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Nelson CE, Miller JM, Jones C, Fingado ER, Baker AM, Fausnaugh J, Treut M, Graham L, Burr KL, Zomorrodi A. Emergency Department Initiative to Decrease High-flow Nasal Cannula Use for Admitted Patients with Bronchiolitis. Pediatr Qual Saf 2024; 9:e728. [PMID: 38751897 PMCID: PMC11093561 DOI: 10.1097/pq9.0000000000000728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 03/20/2024] [Indexed: 05/18/2024] Open
Abstract
Background Despite limited evidence, a high-flow nasal cannula (HFNC) is often used to treat mild to moderate (m/m) bronchiolitis. We aimed to decrease the rate of HFNC use in the pediatric emergency department (PED) for m/m bronchiolitis from a baseline of 37% to less than 18.5%. Methods A multidisciplinary team created a bronchiolitis pathway and implemented it in December 2019. A respiratory score (RS) in the electronic medical record objectively classified bronchiolitis severity as mild, moderate, or severe. We tracked HFNC utilization in the PED among patients with m/m bronchiolitis as our primary outcome measure between December 2019 and December 2021. We monitored the percentage of patients with an RS as a process measure. Interventions through four plan-do-study-act cycles included updating the hospital oxygen therapy policy, applying the RS to all patients in respiratory distress, modifying the bronchiolitis order set, and developing a bronchiolitis-specific HFNC order. Results Three hundred twenty-five patients were admitted from the PED with m/m bronchiolitis during the 11-month baseline period and 600 patients during the 25-month intervention period. The mean rate of HFNC utilization decreased from 37% to 17%. Despite a decrease in bronchiolitis encounters after the pandemic, in the spring of 2021, when volumes returned, we had a sustained HFNC utilization rate of 17%. RS entry increased from 60% to 73% in the intervention period. Conclusions A clinical pathway for bronchiolitis can lead to decreased use of HFNC for m/m bronchiolitis. Consistent RS, order set development with decision support, and education led to sustained improvement despite pandemic-related volumes.
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Affiliation(s)
- Courtney E. Nelson
- From the Department of Pediatrics, Nemours Children’s Health, Wilmington, Del
| | - Jonathan M. Miller
- From the Department of Pediatrics, Nemours Children’s Health, Wilmington, Del
| | - Chalanda Jones
- From the Department of Pediatrics, Nemours Children’s Health, Wilmington, Del
| | - Emily Reese Fingado
- From the Department of Pediatrics, Nemours Children’s Health, Wilmington, Del
| | - Ann-Marie Baker
- From the Department of Pediatrics, Nemours Children’s Health, Wilmington, Del
| | - Julie Fausnaugh
- From the Department of Pediatrics, Nemours Children’s Health, Wilmington, Del
| | - Michael Treut
- Respiratory Care Department, Nemours Children’s Health, Wilmington, Del
| | - Leah Graham
- Respiratory Care Department, Nemours Children’s Health, Wilmington, Del
| | - Katlyn L. Burr
- Respiratory Care Department, Nemours Children’s Health, Wilmington, Del
| | - Arezoo Zomorrodi
- From the Department of Pediatrics, Nemours Children’s Health, Wilmington, Del
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Kızılsoy ÖF, Korkmaz MF, Şenkan GE, Bozdemir ŞE, Korkmaz M. Relationship between the systemic immune-inflammatory index and the severity of acute bronchiolitis in children. Lab Med 2024; 55:169-173. [PMID: 37352474 DOI: 10.1093/labmed/lmad055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2023] Open
Abstract
OBJECTIVE Acute bronchiolitis (AB) is one of the most common respiratory diseases in early childhood and is still an important health problem worldwide. The systemic immune-inflammatory index (SII) is thought to have potential to be a new-generation inflammatory biomarker. We sought to investigate the value of SII for severity assessment in children with AB. METHODS A total of 74 AB patients were included in a prospective observational study. Patients were classified into 3 AB groups according to this classification: mild (1-5 points), moderate (6-10 points), and severe (11-12 points). Complete blood count, C-reactive protein, and procalcitonin tests were carried out. Modified Tal score was evaluated to determine severity. The performance of parameters to predict the severity of AB was assessed using the receiver operating characteristic (ROC). RESULTS Whereas neutrophil count (P = .037), neutrophil-to-lymphocyte ratio (P = .030), and SII (P = .030) values increased significantly with disease severity, red cell distribution width (P = .048) values were higher in the moderate AB group. The SII was found to have the highest area under the curve in the comparison of the mild-moderate groups combination and the high group on ROC analysis (P = .009). CONCLUSION The SII values of pediatric patients hospitalized with the diagnosis of AB were significantly higher in the high-severity group. The SII may offer additional severity stratification in children with AB.
