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Mellick LB. The De-implementation of Bronchiolitis Medications: Is It Time for a Moratorium? Pediatr Emerg Care 2024; 40:e30-e32. [PMID: 37665971 DOI: 10.1097/pec.0000000000003049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Affiliation(s)
- Larry B Mellick
- Department of Emergency Medicine, Augusta University, Augusta, GA
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Zhang L, Mendoza-Sassi RA, Wainwright CE, Aregbesola A, Klassen TP. Nebulised hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database Syst Rev 2023; 4:CD006458. [PMID: 37014057 PMCID: PMC10072872 DOI: 10.1002/14651858.cd006458.pub5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
BACKGROUND Airway oedema (swelling) and mucus plugging are the principal pathological features in infants with acute viral bronchiolitis. Nebulised hypertonic saline solution (≥ 3%) may reduce these pathological changes and decrease airway obstruction. This is an update of a review first published in 2008, and updated in 2010, 2013, and 2017. OBJECTIVES To assess the effects of nebulised hypertonic (≥ 3%) saline solution in infants with acute bronchiolitis. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily, Embase, CINAHL, LILACS, and Web of Science on 13 January 2022. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov on 13 January 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs using nebulised hypertonic saline alone or in conjunction with bronchodilators as an active intervention and nebulised 0.9% saline or standard treatment as a comparator in children under 24 months with acute bronchiolitis. The primary outcome for inpatient trials was length of hospital stay, and the primary outcome for outpatients or emergency department (ED) trials was rate of hospitalisation. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, data extraction, and assessment of risk of bias in included studies. We conducted random-effects model meta-analyses using Review Manager 5. We used mean difference (MD), risk ratio (RR), and their 95% confidence intervals (CI) as effect size metrics. MAIN RESULTS We included six new trials (N = 1010) in this update, bringing the total number of included trials to 34, involving 5205 infants with acute bronchiolitis, of whom 2727 infants received hypertonic saline. Eleven trials await classification due to insufficient data for eligibility assessment. All included trials were randomised, parallel-group, controlled trials, of which 30 were double-blinded. Twelve trials were conducted in Asia, five in North America, one in South America, seven in Europe, and nine in Mediterranean and Middle East regions. The concentration of hypertonic saline was defined as 3% in all but six trials, in which 5% to 7% saline was used. Nine trials had no funding, and five trials were funded by sources from government or academic agencies. The remaining 20 trials did not provide funding sources. Hospitalised infants treated with nebulised hypertonic saline may have a shorter mean length of hospital stay compared to those treated with nebulised normal (0.9%) saline or standard care (mean difference (MD) -0.40 days, 95% confidence interval (CI) -0.69 to -0.11; 21 trials, 2479 infants; low-certainty evidence). Infants who received hypertonic saline may also have lower postinhalation clinical scores than infants who received normal saline in the first three days of treatment (day 1: MD -0.64, 95% CI -1.08 to -0.21; 10 trials (1 outpatient, 1 ED, 8 inpatient trials), 893 infants; day 2: MD -1.07, 95% CI -1.60 to -0.53; 10 trials (1 outpatient, 1 ED, 8 inpatient trials), 907 infants; day 3: MD -0.89, 95% CI -1.44 to -0.34; 10 trials (1 outpatient, 9 inpatient trials), 785 infants; low-certainty evidence). Nebulised hypertonic saline may reduce the risk of hospitalisation by 13% compared with nebulised normal saline amongst infants who were outpatients and those treated in the ED (risk ratio (RR) 0.87, 95% CI 0.78 to 0.97; 8 trials, 1760 infants; low-certainty evidence). However, hypertonic saline may not reduce the risk of readmission to hospital up to 28 days after discharge (RR 0.83, 95% CI 0.55 to 1.25; 6 trials, 1084 infants; low-certainty evidence). We are uncertain whether infants who received hypertonic saline have a lower number of days to resolution of wheezing compared to those who received normal saline (MD -1.16 days, 95% CI -1.43 to -0.89; 2 trials, 205 infants; very low-certainty evidence), cough (MD -0.87 days, 95% CI -1.31 to -0.44; 3 trials, 363 infants; very low-certainty evidence), and pulmonary moist crackles (MD -1.30 days, 95% CI -2.28 to -0.32; 2 trials, 205 infants; very low-certainty evidence). Twenty-seven trials presented safety data: 14 trials (1624 infants; 767 treated with hypertonic saline, of which 735 (96%) co-administered with bronchodilators) did not report any adverse events, and 13 trials (2792 infants; 1479 treated with hypertonic saline, of which 416 (28%) co-administered with bronchodilators and 1063 (72%) hypertonic saline alone) reported at least one adverse event such as worsening cough, agitation, bronchospasm, bradycardia, desaturation, vomiting and diarrhoea, most of which were mild and resolved spontaneously (low-certainty evidence). AUTHORS' CONCLUSIONS Nebulised hypertonic saline may modestly reduce length of stay amongst infants hospitalised with acute bronchiolitis and may slightly improve clinical severity score. Treatment with nebulised hypertonic saline may also reduce the risk of hospitalisation amongst outpatients and ED patients. Nebulised hypertonic saline seems to be a safe treatment in infants with bronchiolitis with only minor and spontaneously resolved adverse events, especially when administered in conjunction with a bronchodilator. The certainty of the evidence was low to very low for all outcomes, mainly due to inconsistency and risk of bias.
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Affiliation(s)
- Linjie Zhang
- Faculty of Medicine, Federal University of Rio Grande, Rio Grande, Brazil
| | | | - Claire E Wainwright
- Department of Respiratory Medicine, Royal Children's Hospital, Brisbane, Australia
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Effects of Different Inhalation Therapy on Ventilator-Associated Pneumonia in Ventilated COVID-19 Patients: A Randomized Controlled Trial. Microorganisms 2022; 10:microorganisms10061118. [PMID: 35744636 PMCID: PMC9228146 DOI: 10.3390/microorganisms10061118] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/13/2022] [Accepted: 05/25/2022] [Indexed: 02/04/2023] Open
Abstract
The effect of routine inhalation therapy on ventilator-associated pneumonia (VAP) in mechanically ventilated patients with the coronavirus disease (COVID-19) has not been well-defined. This randomized controlled trial included 175 eligible adult patients with COVID-19 who were treated with mechanical ventilation at the University Hospital of Split between October 2020 and June 2021. Patients were randomized and allocated to a control group (no routine inhalation) or one of the treatment arms (inhalation of N-acetylcysteine; 5% saline solution; or 8.4% sodium bicarbonate). The primary outcome was the incidence of VAP, while secondary outcomes included all-cause mortality. Routine inhalation therapy had no effect on the incidence of bacterial or fungal VAP nor on all-cause mortality (p > 0.05). Secondary analyses revealed a significant reduction of Gram-positive and methicillin-resistant Staphylococcus aureus (MRSA) VAP in the treatment groups. Specifically, the bicarbonate group had a statistically significantly lower incidence of Gram-positive bacterial VAP (4.8%), followed by the N-acetylcysteine group (10.3%), 5% saline group (19.0%), and control group (34.6%; p = 0.001). This difference was driven by a lower incidence of MRSA VAP in the bicarbonate group (2.4%), followed by the N-acetylcysteine group (7.7%), 5% saline group (14.3%), and control group (34.6%; p < 0.001). Longer duration of ventilator therapy was the only significant, independent predictor of any bacterial or fungal VAP in the multivariate analysis (aOR 1.14, 95% CI 1.01−1.29, p = 0.038 and aOR 1.05, 95% CI 1.01−1.10, p = 0.028, respectively). In conclusion, inhalation therapy had no effect on the overall VAP incidence or all-cause mortality. Further studies should explore the secondary findings of this study such as the reduction of Gram-positive or MRSA-caused VAP in treated patients.
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Ramalingam S, Graham C, Oatey K, Rayson P, Stoddart A, Sheikh A, Cunningham S. Study protocol of the Edinburgh and Lothian Virus Intervention Study in Kids: a randomised controlled trial of hypertonic saline nose drops in children with upper respiratory tract infections (ELVIS Kids). BMJ Open 2021; 11:e049964. [PMID: 33952557 PMCID: PMC8103393 DOI: 10.1136/bmjopen-2021-049964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/02/2021] [Accepted: 03/16/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Edinburgh and Lothians' Viral Intervention Study Kids is a parallel, open-label, randomised controlled trial of hypertonic saline (HS) nose drops (~2.6% sodium chloride) vs standard care in children <7 years of age with symptoms of an upper respiratory tract infection (URTI). METHODS AND ANALYSIS Children are recruited prior to URTI or within 48 hours of developing URTI symptoms by advertising in areas such as local schools/nurseries, health centres/hospitals, recreational facilities, public events, workplaces, local/social media. Willing parents/guardians, of children <7 years of age will be asked to contact the research team at their local site. Children will be randomised to either a control arm (standard symptomatic care), or intervention arm (three drops/nostril of HS, at least four times a day, until 24 hours after asymptomatic or a maximum of 28 days). All participants are requested to provide a nasal swab at the start of the study (intervention arm: before HS drops) and then daily for four more days. Parent/guardian complete a validated daily diary, an end of illness diary, a satisfaction questionnaire and a wheeze questionnaire (day 28). The parent/guardian of a child in the intervention arm is taught to prepare HS nose drops. Parent/guardian of children asymptomatic at recruitment are requested to inform the research team within 48 hours of their child developing an URTI and follow the instructions already provided. The day 28 questionnaire determines if the child experienced a wheeze following illness. Participation in the study ends on day 28. ETHICS AND DISSEMINATION The study has been approved by the West of Scotland Research Ethics Service (18/WS/0080). It is cosponsored by Academic and Clinical Central Office for Research and Development-a partnership between the University of Edinburgh and National Health Service Lothian Health Board. The findings will be disseminated through peer-reviewed publications, conference presentations and via the study website. TRIAL REGISTRATION NUMBER NCT03463694.
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Affiliation(s)
- Sandeep Ramalingam
- Department of Laboratory Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Catriona Graham
- Edinburgh Clinical Research Facility, The University of Edinburgh, Edinburgh, UK
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Phillip Rayson
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Andrew Stoddart
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Aziz Sheikh
- Centre of Medical Informatics, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Steve Cunningham
- Centre for Inflammation Research, Department of Child Life and Health, Royal Hospital for Children and Young People, Edinburgh, UK
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Hsieh CW, Chen C, Su HC, Chen KH. Exploring the efficacy of using hypertonic saline for nebulizing treatment in children with bronchiolitis: a meta-analysis of randomized controlled trials. BMC Pediatr 2020; 20:434. [PMID: 32928154 PMCID: PMC7489028 DOI: 10.1186/s12887-020-02314-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/24/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Inhaled hypertonic saline (HS) has shown benefit in decreasing airway edema in acute bronchiolitis which is the most common lower respiratory infection resulting in dyspnea among infants under 2 years old. The aim of this systematic review and meta-analysis was to evaluate the efficacy and safety of HS in the implementation of treatment with nebulized HS among children with bronchiolitis. METHODS A systematic literature search was conducted using Cochrane Library, PubMed, EMBASE and Airiti Library (Chinese Database) for randomized controlled trials from inception to July 2019. We calculated pooled risk ratios (RR), mean difference (MD) and 95% CI using RevMan 5.3 for meta-analysis. RESULTS There were 4186 children from 32 publications included. Compared to the control group, the HS group exhibited significant reduction of severity of respiratory distress, included studies used the Clinical Severity Score (n = 8; MD, - 0.71; 95% CI, - 1.15 to - 0.27; I2 = 73%) and full stop after Respiratory Distress Assessment Instrument (n = 5; MD, - 0.60; 95% CI, - 0.95 to - 0.26; I2 = 0%) for evaluation respectively. Further, the HS group decreased the length of hospital stay 0.54 days (n = 20; MD, - 0.54; 95% CI, - 0.86 to - 0.23; I2 = 81%). CONCLUSIONS We conclude that nebulization with 3% saline solution is effective in decreasing the length of hospital stay and the severity of symptoms as compared with 0.9% saline solution among children with acute bronchiolitis. Further rigorous randomized controlled trials with large sample size are needed.
