both in the outpatient and inpatient setting remains a challenge to the treating pediatrician. The effectiveness of various interventions used for infants with bronchiolitis remains unclear.

Need and purpose

To evaluate the evidence supporting the use of currently available treatment and preventive strategies for infants with bronchiolitis and to provide practical guidelines to the practitioners managing children with bronchiolitis.

Methods

A search of articles published on bronchiolitis was performed using PubMed. The areas of focus were diagnosis, treatment and prevention of bronchiolitis in children. Relevant information was extracted from English language studies published over the last 20 years. In addition, the Cochrane Database of Systematic Reviews was searched.

Results and Conclusions

Supportive care, comprising of taking care of oxygenation and hydration, remains the corner-stone of therapy in bronchiolitis. Pulse oximetry helps in guiding the need for oxygen administration. Several recent evidence-based reviews have suggested that bronchodilators or corticosteroids lack efficacy in bronchiolitis and should not be routinely used. A number of other novel therapies (such as nebulized hypertonic saline, heliox, CPAP, montelukast, surfactant, and inhaled furosemide) have been evaluated in clinical trials, and although most of them did not show any beneficial results, some like hypertonic saline, surfactant, CPAP have shown promising results.

Acute bronchiolitis in infants, a review

Acute viral bronchiolitis is one of the most common medical emergency situations in infancy, and physicians caring for acutely ill children will regularly be faced with this condition. In this article we present a summary of the epidemiology, pathophysiology and diagnosis, and focus on guidelines for the treatment of bronchiolitis in infants. The cornerstones of the management of viral bronchiolitis are the administration of oxygen and appropriate fluid therapy, and overall a “minimal handling approach” is recommended. Inhaled adrenaline is commonly used in some countries, but the evidences are sparse. Recently, inhalation with hypertonic saline has been suggested as an optional treatment. When medical treatment fails to stabilize the infants, non-invasive and invasive ventilation may be necessary to prevent and support respiratory failure. It is important that relevant treatment algorithms exist, applicable to all levels of the treatment chain and reflecting local considerations and circumstances.

High-flow nasal cannula therapy for infants with bronchiolitis

BACKGROUND

Bronchiolitis is a common lower respiratory tract illness, usually of viral aetiology, affecting infants younger than 24 months of age and is a frequent cause of hospitalisation. It causes airway inflammation, mucus production and mucous plugging, resulting in airway obstruction. Effective pharmacotherapy is lacking and bronchiolitis is a major cause of morbidity and mortality.Conventional treatment consists of supportive therapy in the form of fluids, supplemental oxygen and respiratory support. Traditionally oxygen delivery is as a dry gas at 100% concentration via low-flow nasal prongs. However, the use of heated, humidified, high-flow nasal cannula (HFNC) therapy enables delivery of higher inspired gas flows of an air/oxygen blend, up to 12 L/min in infants and 30 L/min in children. Its use provides some level of continuous positive airway pressure to improve ventilation in a minimally invasive manner. This may reduce the need for invasive respiratory support thus potentially lowering costs, with clinical advantages and fewer adverse effects.

OBJECTIVES

To assess the effects of HFNC therapy compared with conventional respiratory support in the treatment of infants with bronchiolitis.

SEARCH METHODS

We searched CENTRAL (2013, Issue 4), MEDLINE (1946 to May week 1, 2013), EMBASE (January 2010 to May 2013), CINAHL (1981 to May 2013), LILACS (1982 to May 2013) and Web of Science (1985 to May 2013). In addition we consulted ongoing trial registers and experts in the field to identify ongoing studies, checked reference lists of relevant articles and searched conference abstracts.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs which assessed the effects of HFNC (delivering oxygen or oxygen/room air blend at flow rates greater than 4 L/min) compared to conventional treatment in infants (< 24 months) with a clinical diagnosis of bronchiolitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently used a standard template to assess trials for inclusion and extract data on study characteristics, 'Risk of bias' elements and outcomes. We contacted trial authors to request missing data. Outcome measures included the need for invasive respiratory support and time until discharge, clinical severity measures, oxygen saturation, duration of oxygen therapy and adverse events.