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Affiliation(s)
- Ömer Furkan Kızılsoy
- Department of Pediatrics, University of Health Sciences, Bursa Faculty of Medicine, City Training and Research Hospital, Bursa, Turkey
| | - Muhammet Furkan Korkmaz
- Department of Pediatrics, University of Health Sciences, Bursa Faculty of Medicine, City Training and Research Hospital, Bursa, Turkey
| | - Gülsüm Elif Şenkan
- Department of Pediatrics, University of Health Sciences, Bursa Faculty of Medicine, City Training and Research Hospital, Bursa, Turkey
| | - Şefika Elmas Bozdemir
- Department of Pediatric Infectious Diseases, University of Health Sciences, Bursa Faculty of Medicine, City Training and Research Hospital, Bursa, Turkey
| | - Merve Korkmaz
- Department of Pediatric Pulmonology, Uludag Faculty of Medicine, Bursa, Turkey
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3
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Lopez M, Wilson M, Cobbina E, Kaufman D, Fluitt J, Grainger M, Ruiz R, Abudukadier G, Tiras M, Carlson B, Spaid J, Falsone K, Cocjin I, Moretti A, Vercio C, Tinsley C, Chandnani HK, Samayoa C, Cianci C, Pappas J, Chang NY. Decreasing ICU and Hospital Length of Stay through a Standardized Respiratory Therapist-driven Electronic Clinical Care Pathway for Status Asthmaticus. Pediatr Qual Saf 2023; 8:e697. [PMID: 38058471 PMCID: PMC10697623 DOI: 10.1097/pq9.0000000000000697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 09/07/2023] [Indexed: 12/08/2023] Open
Abstract
Introduction Status asthmaticus (SA) is a cause of many pediatric hospitalizations. This study sought to evaluate how a standardized asthma care pathway (ACP) in the electronic medical record impacted the length of stay (LOS). Methods An interdisciplinary team internally validated a standardized respiratory score for patients admitted with SA to a 25-bed pediatric intensive care unit (PICU) at a tertiary children's hospital. The respiratory score determined weaning schedules for albuterol and steroid therapies. In addition, pharmacy and information technology staff developed an electronic ACP within our electronic medical record system using best practice alerts. These best practice alerts informed staff to initiate the pathway, wean/escalate treatment, transition to oral steroids, transfer level of care, and complete discharge education. The PICU, stepdown ICU (SD ICU), and acute care units implemented the clinical pathway. Pre- and postintervention metrics were assessed using process control charts and compared using Welch's t tests with a significance level of 0.05. Results Nine hundred two consecutive patients were analyzed (598 preintervention, 304 postintervention). Order set utilization significantly increased from 68% to 97% (P < 0.001), PICU LOS decreased from 38.4 to 31.1 hours (P = 0.013), and stepdown ICU LOS decreased from 25.7 to 20.9 hours (P = 0.01). Hospital LOS decreased from 59.5 to 50.7 hours (P = 0.003), with cost savings of $1,215,088 for the patient cohort. Conclusions Implementing a standardized respiratory therapist-driven ACP for children with SA led to significantly increased order set utilization and decreased ICU and hospital LOS. Leveraging information technology and standardized pathways may improve care quality, outcomes, and costs for other common diagnoses.
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Affiliation(s)
- Merrick Lopez
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Michele Wilson
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Ekua Cobbina
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Danny Kaufman
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Julie Fluitt
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Michele Grainger
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Robert Ruiz
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Gulixian Abudukadier
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Michael Tiras
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Bronwyn Carlson
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Jeane Spaid
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Kim Falsone
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Invest Cocjin
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Anthony Moretti
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Chad Vercio
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
- Patient Safety and Reliability, Loma Linda University Medical Center, Loma Linda, Calif
- Department of Pediatrics, Riverside University Health System, Moreno Valley, Calif
| | - Cynthia Tinsley
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Harsha K. Chandnani
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
| | - Carlos Samayoa
- Patient Safety and Reliability, Loma Linda University Medical Center, Loma Linda, Calif
| | - Carissa Cianci
- Patient Safety and Reliability, Loma Linda University Medical Center, Loma Linda, Calif
| | - James Pappas
- Patient Safety and Reliability, Loma Linda University Medical Center, Loma Linda, Calif
| | - Nancy Y. Chang
- From the Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, Calif
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Forster BL, Thomas F, Arnold SR, Snider MA. Early Intravenous Magnesium Sulfate Administration in the Emergency Department for Severe Asthma Exacerbations. Pediatr Emerg Care 2023; 39:524-529. [PMID: 36728409 DOI: 10.1097/pec.0000000000002890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Severe asthma exacerbations in pediatric patients occur frequently and can require pediatric intensive care unit (PICU) admission. OBJECTIVE To determine if early administration of intravenous magnesium sulfate (IVMg) to pediatric patients experiencing severe asthma exacerbations, defined as a respiratory clinical score (RCS) of 9 to 12, resulted in fewer PICU admissions. METHODS Retrospective chart review of pediatric patients aged from 2 to 17 years presenting with a severe asthma exacerbation to a single tertiary care pediatric emergency department. Univariable and multivariable logistic regression analyses were used to determine if admission to the PICU was associated with early IVMg treatment, within 60 minutes of registration. RESULTS A total of 1911 patients were included in the study, of which 1541 received IVMg. The average time to IVMg was 79 minutes, with 35% of the patients receiving it within 60 minutes of arrival. Two hundred forty-eight (13%) were admitted to the PICU, 641 (34%) were admitted to the general inpatient floor, and 1022 (53%) were discharged home. Factors associated with increased odds ratio (OR) of PICU admission were: early IVMg (OR, 1.63; 95% CI: 1.16-2.28), arrival mode to the emergency department via ambulance (OR, 2.23; 95% CI: 1.45-3.43), history of PICU admission for asthma (OR, 1.73; 95% CI: 1.22-2.44), and diagnosis of status asthmaticus (OR, 8.88; 95% CI: 3.49-30.07). Calculated OR of PICU admission subcategorized by RCS for early IVMg patients, after controlling for PICU risk factors, are as follows: RCS 9 (reference), RCS 10 (OR, 2.52; 95% CI: 0.89-2.23), RCS 11 (OR, 2.19; 95% CI: 1.3-3.70), and RCS 12 (OR, 4.12; 95% CI: 2.13-7.95). CONCLUSIONS Early administration of IVMg to pediatric patients experiencing severe asthma exacerbations does not result in fewer PICU admissions.