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Affiliation(s)
- Chia-Wen Hsieh
- Department of Nursing, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chiehfeng Chen
- Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
- Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, No.111, Sec. 3, Xinglong Rd., Wenshan Dist., Taipei City, 116 Taiwan, Republic of China
- Evidence-based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Hui-Chuan Su
- Department of Nursing, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Kee-Hsin Chen
- Department of Nursing, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
- Post-Baccalaureate Program in Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
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Impact of a modification of the clinical practice guide of the American Academy of Pediatrics in the management of severe acute bronchiolitis in a pediatric intensive care unit. Med Intensiva 2020; 45:289-297. [PMID: 34059219 PMCID: PMC7170801 DOI: 10.1016/j.medine.2019.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/29/2019] [Indexed: 11/30/2022]
Abstract
Objective To describe the characteristics and evolution of patients with bronchiolitis admitted to a pediatric intensive care unit, and compare treatment pre- and post-publication of the American Academy of Pediatrics clinical practice guide. Design A descriptive and observational study was carried out between September 2010 and September 2017. Setting Pediatric intensive care unit. Patients Infants under one year of age with severe bronchiolitis. Interventions Two periods were compared (2010–14 and 2015–17), corresponding to before and after modification of the American Academy of Pediatrics guidelines for the management of bronchiolitis in hospital. Main variables Patient sex, age, comorbidities, severity, etiology, administered treatment, bacterial infections, respiratory and inotropic support, length of stay and mortality. Results A total of 706 patients were enrolled, of which 414 (58.6%) males, with a median age of 47 days (IQR 25–100.25). Median bronchiolitis severity score (BROSJOD) upon admission: 9 points (IQR 7–11). Respiratory syncytial virus appeared in 460 (65.16%) patients. The first period (2010–14) included 340 patients and the second period (2015–17) 366 patients. More adrenalin and hypertonic saline nebulizations and more corticosteroid treatment were administered in the second period. More noninvasive ventilation and less conventional mechanical ventilation were used, and less inotropic support was needed, with no significant differences. The antibiotherapy rate decreased significantly (p = 0.003). Conclusions Despite the decrease in antibiotherapy, the use of nebulizations and glucocorticoids in these patients should be limited, as recommended by the guide.
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Jaquet-Pilloud R, Verga ME, Russo M, Gehri M, Pauchard JY. Nebulised hypertonic saline in moderate-to-severe bronchiolitis: a randomised clinical trial. Arch Dis Child 2020; 105:236-240. [PMID: 31488402 DOI: 10.1136/archdischild-2019-317160] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 08/20/2019] [Accepted: 08/21/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate whether nebulised hypertonic saline (HS) treatment would decrease length of hospital stay (LOS) among infants with moderate-to severe-bronchiolitis compared with standard supportive care (SC). METHODS We conducted an open, multicentre, randomised clinical trial from 1 April 2013 to 31 March 2016, in Swiss children's hospitals. Patients aged 6 weeks to 24 months with a primary diagnosis of moderate or severe bronchiolitis were included. Children with previous episodes of wheezing, cardiac disease, chronic respiratory disease, immunodeficiency, prematurity (gestational age <34 weeks), corticotherapy in the preceding 2 weeks or inhaled bronchodilators within 24 hours before presentation were excluded. Patients were randomised to receive standard SC with nebulisation of 4 mL of 3% sodium chloride every 6 hours versus SSC. Main outcomes and measures were LOS duration of oxygen therapy, transfer to intensive care unit (ICU), readmission within 7 days following discharge and adverse events. RESULTS 121 children were randomised. No statistically significant differences were found between treatment groups at baseline (age, Wang Score, atopic history, smoking exposure). Children in the HS group had a non-significant difference in length of stay -2.8 hours (-10; 16) compared with the SC group. There were no differences in oxygen therapy duration, transfer to ICU, readmission rate or adverse events. The intervention was discontinued at the parents' request in 16% of the cases. CONCLUSION Our study does not support the use of HS nebulisation in children with moderate to severe bronchiolitis. TRIAL REGISTRATION NUMBER NCT01812525.
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Affiliation(s)
- Raphaelle Jaquet-Pilloud
- Department of Medical and Surgical Pediatrics, University Hospital of Lausanne, Lausanne, Switzerland
| | - Marie-Elise Verga
- Department of Medical and Surgical Pediatrics, University Hospital of Lausanne, Lausanne, Switzerland
| | - Michel Russo
- Pediatrics & Neonatal Medicine Department Hospital, Sion, Valais, Switzerland
| | - Mario Gehri
- Department of Medical and Surgical Pediatrics, University Hospital of Lausanne, Lausanne, Switzerland
| | - Jean-Yves Pauchard
- Department of Medical and Surgical Pediatrics, University Hospital of Lausanne, Lausanne, Switzerland
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Nebulized hypertonic saline 3% for 1 versus 3 days in hospitalized bronchiolitis: a blinded non-inferiority randomized controlled trial. BMC Pediatr 2019; 19:417. [PMID: 31699072 PMCID: PMC6839239 DOI: 10.1186/s12887-019-1804-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 10/24/2019] [Indexed: 11/16/2022] Open
Abstract
Background The use and optimal duration of treatment with nebulized hypertonic saline (HS) in infants hospitalized for acute bronchiolitis is unclear. The objective was to compare the efficacy of 1 versus 3 days of nebulized 3% HS at 72 h of treatment. We conducted a blinded non-inferiority randomized controlled trial including infants aged less than 12 months old, hospitalized for a moderate bronchiolitis. Methods Nebulisations of 3% HS for 1 day were followed by either the continuation of 3% HS (HS3d group) or switched to 0.9% normal isotonic saline (HS1d group) for 2 days Randomization was performed according to a predefined list with a 1:1 ratio, obtained with a random generator number with blocks.. Main outcome was mean Wang clinical severity score (CSS) after 72 h of treatment. Results One hundred sixteen infants (HS1d n = 59 and HS3d n = 57), were included over two epidemic seasons from 2014 to 2016, but recruitement did not reach the planned sample size. The difference for the Wang CSS score in the HS3d vs HS1d group was 0.71 [IC 90% 0.1; 1.3], above the precluded value of 0.4 set in the protocol defining the non-inferiority of shorter treatment duration. Clinical remission was more rapidly obtained in the HS3d than in HS1d (2.3 ± 1.6 vs 2.9 ± 1.4 days, p = 0.04), with a non-significant tendency for less need of nutritional support and supplemental oxygen in HS3d group. Clinical worsening and treatment intolerance were similar in the 2 groups. Conclusions Despite being underpowered, results seem not to be in favour of reducing the duration of nebulised HS treatment from 3 to 1 day in acute moderate bronchiolitis. Trial registration Clinical trials NCT 02538458, October 2014.
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Dao VA, Overhagen S, Bilstein A, Kolot C, Sonnemann U, Mösges R. Ectoine lozenges in the treatment of acute viral pharyngitis: a prospective, active-controlled clinical study. Eur Arch Otorhinolaryngol 2019; 276:775-783. [PMID: 30739176 PMCID: PMC6411829 DOI: 10.1007/s00405-019-05324-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 01/30/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Acute pharyngitis is an uncomfortable disorder mostly caused by viruses and for which antibiotics are unwarranted. This study compared lozenges containing ectoine, a natural extremolyte, with hyaluronic acid lozenges and hypertonic saline gargle for symptomatic treatment of acute viral pharyngitis. METHODS This prospective, controlled clinical study, recruited 90 patients with moderate-to-severe pharyngitis symptoms who chose to use either ectoine (n = 35), hyaluronic acid (n = 35), or saline gargle (n = 20). Patients applied their 7-day treatment from the inclusion visit (V1) until the end-of-study visit (V2). Patients' pharyngitis symptoms, general health, general treatment effectiveness and tolerability, and patient compliance were assessed by investigators and patients. RESULTS The sum score for three primary symptoms (pain on swallowing, urge to cough, and hoarseness) decreased by 79.5% (ectoine), 72.2% (hyaluronic acid), and 44.8% (saline gargle). Both lozenges were significantly superior to saline gargle (P < 0.05). Regarding general health improvement, ectoine was significantly superior to saline gargle (72.5% vs. 45.2%, P < 0.05), but hyaluronic acid (63.3%) was not. At V2, 65.7% of patients receiving ectoine reported "very good" general health vs. 48.6% of those receiving hyaluronic acid and 20.0% using saline gargle. Ectoine was significantly superior (P < 0.05) to both hyaluronic acid and saline gargle in terms of tolerability and patient compliance. No patients taking ectoine reported unpleasant sensations while applying their treatment, whereas almost half of patients using hyaluronic acid lozenges and saline gargle did. CONCLUSION Treatment with ectoine lozenges significantly relieves moderate-to-severe symptoms of acute viral pharyngitis and is more effective and tolerable than treatments with hyaluronic acid lozenges and hypertonic saline gargle.
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Affiliation(s)
- Van-Anh Dao
- CRI-Clinical Research International Ltd., Cologne, Germany
| | | | | | | | - Uwe Sonnemann
- Private Health Centre, Institute for ENT Elmshorn, Elmshorn, Germany
| | - Ralph Mösges
- CRI-Clinical Research International Ltd., Cologne, Germany
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van Miert C, Fernandes RM, Eccleson H, Bedson E, Lane S, Peak M, Thorburn K, Compton V, Woolfall K, Lacy D, Williamson P, McNamara PS. Non-invasive ventilation for the management of children with bronchiolitis (NOVEMBR): a feasibility study and core outcome set development protocol. Trials 2018; 19:627. [PMID: 30428935 PMCID: PMC6236891 DOI: 10.1186/s13063-018-2969-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 10/08/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Bronchiolitis is an acute lower respiratory infection which predominantly affects young children. Treatment for bronchiolitis is limited to supportive therapy. Nasal oxygen therapy is part of routine care, and delivery now incorporates varying levels of non-invasive continuous positive airway pressure and/or high-flow nasal cannula oxygen therapy. Despite wide clinical use, there remains a lack of evidence on the comparative effectiveness and safety of these interventions. Furthermore, research in this field is hampered by the use of multiple outcome measures in current clinical trials. METHODS/DESIGN This mixed methods study includes a systematic review of outcome measures, telephone interviews with parents, focus group workshops and a Delphi survey with healthcare professionals and parents. These methods will be used to identify and prioritise outcomes for inclusion in a core outcome set and to explore issues pertinent to the design of a future randomised controlled trial comparing different modes of oxygen therapy for bronchiolitis. UK hospitals will also be contacted and asked to complete a survey to provide an overview of current practice to enable assessment of capability and capacity to run a future clinical trial. DISCUSSION This study will facilitate the design of a future clinical trial of non-invasive ventilation in children with bronchiolitis which is acceptable to important stakeholders. Furthermore, core outcome set development will improve standardisation, measurement and reporting of clinically important outcomes in bronchiolitis. TRIAL REGISTRATION ISRCTN Registry, ISRCTN75766048. Registered on 18 December 2017. This study was retrospectively registered in the ISRCTN Registry and on the Core Outcome Measures in Effectiveness Trials (COMET) Initiative database (15 September 2017).