MAIN RESULTS

We included one RCT which was a pilot study with 19 participants that compared HFNC therapy with oxygen delivery via a head box. In this study, we judged the risk of selection, attrition and reporting bias to be low, and we judged the risk of performance and detection bias to be unclear due to lack of blinding. The median oxygen saturation (SpO2) was higher in the HFNC group at eight hours (100% versus 96%, P = 0.04) and at 12 hours (99% versus 96%, P = 0.04) but similar at 24 hours. There was no clear evidence of a difference in total duration of oxygen therapy, time to discharge or total length of stay between groups. No adverse events were reported in either group and no participants in either group required further respiratory support. Five ongoing trials were identified but no data were available in May 2013. We were not able to perform a meta-analysis.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the effectiveness of HFNC therapy for treating infants with bronchiolitis. The current evidence in this review is of low quality, from one small study with uncertainty about the estimates of effect and an unclear risk of performance and detection bias. The included study provides some indication that HFNC therapy is feasible and well tolerated. Further research is required to determine the role of HFNC in the management of bronchiolitis in infants. The results of the ongoing studies identified will contribute to the evidence in future updates of this review.

Chest radiographs for acute lower respiratory tract infections

BACKGROUND

Acute lower respiratory tract infections (LRTIs) (e.g. pneumonia) are a major cause of morbidity and mortality and management focuses on early treatment. Chest radiographs (X-rays) are one of the commonly used strategies. Although radiological facilities are easily accessible in high-income countries, access can be limited in low-income countries. The efficacy of chest radiographs as a tool in the management of acute LRTIs has not been determined. Although chest radiographs are used for both diagnosis and management, our review focuses only on management.

OBJECTIVES

To assess the effectiveness of chest radiographs in addition to clinical judgement, compared to clinical judgement alone, in the management of acute LRTIs in children and adults.

SEARCH METHODS

We searched CENTRAL 2013, Issue 1; MEDLINE (1948 to January week 4, 2013); EMBASE (1974 to February 2013); CINAHL (1985 to February 2013) and LILACS (1985 to February 2013). We also searched NHS EED, DARE, ClinicalTrials.gov and WHO ICTRP (up to February 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of chest radiographs versus no chest radiographs in acute LRTIs in children and adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the inclusion criteria, extracted data and assessed risk of bias. A third review author compiled the findings and any discrepancies were discussed among all review authors. We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

Two RCTs involving 2024 patients (1502 adults and 522 children) were included in this review. Both RCTs excluded patients with suspected severe disease. It was not possible to pool the results due to incomplete data. Both included trials concluded that the use of chest radiographs did not result in a better clinical outcome (duration of illness and of symptoms) for patients with acute LRTIs. In the study involving children in South Africa, the median time to recovery was seven days (95% confidence interval (CI) six to eight days (radiograph group) and six to nine days (control group)), P value = 0.50, log-rank test) and the hazard ratio for recovery was 1.08 (95% CI 0.85 to 1.34). In the study with adult participants in the USA, the average duration of illness was 16.9 days versus 17.0 days (P value > 0.05) in the radiograph and no radiograph groups respectively. This result was not statistically significant and there were no significant differences in patient outcomes between the groups with or without chest radiograph.The study in adults also reports that chest radiographs did not affect the frequencies with which clinicians ordered return visits or antibiotics. However, there was a benefit of chest radiographs in a subgroup of the adult participants with an infiltrate on their radiograph, with a reduction in length of illness (16.2 days in the group allocated to chest radiographs and 22.6 in the non-chest radiograph group, P < 0.05), duration of cough (14.2 versus 21.3 days, P < 0.05) and duration of sputum production (8.5 versus 17.8 days, P < 0.05). The authors mention that this difference in outcome between the intervention and control group in this particular subgroup only was probably a result of "the higher proportion of patients treated with antibiotics when the radiograph was used in patient care".Hospitalisation rates were only reported in the study involving children and it was found that a higher proportion of patients in the radiograph group (4.7%) required hospitalisation compared to the control group (2.3%) with the result not being statistically significant (P = 0.14). None of the trials report the effect on mortality, complications of infection or adverse events from chest radiographs. Overall, the included studies had a low or unclear risk for blinding, attrition bias and reporting bias, but a high risk of selection bias. Both trials had strict exclusion criteria which is important but may limit the clinical practicability of the results as participants may not reflect those presenting in clinical practice.

AUTHORS' CONCLUSIONS

Data from two trials suggest that routine chest radiography does not affect the clinical outcomes in adults and children presenting to a hospital with signs and symptoms suggestive of a LRTI. This conclusion may be weakened by the risk of bias of the studies and the lack of complete data available.