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Affiliation(s)
- Brian L Forster
- From the Division of Emergency Services, Department of Pediatrics, The University of Tennessee Health Science Center and Le Bonheur Children's Hospital
| | - Fridtjof Thomas
- Division of Biostatistics, Department of Preventative Medicine, The University of Tennessee Health Science Center
| | - Sandra R Arnold
- Division of Infectious Diseases, Department of Pediatrics, The University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, TN
| | - Mark A Snider
- From the Division of Emergency Services, Department of Pediatrics, The University of Tennessee Health Science Center and Le Bonheur Children's Hospital
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Broderick D, Marsh R, Waite D, Pillarisetti N, Chang AB, Taylor MW. Realising respiratory microbiomic meta-analyses: time for a standardised framework. MICROBIOME 2023; 11:57. [PMID: 36945040 PMCID: PMC10031919 DOI: 10.1186/s40168-023-01499-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 02/20/2023] [Indexed: 06/18/2023]
Abstract
In microbiome fields of study, meta-analyses have proven to be a valuable tool for identifying the technical drivers of variation among studies and results of investigations in several diseases, such as those of the gut and sinuses. Meta-analyses also represent a powerful and efficient approach to leverage existing scientific data to both reaffirm existing findings and generate new hypotheses within the field. However, there are currently limited data in other fields, such as the paediatric respiratory tract, where extension of original data becomes even more critical due to samples often being difficult to obtain and process for a range of both technical and ethical reasons. Performing such analyses in an evolving field comes with challenges related to data accessibility and heterogeneity. This is particularly the case in paediatric respiratory microbiomics - a field in which best microbiome-related practices are not yet firmly established, clinical heterogeneity abounds and ethical challenges can complicate sharing of patient data. Having recently conducted a large-scale, individual participant data meta-analysis of the paediatric respiratory microbiota (n = 2624 children from 20 studies), we discuss here some of the unique barriers facing these studies and open and invite a dialogue towards future opportunities. Video Abstract.
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Affiliation(s)
- David Broderick
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Robyn Marsh
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - David Waite
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | | | - Anne B Chang
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, QLD, Australia
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Michael W Taylor
- School of Biological Sciences, University of Auckland, Auckland, New Zealand.
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6
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Granda E, Urbano M, Andrés P, Corchete M, Cano A, Velasco R. Comparison of severity scales for acute bronchiolitis in real clinical practice. Eur J Pediatr 2023; 182:1619-1626. [PMID: 36702906 DOI: 10.1007/s00431-023-04840-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 01/09/2023] [Accepted: 01/21/2023] [Indexed: 01/28/2023]
Abstract
Several clinical scales have been developed to assess the severity of bronchiolitis as well as the probability of needing in-hospital care. A recent systematic review of 32 validated clinical scores for bronchiolitis concluded that 6 of them (Wood-Downes, M-WCAS, Respiratory Severity Score, Respiratory Clinical Score, Respiratory Score and Bronchiolitis risk of admission score) were the best ones regarding reliability, sensitivity, validity, and usability. However, to the best of our knowledge, no study has compared all of them in a clinical scenario. Also, after this review, three more scales were published: BROSJOD, Tal modified, and one score developed by PERN. Our main aim was to compare the ability of different clinical scales for bronchiolitis to predict any relevant outcome. A prospective observational study was conducted that included patients of up to 12 months old attended to, due to bronchiolitis, in the paediatric Emergency Department of a secondary university hospital from October 2019 to January 2022. For each patient, the attending clinician filled in a form with the items of the scales, decomposed, in order to prevent the clinician from knowing the score of each scale. Then, the patient was managed according to the protocol of our Emergency Department. A phone call was made to each patient in order to check whether the patient ended up being admitted in the next 48 h. In the case of those that were impossible to contact by phone, the clinical history was reviewed. For the purpose of the study, any of the following were considered to be a relevant outcome: admission to ward and need for supplementary oxygen, non-invasive ventilation (NIV) or intravenous fluids, and admission to the paediatric intensive care unit (PICU) within the next 48 h or death. For the aim of the study, the area under the curve (AUC) and the odds ratio (OR) for a relevant outcome were calculated in each scale. Also, the best cut-off point was estimated according to the Youden index, and its sensitivity (Sn) and specificity (Sp) for a relevant outcome were calculated. We included 265 patients (52.1% male) with a median age of 5.3 months (P25-P75 2.6-7.4). Among them, 46 (17.4%) had some kind of relevant outcome. AUC for prediction of a relevant outcome ranged from 0.705 (Respiratory Score) to 0.786 (BRAS), although no scale performed significantly better than others. A score ≤ 2 in the PERN scale showed a sensitivity of 91.3% (CI95% 79.7-96.6) for a relevant outcome, with only 4 misdiagnosed patients (only 2 of them needed NIV). Conclusions: There were no differences in the performance of the nine scales to predict relevant outcomes in patients with bronchiolitis. However, the PERN scale might be more useful to select patients at low risk of a severe outcome. What is Known: • Several clinical scales are used to assess the severity of bronchiolitis. Nevertheless, none of them seems to be better than others. What is New: • This is the first study comparing different bronchiolitis scales in a real clinical scenario. None of the nine scales compared performed better than the other. However, the PERN scale might be more useful to select patients at low risk of relevant outcomes.
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Affiliation(s)
- Elena Granda
- Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain.