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Affiliation(s)
- Clare van Miert
- School of Nursing and Allied Health, Liverpool John Moores University, Room 3.12 Henry Cotton Building, 15-21 Webster Street, Liverpool, L3 2ET UK
- Paediatric Medicines Research Unit, Alder Hey Children’s NHS Foundation Hospital Trust, Eaton Road, Liverpool, L12 2AP UK
| | - Ricardo M. Fernandes
- Clinical Pharmacology Lab/Unit, Faculty of Medicine and Instituto de Medicina Molecular, Universidade de Lisboa, Lisbon, Portugal
- Department of Pediatrics, Hospital Santa Maria, Lisbon, Portugal
| | - Helen Eccleson
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, University of Liverpool, Institute of Child Health, Alder Hey Children’s NHS Foundation Trust, Liverpool, L12 2AP UK
| | - Emma Bedson
- Medicines for Children Clinical Trials Unit, Clinical Trials Research Centre, University of Liverpool, Institute of Child Health, Alder Hey Children’s NHS Foundation Trust, Liverpool, L12 2AP UK
| | - Steven Lane
- Department of Biostatistics, Block F, Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL UK
| | - Matthew Peak
- Paediatric Medicines Research Unit, Alder Hey Children’s NHS Foundation Hospital Trust, Eaton Road, Liverpool, L12 2AP UK
| | - Kent Thorburn
- Paediatric Intensive Care Unit, Alder Hey Children’s NHS Foundation Hospital Trust, Eaton Road, Liverpool, L12 2AP UK
| | - Vanessa Compton
- Paediatric Intensive Care Unit, Alder Hey Children’s NHS Foundation Hospital Trust, Eaton Road, Liverpool, L12 2AP UK
| | - Kerry Woolfall
- MRC North West Hub for Trials Methodology Research Institute of Psychology, Health and Society, Block B, Room B112, 1st Floor Waterhouse Building, Liverpool, L69 3GL UK
| | - David Lacy
- Department of Paediatrics, Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Road, Upton, Wirral, CH49 5PE UK
| | - Paula Williamson
- Department of Biostatistics, Block F, Waterhouse Building, 1-5 Brownlow Street, Liverpool, L69 3GL UK
| | - Paul S. McNamara
- Institute of Child Health, University of Liverpool, Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP UK
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Ghazaly M, Nadel S. Overview of prevention and management of acute bronchiolitis due to respiratory syncytial virus. Expert Rev Anti Infect Ther 2018; 16:913-928. [PMID: 30381972 DOI: 10.1080/14787210.2018.1543589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Respiratory Syncytial Virus (RSV) is the most common cause of Acute Bronchiolitis (AVB) in infants. AVB causes significant morbidity and mortality worldwide, most deaths occurring in the developing world. AVB causes respiratory distress in infants, leading to respiratory failure in some cases. Disease is more severe in infants with risk factors, such as prematurity, chronic cardiac and lung disease and immunodeficiency. Areas covered: Despite major advances in supportive care in the developed world, which has led to a significant reduction in mortality, treatment remains symptomatic and supportive. No specific antiviral treatment has yet proven to be effective. Prevention of disease with monoclonal antibodies has proven to reduce illness severity in those with risk factors, however, this is prohibitively expensive, particularly for the developing world. Prospects for vaccine development are improving. However, because most disease is in young infants, maternal immunization is necessary. However, due to the transient nature of RSV immunity and the circulation of multiple subtypes, vaccines proven to be effective in adult challenge models have yet to be translated to protection in infants. Expert commentary: Despite advances in preventative treatments, adherence to evidence-based guidelines provides the best prospect for successful reduction in morbidity and mortality.
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Affiliation(s)
- Marwa Ghazaly
- a Paediatric Intensive Care, Paediatric Intensive Care Unit , St. Mary's Hospital , London , UK.,b Department of Paediatrics , Assuit University , Assiut , Egypt
| | - Simon Nadel
- a Paediatric Intensive Care, Paediatric Intensive Care Unit , St. Mary's Hospital , London , UK
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Mecklin M, Heikkilä P, Korppi M. The change in management of bronchiolitis in the intensive care unit between 2000 and 2015. Eur J Pediatr 2018; 177:1131-1137. [PMID: 29766326 DOI: 10.1007/s00431-018-3156-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 03/19/2018] [Accepted: 04/16/2018] [Indexed: 11/29/2022]
Abstract
This case-control study evaluated interventions for bronchiolitis in relation to time in the pediatric intensive care unit (PICU) during a 16-year surveillance period. Together, 105 infants aged < 12 months were treated for bronchiolitis in the PICU, and for them, we selected 210 controls admitted for bronchiolitis closest to cases. We collected data on treatments in the PICU, at the ward and in the emergency department for three periods: years 2000-2005, 2006-2010, and 2011-2015. Median hospital length of stay for PICU patients were 7 days (interquartile range 5-12), 5 days (4-8) and 8 days (4-12.5, p = 0.127), respectively. By time, the use of inhaled beta-agonist (68 vs. 44 vs. 38%, p = 0.019) and systemic corticosteroids (29 vs. 15 vs. 5%, p = 0.019) decreased, but that of racemic adrenaline (59 vs. 78 vs. 84%, p = 0.035) and hypertonic saline (0 vs. 0 vs. 54%, p < 0.001) inhalations increased in the PICU. Similar changes were seen at the ward. In the PICU, non-invasive ventilation therapies increased significantly, but intubation rates did not decline.Conclusion: Beta-agonists and systemic corticosteroids were used less by time in intensive care for infant bronchiolitis, but the use of hypertonic saline and racemic adrenaline increased, though their effectiveness has been questioned. What is Known: • Until now, studies have shown which treatments do not work in bronchiolitis, and so, there is no consensus how infants with bronchiolitis should be treated. In particular, there is no consensus on different interventions in intensive care for bronchiolitis. What is New: • During 2000-2015, treatments with inhaled beta-agonists and systemic corticosteroids decreased but treatments with racemic adrenaline and hypertonic saline inhalations increased in intensive care for bronchiolitis. Similar changes were seen at the ward. Though non-invasive ventilation therapies increased, the intubation rate did not decline.
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Affiliation(s)
- Minna Mecklin
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Arvo Building, FI-33014, Tampere, Finland.
| | - Paula Heikkilä
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Arvo Building, FI-33014, Tampere, Finland
| | - Matti Korppi
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Arvo Building, FI-33014, Tampere, Finland
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Chandelia S, Yadav AK, Kumar D, Chadha N. Magnesium sulphate for acute bronchiolitis in children under two years of age. Hippokratia 2018. [DOI: 10.1002/14651858.cd012965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Sudha Chandelia
- PGIMER and Dr. RML Hospital; Pediatric Emergency and Critical Care; New Delhi India 110001
| | - Arun K Yadav
- AIIMS; Department of Neurology; Delhi India 110029
| | - Dinesh Kumar
- PGIMER; Division of Pediatric Cardiology, Department of Pediatrics; Delhi India 110001
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Heikkilä P, Mecklin M, Korppi M. The cost-effectiveness of hypertonic saline inhalations for infant bronchiolitis: a decision analysis. World J Pediatr 2018; 14:26-34. [PMID: 29476325 DOI: 10.1007/s12519-017-0112-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 04/11/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study evaluated the cost-effectiveness of hypertonic saline (HS) inhalations for infant bronchiolitis, compared to normal saline inhalations or standard treatment without inhalations as controls. METHODS The decision tree in the decision analysis was used to calculate the expected costs. Actual cost data were obtained from our retrospective case-control study on bronchiolitis treatment. The effectiveness of treatment, based on the hospitalization rate of those admitted to the emergency department and the length of stay (LOS) of those who were hospitalized, was collected from previous studies. For the effectiveness estimations, we made a meta-analysis summarizing the results of the meta-analysis of the Cochrane review in 2013 and the results of 10 studies published after it. RESULTS The mean hospitalization rate was 24.7% in the HS inhalation group and 32.6% in the control group [risk ratio: 0.80, 95% confidence interval (CI) 0.67-0.96] and the mean LOS was 3.736 (HS group) and 4.292 (controls) days (mean difference: - 0.55 days, 95% CI - 0.96 to - 0.15), respectively. The expected costs per patient, when both inpatients and outpatients were included, were €816 ($1111) in the HS inhalation group and €962 ($1310) in the control group. The expected costs per hospitalization, when only inpatients were included, were €2600 ($3540) in the HS inhalation group and €2890 ($3935) in the control group. CONCLUSIONS HS inhalations slightly reduced the expected hospitalization costs of infant bronchiolitis. However, the low effectiveness, rather than the cost, is the factor that will limit the use of HS inhalations in infant bronchiolitis.
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Affiliation(s)
- Paula Heikkilä
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland. .,Department of Pediatrics, Tampere University Hospital, PO BOX 2000, 33521, Tampere, Finland.
| | - Minna Mecklin
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Matti Korppi
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
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Zhang L, Mendoza‐Sassi RA, Wainwright C, Klassen TP. Nebulised hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database Syst Rev 2017; 12:CD006458. [PMID: 29265171 PMCID: PMC6485976 DOI: 10.1002/14651858.cd006458.pub4] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Airway oedema (swelling) and mucus plugging are the principal pathological features in infants with acute viral bronchiolitis. Nebulised hypertonic saline solution (≥ 3%) may reduce these pathological changes and decrease airway obstruction. This is an update of a review first published in 2008, and previously updated in 2010 and 2013. OBJECTIVES To assess the effects of nebulised hypertonic (≥ 3%) saline solution in infants with acute bronchiolitis. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily, Embase, CINAHL, LILACS, and Web of Science on 11 August 2017. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov on 8 April 2017. SELECTION CRITERIA We included randomised controlled trials and quasi-randomised controlled trials using nebulised hypertonic saline alone or in conjunction with bronchodilators as an active intervention and nebulised 0.9% saline, or standard treatment as a comparator in children under 24 months with acute bronchiolitis. The primary outcome for inpatient trials was length of hospital stay, and the primary outcome for outpatients or emergency department trials was rate of hospitalisation. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, data extraction, and assessment of risk of bias in included studies. We conducted random-effects model meta-analyses using Review Manager 5. We used mean difference (MD), risk ratio (RR), and their 95% confidence intervals (CI) as effect size metrics. MAIN RESULTS We identified 26 new trials in this update, of which 9 await classification due to insufficient data for eligibility assessment, and 17 trials (N = 3105) met the inclusion criteria. We included a total of 28 trials involving 4195 infants with acute bronchiolitis, of whom 2222 infants received hypertonic saline.Hospitalised infants treated with nebulised hypertonic saline had a statistically significant shorter mean length of hospital stay compared to those treated with nebulised 0.9% saline (MD -0.41 days, 95% CI -0.75 to -0.07; P = 0.02, I² = 79%; 17 trials; 1867 infants) (GRADE quality of evidence: low). Infants who received hypertonic saline also had statistically significant lower post-inhalation clinical scores than infants who received 0.9% saline in the first three days of treatment (day 1: MD -0.77, 95% CI -1.18 to -0.36, P < 0.001; day 2: MD -1.28, 95% CI -1.91 to -0.65, P < 0.001; day 3: MD -1.43, 95% CI -1.82 to -1.04, P < 0.001) (GRADE quality of evidence: low).Nebulised hypertonic saline reduced the risk of hospitalisation by 14% compared with nebulised 0.9% saline among infants who were outpatients and those treated in the emergency department (RR 0.86, 95% CI 0.76 to 0.98; P = 0.02, I² = 7%; 8 trials; 1723 infants) (GRADE quality of evidence: moderate).Twenty-four trials presented safety data: 13 trials (1363 infants, 703 treated with hypertonic saline) did not report any adverse events, and 11 trials (2360 infants, 1265 treated with hypertonic saline) reported at least one adverse event, most of which were mild and resolved spontaneously. AUTHORS' CONCLUSIONS Nebulised hypertonic saline may modestly reduce length of stay among infants hospitalised with acute bronchiolitis and improve clinical severity score. Treatment with nebulised hypertonic saline may also reduce the risk of hospitalisation among outpatients and emergency department patients. However, we assessed the quality of the evidence as low to moderate.
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Affiliation(s)
- Linjie Zhang
- Federal University of Rio GrandeFaculty of MedicineRua Visconde Paranaguá 102CentroRio GrandeRSBrazil96201‐900
| | - Raúl A Mendoza‐Sassi
- Federal University of Rio GrandeFaculty of MedicineRua Visconde Paranaguá 102CentroRio GrandeRSBrazil96201‐900
| | - Claire Wainwright
- Royal Children's HospitalDepartment of Respiratory MedicineHerston RoadHerstonBrisbaneQueenslandAustralia4029
| | - Terry P Klassen
- Manitoba Institute of Child Health513‐715 McDermot AvenueWinnipegMBCanadaR3E 3P4
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Elenius V, Bergroth E, Koponen P, Remes S, Piedra PA, Espinola JA, Korppi M, Camargo CA, Jartti T. Marked variability observed in inpatient management of bronchiolitis in three Finnish hospitals. Acta Paediatr 2017; 106:1512-1518. [PMID: 28544041 PMCID: PMC7159377 DOI: 10.1111/apa.13931] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 04/26/2017] [Accepted: 05/17/2017] [Indexed: 02/05/2023]
Abstract
AIM Infants hospitalised for bronchiolitis undergo examinations and treatments not supported by current research evidence and we investigated practice variations with regard to Finnish children under the age of two. METHODS This prospective, multicentre cohort study was conducted in paediatric units in three university hospitals in Finland from 2008 to 2010. Hospital medical records were reviewed to collect data on clinical course, testing and treatment. Data were analysed separately for children meeting our strict definition of bronchiolitis, aged under 12 months without a history of wheezing, and a loose definition, aged 12-23 months or with a history of wheezing. RESULTS The median age of the 408 children was 8.1 months. Clinical management varied between the three hospitals when stratified by strict and loose bronchiolitis subgroup definitions: complete blood counts ranged from 15-95% vs 16-94%, respectively, and the other measures were chest x-ray (16-91% vs 14-72%), intravenous fluids (2-47% vs 2-41%), use of nebulised epinephrine (10-84% vs 7-50%), use of salbutamol (18-21% vs 13-84%) and use of corticosteroids (6-23% vs 60-76%). CONCLUSION The clinical management of bronchiolitis varied considerably with regard to the three hospitals and the two definitions of bronchiolitis. A stronger commitment to evidence-based bronchiolitis guidelines is needed in Finland.