Respiratory syncytial virus--a comprehensive review

Respiratory syncytial virus (RSV) is amongst the most important pathogenic infections of childhood and is associated with significant morbidity and mortality. Although there have been extensive studies of epidemiology, clinical manifestations, diagnostic techniques, animal models and the immunobiology of infection, there is not yet a convincing and safe vaccine available. The major histopathologic characteristics of RSV infection are acute bronchiolitis, mucosal and submucosal edema, and luminal occlusion by cellular debris of sloughed epithelial cells mixed with macrophages, strands of fibrin, and some mucin. There is a single RSV serotype with two major antigenic subgroups, A and B. Strains of both subtypes often co-circulate, but usually one subtype predominates. In temperate climates, RSV infections reflect a distinct seasonality with onset in late fall or early winter. It is believed that most children will experience at least one RSV infection by the age of 2 years. There are several key animal models of RSV. These include a model in mice and, more importantly, a bovine model; the latter reflects distinct similarity to the human disease. Importantly, the prevalence of asthma is significantly higher amongst children who are hospitalized with RSV in infancy or early childhood. However, there have been only limited investigations of candidate genes that have the potential to explain this increase in susceptibility. An atopic predisposition appears to predispose to subsequent development of asthma and it is likely that subsequent development of asthma is secondary to the pathogenic inflammatory response involving cytokines, chemokines and their cognate receptors. Numerous approaches to the development of RSV vaccines are being evaluated, as are the use of newer antiviral agents to mitigate disease. There is also significant attention being placed on the potential impact of co-infection and defining the natural history of RSV. Clearly, more research is required to define the relationships between RSV bronchiolitis, other viral induced inflammatory responses, and asthma.

Respiratory syncytial virus bronchiolitis in children

Respiratory syncytial virus is a highly infectious virus that commonly causes bronchiolitis and leads to high morbidity and a low, but important, incidence of mortality. Supportive therapy is the foundation of management. Hydration/nutrition and respiratory support are important evidence-based interventions. For children with severe disease, continuous positive airway pressure or mechanical ventilation may be necessary. Ribavirin may be used for treatment of patients with severe disease. Palivizumab provides important ongoing immunoprophylaxis during epidemic months for high-risk infants. Caregiver education and incorporating an explanation of all therapies and anticipatory guidance, including strategies for reducing the risk of infection, are vital.

Anti-inflammatory effects of macrolides in childhood lung diseases

Macrolides are drugs that have antimicrobial effects, especially against intracellular pathogens. Various studies have shown that macrolides might also have anti-inflammatory effects. Macrolides inhibit the production of interleukins and can reduce pulmonary neutrophilic inflammation. Clinical trials have demonstrated beneficial effects of macrolides in various chronic lung diseases. The objective of this study was to review recent data in the medical literature on the anti-inflammatory effects of macrolides in childhood lung diseases by searching the Medline (PubMed) database. We used the following search terms: "macrolide and cystic fibrosis"; "macrolide and asthma"; "macrolide and bronchiolitis obliterans"; and "macrolide and acute bronchiolitis". We selected articles published in international scientific journals between 2001 and 2012. Clinical studies and in vitro evidence have confirmed the anti-inflammatory effect of macrolides in respiratory diseases. Some clinical trials have shown the benefits of the administration of macrolides in patients with cystic fibrosis, although the risk of bacterial resistance should be considered in the analysis of those benefits. Such benefits are controversial in other respiratory diseases, and the routine use of macrolides is not recommended. Further controlled clinical trials are required in order to assess the efficacy of macrolides as anti-inflammatory drugs, so that the benefits in the treatment of each specific clinical condition can be better established.

Viral bronchiolitis in children: a common condition with few therapeutic options

Even though bronchiolitis is a disease that has been recognized for many years, there are still few therapeutic strategies beyond supportive therapies. Bronchiolitis is the most frequent cause of hospital admission in children less than 1 year of age. The incidence is estimated to be about 150° million cases a year worldwide, and 2-3% of these cases require hospitalization. It is acknowledged that viruses cause bronchiolitis, but most of the studies focus on RSV. The RSV causes a more severe form of bronchiolitis in children with risk factors including prematurity, cardiovascular disease and immunodeficiency. Other viruses involved in causing bronchiolitis include RV, hMPV, hBoV and co-infections. The RV seems to be associated with a less severe acute disease, but there is a correlation between the early infection and subsequent wheezing bronchitis and asthma in later childhood and adulthood. The supportive therapies used are intravenous fluids and oxygen supplement administered by nasal cannula or CPAP in most complicated patients. Additional pharmacological therapies include epinephrine, 3% hypertonic saline and corticosteroids. The Epinephrine seems to have the greatest short-term benefits and reduces the need of hospital admission, whereas hypertonic saline and corticosteroids seem to reduce the length of hospital stay. As bronchiolitis is such a prevalent disease in children and RV seems to play an important role, perhaps more studies should center around the RV's contribution to the initial disease and following pathology.