| | - Mario Urbano
- Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Pilar Andrés
- Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Marina Corchete
- Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Alfredo Cano
- Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Roberto Velasco
- Pediatric Emergency Department, Hospital Universitario Río Hortega, Valladolid, Spain
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7
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Feeding Pathway for Children on High Flow Nasal Cannula Decreases Time to Enteral Nutrition. Pediatr Qual Saf 2022; 7:e608. [PMID: 36518156 PMCID: PMC9742081 DOI: 10.1097/pq9.0000000000000608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 09/01/2022] [Indexed: 02/05/2023] Open
Abstract
UNLABELLED High Flow Nasal Cannula (HFNC) is commonly used for children with respiratory failure, yet no standardized guidelines exist on how to initiate, escalate, and maintain enteral nutrition (EN) for these patients. EN in critically ill children is associated with decreased hospital length of stay, decreased ventilator days, and fewer acquired infections. We aimed to decrease the mean time to EN initiation by 50% after the start of HFNC in 6 months. METHODS This quality improvement project used the Model for Improvement to inform interventions. A multidisciplinary team created an EN pathway for critically ill patients on HFNC. We conducted Plan-Do-Study-Act cycles related to implementing a standardized pathway for EN on HFNC. The primary outcome was time to EN initiation once on HFNC. Secondary outcomes were time to goal caloric EN, duration of HFNC, and adverse events. Outcomes were plotted on statistical process control charts and analyzed for special cause variation between baseline and intervention periods. RESULTS We included 112 patients in the study. Special cause variation occurred for both primary and secondary outcomes. The mean time to EN initiation decreased from 24.6 hours to 11.7 hours (47.5%). Mean time to goal feeds decreased from 25.8 hours to 15.1 hours (58.5%). Mean HFNC duration did not show any special cause variation. There were no episodes of aspiration. CONCLUSION Implementation of a standardized pathway for EN on patients receiving HFNC resulted in decreased time to initiation of EN and time to goal caloric EN with no significant increase in adverse events.
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8
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Eşki A, Öztürk GK, Turan C, Özgül S, Gülen F, Demir E. High-flow nasal cannula oxygen in children with bronchiolitis: A randomized controlled trial. Pediatr Pulmonol 2022; 57:1527-1534. [PMID: 35293153 DOI: 10.1002/ppul.25893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 01/22/2022] [Accepted: 03/14/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To determine whether high-flow nasal cannula oxygen (HFNCO) provided enhanced respiratory support in bronchiolitis than low-flow oxygen (LFO). METHODS We conducted a prospective, randomized controlled trial in children between 1 and 24 months diagnosed with moderate-to-severe bronchiolitis requiring oxygen therapy. Participants received LFO via face mask (6-10 L/min) or HFNCO (2 L/kg/min). Primary outcomes were the time that heart rate (HR) and respiratory rate (RR) return to their normal range for age and the time that baseline clinical respiratory score (CRS) regress to a lower severity score. Secondary outcomes were changes in HR, RR, and CRS over time, length of stay (LOS), duration of oxygen requirement, treatment failure, and adverse event (AE). RESULTS Eighty-seven children were enrolled (48 in LFO; 39 in HFNCO). The time that HR and RR baseline values reached their normal range for age was shorter in HFNCO therapy (2.0 h [1.0-4.0] vs. 12.0 h [2.0-24.0], and 4.0 h [2.0-12.0] vs. 24.0 h [4.0-48.0], respectively; p < 0.001); additionally, the improvement in CRS emerged more quickly in children treated with HFNCO (2.0 h [1.0-4.0] vs. 4.0 h [2.0-24.0]; p = 0.003). While the duration of oxygen requirement (19.0 h [4.0-30.0] vs. 29.5 h [14.0-45.7]; p = 0.009) and treatment failure (3% vs. 21%) was statistically lower in children who received HFNCO, there were no differences in LOS and AE between groups. CONCLUSION HFNCO may provide enhanced respiratory support with a notable improvement in HR, RR, and CRS than LFO. Comprehensive studies are needed to assess the clinical efficacy of HFNCO therapy.
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Affiliation(s)
- Aykut Eşki
- Division of Pediatric Pulmonology, Department of Pediatrics, Gazi Yaşargil Gynecology, Child Health, and Diseases Training and Research Hospital, University of Health Sciences, Diyarbakır, Turkey
| | - Gökçen Kartal Öztürk
- Division of Pediatric Pulmonology, Department of Pediatrics, Ege University Medical Faculty, Ege University Children Hospital, Izmir, Turkey
| | - Caner Turan
- Division of Emergency Medicine, Department of Pediatrics, Ege University Medical Faculty, Ege University Children Hospital, Izmir, Turkey
| | - Semiha Özgül
- Department of Medical Informatics, School of Medicine, Ege University, Izmir, Turkey
| | - Figen Gülen
- Division of Pediatric Pulmonology, Department of Pediatrics, Ege University Medical Faculty, Ege University Children Hospital, Izmir, Turkey
| | - Esen Demir
- Division of Pediatric Pulmonology, Department of Pediatrics, Ege University Medical Faculty, Ege University Children Hospital, Izmir, Turkey
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9
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Itdhiamornkulchai S, Preutthipan A, Vaewpanich J, Anantasit N. Modified high-flow nasal cannula for children with respiratory distress. Clin Exp Pediatr 2022; 65:136-141. [PMID: 34044481 PMCID: PMC8898618 DOI: 10.3345/cep.2020.01403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 05/13/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND High-flow nasal cannula (HFNC) is a noninvasive respiratory support that provides the optimum flow of an air-oxygen mixture. Several studies demonstrated its usefulness and good safety profile for treating pediatric respiratory distress patients. However, the cost of the commercial HFNC is high; therefore, the modified high-flow nasal cannula was developed. PURPOSE This study aimed to compare the effectiveness, safety, and nurses' satisfaction of the modified system versus the standard commercial HFNC. METHODS This prospective comparative study was performed in a tertiary care hospital. We recruited children aged 1 month to 5 years who developed acute respiratory distress and were admitted to the pediatric intensive care unit. Patients were assigned to 2 groups (modified vs. commercial). The effectiveness and safety assessments included vital signs, respiratory scores, intubation rate, adverse events, and nurses' satisfaction. RESULTS A total of 74 patients were treated with HFNC. Thirty- nine patients were assigned to the modified group, while the remaining 35 patients were in the commercial group. Intubation rate and adverse events did not differ significantly between the 2 groups. However, the commercial group had higher nurses' satisfaction scores than the modified group. CONCLUSION Our findings suggest that our low-cost modified HFNC could be a useful respiratory support option for younger children with acute respiratory distress, especially in hospital settings with financial constraints.