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Affiliation(s)
- Varpu Elenius
- Department of Paediatrics and Adolescent Medicine; Turku University Hospital; Turku Finland
| | - Eija Bergroth
- Department of Paediatrics; Kuopio University Hospital; Kuopio Finland
| | - Petri Koponen
- Department of Paediatrics; Tampere University Hospital; Tampere Finland
| | - Sami Remes
- Department of Paediatrics; Kuopio University Hospital; Kuopio Finland
| | - Pedro A. Piedra
- Departments of Molecular Virology and Microbiology and Pediatrics; Baylor College of Medicine; Houston TX USA
| | - Janice A. Espinola
- Department of Emergency Medicine; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Matti Korppi
- Department of Paediatrics; Tampere University Hospital; Tampere Finland
| | - Carlos A. Camargo
- Department of Emergency Medicine; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Tuomas Jartti
- Department of Paediatrics and Adolescent Medicine; Turku University Hospital; Turku Finland
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Angoulvant F, Bellêttre X, Milcent K, Teglas JP, Claudet I, Le Guen CG, de Pontual L, Minodier P, Dubos F, Brouard J, Soussan-Banini V, Degas-Bussiere V, Gatin A, Schweitzer C, Epaud R, Ryckewaert A, Cros P, Marot Y, Flahaut P, Saunier P, Babe P, Patteau G, Delebarre M, Titomanlio L, Vrignaud B, Trieu TV, Tahir A, Regnard D, Micheau P, Charara O, Henry S, Ploin D, Panjo H, Vabret A, Bouyer J, Gajdos V. Effect of Nebulized Hypertonic Saline Treatment in Emergency Departments on the Hospitalization Rate for Acute Bronchiolitis: A Randomized Clinical Trial. JAMA Pediatr 2017; 171:e171333. [PMID: 28586918 PMCID: PMC6583778 DOI: 10.1001/jamapediatrics.2017.1333] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Acute bronchiolitis is the leading cause of hospitalization among infants. Previous studies, underpowered to examine hospital admission, have found a limited benefit of nebulized hypertonic saline (HS) treatment in the pediatric emergency department (ED). OBJECTIVE To examine whether HS nebulization treatment would decrease the hospital admission rate among infants with a first episode of acute bronchiolitis. DESIGN, SETTING, AND PARTICIPANTS The Efficacy of 3% Hypertonic Saline in Acute Viral Bronchiolitis (GUERANDE) study was a multicenter, double-blind randomized clinical trial on 2 parallel groups conducted during 2 bronchiolitis seasons (October through March) from October 15, 2012, through April 15, 2014, at 24 French pediatric EDs. Among the 2445 infants (6 weeks to 12 months of age) assessed for inclusion, 777 with a first episode of acute bronchiolitis with respiratory distress and no chronic medical condition were included. INTERVENTIONS Two 20-minute nebulization treatments of 4 mL of HS, 3%, or 4 mL of normal saline (NS), 0.9%, given 20 minutes apart. MAIN OUTCOMES AND MEASURES Hospital admission rate in the 24 hours after enrollment. RESULTS Of the 777 infants included in the study (median age, 3 months; interquartile range, 2-5 months; 468 [60.2%] male), 385 (49.5%) were randomized to the HS group and 387 (49.8%) to the NS group (5 patients did not receive treatment). By 24 hours, 185 of 385 infants (48.1%) in the HS group were admitted compared with 202 of 387 infants (52.2%) in the NS group. The risk difference for hospitalizations was not significant according to the mixed-effects regression model (adjusted risk difference, -3.2%; 95% CI, -8.7% to 2.2%; P = .25). The mean (SD) Respiratory Distress Assessment Instrument score improvement was greater in the HS group (-3.1 [3.2]) than in the NS group (-2.4 [3.3]) (adjusted difference, -0.7; 95% CI, -1.2 to -0.2; P = .006) and similarly for the Respiratory Assessment Change Score. Mild adverse events, such as worsening of cough, occurred more frequently among children in the HS group (35 of 392 [8.9%]) than among those in the NS group (15 of 384 [3.9%]) (risk difference, 5.0%; 95% CI, 1.6%-8.4%; P = .005), with no serious adverse events. CONCLUSIONS AND RELEVANCE Nebulized HS treatment did not significantly reduce the rate of hospital admissions among infants with a first episode of acute moderate to severe bronchiolitis who were admitted to the pediatric ED relative to NS, but mild adverse events were more frequent in the HS group. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01777347.
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Affiliation(s)
- François Angoulvant
- Service d'accueil des urgences pédiatriques, Necker-Enfants Malades University Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France,Epidémiologie Clinique et Évaluation Économique Appliquées aux Populations Vulnérables, INSERM, Unité Mixte de Recherche 1123, Paris, France
| | - Xavier Bellêttre
- Service d'accueil des urgences pédiatriques, Robert Debré University Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Karen Milcent
- Service de Pédiatrie, Antoine Béclère University Hospital, Assistance Publique–Hôpitaux de Paris, Clamart, France,Centre for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France
| | - Jean-Paul Teglas
- Centre for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France
| | - Isabelle Claudet
- Service d'accueil des urgences pédiatriques, Toulouse University Hospital, Toulouse, France
| | | | - Loïc de Pontual
- Service de Pédiatrie, Jean Verdier University Hospital, Assistance Publique–Hôpitaux de Paris, Bondy, France
| | - Philippe Minodier
- Service d'accueil des urgences pédiatriques, Marseille Nord University Hospital, Assistance Publique–Hôpitaux de Marseille, Marseille, France
| | - François Dubos
- Service d'accueil des urgences pédiatriques, Lille University Hospital, Lille, France
| | - Jacques Brouard
- Service de Pédiatrie, Caen University Hospital, Caen, France
| | - Valérie Soussan-Banini
- Service de Pédiatrie, Ambroise Paré University Hospital, Assistance Publique–Hôpitaux de Paris, Boulogne-Billancourt, France
| | | | - Amélie Gatin
- Service de médecine infantile, Nancy University Hospital, Vandoeuvre-Lès-Nancy, France
| | - Cyril Schweitzer
- Service de médecine infantile, Nancy University Hospital, Vandoeuvre-Lès-Nancy, France
| | - Ralph Epaud
- Service d'accueil des urgences pédiatriques, Creteil Intercommunal Hospital, Creteil, France
| | - Amélie Ryckewaert
- Service d'accueil des urgences pédiatriques, Rennes University Hospital, Rennes, France
| | - Pierrick Cros
- Service de Pédiatrie, Brest University Hospital, Brest, France
| | - Yves Marot
- Service d'accueil des urgences pédiatriques, Tours University Hospital, Tours, France
| | - Philippe Flahaut
- Service d'accueil des urgences pédiatriques, Rouen University Hospital, Rouen, France
| | - Pascal Saunier
- Service de Pédiatrie, Fontainebleau Hospital, Fontainebleau, France
| | - Philippe Babe
- Service d'accueil des urgences pédiatriques, Lenval University Hospital, Nice, France
| | - Géraldine Patteau
- Service d'accueil des urgences pédiatriques, Necker-Enfants Malades University Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Mathilde Delebarre
- Service d'accueil des urgences pédiatriques, Lille University Hospital, Lille, France
| | - Luigi Titomanlio
- Service d'accueil des urgences pédiatriques, Robert Debré University Hospital, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Bénédicte Vrignaud
- Service d'accueil des urgences pédiatriques, Nantes University Hospital, Nantes, France
| | - Thanh-Van Trieu
- Service de Pédiatrie, Jean Verdier University Hospital, Assistance Publique–Hôpitaux de Paris, Bondy, France
| | - Abdelilah Tahir
- Service d'accueil des urgences pédiatriques, Limoges University Hospital, Limoges, France
| | - Delphine Regnard
- Service d'accueil des urgences pédiatriques, Bicêtre University Hospital, Assistance Publique–Hôpitaux de Paris, Kremlin-Bicêtre, France
| | - Pascale Micheau
- Service d'accueil des urgences pédiatriques, Toulouse University Hospital, Toulouse, France
| | - Oussama Charara
- Service de Pédiatrie, André Mignot Hospital, Le Chesnay, France
| | - Simon Henry
- Service de Pédiatrie, Laennec Hospital, Quimper, France
| | - Dominique Ploin
- Service d'accueil des urgences pédiatriques, Mother Child University Hospital, Bron, France,Epidémiologie, Pharmacologie, Investigation Clinique, Information médicale, Mère-Enfant (EPICIME), Clinical Investigation Center, INSERM Clinical Investigation Center 1407, Bron, France
| | - Henri Panjo
- Centre for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France
| | - Astrid Vabret
- Service de Pédiatrie, Caen University Hospital, Caen, France
| | - Jean Bouyer
- Centre for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France
| | - Vincent Gajdos
- Service de Pédiatrie, Antoine Béclère University Hospital, Assistance Publique–Hôpitaux de Paris, Clamart, France,Centre for Research in Epidemiology and Population Health, INSERM U1018, Villejuif, France
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Davis J, Thompson AD, Mansbach JM, Piedra PA, Kasagawa K, Sullivan AF, Espinola JA, Camargo CA. Multicenter Observational Study of the Use of Nebulized Hypertonic Saline to Treat Children Hospitalized for Bronchiolitis From 2008 to 2014. Hosp Pediatr 2017; 7:hpeds.2017-0002. [PMID: 28761004 PMCID: PMC5525378 DOI: 10.1542/hpeds.2017-0002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Among children hospitalized for bronchiolitis, we examined temporal trends in the use of hypertonic saline (HTS) and the characteristics associated with receiving this treatment. METHODS We conducted a secondary analysis of data from 2 large, multicenter prospective cohort studies that included young children hospitalized with bronchiolitis during 5 winter seasons (2008-2014). Our outcome was receipt of HTS any time during the preadmission visit or hospitalization. For comparison with the observed trends in HTS use, we conducted a PubMed literature review of studies evaluating HTS use for bronchiolitis. We classified publications according to their assessment of HTS efficacy (positive, negative, or neutral). RESULTS Among 2709 hospitalized children, 241 (8.9%) received HTS. There was marked variability in HTS use by site (0%-91%), with use more common among children admitted to the ICU than those treated on the ward (31% vs 15%). Over the study period, administration of HTS increased from 2% during the 2008-2009 season to 27% during the 2011-2012 season, but then it decreased to 11% during the 2013-2014 season. Before 2010, the number of PubMed HTS publications ranged from 0 to 3 articles per year, with all classified as either positive or neutral. The number of positive publications increased in 2010 (n = 5), whereas negative publications peaked in 2014 (n = 4). CONCLUSIONS Use of HTS in children hospitalized with bronchiolitis increased during the 2008 to 2012 winter seasons and then declined. These findings paralleled trends in the HTS literature, with positive articles encouraging HTS use in early years followed by a growing number of neutral and negative articles after 2012.
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Affiliation(s)
- Joshua Davis
- Department of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Amy D Thompson
- Department of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware;
| | | | - Pedro A Piedra
- Departments of Molecular Virology and Microbiology, and Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Kohei Kasagawa
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Ashley F Sullivan
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Janice A Espinola
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and
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Abstract
Bronchiolitis is the leading cause of morbidity and hospitalization in infants under the age of one year. Supportive treatments and regular assessment remain the mainstay of care for infants admitted to hospital. Nurses play an important role in the assessment of infants with bronchiolitis; however, this is not well described in the literature and consequently little is known about what strategies nurses employ in assessing infants with bronchiolitis. The aim of this study was to explore bronchiolitis assessment in the context of nursing practice. A naturalistic inquiry study was undertaken using think aloud and retrospective probing data collection methods. The results revealed that the information gathered by nurses in their assessment of infants with bronchiolitis was varied and the process of acquiring and evaluating this information was multifaceted and holistic in nature. A close partnership between the nurse and mother was identified, and the mother's expert knowledge and ability to identify subtle changes in the infant's clinical condition over time was essential to the assessment process. The assessment partnership with families provides nurses with the most comprehensive and holistic view of the infant's clinical condition and vital assessment information could be lost if this partnership does not occur.