A single dose of azithromycin does not improve clinical outcomes of children hospitalised with bronchiolitis: a randomised, placebo-controlled trial

Objective

Bronchiolitis, one of the most common reasons for hospitalisation in young children, is particularly problematic in Indigenous children. Macrolides may be beneficial in settings where children have high rates of nasopharyngeal bacterial carriage and frequent prolonged illness. The aim of our double-blind placebo-controlled randomised trial was to determine if a large single dose of azithromycin (compared to placebo) reduced length of stay (LOS), duration of oxygen (O₂) and respiratory readmissions within 6 months of children hospitalised with bronchiolitis. We also determined the effect of azithromycin on nasopharyngeal microbiology.

Methods

Children aged ≤18 months were randomised to receive a single large dose (30 mg/kg) of either azithromycin or placebo within 24 hrs of hospitalisation. Nasopharyngeal swabs were collected at baseline and 48hrs later. Primary endpoints (LOS, O₂) were monitored every 12 hrs. Hospitalised respiratory readmissions 6-months post discharge was collected.

Results

97 children were randomised (n = 50 azithromycin, n = 47 placebo). Median LOS was similar in both groups; azithromycin = 54 hours, placebo = 58 hours (difference between groups of 4 hours 95%CI -8, 13, p = 0.6). O₂ requirement was not significantly different between groups; Azithromycin = 35 hrs; placebo = 42 hrs (difference 7 hours, 95%CI -9, 13, p = 0.7). Number of children re-hospitalised was similar 10 per group (OR = 0.9, 95%CI 0.3, 2, p = 0.8). At least one virus was detected in 74% of children. The azithromycin group had reduced nasopharyngeal bacterial carriage (p = 0.01) but no difference in viral detection at 48 hours.

Conclusion

Although a single dose of azithromycin reduces carriage of bacteria, it is unlikely to be beneficial in reducing LOS, duration of O₂ requirement or readmissions in children hospitalised with bronchiolitis. It remains uncertain if an earlier and/or longer duration of azithromycin improves clinical and microbiological outcomes for children. The trial was registered with the Australian and New Zealand Clinical Trials Register. Clinical trials number: ACTRN12608000150347. http://www.anzctr.org.au/TrialSearch.aspx.

Treatment of bronchiolitis: state of the art

Bronchiolitis is a leading cause of acute illness and hospitalization for infants and young children worldwide. It is usually a mild disease, but the few children developing severe symptoms need to be hospitalized and some will need ventilatory support. To date, the mainstay of therapy has been supportive care, i.e. assisted feeding and hydration, minimal handling, nasal suctioning and oxygen therapy. In recent years the delivery of oxygen has been improved by using a high-flow nasal cannula. At the same time, the discovery of nebulized hypertonic saline enables better airway cleaning with a benefit for respiratory function. The possible role of any pharmacological approach is still debated: many pharmacological therapies tried in the past, ranging from bronchodilators to corticosteroids, were found to offer no benefit in this disease. More recently, nebulized adrenaline demonstrated a short-term benefit. Prophylaxis and prevention, especially in children at high risk of severe infection, such as prematurely born infants and children with bronchopulmonary dysplasia, have a fundamental role in dealing with this disease. In this review, we focus on current recommendations for the management and prevention of bronchiolitis, paying particular attention to the latest literature in search of answers to the questions that remain open.

Antibiotics for persistent cough or wheeze following acute bronchiolitis in children

BACKGROUND

Bronchiolitis is a common acute respiratory infectious condition, with a high prevalence worldwide. It is a clinically diagnosed syndrome, manifested by tachypnoea (rapid breathing), with crackles or wheeze in young children. In the acute phase of bronchiolitis (< 14 days), antibiotics have only been recommended when a secondary bacterial infection is suspected. Although bronchiolitis is usually a self-limiting condition, a number of children have persistent respiratory symptoms such as cough and wheezing in post-acute bronchiolitis, and they present or re-present to secondary care.