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Affiliation(s)
- Sarocha Itdhiamornkulchai
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Aroonwan Preutthipan
- Division of Pediatric Pulmonology, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jarin Vaewpanich
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nattachai Anantasit
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Adair E, Dibaba D, Fowke JH, Snider M. The Impact of Terbutaline as Adjuvant Therapy in the Treatment of Severe Asthma in the Pediatric Emergency Department. Pediatr Emerg Care 2022; 38:e292-e294. [PMID: 33136831 DOI: 10.1097/pec.0000000000002269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
METHODS Patients were identified using a retrospective cohort analysis from a single, tertiary care, urban children's hospital. Patients presenting directly to our emergency department aged 2 to 18 years were included if they had a diagnosis of severe asthma exacerbation, defined by an initial Respiratory Clinical Score (RCS) of 9 or higher. A total of 787 patients were identified during the study timeframe (December 16, 2017, to December 31, 2018), and of those, 651 patients met study criteria and were included in the analysis. The χ2 test was used to establish P values for categorical variables. For normally distributed variables, a t test was used. For nonnormally distributed variables, the Kruskal-Wallis test was used. A P value of 0.05 or less was interpreted as statistically significant. RESULTS Patients who received terbutaline had an increased risk of admission to the PICU (P < 0.001). This association was lost after controlling for age, sex, continuous albuterol use, and intramuscular epinephrine use (P = 0.362). Patients receiving terbutaline in the emergency department also had a higher risk of admission to the hospital (odds ratio, 1.55; confidence interval, 1.08-2.22; P = 0.020) as compared with their nonterbutaline counterparts. Overall, patients in the terbutaline group had a higher initial RCS at presentation. Upon further analysis, patients with the same RCS at presentation were more likely to be admitted if they received terbutaline than those who did not. There was no statistically significant difference in length of stay (P = 0.298) and BiPAP/CPAP use (P = 0.107). The patients on terbutaline were relatively more likely to require oxygen (P = 0.003) and intramuscular epinephrine (P = 0.010) than the patients not on terbutaline. CONCLUSIONS Terbutaline administration given to pediatric patients experiencing a severe asthma exacerbation was not associated with decreased PICU or general hospital floor admission. The study is limited given that it was a retrospective analysis. Further randomized controlled trials are needed to assess the role of terbutaline in severe acute asthma exacerbations in pediatric patients.
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Affiliation(s)
| | - Daniel Dibaba
- Tennessee Clinical and Translational Science Institute
| | - Jay H Fowke
- Division of Epidemiology, Department of Preventive Medicine, The University of Tennessee Health Science Center, Memphis, TN
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11
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Liu J, Li D, Luo L, Liu Z, Li X, Qiao L. Analysis of risk factors for the failure of respiratory support with high-flow nasal cannula oxygen therapy in children with acute respiratory dysfunction: A case-control study. Front Pediatr 2022; 10:979944. [PMID: 36081624 PMCID: PMC9445578 DOI: 10.3389/fped.2022.979944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/05/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Evidence-based clinical practice guidelines regarding high-flow nasal cannula (HFNC) use for respiratory support in critically ill children are lacking. Therefore, we aimed to determine the risk factors for early HFNC failure to reduce the failure rate and prevent adverse consequences of HFNC failure in children with acute respiratory dysfunction. METHODS Demographic and laboratory data were compared among patients, admitted to the pediatric intensive care unit between January 2017 and December 2018, who were included in a retrospective cohort study. Univariate and multivariate analyses were performed to determine risk factors for eventual entry into the predictive model for early HFNC failure and to perform an external validation study in a prospective observational cohort study from January to February 2019. Further, the association of clinical indices and trends pre- and post-treatment with HFNC treatment success or failure in these patients was dynamically observed. RESULTS In total, 348 pediatric patients were included, of these 282 (81.0%) were included in the retrospective cohort study; HFNC success was observed in 182 patients (64.5%), HFNC 0-24 h failure in 74 patients (26.2%), and HFNC 24-48 h failure in 26 patients (9.2%). HFNC 24 h failure was significantly associated with the pediatric risk of mortality (PRISM) III score [odds ratio, 1.391; 95% confidence interval (CI): 1.249-1.550], arterial partial pressure of carbon dioxide-to-arterial partial pressure of oxygen (PaCO2/PaO2) ratio (odds ratio, 38.397; 95% CI: 6.410-230.013), and respiratory rate-oxygenation (ROX) index (odds ratio, 0.751; 95% CI: 0.616-0.915). The discriminating cutoff point for the new scoring system based on the three risk factors for HFNC 24 h failure was ≥ 2.0 points, with an area under the receiver operating characteristic curve of 0.794 (95% CI, 0.729-0.859, P < 0.001), sensitivity of 68%, and specificity of 79%; similar values were noted on applying the model to the prospective observational cohort comprising 66 patients (AUC = 0.717, 95% CI, 0.675-0.758, sensitivity 83%, specificity 44%, P = 0.009). In this prospective cohort, 11 patients with HFNC failure had an upward trend in PaCO2/PaO2 ratio and downward trends in respiratory failure index (P/F ratio) and ROX index; however, opposite directions of change were observed in 55 patients with HFNC success. Furthermore, the fractional changes (FCs) in PaCO2/PaO2 ratio, P/F ratio, percutaneous oxygen saturation-to-fraction of inspired oxygen (S/F) ratio, and ROX index at 2 h post-HFNC therapy onset were statistically significant between the two groups (all, P < 0.05). CONCLUSION In the pediatric patients with acute respiratory insufficiency, pre-treatment PRISM III score, PaCO2/PaO2 ratio, and ROX index were risk factors for HFNC 24 h failure, and the direction and magnitude of changes in the PaCO2/PaO2 ratio, P/F ratio, and ROX index before and 2 h after HFNC treatment were warning indicators for HFNC 24 h failure. Further close monitoring should be considered for patients with these conditions.