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Affiliation(s)
- Clare Davies
- 1 Sydney Nursing School, University of Sydney, 88, Mallett Street, Camperdown, New South Wales, Australia
| | - Donna Waters
- 1 Sydney Nursing School, University of Sydney, 88, Mallett Street, Camperdown, New South Wales, Australia
| | - Andrea Marshall
- 2 NHMRC Centre of Research Excellence in Nursing, Menzies Health Institute, Griffith University, Nathan, Queensland, Australia
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20
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Abstract
Evidence-based practice is an important component of health care service delivery. However, there is a tendency, embodied in tools such as Grades of Recommendation, Assessment, Development, and Evaluation, to focus principally on the classification of study design, at the expense of a detailed assessment of the strengths and limitations of the individual study. Randomized controlled trials (RCTs), and in particular the classical “explanatory” RCT, have a privileged place in the hierarchy of evidence. However, classical RCTs have substantial limitations, most notably a lack of generalizability, which limit their direct applicability to clinical practice implementation. Pragmatic and observational studies can provide an invaluable perspective into real-world applicability. This evidence could be used more widely to complement ideal-condition results from classical RCTs, following the principle of triangulation. In this review article, we discuss several types of pragmatic and observational studies that could be used in this capacity. We discuss their particular strengths and how their limitations may be overcome and provide real-life examples by means of illustration.
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Affiliation(s)
| | - Steve Turner
- Child Health, University of Aberdeen, Aberdeen, UK
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Prospective Multicentre Study on the Epidemiology and Current Therapeutic Management of Severe Bronchiolitis in Spain. BIOMED RESEARCH INTERNATIONAL 2017; 2017:2565397. [PMID: 28421191 PMCID: PMC5380832 DOI: 10.1155/2017/2565397] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 02/14/2017] [Accepted: 02/27/2017] [Indexed: 12/04/2022]
Abstract
Objective. To determine the epidemiology and therapeutic management of patients with severe acute bronchiolitis (AB) admitted to paediatric intensive care units (PICUs) in Spain. Design. Descriptive, prospective, multicentre study. Setting. Sixteen Spanish PICUs. Patients. Patients with severe AB who required admission to any of the participating PICUs over 1 year. Interventions. Both epidemiological variables and medical treatment received were recorded. Results. A total of 262 patients were recruited; 143 were male (54.6%), with median age of 1 month (0–23). Median stay in the PICU was 7 days (1–46). Sixty patients (23%) received no nebuliser treatment, while the rest received a combination of inhalation therapies. One-quarter of patients (24.8%) received corticosteroids and 56.5% antibiotic therapy. High-flow oxygen therapy was used in 14.3% and noninvasive ventilation (NIV) was used in 75.6%. Endotracheal intubation was required in 24.4% of patients. Younger age, antibiotic therapy, and invasive mechanical ventilation (IMV) were risk factors that significantly increased the stay in the PICU. Conclusions. Spanish PICUs continue to routinely use nebulised bronchodilator treatment and corticosteroid therapy. Despite NIV being widely used in this condition, intubation was required in one-quarter of cases. Younger age, antibiotic therapy, and IMV were associated with a longer stay in the PICU.
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Chang AB. In search for the Holy Grail of cough guidelines. ANNALS OF TRANSLATIONAL MEDICINE 2017; 4:516. [PMID: 28149878 DOI: 10.21037/atm.2016.12.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Anne B Chang
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, Qld University of Technology, South Brisbane, Queensland 4101, Australia; ; Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
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23
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Gupta HV, Gupta VV, Kaur G, Baidwan AS, George PP, Shah JC, Shinde K, Malik R, Chitkara N, Bajaj KV. Effectiveness of 3% hypertonic saline nebulization in acute bronchiolitis among Indian children: A quasi-experimental study. Perspect Clin Res 2016; 7:88-93. [PMID: 27141475 PMCID: PMC4840797 DOI: 10.4103/2229-3485.179434] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To compare the effects of 3% hypertonic saline (HS) and 0.9% normal saline with nebulized 0.9% normal saline with salbutamol in patients of acute viral bronchiolitis. MATERIALS AND METHODS Participants were divided into three groups, that is, 3% HS group, 0.9% normal saline group and 0.9% saline with salbutamol group. Four doses at interval of 6 h were given daily until discharge. Average CS score and length of hospital stay were compared. One-way analysis of variance paired t-test and Chi-square test were utilized for statistical analysis. RESULTS The mean ages of the patients in three groups were 6.03 ± 3.71, 5.69 ± 3.34 and 5.48 ± 3.35 respectively. The 3(rd) day CS scores for all the groups were 1.0 ± 1.1, 1.9 ± 1.1 and 3.3 ± 0.5 respectively (P = 0.000). The average length of hospital stay was 3.4 ± 1.7, 3.7 ± 1.9 and 4.9 ± 1.4 days respectively (P = 0.001). CONCLUSION The present study concludes that 3% HS nebulization (without additional bronchodilators) is an effective and safe treatment for nonasthmatic, moderately ill patients of acute bronchiolitis. The economic benefit of this comparably priced modality of treatment can be enormous in terms of hospital costs with parents returning to work sooner.
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Affiliation(s)
- Harsh V. Gupta
- Department of Pediatrics, GGS Medical College and Hospital, Faridkot, Punjab, India
| | - Vivek V. Gupta
- Department of Public Health Dentistry, Pacific Dental College and Hospital, Udaipur, Rajasthan, India
| | - Gurmeet Kaur
- Department of Pediatrics, GGS Medical College and Hospital, Faridkot, Punjab, India
| | | | - Pardeep P. George
- Department of Orthodontics, AL Azhar Dental College and Hospital, Kerala, India
| | - Jay C. Shah
- Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Ahmedabad, Gujarat, India
| | - Kushal Shinde
- Department of Public Health Dentistry, Pacific Dental College and Hospital, Udaipur, Rajasthan, India
| | - Ruku Malik
- Department of Public Health Dentistry, Pacific Dental College and Hospital, Udaipur, Rajasthan, India
| | - Neha Chitkara
- Department of Oral Medicine and Radiology, Mahatma Gandhi Dental College and Hospital, Jaipur, Rajasthan, India
| | - Krushnan V. Bajaj
- Department of Prosthodontics, Pacific Dental College and Hospital, Udaipur, Rajasthan, India
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Baron J, El-Chaar G. Hypertonic Saline for the Treatment of Bronchiolitis in Infants and Young Children: A Critical Review of the Literature. J Pediatr Pharmacol Ther 2016; 21:7-26. [PMID: 26997926 DOI: 10.5863/1551-6776-21.1.7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Bronchiolitis, an infection of the lower respiratory tract, is the leading cause of infant and child hospitalization in the United States. Therapeutic options for management of bronchiolitis are limited. Hypertonic saline inhalation therapy has been studied in numerous clinical trials with mixed results. In 2014, the American Academy of Pediatrics (AAP) published updated guidelines on the diagnosis and management of bronchiolitis, which include new recommendations on the use of hypertonic saline. We reviewed all published clinical trials mentioned in the 2014 AAP guidelines, as well as additional trials published since the guidelines, and critically evaluated each trial to determine efficacy, safety, and expectations of hypertonic saline inhalation therapy. A total of 2682 infants were studied over the course of 22 clinical trials. Nine trials were carried out in the outpatient/clinic/emergency department and 13 in the inpatient setting. We agree with the AAP guidelines regarding the recommendation to use nebulized hypertonic saline for infants hospitalized with bronchiolitis, with the expectation of reducing bronchiolitis scores and length of stay when it is expected to last more than 72 hours. However, we also believe there might be an advantage for hypertonic saline in reducing admission rates from the emergency department, based on close examination of the results of recent trials. This review also highlights important gaps in the available literature that need to be addressed in order to define the role of inhaled hypertonic saline therapy.
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Affiliation(s)
- Jeffrey Baron
- Pharmacy Department, Roswell Park Cancer Institute, Buffalo, New York
| | - Gladys El-Chaar
- Pharmacy Department, Roswell Park Cancer Institute, Buffalo, New York ; Department of Pharmacy, Winthrop-University Hospital, Mineola, New York ; Department of Clinical Pharmacy Practice, St John's University College of Pharmacy and Health Sciences, Jamaica, New York
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25
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Köse S, Şehriyaroğlu A, Esen F, Özdemir A, Kardaş Z, Altuğ U, Karakuş E, Özcan A, Kısaarslan AF, Elmalı F, Torun YA, Köse M. Comparing the Efficacy of 7%, 3% and 0.9% Saline in Moderate to Severe Bronchiolitis in Infants. Balkan Med J 2016; 33:193-7. [PMID: 27403389 DOI: 10.5152/balkanmedj.2016.16840] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 10/07/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There is no standard treatment option in acute bronchiolitis. 3-7% hypertonic saline (HS) seems to be the effective treatment choice for reducing the hospitalization day. AIMS To compare the effect of nebulized 7% HS/salbutamol and 3% HS/salbutamol to 0.9% saline/salbutamol. The primary outcome measure was the effect of study drugs on the length of hospital stay (LOS). Secondary outcome measures were safety and efficacy in reducing the clinical severity score (CSS) at the 24 hours of the study. STUDY DESIGN Prospective, double-blinded randomized clinical study. METHODS The study consists of 104 infants. Groups were constituted according to the treatment they received: These are, group A - 0.9% saline/salbutamol, group B -3% HS/salbutamol and group C-7% HS/salbutamol. Heart beat, Bronchiolitis CSS and oxygen saturation of the patients were determined before and after nebulization. The patients were monitored for adverse reactions. RESULTS Length of hospital stay in group A, B and C were as follows; 72.0 (20-288) hours in group A, 64.0 (12-168) hours in group B and 60.0 (12-264) hours in group C. No significant differences was observed among three groups (p>0.05). CONCLUSION 7% HS and 3% HS does not have any effect to decrease LOS for infants with bronchiolitis.
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Affiliation(s)
- Seçil Köse
- Department of Pediatrics, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Ahmet Şehriyaroğlu
- Department of Pediatrics, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Feyza Esen
- Department of Pediatrics, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Ahmet Özdemir
- Department of Pediatrics, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Zehra Kardaş
- Department of Pediatrics, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Umut Altuğ
- Department of Pediatrics, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Esef Karakuş
- Department of Pediatrics, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Alper Özcan
- Department of Pediatrics, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Ali Fatih Kısaarslan
- Department of Pediatrics, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Ferhan Elmalı
- Departments of Biostatistics and Bioinformatics, Erciyes University School of Medicine, Kayseri, Turkey
| | | | - Mehmet Köse
- Department of Pediatrics, Division of Pediatric Pulmonology Unit, Erciyes University School of Medicine, Kayseri, Turkey
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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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Bollani L, Baraldi E, Chirico G, Dotta A, Lanari M, Del Vecchio A, Manzoni P, Boldrini A, Paolillo P, Di Fabio S, Orfeo L, Stronati M, Romagnoli C. Revised recommendations concerning palivizumab prophylaxis for respiratory syncytial virus (RSV). Ital J Pediatr 2015; 41:97. [PMID: 26670908 PMCID: PMC4681171 DOI: 10.1186/s13052-015-0203-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 11/25/2015] [Indexed: 11/12/2022] Open
Abstract
Respiratory Syncytial Virus infections are one of the leading causes of severe respiratory diseases that require hospitalization and, in some cases, intensive care. Once resolved, there may be respiratory sequelae of varying severity. The lack of effective treatments for bronchiolitis and the lack of vaccines for RSV accentuate the role of prevention in decreasing the impact of this disease. Prevention of bronchiolitis strongly relies on the adoption of environment and the hygienic behavior measures; an additional prophylactic effect may be offered, in selected cases, by Palivizumab, a humanized monoclonal antibody produced by recombinant DNA technology, able to prevent RSV infection by blocking viral replication.After many years the Italian Society of Neonatology, on the basis of the most recent scientific knowledge, has decided to revise recommendations for the use of palivizumab in the prevention of RSV infection.