OBJECTIVES

To determine the effectiveness of antibiotics compared to a control (no treatment or placebo) for persistent respiratory symptoms (within six months), following acute bronchiolitis.

SEARCH METHODS

The following databases were searched, The Cochrane Airways Group Register of Trials, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), EMBASE (Ovid) and ClinicalTrials.gov. We searched all databases from their inception to the present, and did not impose restriction on language of publication. The search was performed in October 2012.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing antibiotics with controls (placebo or no treatment) given in the post-acute phase of bronchiolitis (> 14 days) for children younger than two years of age diagnosed with bronchiolitis were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies against pre-defined criteria; and selected, extracted and assessed the data for inclusion. Several subgroup analyses were planned and this included when antibiotics commenced (early commencement classified as preventing; later commencement as treatment for post-bronchiolitis symptoms).

MAIN RESULTS

A single study met the inclusion criteria but had a high attrition rate. Thirty infants with respiratory syncytial virus (RSV)-confirmed bronchiolitis were randomised to receive either a daily dose of oral clarithromycin 15 mg/kg or placebo for three weeks. Using an intention-to-treat (ITT) analysis, there was no significant difference between groups for the proportion of children who had persistent symptoms (odds ratio (OR) 0.20; 95% confidence interval (CI) 0.02 to 2.02) or re-hospitalisation within six months (OR 0.11; 95% CI 0.01 to 1.29). There were no treatment studies of later commencement of antibiotics.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence to inform whether antibiotics should be used to treat or prevent persistent respiratory symptoms in the post-acute bronchiolitis phase. Future RCTs that evaluate the efficacy of antibiotics to reduce persistent respiratory symptoms are required, especially in areas where both acute and post-bronchiolitis morbidity is high such as in Indigenous communities in the US, New Zealand and Australia.

Surfactant therapy for bronchiolitis in critically ill infants

BACKGROUND

Bronchiolitis is one of the most frequent causes of respiratory failure in infants; some infants will require intensive care and mechanical ventilation. There is lack of evidence regarding effective treatment for bronchiolitis other than supportive care. Abnormalities of surfactant quantity or quality (or both) have been observed in severe cases of bronchiolitis. Exogenous surfactant administration appears to favourably change the haemodynamics of the lungs and may be a potentially promising therapy for severe bronchiolitis. 

OBJECTIVES

To evaluate the efficacy of exogenous surfactant administration (i.e. intratracheal administration of surfactant of any type (whether animal-derived or synthetic), at any dose and at any time after start of ventilation) compared to placebo, no intervention or standard care in reducing mortality and the duration of ventilation in infants and children with bronchiolitis requiring mechanical ventilation.

SEARCH METHODS

We searched CENTRAL 2012, Issue 4 which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1948 to May week 1, 2012), EMBASE (1974 to May 2012), CINAHL (1982 to May 2012), LILACS (1985 to May 2012) and Web of Science (1985 to May 2012).

SELECTION CRITERIA

We considered prospective, randomised controlled trials (RCTs) and quasi-RCTs evaluating the effect of exogenous surfactant in infants and children with bronchiolitis requiring mechanical ventilation.

DATA COLLECTION AND ANALYSIS

Two review authors selected studies independently. We extracted the data using a predefined proforma, independently analysed the data and performed meta-analyses.

MAIN RESULTS

We included three small RCTs enrolling 79 participants. Two trials did not use a placebo in the control arms and the third trial used air placebo. Two included studies did not describe mortality. We judged some of the included studies to have an unclear risk of bias but none of the included studies had a high risk of bias. Our pooled analysis of the three trials revealed that duration of mechanical ventilation was not different between the groups (mean difference (MD) -63.04, 95% confidence interval (CI) -130.43 to 4.35 hours) but duration of intensive care unit (ICU) stay was less in the surfactant group compared to the control group: MD -3.31 (95% CI -6.38 to -0.25 days). After excluding one trial which produced significant heterogeneity, the duration of mechanical ventilation and duration of ICU stay were significantly lower in the surfactant group compared to the control group: MD -28.99 (95% CI -40.10 to -17.87 hours) and MD -1.81 (95% CI -2.42 to -1.19 days), respectively. Use of surfactant had favourable effects on oxygenation and CO(2) elimination. No adverse effects and no complications were observed in any of the three included studies.

