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

Noninvasive Positive Pressure Ventilation Use and In-Hospital Cardiac Arrest in Bronchiolitis

IMPORTANCE

A recent study showed an association between high hospital-level noninvasive positive pressure ventilation (NIPPV) use and in-hospital cardiac arrest (IHCA) in children with bronchiolitis.

OBJECTIVES

We aimed to determine if patient-level exposure to NIPPV in children with bronchiolitis was associated with IHCA.

DESIGN, SETTING AND PARTICIPANTS

Retrospective cohort study at a single-center quaternary PICU in North America including children with International Classification of Diseases primary or secondary diagnoses of bronchiolitis in the Virtual Pediatric Systems database.

MAIN OUTCOMES AND MEASURES

The primary exposure was NIPPV and the primary outcome was IHCA.

MEASUREMENTS AND MAIN RESULTS

Of 4698 eligible ICU admissions with bronchiolitis diagnoses, IHCA occurred in 1.2% (57/4698). At IHCA onset, invasive mechanical ventilation (IMV) was the most frequent level of respiratory support (65%, 37/57), with 12% (7/57) receiving NIPPV. Patients with IHCA had higher Pediatric Risk of Mortality-III scores (3 [0-8] vs. 0 [0-2]; p < 0.001), more frequently had a complex chronic condition (94.7% vs. 46.2%; p < 0.001), and had higher mortality (21.1% vs. 1.0%; p < 0.001) compared with patients without IHCA. Return of spontaneous circulation (ROSC) was achieved in 93% (53/57) of IHCAs; 79% (45/57) survived to hospital discharge. All seven children without chronic medical conditions and with active bronchiolitis symptoms at the time of IHCA achieved ROSC, and 86% (6/7) survived to discharge. In multivariable analysis restricted to patients receiving NIPPV or IMV, NIPPV exposure was associated with lower odds of IHCA (adjusted odds ratio [aOR], 0.07; 95% CI, 0.03-0.18) compared with IMV. In secondary analysis evaluating categorical respiratory support in all patients, compared with IMV, NIPPV was associated with lower odds of IHCA (aOR, 0.35; 95% CI, 0.14-0.87), whereas no difference was found for minimal respiratory support (none/nasal cannula/humidified high-flow nasal cannula [aOR, 0.56; 95% CI, 0.23-1.36]).

CONCLUSIONS AND RELEVANCE

Cardiac arrest in children with bronchiolitis is uncommon, occurring in 1.2% of bronchiolitis ICU admissions. NIPPV use in children with bronchiolitis was associated with lower odds of IHCA.

Bronchodilator-responsive bronchiolar obstruction in term neonates: a case series

BACKGROUND

Bronchiolar obstruction, which causes airway obstruction in hyperresponsive airways, often results from the contraction of the airway's smooth muscles, increased viscid mucous secretions, and mucosal oedema consequent upon a reduced cyclic 3,5-adenosine monophosphate (c-AMP). These processes respond to bronchodilators. The six cases presented to us, in Edward Francis Small Teaching Hospital (EFSTH), Banjul, The Gambia, in the newborn period with clinical features suggesting obstruction with airway reactivity with response to bronchodilator treatment are presented here. Our capacity-limited literature search did not show any such report in neonates. This report highlights the need for this condition to be sought in neonates, medically managed in resource-poor countries without resorting to high-cost equipment use, and for its possible future classification.

CASE PRESENTATION

We report six cases of Gambian neonates consisting of four males and two females ages 2-27 days who presented to us with histories of fast breathing of a few hours duration and expiratory respiratory distress. All were term babies with rhonchi and demonstrable prolonged expiration with terminal effort. They all had a diagnosis of hyperreactive airway disease with bronchiolar obstruction. Five cases were first-time wheezers, while one was a recurrence. All were eventually treated with bronchodilators and steroids with good results. The median duration for resolution of most symptoms with treatment was two days, with a range of 1-5 days.

CONCLUSION

Clinically determined bronchiolar obstructions in term neonates can be relieved with bronchodilators and steroids, and this treatment modality, if employed where the pathological process can be established, can reduce the demand on scarce resources in resource-poor countries.

UPDATE - 2022 Italian guidelines on the management of bronchiolitis in infants

Bronchiolitis is an acute respiratory illness that is the leading cause of hospitalization in young children. This document aims to update the consensus document published in 2014 to provide guidance on the current best practices for managing bronchiolitis in infants. The document addresses care in both hospitals and primary care. The diagnosis of bronchiolitis is based on the clinical history and physical examination. The mainstays of management are largely supportive, consisting of fluid management and respiratory support. Evidence suggests no benefit with the use of salbutamol, glucocorticosteroids and antibiotics with potential risk of harm. Because of the lack of effective treatment, the reduction of morbidity must rely on preventive measures. De-implementation of non-evidence-based interventions is a major goal, and educational interventions for clinicians should be carried out to promote high-value care of infants with bronchiolitis. Well-prepared implementation strategies to standardize care and improve the quality of care are needed to promote adherence to guidelines and discourage non-evidence-based attitudes. In parallel, parents' education will help reduce patient pressure and contribute to inappropriate prescriptions. Infants with pre-existing risk factors (i.e., prematurity, bronchopulmonary dysplasia, congenital heart diseases, immunodeficiency, neuromuscular diseases, cystic fibrosis, Down syndrome) present a significant risk of severe bronchiolitis and should be carefully assessed. This revised document, based on international and national scientific evidence, reinforces the current recommendations and integrates the recent advances for optimal care and prevention of acute bronchiolitis.

A prediction model for the efficacy of continuous positive airway pressure on bronchiolitis

OBJECTIVES

Prediction of the efficacy of continuous positive airway pressure (CPAP) on bronchiolitis is necessary for timely treatment. This study aims to establish a nomogram for efficacy of CPAP on bronchiolitis, and compares accuracy with Pediatric Risk of Mortality III (PRISM III), Brighton Pediatric Early Warning Score (Brighton PEWS) and Pediatric Critical Illness Score (PCIS).

METHODS

From February 2014 to December 2020, data on children diagnosed with bronchiolitis and treated with CPAP in Chongqing was collected. The nomogram was evaluated by using multivariate logistic regression analysis. We compared the predictive value of model with PRISM III, PEWS and PCIS.

RESULTS

A total of 510 children were included. The nomogram prediction model including fever, APTT, white blood cells, serum potassium concentration, lactic acid, immunodeficiency, atelectasis, lung consolidation, congenital airway dysplasia and congenital heart disease was established. The AUC of the nomogram was 0.919 in the training set and 0.947 in the validating set. The model fitted well, as evidenced by the calibration curve and Hosmer-Lemeshow goodness-of-fit test. We discovered that the nomogram significantly performed better than PRISM III, PCIS and PEWS.

CONCLUSIONS

A nomogram including ten factors for predicting the efficacy of CPAP on bronchiolitis was established. It had higher performance than the PRISM III, PCIS, and PEWS in terms of clinical benefits.