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Affiliation(s)
- Lina Bollani
- Unità di Neonatologia, Patologia Neonatale e Terapia Intensiva, Policlinico S. Matteo, Pavia, Italy.
| | - Eugenio Baraldi
- U.O.C. Terapia Intensiva e patologia neonatale, A.O. Padova, Padova, Italy.
| | - Gaetano Chirico
- U.O. C. Neonatologia e Terapia Intensiva neonatale, A.O. Spedali civili, Brescia, Italy.
| | - Andrea Dotta
- U.O.C. Terapia intensiva neonatale, Ospedale pediatrico Bambino Gesù, Roma, Italy.
| | - Marcello Lanari
- U.O. Pediatria E Neonatologia , Ospedale Nuovo S. Maria della Scaletta, Imola, Italy.
| | - Antonello Del Vecchio
- U.O. Utin e Neonatologia, Azienda Ospedaliera di Venere e Giovanni XXIII, Bari, Italy.
| | - Paolo Manzoni
- U.O. Neonatologia e TIN ospedaliera, Azienda Ospedaliera OIRM-S. Anna, Torino, Italy.
| | - Antonio Boldrini
- U.O. Nido, Patologia Neonatale e Terapia Intensiva Neonatale, Ospedale Santa Chiara, Pisa, Italy.
| | | | - Sandra Di Fabio
- U.O. Neonatologia, Presidio Ospedaliero S. Salvatore, L'Aquila, Italy.
| | - Luigi Orfeo
- U.O. Nido, Patologia Neonatale e Terapia Intensiva Neonatale, Azienda Ospedaliera G. Rummo, Benevento, Italy.
| | - Mauro Stronati
- Unità di Neonatologia, Patologia Neonatale e Terapia Intensiva, Ospedale Policlinico S. Matteo, Pavia, Italy.
| | - Costantino Romagnoli
- U.O.C. Neonatologia, Policlinico Universitario A. Gemelli, Roma, Italy.
- Division of Neonatology, Department of Pediatrics, Catholic University S.H., Largo A. Gemelli,8, Rome, 00168, Italy.
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Maguire C, Cantrill H, Hind D, Bradburn M, Everard ML. Hypertonic saline (HS) for acute bronchiolitis: Systematic review and meta-analysis. BMC Pulm Med 2015; 15:148. [PMID: 26597174 PMCID: PMC4657365 DOI: 10.1186/s12890-015-0140-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 11/10/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Acute bronchiolitis is the commonest cause of hospitalisation in infancy. Currently management consists of supportive care and oxygen. A Cochrane review concluded that, "nebulised 3 % saline may significantly reduce the length of hospital stay". We conducted a systematic review of controlled trials of nebulised hypertonic saline (HS) for infants hospitalised with primary acute bronchiolitis. METHODS Searches to January 2015 involved: Cochrane Central Register of Controlled Trials; Ovid MEDLINE; Embase; Google Scholar; Web of Science; and, a variety of trials registers. We hand searched Chest, Paediatrics and Journal of Paediatrics on 14 January 2015. Reference lists of eligible trial publications were checked. Randomised or quasi-randomised trials which compared HS versus either normal saline (+/- adjunct treatment) or no treatment were included. Eligible studies involved children less than 2 years old hospitalised due to the first episode of acute bronchiolitis. Two reviewers extracted data to calculate mean differences (MD) and 95 % Confidence Intervals (CIs) for length of hospital stay (LoS-primary outcome), Clinical Severity Score (CSS) and Serious Adverse Events (SAEs). Meta-analysis was undertaken using a fixed effect model, supplemented with additional sensitivity analyses. We investigated statistical heterogeneity using I(2). Risk of bias, within and between studies, was assessed using the Cochrane tool, an outcome reporting bias checklist and a funnel plot. RESULTS Fifteen trials were included in the systematic review (n = 1922), HS reduced mean LoS by 0.36, (95 % CI 0.50 to 0.22) days, but with considerable heterogeneity (I(2) = 78 %) and sensitivity to alternative analysis methods. A reduction in CSS was observed where assessed [n = 516; MD -1.36, CI -1.52, -1.20]. One trial reported one possible intervention related SAE, no other studies described intervention related SAEs. CONCLUSIONS There is disparity between the overall combined effect on LoS as compared with the negative results from the largest and most precise trials. Together with high levels of heterogeneity, this means that neither individual trials nor pooled estimates provide a firm evidence-base for routine use of HS in inpatient acute bronchiolitis.
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Affiliation(s)
- Chin Maguire
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK.
| | - Hannah Cantrill
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK.
| | - Daniel Hind
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK.
| | - Mike Bradburn
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK.
| | - Mark L Everard
- School of Paediatrics and Child Health (SPACH), The University of Western Australia, Perth, Australia.
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Flores-González JC, Matamala-Morillo MA, Rodríguez-Campoy P, Pérez-Guerrero JJ, Serrano-Moyano B, Comino-Vazquez P, Palma-Zambrano E, Bulo-Concellón R, Santos-Sánchez V, Lechuga-Sancho AM. Epinephrine Improves the Efficacy of Nebulized Hypertonic Saline in Moderate Bronchiolitis: A Randomised Clinical Trial. PLoS One 2015; 10:e0142847. [PMID: 26575036 PMCID: PMC4648584 DOI: 10.1371/journal.pone.0142847] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Accepted: 10/07/2015] [Indexed: 11/23/2022] Open
Abstract
Background and Aims There is no evidence that the epinephrine-3% hypertonic saline combination is more effective than 3% hypertonic saline alone for treating infants hospitalized with acute bronchiolitis. We evaluated the efficacy of nebulized epinephrine in 3% hypertonic saline. Patients and Methods We performed a randomized, double-blind, placebo-controlled clinical trial in 208 infants hospitalized with acute moderate bronchiolitis. Infants were randomly assigned to receive nebulized 3% hypertonic saline with either 3 mL of epinephrine or 3 mL of placebo, administered every four hours. The primary outcome measure was the length of hospital stay. Results A total of 185 infants were analyzed: 94 in the epinephrine plus 3% hypertonic saline group and 91 in the placebo plus 3% hypertonic saline group. Baseline demographic and clinical characteristics were similar in both groups. Length of hospital stay was significantly reduced in the epinephrine group as compared with the placebo group (3.94 ±1.88 days vs. 4.82 ±2.30 days, P = 0.011). Disease severity also decreased significantly earlier in the epinephrine group (P = 0.029 and P = 0.036 on days 3 and 5, respectively). Conclusions In our setting, nebulized epinephrine in 3% hypertonic saline significantly shortens hospital stay in hospitalized infants with acute moderate bronchiolitis compared to 3% hypertonic saline alone, and improves the clinical scores of severity from the third day of treatment, but not before. Trial Registration EudraCT 2009-016042-57
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Affiliation(s)
| | | | | | | | - Belén Serrano-Moyano
- Department of Clinical Pediatrics, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - Paloma Comino-Vazquez
- Department of Clinical Pediatrics, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | | | | | | | - Alfonso M. Lechuga-Sancho
- Department of Clinical Pediatrics, Hospital Universitario Puerta del Mar, Cádiz, Spain
- Department of Maternal and Child Health Care and Radiology, University of Cádiz, Cádiz, Spain
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Lower respiratory tract infection caused by respiratory syncytial virus: current management and new therapeutics. THE LANCET RESPIRATORY MEDICINE 2015; 3:888-900. [PMID: 26411809 DOI: 10.1016/s2213-2600(15)00255-6] [Citation(s) in RCA: 215] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 06/15/2015] [Accepted: 06/22/2015] [Indexed: 01/20/2023]
Abstract
Respiratory syncytial virus (RSV) is a major worldwide cause of morbidity and mortality in children under five years of age. Evidence-based management guidelines suggest that there is no effective treatment for RSV lower respiratory tract infection (LRTI) and that supportive care, ie, hydration and oxygenation, remains the cornerstone of clinical management. However, RSV treatments in development in the past decade include 10 vaccines and 11 therapeutic agents in active clinical trials. Maternal vaccination is particularly relevant because the most severe disease occurs within the first 6 months of life, when children are unlikely to benefit from active immunisation. We must optimise the implementation of novel RSV therapeutics by understanding the target populations, showing safety, and striving for acceptable pricing in the context of this worldwide health problem. In this Review, we outline the limitations of RSV LRTI management, the drugs in development, and the remaining challenges related to study design, regulatory approval, and implementation.
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Nebulised hypertonic saline (3%) among children with mild to moderately severe bronchiolitis--a double blind randomized controlled trial. BMC Pediatr 2015; 15:115. [PMID: 26357896 PMCID: PMC4644020 DOI: 10.1186/s12887-015-0434-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 08/26/2015] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND To Assess the efficacy of nebulised hypertonic saline (HS) (3%) among children with mild to moderately severe bronchiolitis. METHODS Infants aged 6 weeks to 24 months, with a first episode of wheezing and Clinical Severity scores (Arch Dis Child 67:289-93, 1992) between 1 and 8, were enrolled over 4 months duration. Those with severe disease, co-morbidities, prior wheezing, recent bronchodilator and steroid use were excluded. Patients were randomized in a double-blind fashion, to receive two doses of nebulized 3% HS (Group 1) or 0.9% normal saline (Group 2) with 1.5 mg of L-Epineprine, delivered 30 min apart. Parents were contacted at 24 h and 7 days. The principal outcome measure was the mean change in clinical severity score at the end of 2 h of observation. RESULTS A total of 100 infants (mean age 9.6 months, range 2-23 months; 61 % males) were enrolled. Patients in both groups had mild to moderately severe disease at presentation. On an intention-to-treat basis, the infants in the HS group had a significant reduction (3.57 ± 1.41) in the mean clinical severity score compared to those in the NS group (2.26 ± 1.15); [p < 0.001; CI: 0.78-1.82]. More children in the HS group (n = 35/50; 70.0%) were eligible for ER/OPD discharge at the end of 2 h than those in the NS group (n = 15/50; 30%; p < 0.001), and less likely to need a hospital re-visit (n = 5/50; 10.0%) in the next 24 h as compared to the NS group (n = 15/50, 30.0%; p < 0.001). The treatment was well tolerated, with no adverse effects. CONCLUSIONS Nebulized 3% HS is effective, safe and superior to normal saline for outpatient management of infants with mild to moderately severe viral bronchiolitis in improving Clinical Severity Scores, facilitating early Out-Patient Department discharge and preventing hospital re-visits and admissions in the 24 h of presentation. TRIAL REGISTRATION Clinicaltrials.gov NCTID012766821. Registered on January 12, 2011.
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Castro-Rodriguez JA, Rodriguez-Martinez CE, Sossa-Briceño MP. Principal findings of systematic reviews for the management of acute bronchiolitis in children. Paediatr Respir Rev 2015; 16:267-75. [PMID: 25636596 DOI: 10.1016/j.prrv.2014.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 11/18/2014] [Accepted: 11/23/2014] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Jose A Castro-Rodriguez
- Departments of Pediatrics and Family Medicine, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Carlos E Rodriguez-Martinez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia; Department of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Bogota, Colombia; Research Unit, Military Hospital of Colombia, Bogota, Colombia
| | - Monica P Sossa-Briceño
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia
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Acute Bronchiolitis: Still No New Treatments to Offer. Indian J Pediatr 2015; 82:777-8. [PMID: 26141546 DOI: 10.1007/s12098-015-1802-7] [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] [Received: 05/21/2015] [Accepted: 05/21/2015] [Indexed: 10/23/2022]
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Abstract
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. This is an update of a review published in Issue 9, 2012. We did not identify any new studies for inclusion, and our conclusions remain unchanged. 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 the Cochrane Central Register of Controlled Studies (CENTRAL; 2015, Issue 5) which contains the Cochrane Acute Respiratory Infections Group's Specialised Register; MEDLINE (1948 to June week 3, 2015); EMBASE (1974 to June 2015); CINAHL (1982 to June 2015); LILACS (1985 to June 2015); and Web of Science (1985 to June 2015). 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 reported no mortality. We judged all three of the included studies to be at low risk or unclear risk across all risk of bias categories; we did not judge any of the studies to be at high risk of bias in any category. Our pooled analysis of the three trials revealed that duration of mechanical ventilation was not significantly 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 CO2 elimination. No adverse effects and no complications were observed in any of the three included studies. The level of evidence for duration of mechanical ventilation, duration of intensive care unit stay, oxygenation parameters, and carbon dioxide parameters was of moderate quality. AUTHORS' CONCLUSIONS Use of surfactant had favourable effects on duration of mechanical ventilation, duration of ICU stay, oxygenation, and CO2 elimination. However, the studies are few and small (n = 79) so 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.