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Affiliation(s)
- Jie Liu
- Department of Pediatric Intensive Care Unit, West China Second Universal Hospital, Sichuan University, Chengdu, China.,NHC Key Laboratory of Chronobiology (Sichuan University), Ministry of Education, Chengdu, China
| | - Deyuan Li
- Department of Pediatric Intensive Care Unit, West China Second Universal Hospital, Sichuan University, Chengdu, China.,NHC Key Laboratory of Chronobiology (Sichuan University), Ministry of Education, Chengdu, China
| | - Lili Luo
- Department of Pediatric Intensive Care Unit, West China Second Universal Hospital, Sichuan University, Chengdu, China.,NHC Key Laboratory of Chronobiology (Sichuan University), Ministry of Education, Chengdu, China
| | - Zhongqiang Liu
- Department of Pediatric Intensive Care Unit, West China Second Universal Hospital, Sichuan University, Chengdu, China.,NHC Key Laboratory of Chronobiology (Sichuan University), Ministry of Education, Chengdu, China
| | - Xiaoqing Li
- Department of Pediatric Intensive Care Unit, West China Second Universal Hospital, Sichuan University, Chengdu, China.,NHC Key Laboratory of Chronobiology (Sichuan University), Ministry of Education, Chengdu, China
| | - Lina Qiao
- Department of Pediatric Intensive Care Unit, West China Second Universal Hospital, Sichuan University, Chengdu, China.,NHC Key Laboratory of Chronobiology (Sichuan University), Ministry of Education, Chengdu, China
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Hakizimana B, Kalimba E, Ndatinya A, Saint G, van Miert C, Cartledge PT. Field testing two existing, standardized respiratory severity scores (LIBSS and ReSViNET) in infants presenting with acute respiratory illness to tertiary hospitals in Rwanda - a validation and inter-rater reliability study. PLoS One 2021; 16:e0258882. [PMID: 34735488 PMCID: PMC8568200 DOI: 10.1371/journal.pone.0258882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/07/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION There is a substantial burden of respiratory disease in infants in the sub-Saharan Africa region. Many health care providers (HCPs) that initially receive infants with respiratory distress may not be adequately skilled to differentiate between mild, moderate and severe respiratory symptoms, which may contribute to poor management and outcome. Therefore, respiratory severity scores have the potential to contributing to address this gap. OBJECTIVES to field-test the use of two existing standardized bronchiolitis severity scores (LIBSS and ReSViNET) in a population of Rwandan infants (1-12 months) presenting with respiratory illnesses to urban, tertiary, pediatric hospitals and to assess the severity of respiratory distress in these infants and the treatments used. METHODS A cross-sectional, validation study, was conducted in four tertiary hospitals in Rwanda. Infants presenting with difficulty in breathing were included. The LIBSS and ReSViNET scores were independently employed by nurses and residents to assess the severity of disease in each infant. RESULTS 100 infants were recruited with a mean age of seven months. Infants presented with pneumonia (n = 51), bronchiolitis (n = 36) and other infectious respiratory illnesses (n = 13). Thirty-three infants had severe disease and survival was 94% using nurse applied LIBSS. Regarding inter-rater reliability, the intra-class correlation coefficient (ICC) for LIBSS and ReSViNET between nurses and residents was 0.985 (95% CI: 0.98-0.99) and 0.980 (0.97-0.99). The convergent validity (Pearson's correlation) between LIBSS and ReSViNET for nurses and residents was R = 0.836 (p<0.001) and R = 0.815 (p<0.001). The area under the Receiver Operator Curve (aROC) for admission to PICU or HDU was 0.956 (CI: 0.92-0.99, p<0.001) and 0.880 (CI: 0.80-0.96, p<0.001) for nurse completed LIBSS and ReSViNET respectively. CONCLUSION LIBSS and ReSViNET were designed for infants with bronchiolitis in resource-rich settings. Both LIBSS and ReSViNET demonstrated good reliability and validity results, in this cohort of patients presenting to tertiary level hospitals. This early data demonstrate that these two scores have the potential to be used in conjunction with clinical reasoning to identify infants at increased risk of clinical deterioration and allow timely admission, treatment escalation and therefore support resource allocation in Rwanda.
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Affiliation(s)
- Boniface Hakizimana
- Department of Pediatrics, School of Medicine, University of Rwanda, Kigali, Rwanda
- Department of Pediatrics, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Edgar Kalimba
- Department of Pediatrics, School of Medicine, University of Rwanda, Kigali, Rwanda
- King Faisal Hospital, Kigali, Rwanda
| | | | - Gemma Saint
- Institute of Child Health, University of Liverpool, Liverpool, United Kingdom
- Department of Respiratory Pediatrics, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - Clare van Miert
- School of Nursing and Allied Health Liverpool John Moores University, Liverpool, United Kingdom
| | - Peter Thomas Cartledge
- Department of Pediatrics, School of Medicine, University of Rwanda, Kigali, Rwanda
- Department of Emergency Medicine, Yale University, New Haven, Connecticut, United States of America
- Rwanda Human Resources for Health (HRH) Program, Ministry of Health, Kigali, Rwanda
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Hemani SA, Glover B, Ball S, Rechler W, Wetzel M, Hames N, Jenkins E, Lantis P, Fitzpatrick A, Varghese S. Dexamethasone Versus Prednisone in Children Hospitalized for Acute Asthma Exacerbations. Hosp Pediatr 2021; 11:1263-1272. [PMID: 34610967 DOI: 10.1542/hpeds.2020-004788] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Extensive literature supports using dexamethasone (DEX) in children presenting to the emergency department (ED) with mild-to-moderate asthma exacerbations; however, only limited studies have assessed this in hospitalized children. In this study, we evaluate the outcomes of DEX versus prednisone/prednisolone (PRED) use in children hospitalized for mild-to-moderate asthma exacerbations. METHODS This multisite retrospective cohort study included children between 3 and 21 years of age hospitalized to a tertiary care children's hospital system between January 1, 2013, and December 31, 2017, with a primary discharge diagnosis of acute asthma exacerbation or status asthmaticus. Primary study outcome was mean hospital length of stay (LOS). Secondary outcomes included PICU transfers during initial hospitalization and ED revisits and hospital readmissions within 10 days after discharge. Generalized linear models were used to model logged LOS as a function of steroid and demographic and clinical covariates. The analysis was stratified by initial steroid timing. RESULTS Of the 1410 children included, 981 received only DEX and 429 received only PRED. For children who started oral steroids after hospital arrival, DEX cohort had a significantly shorter adjusted mean hospital LOS (DEX 24.43 hours versus PRED 29.38 hours; P = .03). For children who started oral steroids before hospital arrival, LOS did not significantly differ (DEX 26.72 hours versus PRED 25.20 hours; P = .45). Rates of PICU transfers, ED revisits, and hospital readmissions were uncommon events. CONCLUSION Children hospitalized with mild-to-moderate asthma exacerbations have significantly shorter hospital LOS when starting DEX rather than PRED on admission.