AUTHORS' CONCLUSIONS

The available evidence is insufficient to establish the effectiveness of surfactant therapy for bronchiolitis in critically ill infants who require mechanical ventilation. There is a need for larger trials with adequate power and a cost-effectiveness analysis to evaluate the effectiveness of exogenous surfactant therapy for infants with bronchiolitis who require intensive care management.

IL1RL1 gene variants and nasopharyngeal IL1RL-a levels are associated with severe RSV bronchiolitis: a multicenter cohort study

Background

Targets for intervention are required for respiratory syncytial virus (RSV) bronchiolitis, a common disease during infancy for which no effective treatment exists. Clinical and genetic studies indicate that IL1RL1 plays an important role in the development and exacerbations of asthma. Human IL1RL1 encodes three isoforms, including soluble IL1RL1-a, that can influence IL33 signalling by modifying inflammatory responses to epithelial damage. We hypothesized that IL1RL1 gene variants and soluble IL1RL1-a are associated with severe RSV bronchiolitis.

Methodology/Principal Findings

We studied the association between RSV and 3 selected IL1RL1 single-nucleotide polymorphisms rs1921622, rs11685480 or rs1420101 in 81 ventilated and 384 non-ventilated children under 1 year of age hospitalized with primary RSV bronchiolitis in comparison to 930 healthy controls. Severe RSV infection was defined by need for mechanical ventilation. Furthermore, we examined soluble IL1RL1-a concentration in nasopharyngeal aspirates from children hospitalized with primary RSV bronchiolitis. An association between SNP rs1921622 and disease severity was found at the allele and genotype level (p = 0.011 and p = 0.040, respectively). In hospitalized non-ventilated patients, RSV bronchiolitis was not associated with IL1RL1 genotypes. Median concentrations of soluble IL1RL1-a in nasopharyngeal aspirates were >20-fold higher in ventilated infants when compared to non-ventilated infants with RSV (median [and quartiles] 9,357 [936–15,528] pg/ml vs. 405 [112–1,193] pg/ml respectively; p<0.001).

Conclusions

We found a genetic link between rs1921622 IL1RL1 polymorphism and disease severity in RSV bronchiolitis. The potential biological role of IL1RL1 in the pathogenesis of severe RSV bronchiolitis was further supported by high local concentrations of IL1RL1 in children with most severe disease. We speculate that IL1RL1a modifies epithelial damage mediated inflammatory responses during RSV bronchiolitis and thus may serve as a novel target for intervention to control disease severity.

Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old

BACKGROUND

This is an update of the original Cochrane review published in 2005 and updated in 2007. Acute bronchiolitis is the leading cause of medical emergencies during winter in children younger than two years of age. Chest physiotherapy is thought to assist infants in the clearance of secretions and to decrease ventilatory effort.

OBJECTIVES

The main objective was 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 the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4) which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to November week 3, 2011), MEDLINE in-process and other non-indexed citations (8 December 2011), EMBASE.com (1990 to December 2011), CINAHL (1982 to December 2011), LILACS (1985 to December 2011) and Web of Science (1985 to December 2011).

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 respiratory parameters and improvement in severity of disease. Secondary outcomes were length of hospital stay, duration of oxygen supplementation and the use of bronchodilators and steroids. No pooling of data was possible.

MAIN RESULTS

Nine clinical trials including 891 participants were included comparing physiotherapy with no intervention. Five trials (246 participants) evaluated vibration and percussion techniques and four trials (645 participants) evaluated passive expiratory techniques. We observed no significant differences in the severity of disease (eight trials, 867 participants). Results were negative for both types of physiotherapy. We observed no differences between groups in respiratory parameters (two trials, 118 participants), oxygen requirements (one trial, 50 participants), length of stay (five trials, 222 participants) or severe side effects (two trials, 595 participants). Differences in mild transient adverse effects (vomiting and respiratory instability) have been observed (one trial, 496 participants).

AUTHORS' CONCLUSIONS

Since the last publication of this review new good-quality evidence has appeared, strengthening the conclusions of the review. Chest physiotherapy does not improve the severity of the disease, respiratory parameters, or reduce length of hospital stay or oxygen requirements in hospitalised infants with acute bronchiolitis not on mechanical ventilation. Chest physiotherapy modalities (vibration and percussion or forced expiratory techniques) have shown equally negative results.