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Affiliation(s)
- Kana R Jat
- All India Institute of Medical SciencesDepartment of PediatricsAnsari NagarNew DelhiDelhiIndia110029
| | - Deepak Chawla
- Government Medical College and HospitalDepartment of PediatricsChandigarhIndia160030
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Lin JA, Madikians A. From bronchiolitis guideline to practice: A critical care perspective. World J Crit Care Med 2015; 4:152-158. [PMID: 26261767 PMCID: PMC4524812 DOI: 10.5492/wjccm.v4.i3.152] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 06/12/2015] [Accepted: 07/14/2015] [Indexed: 02/06/2023] Open
Abstract
Acute viral bronchiolitis is a leading cause of admission to pediatric intensive care units, but research on the care of these critically ill infants has been limited. Pathology of viral bronchiolitis revealed respiratory obstruction due to intraluminal debris and edema of the airways and vasculature. This and clinical evidence suggest that airway clearance interventions such as hypertonic saline nebulizers and pulmonary toilet devices may be of benefit, particularly in situations of atelectasis associated with bronchiolitis. Research to distinguish an underlying asthma predisposition in wheezing infants with viral bronchiolitis may one day lead to guidance on when to trial bronchodilator therapy. Considering the paucity of critical care research in pediatric viral bronchiolitis, intensive care practitioners must substantially rely on individualization of therapies based on bedside clinical assessments. However, with the introduction of new diagnostic and respiratory technologies, our ability to support critically ill infants with acute viral bronchiolitis will continue to advance.
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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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Florin TA, Byczkowski T, Ruddy RM, Zorc JJ, Test M, Shah SS. Utilization of nebulized 3% saline in infants hospitalized with bronchiolitis. J Pediatr 2015; 166:1168-1174.e2. [PMID: 25747800 PMCID: PMC4414866 DOI: 10.1016/j.jpeds.2015.01.045] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 12/22/2014] [Accepted: 01/23/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To describe utilization of 3% hypertonic saline (HTS) in hospitalized infants and to evaluate the association between HTS use and length of stay (LOS) in a real-world setting. STUDY DESIGN This multicenter retrospective cohort study included infants≤12 months hospitalized with bronchiolitis between October 2008 and September 2011 using the Pediatric Health Information System. HTS use was categorized as trial, rescue, daily, or sporadic. Differences in LOS were compared after matching daily HTS recipients and nonrecipients on propensity score. RESULTS There were 63,337 hospitalizations for bronchiolitis. HTS was used in 24 of 42 hospitals and 2.9% of all hospitalizations. HTS use increased from 0.4% of visits in 2008 to 9.2% of visits in 2011. There was substantial variation in HTS use across hospitals (range 0.1%-32.6%). When used, HTS was given daily during 60.6% of hospitalizations, sporadically in 10.4%, as a trial in 11.3%, and as a rescue in 17.7%. The propensity score-matched analysis of daily HTS recipients (n=953) vs nonrecipients (n=953) showed no difference in mean LOS (HTS 2.3 days vs nonrecipients 2.5 days; β-coefficient -0.04; 95% CI -0.15, 0.07; P=.5) or odds of staying longer than 1, 2, or 3 days. Daily HTS recipients had a 33% decreased odds of staying in the hospital>4 days compared with nonrecipients (OR 0.67; 95% CI 0.47, 0.97; P=.03). CONCLUSIONS Variation in HTS use and the lack of association between HTS and mean LOS demonstrates the need for further research to standardize HTS use and better define the infants for whom HTS will be most beneficial.
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Affiliation(s)
- Todd A. Florin
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Terri Byczkowski
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Richard M. Ruddy
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Joseph J. Zorc
- Division of Emergency Medicine, the Children’s Hospital of Philadelphia, and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Matthew Test
- Department of Pediatrics, Seattle Children’s Hospital, Seattle, WA
| | - Samir S. Shah
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH,Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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Liu F, Ouyang J, Sharma AN, Liu S, Yang B, Xiong W, Xu R. Leukotriene inhibitors for bronchiolitis in infants and young children. Cochrane Database Syst Rev 2015; 2015:CD010636. [PMID: 25773054 PMCID: PMC10879915 DOI: 10.1002/14651858.cd010636.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Bronchiolitis is an acute inflammatory illness of the bronchioles common among infants and young children. It is often caused by the respiratory syncytial virus (RSV). Management of bronchiolitis varies between clinicians, reflecting the lack of evidence for a specific treatment approach. The leukotriene pathway has been reported to be involved in the pathogenesis of bronchiolitis. Leukotriene inhibitors such as montelukast have been used in infants and young children with bronchiolitis. However, the results from limited randomised controlled trials (RCTs) are controversial and necessitate a thorough evaluation of their efficacy for bronchiolitis in infants and young children. OBJECTIVES To assess the efficacy and safety of leukotriene inhibitors for bronchiolitis in infants and young children. SEARCH METHODS We searched CENTRAL (2014, Issue 5), MEDLINE (1946 to April week 4, 2014), EMBASE (1974 to May 2014), CINAHL (1981 to May 2014), LILACS (1982 to May 2014), Web of Science (1985 to May 2014), WHO ICTRP and ClinicalTrials.gov (6 May 2014). SELECTION CRITERIA RCTs comparing leukotriene inhibitors versus placebo or another intervention in infants and young children under two years of age diagnosed with bronchiolitis. Our primary outcomes were length of hospital stay and all-cause mortality. Secondary outcomes included clinical severity score, percentage of symptom-free days, percentage of children requiring ventilation, oxygen saturation, recurrent wheezing, respiratory rate and clinical adverse effects. DATA COLLECTION AND ANALYSIS We used standard Cochrane Collaboration methodological practices. Two authors independently assessed trial eligibility and extracted data, such as general information, participant characteristics, interventions and outcomes. We assessed risk of bias and graded the quality of the evidence. We used Review Manager software to pool results and chose random-effects models for meta-analysis. MAIN RESULTS We included five studies with a total of 1296 participants under two years of age hospitalised with bronchiolitis. Two studies with low risk of bias compared 4 mg montelukast (a leukotriene inhibitor) daily use from admission until discharge with a matching placebo. Both selected length of hospital stay as a primary outcome and clinical severity score as a secondary outcome. However, the effects of leukotriene inhibitors on length of hospital stay and clinical severity score were uncertain due to considerable heterogeneity between the study results and wide confidence intervals around the estimated effects (hospital stay: mean difference (MD) -0.95 days, 95% confidence interval (CI) -3.08 to 1.19, P value = 0.38, low quality evidence; clinical severity score on day two: MD -0.57, 95% CI -2.37 to 1.23, P value = 0.53, low quality evidence; clinical severity score on day three: MD 0.17, 95% CI -1.93 to 2.28, P value = 0.87, low quality evidence). The other three studies compared montelukast for several weeks for preventing post-bronchiolitis symptoms with placebo. We assessed one study as low risk of bias, whereas we assessed the other two studies as having a high risk of attrition bias. Due to the significant clinical heterogeneity in severity of disease, duration of treatment, outcome measurements and timing of assessment, we did not pool the results. Individual analyses of these studies did not show significant differences between the leukotriene inhibitors group and the control group in symptom-free days and incidence of recurrent wheezing. One study of 952 children reported two deaths in the leukotriene inhibitors group: neither was determined to be drug-related. No data were available on the percentage of children requiring ventilation, oxygen saturation and respiratory rate. Finally, three studies reported adverse events including diarrhoea, wheezing shortly after administration and rash. No differences were reported between the study groups. AUTHORS' CONCLUSIONS The current evidence does not allow definitive conclusions to be made about the effects of leukotriene inhibitors on length of hospital stay and clinical severity score in infants and young children with bronchiolitis. The quality of the evidence was low due to inconsistency (unexplained high levels of statistical heterogeneity) and imprecision arising from small sample sizes and wide confidence intervals, which did not rule out a null effect or harm. Data on symptom-free days and incidence of recurrent wheezing were from single studies only. Further large studies are required. We identified one registered ongoing study, which may make a contribution in the updates of this review.
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Affiliation(s)
- Fang Liu
- First Affiliated Hospital of the Third Military Medical UniversityPharmacy Department30 Gaotanyan StreetShapingba DistrictChongqingChina400038
| | - Jing Ouyang
- First Affiliated Hospital of the Third Military Medical UniversityPharmacy Department30 Gaotanyan StreetShapingba DistrictChongqingChina400038
| | - Atul N Sharma
- California Emergency Physician (CEP) ‐ Mercy San Juan HospitalDepartment of Emergency Medicine6501 Coyle AvenueCarmichaelUSA95608
| | - Songqing Liu
- First Affiliated Hospital of the Third Military Medical UniversityPharmacy Department30 Gaotanyan StreetShapingba DistrictChongqingChina400038
| | - Bo Yang
- First Affiliated Hospital of the Third Military Medical UniversityPharmacy Department30 Gaotanyan StreetShapingba DistrictChongqingChina400038
| | - Wei Xiong
- First Affiliated Hospital of the Third Military Medical UniversityDepartment of Respiratory Diseases30 Gaotanyan StreetShapingba DistrictChongqingChina400038
| | - Rufu Xu
- Third Military Medical UniversityDepartment of Military Epidemiology, Military Preventive Medical College29 Gaotanyan StreetShapingba DistrictChongqingChina400038
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Everard ML, Hind D, Ugonna K, Freeman J, Bradburn M, Cooper CL, Cross E, Maguire C, Cantrill H, Alexander J, McNamara PS. SABRE: a multicentre randomised control trial of nebulised hypertonic saline in infants hospitalised with acute bronchiolitis. Thorax 2015; 69:1105-12. [PMID: 25389139 PMCID: PMC4251206 DOI: 10.1136/thoraxjnl-2014-205953] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Aim Acute bronchiolitis is the commonest cause for hospitalisation in infancy. Supportive care remains the cornerstone of current management and no other therapy has been shown to influence the course of the disease. It has been suggested that adding nebulised hypertonic saline to usual care may shorten the duration of hospitalisation. To determine whether hypertonic saline does have beneficial effects we undertook an open, multi-centre parallel-group, pragmatic RCT in ten UK hospitals. Methods Infants admitted to hospital with a clinical diagnosis of acute bronchiolitis and requiring oxygen therapy were randomised to receive usual care alone or nebulised 3% hypertonic saline (HS) administered 6-hourly. Randomisation was within 4 h of admission. The primary outcome was time to being assessed as ‘fit’ for discharge with secondary outcomes including time to discharge, incidence of adverse events together with follow up to 28 days assessing patient centred health related outcomes. Results A total of 317 infants were recruited to the study. 158 infants were randomised to HS (141 analysed) and 159 to standard care (149 analysed). There was no difference between the two arms in time to being declared fit for discharge (hazard ratio: 0−95, 95% CI: 0.75−1.20) nor to actual discharge (hazard ratio: 0.97, 95% CI: 0.76−1.23). There was no difference in adverse events. One infant in the HS group developed bradycardia with desaturation. Conclusion This study does not support the use of nebulised HS in the treatment of acute bronchiolitis over usual care with minimal handlings. ClinicalTrials.gov registration number NCT01469845.
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Affiliation(s)
- Mark L Everard
- University of Western Australia, Perth, Western Australia, Australia
| | | | - Kelechi Ugonna
- Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | | | | | | | | | | | | | - John Alexander
- University Hospital of North Staffordshire NHS Trust, Stoke-on-Trent, UK
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Abstract
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.