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Affiliation(s)
- Sunita Ali Hemani
- Division of Hospital Medicine .,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Brianna Glover
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Samantha Ball
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Willi Rechler
- Rollins School of Public Health and Emory University School of Medicine, Atlanta, Georgia
| | - Martha Wetzel
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Nicole Hames
- Division of Hospital Medicine.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Elan Jenkins
- Division of Hospital Medicine.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Patricia Lantis
- Division of General Pediatrics and Adolescent Medicine.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Anne Fitzpatrick
- Division of Pulmonology, Allergy/Immunology, Cystic Fibrosis and Sleep.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Sarah Varghese
- Division of Hospital Medicine.,Children's Healthcare of Atlanta, Atlanta, Georgia
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Reducing High-flow Nasal Cannula Overutilization in Viral Bronchiolitis. Pediatr Qual Saf 2021; 6:e420. [PMID: 34179674 PMCID: PMC8225359 DOI: 10.1097/pq9.0000000000000420] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 12/12/2020] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: Heated high-flow nasal cannula (HHFNC) therapy for bronchiolitis has become increasingly prevalent without evidence that this therapy impacts patient outcomes. Lack of criteria for appropriate use may lead to overutilization, resulting in increased costs without patient benefit. Our primary aim was to decrease use of HHFNC in patients with bronchiolitis over one season. Methods: Patients with Bronchiolitis younger than 2 years of age admitted to the Hospital Medicine Service were included in this study. Using the model for improvement framework, we identified key drivers for HHFNC overuse and revised our bronchiolitis protocol to include low-flow nasal cannula trials before HHFNC initiation. We compared preintervention HHFNC utilization (December 2018–April 2019) with postintervention HFNC utilization (December 2019–March 2020). Results: One hundred ninety patients met inclusion criteria, 98 of them in the preintervention cohort and 92 in the postintervention cohort. Overall, the median age was 9 months and 65% of patients were male. Our HHFNC utilization rate decreased from 62% (61/98) to 43% (40/92) in the postintervention period. Our SPC analysis suggested special cause variation based on 7 points below the preintervention mean. Conclusions: This QI intervention implementing a specified low-flow nasal cannula trial before the initiation of HHFNC shows promise in reducing overall HHFNC use. Future studies should focus on clear initiation and discontinuation criteria for HHFNC use in bronchiolitis.
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15
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Siraj S, Stark W, McKinley SD, Morrison JM, Sochet AA. The bronchiolitis severity score: An assessment of face validity, construct validity, and interobserver reliability. Pediatr Pulmonol 2021; 56:1739-1744. [PMID: 33629813 DOI: 10.1002/ppul.25337] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 02/02/2021] [Accepted: 02/20/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess face validity, interobserver reliability, and the ability to discriminate escalations of care within 24-h of admission (late rescues) for the bronchiolitis severity score (BSS) for children hospitalized for acute bronchiolitis. HYPOTHESES The BSS will yield variable face validity, have clinically relevant interobserver reliability (kappa > 0.7), and distinguish late rescues during hospitalization. METHODS We performed a combined retrospective and prospective, mixed methods study where (1) interobserver agreement was prospectively assessed by overall and subcategory congruence (kappa) calculations, (2) face value were qualitatively assessed from aggregate questionnaire responses, and (3) construct validity for late rescues were assessed using receiver operator characteristic (ROC) curve analyses. RESULTS Face validity, assessed from 39 questionnaire respondents, were generally positive for BSS utility, reliability, and usability. The BSS exhibited weak interobserver reliability (kappa = 0.22, 95% confidence interval [CI]: 0.11-0.31) calculated from 72 sequential, blinded calculations. Retrospectively, 181 children less than 2 years of age admitted to the general pediatric ward for acute bronchiolitis from November 2017 to April 2019 were identified of which 18 (9.9%) experienced late rescues. Admission BSS values were no different for children with and without late rescues (6[3,6] vs. 4[3,6]; p = .09). An ROC curve analysis revealed an area under the curve of 0.61 (95% CI: 0.48-0.75; threshold ≥6 with sensitivity = 56%, specificity = 69%) for BSS to discriminate late rescues. CONCLUSION Although clinicians expressed favorable perceptions of BSS face and content validity, we noted weak interobserver reliability and limited construct validity. Further development and validation are needed to strengthen the BSS before routine use.