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Affiliation(s)
- Kana R Jat
- Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, Delhi, India, 110029
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41
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Zhang L. Multiple-dose hypertonic saline decreases bronchiolitis admissions. J Pediatr 2015; 166:207. [PMID: 25527856 DOI: 10.1016/j.jpeds.2014.10.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Linjie Zhang
- Federal University of Rio Grande, Rio Grande, Brazil
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42
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Friedman JN, Rieder MJ, Walton JM. Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age. Paediatr Child Health 2014; 19:485-98. [PMID: 25414585 DOI: 10.1093/pch/19.9.485] [Citation(s) in RCA: 141] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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43
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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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44
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Baraldi E, Lanari M, Manzoni P, Rossi GA, Vandini S, Rimini A, Romagnoli C, Colonna P, Biondi A, Biban P, Chiamenti G, Bernardini R, Picca M, Cappa M, Magazzù G, Catassi C, Urbino AF, Memo L, Donzelli G, Minetti C, Paravati F, Di Mauro G, Festini F, Esposito S, Corsello G. Inter-society consensus document on treatment and prevention of bronchiolitis in newborns and infants. Ital J Pediatr 2014; 40:65. [PMID: 25344148 PMCID: PMC4364570 DOI: 10.1186/1824-7288-40-65] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 04/18/2014] [Indexed: 01/14/2023] Open
Abstract
Acute bronchiolitis is the leading cause of lower respiratory tract infection and hospitalization in children less than 1 year of age worldwide. It is usually a mild disease, but some children may develop severe symptoms, requiring hospital admission and ventilatory support in the ICU. Infants with pre-existing risk factors (prematurity, bronchopulmonary dysplasia, congenital heart diseases and immunodeficiency) may be predisposed to a severe form of the disease. Clinical diagnosis of bronchiolitis is manly based on medical history and physical examination (rhinorrhea, cough, crackles, wheezing and signs of respiratory distress). Etiological diagnosis, with antigen or genome detection to identify viruses involved, may have a role in reducing hospital transmission of the infection. Criteria for hospitalization include low oxygen saturation (<90-92%), moderate-to-severe respiratory distress, dehydration and presence of apnea. Children with pre-existing risk factors should be carefully assessed.To date, there is no specific treatment for viral bronchiolitis, and the mainstay of therapy is supportive care. This consists of nasal suctioning and nebulized 3% hypertonic saline, assisted feeding and hydration, humidified O2 delivery. The possible role of any pharmacological approach is still debated, and till now there is no evidence to support the use of bronchodilators, corticosteroids, chest physiotherapy, antibiotics or antivirals. Nebulized adrenaline may be sometimes useful in the emergency room. Nebulized adrenaline can be useful in the hospital setting for treatment as needed. Lacking a specific etiological treatment, prophylaxis and prevention, especially in children at high risk of severe infection, have a fundamental role. Environmental preventive measures minimize viral transmission in hospital, in the outpatient setting and at home. Pharmacological prophylaxis with palivizumab for RSV bronchiolitis is indicated in specific categories of children at risk during the epidemic period. Viral bronchiolitis, especially in the case of severe form, may correlate with an increased incidence of recurrent wheezing in pre-schooled children and with asthma at school age.The aim of this document is to provide a multidisciplinary update on the current recommendations for the management and prevention of bronchiolitis, in order to share useful indications, identify gaps in knowledge and drive future research.
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Affiliation(s)
- Eugenio Baraldi
- />SIMRI-Società Italiana per le Malattie Respiratorie Infantili, Kragujevac, Italy
- />Women’s and Children’s Health Department, Unit of Pediatric Respiratory Medicine and Allergy, University of Padova, Via Giustiniani 3, 35128 Padova, Italy
| | | | - Paolo Manzoni
- />SIN-Società Italiana di Neonatologia, Kragujevac, Italy
| | - Giovanni A Rossi
- />SIMRI-Società Italiana per le Malattie Respiratorie Infantili, Kragujevac, Italy
| | - Silvia Vandini
- />SIN-Società Italiana di Neonatologia, Kragujevac, Italy
| | - Alessandro Rimini
- />SICP-Società Italiana di Cardiologia Pediatrica, Kragujevac, Italy
| | | | - Pierluigi Colonna
- />SICP-Società Italiana di Cardiologia Pediatrica, Kragujevac, Italy
| | - Andrea Biondi
- />AIEOP - Società Italiana di Ematologia e Oncologia Pediatrica, Kragujevac, Italy
| | - Paolo Biban
- />AMIETIP - Accademia Medica Infermieristica di Emergenza e Terapia Intensiva Pediatrica, Kragujevac, Italy
| | | | - Roberto Bernardini
- />SIAIP - Società Italiana di Allergologia e Immunologia Pediatrica, Kragujevac, Italy
| | - Marina Picca
- />SICuPP - Società Italiana delle Cure Primarie Pediatriche, Kragujevac, Italy
| | - Marco Cappa
- />SIEDP - Società Italiana di Endocrinologia e Diabetologia Pediatrica, Kragujevac, Italy
| | - Giuseppe Magazzù
- />SIFC - Società Italiana per lo studio della Fibrosi Cistica, Kragujevac, Italy
| | - Carlo Catassi
- />SIGENP - Società Italiana Gastroenterologia Epatologia e Nutrizione Pediatrica, Kragujevac, Italy
| | | | - Luigi Memo
- />SIMGePeD - Società Italiana Malattie Genetiche Pediatriche e Disabilità Congenite, Kragujevac, Italy
| | | | - Carlo Minetti
- />SINP - Società Italiana di Neurologia Pediatrica, Kragujevac, Italy
| | | | - Giuseppe Di Mauro
- />SIPPS - Società Italiana di Pediatria Preventiva e Sociale, Kragujevac, Italy
| | - Filippo Festini
- />SISIP - Società Italiana di Scienze Infermieristiche Pediatriche, Kragujevac, Italy
| | - Susanna Esposito
- />SITIP - Società Italiana di Infettivologia Pediatrica, Kragujevac, Italy
| | | | - on behalf of their respective Scientific Pediatric Societies
- />SIMRI-Società Italiana per le Malattie Respiratorie Infantili, Kragujevac, Italy
- />Women’s and Children’s Health Department, Unit of Pediatric Respiratory Medicine and Allergy, University of Padova, Via Giustiniani 3, 35128 Padova, Italy
- />SIN-Società Italiana di Neonatologia, Kragujevac, Italy
- />SICP-Società Italiana di Cardiologia Pediatrica, Kragujevac, Italy
- />AIEOP - Società Italiana di Ematologia e Oncologia Pediatrica, Kragujevac, Italy
- />AMIETIP - Accademia Medica Infermieristica di Emergenza e Terapia Intensiva Pediatrica, Kragujevac, Italy
- />FIMP - Federazione Italiana Medici Pediatri, Kragujevac, Italy
- />SIAIP - Società Italiana di Allergologia e Immunologia Pediatrica, Kragujevac, Italy
- />SICuPP - Società Italiana delle Cure Primarie Pediatriche, Kragujevac, Italy
- />SIEDP - Società Italiana di Endocrinologia e Diabetologia Pediatrica, Kragujevac, Italy
- />SIFC - Società Italiana per lo studio della Fibrosi Cistica, Kragujevac, Italy
- />SIGENP - Società Italiana Gastroenterologia Epatologia e Nutrizione Pediatrica, Kragujevac, Italy
- />SIMEUP - Società Italiana di Medicina di Emergenza ed Urgenza Pediatrica, Kragujevac, Italy
- />SIMGePeD - Società Italiana Malattie Genetiche Pediatriche e Disabilità Congenite, Kragujevac, Italy
- />SIMP - Società Italiana di Medicina Perinatale, Kragujevac, Italy
- />SINP - Società Italiana di Neurologia Pediatrica, Kragujevac, Italy
- />SIPO - Società Italiana Pediatria Ospedaliera, Kragujevac, Italy
- />SIPPS - Società Italiana di Pediatria Preventiva e Sociale, Kragujevac, Italy
- />SISIP - Società Italiana di Scienze Infermieristiche Pediatriche, Kragujevac, Italy
- />SITIP - Società Italiana di Infettivologia Pediatrica, Kragujevac, Italy
- />SIP-Società Italiana di Pediatria, Kragujevac, Italy
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45
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Abstract
This article discusses and evaluates the management options for children with bronchiolitis, and identifies children at high risk of a clinically severe illness.
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Affiliation(s)
- S Datsopoulos
- Specialist Registrar in Paediatrics, Great Ormond Street Hospital, London WC1N 3JH
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46
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Abstract
PURPOSE OF REVIEW Bronchiolitis is a common condition in children less than 2 years of age and is a leading cause of infant hospitalization. Although there is significant variability in testing and treatment of children with bronchiolitis, diagnostic testing rarely improves care, and no currently available pharmacologic options have been proven to provide meaningful benefits or improve outcomes. RECENT FINDINGS Beta-agonists continue to be used frequently despite evidence that they do not reduce hospital admissions or length of stay. In general, therapies initially considered promising were subsequently proven ineffective, a pattern seen in studies on corticosteroids, and more recently with nebulized racemic epinephrine and hypertonic saline. Recent research has improved our understanding of the viral epidemiology of bronchiolitis, with increasing recognition of viruses other than respiratory syncytial virus and better awareness of the role of viral coinfections. How these findings will translate into improved outcomes remains uncertain. SUMMARY Much of the emphasis of the last few decades of bronchiolitis clinical care and research has centered on the identification and testing of novel therapies. Future quality improvement efforts should focus more on the limitation of unnecessary testing and treatments. Future research should include identification of subgroups of children with bronchiolitis that may benefit from focused clinical interventions.
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Affiliation(s)
- Alan R. Schroeder
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, CA
| | - Jonathan M. Mansbach
- Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Beigelman A, Bacharier LB. Infection-induced wheezing in young children. J Allergy Clin Immunol 2014; 133:603-4. [PMID: 24636478 DOI: 10.1016/j.jaci.2013.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 11/26/2013] [Accepted: 12/04/2013] [Indexed: 11/17/2022]
Affiliation(s)
- Avraham Beigelman
- Department of Pediatrics, Washington University and St Louis Children's Hospital, St Louis, Mo
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University and St Louis Children's Hospital, St Louis, Mo.
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48
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Thornby KA, Johnson A, Axtell S. Dornase Alfa for Non–Cystic Fibrosis Pediatric Pulmonary Atelectasis. Ann Pharmacother 2014; 48:1040-1049. [PMID: 24811400 DOI: 10.1177/1060028014535199] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To review the literature evaluating the efficacy of dornase alfa for non–cystic fibrosis pediatric patients with pulmonary atelectasis. Data Sources: Articles were retrieved after a search of MEDLINE/PubMed (1946 to April 2014), and International Pharmaceutical Abstracts (1970-April 2014) was performed using the terms dornase alfa, recombinant human deoxyribonuclease, pulmonary, persistent, and atelectasis. Other relevant articles referenced from the MEDLINE search were also utilized. Study Selection and Data Extraction: Data sources were limited to English language clinical trials and case studies including only children; 8 clinical trials and 12 case reports met the criteria. Data Synthesis: Dornase alfa is used as an off-label treatment option for pulmonary atelectasis because limited treatment modalities exist after conventional therapy has failed. We evaluated 8 clinical trials and 12 case reports involving this pediatric population with varying primary diagnoses. The majority of patients experienced improvement in atelectasis, suggesting benefit after receiving treatment with dornase alfa. However, the outcomes were possibly confounded by those receiving combination therapies, varying primary diagnoses, and varying end points evaluated. Dornase alfa was overall well tolerated, with only a few patients experiencing worsening atelectasis posttreatment. Conclusions: Dornase alfa may be considered as a therapeutic option in non–cystic fibrosis pediatric patients with pulmonary atelectasis, who require treatment intervention when conventional therapy is unsuccessful.
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Affiliation(s)
| | - Ashley Johnson
- Palm Beach Atlantic University, West Palm Beach, FL, USA
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49
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Øymar K, Skjerven HO, Mikalsen IB. Acute bronchiolitis in infants, a review. Scand J Trauma Resusc Emerg Med 2014; 22:23. [PMID: 24694087 PMCID: PMC4230018 DOI: 10.1186/1757-7241-22-23] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 03/28/2014] [Indexed: 12/26/2022] Open
Abstract
Acute viral bronchiolitis is one of the most common medical emergency situations in infancy, and physicians caring for acutely ill children will regularly be faced with this condition. In this article we present a summary of the epidemiology, pathophysiology and diagnosis, and focus on guidelines for the treatment of bronchiolitis in infants. The cornerstones of the management of viral bronchiolitis are the administration of oxygen and appropriate fluid therapy, and overall a “minimal handling approach” is recommended. Inhaled adrenaline is commonly used in some countries, but the evidences are sparse. Recently, inhalation with hypertonic saline has been suggested as an optional treatment. When medical treatment fails to stabilize the infants, non-invasive and invasive ventilation may be necessary to prevent and support respiratory failure. It is important that relevant treatment algorithms exist, applicable to all levels of the treatment chain and reflecting local considerations and circumstances.
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Affiliation(s)
- Knut Øymar
- Department of Paediatrics, Stavanger University Hospital, PO Box 8100, N-4068 Stavanger, Norway.
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