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Affiliation(s)
- Shaila Siraj
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Pediatrics, University of South Florida College of Medicine, Tampa, Florida, USA.,Division of Hospital Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Wayne Stark
- Divisions of Emergency Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Scott Daniel McKinley
- Division of Pulmonlogy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - John Michael Morrison
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Division of Hospital Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Anthony Alexander Sochet
- Department of Pediatrics, University of South Florida College of Medicine, Tampa, Florida, USA.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Division of Pediatric Critical Care Medicine, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
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16
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Karthika IK, John J, Kaul A. Should High Flow Nasal Cannula Therapy Be the Primary Mode of Respiratory Support in a Pediatric Intensive Care Unit? Questions Remain! Indian Pediatr 2021. [PMID: 33883319 PMCID: PMC8079843 DOI: 10.1007/s13312-021-2206-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- I. K. Karthika
- Department of Pediatrics, AIIMS, Bhubaneswar, Odisha, India
| | - Joseph John
- Department of Pediatrics, AIIMS, Bhubaneswar, Odisha, India
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Rivera-Sepulveda A, Isona M. Assessing Resident Diagnostic Skills Using a Modified Bronchiolitis Score. ACTA ACUST UNITED AC 2021; 18:11-16. [PMID: 33679039 DOI: 10.7199/ped.oncall.2021.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Resident milestones are objective instruments that assess the resident's growth, progression in knowledge, and clinical diagnostic reasoning; but they rely on the subjective appraisal of the supervising attending. Little is known about the use of standardized instruments that may complement the evaluation of resident diagnostic skills in the academic setting. Objectives Evaluate a modified bronchiolitis severity assessment tool by appraising the inter-rater variability and reliability between pediatric attendings and pediatric residents. Methods Cross-sectional study of children under 24 months of age who presented to a Community Hospital's Emergency Department with bronchiolitis between January-June 2014. A paired pediatric attending and resident evaluated each patient. Evaluation included age-based respiratory rate (RR), retractions, peripheral saturation, and auscultation. Cohen's kappa (K) measured inter-rater agreement. Inter-rater reliability (IRR) was assessed using a one-way random, average measures intra-class correlation (ICC) to evaluate the degree of consistency and magnitude of disagreement between inter-raters. Value of >0.6 was considered substantial for kappa and good internal consistency for ICC. Results Twenty patients were evaluated. Analysis showed fair agreement for the presence of retractions (K=0.31), auscultation (K=0.33), and total score (K=0.3). The RR (ICC=0.97), SpO2 (ICC=1.0), auscultation (ICC=0.77), and total score (ICC=0.84) were scored similarly across both raters, indicating excellent IRR. Identification of retractions had the least agreement across all statistical analysis. Conclusion The use of a standardized instrument, in conjunction with a trained resident-teaching staff, can help identify deficiencies in clinical competencies among residents and facilitate the learning process for the identification of pertinent clinical findings.
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Affiliation(s)
- Andrea Rivera-Sepulveda
- Pediatrics, Emergency Medicine, Nemours Children's Hospital, Orlando, FL, United States.,University of Puerto Rico Medical Sciences Campus, School of Health Professions and School of Medicine, San Juan, Puerto Rico
| | - Muguette Isona
- San Juan City Hospital, Emergency Department, San Juan, Puerto Rico
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Miksa M, Kaushik S, Antovert G, Brown S, Ushay HM, Katyal C. Implementation of a Critical Care Asthma Pathway in the PICU. Crit Care Explor 2021; 3:e0334. [PMID: 33604577 PMCID: PMC7886451 DOI: 10.1097/cce.0000000000000334] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES Acute asthma management has improved significantly across hospitals in the United States due to implementation of standardized care pathways. Management of severe acute asthma in ICUs is less well studied, and variations in management may delay escalation and/or deescalation of therapies and increase length of stay. In order to standardize the management of severe acute asthma in our PICU, a nurse- and respiratory therapist-driven critical care asthma pathway was designed, implemented, and tested. DESIGN Cross-sectional study of severe acute asthma at baseline followed by implementation of a critical care asthma pathway. SETTING Twenty-six-bed urban quaternary PICU within a children's hospital. PATIENTS Patients 24 months to 18 years old admitted to the PICU in status asthmaticus. Patients with severe bacterial infections, chronic lung disease, heart disease, or immune disorders were excluded. INTERVENTIONS Implementation of a nurse- and respiratory therapist-driven respiratory scoring tool and critical care asthma pathway with explicit escalation/deescalation instructions. MEASUREMENTS AND MAIN RESULTS Primary outcome was PICU length of stay. Secondary outcomes were time to resolution of symptoms and hospital length of stay. Compliance approached 90% for respiratory score documentation and critical care asthma pathway adherence. Severity of illness at admission and clinical baseline characteristics were comparable in both groups. Pre intervention, the median ICU length of stay was 2 days (interquartile range, 1-3 d) with an overall hospital length of stay of 4 days (interquartile range, 3-6 d) (n = 74). After implementation of the critical care asthma pathway, the ICU length of stay was 1 day (interquartile range, 1-2 d) (p = 0.0013; n = 78) with an overall length of stay of 3 days (interquartile range, 2-3.75 d) (p < 0.001). The time to resolution of symptoms was reduced from a median of 66.5 hours in the preintervention group to 21 hours in the postintervention compliant group (p = 0.036). CONCLUSIONS The use of a structured critical care asthma pathway, driven by an ICU nurse and respiratory therapist, is associated with faster resolution of symptoms, decreased ICU, and overall hospital lengths of stay in children admitted to an ICU for severe acute asthma.
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Affiliation(s)
- Michael Miksa
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - Shubhi Kaushik
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - Gerald Antovert
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - Sakar Brown
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - H Michael Ushay
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
| | - Chhavi Katyal
- All authors: Children's Hospital at Montefiore and Albert Einstein College of Medicine, Pediatric Critical Care Medicine, New York, NY
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Shah S, Kaul A, Bhosale R, Shiwarkar G. High Flow Nasal Cannula Therapy as a Primary Mode of Respiratory Support in a Pediatric Intensive Care Unit. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2095-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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20
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Chacko J, King C, Harkness D, Messahel S, Grice J, Roe J, Mullen N, Sinha IP, Hawcutt DB. Pediatric acute asthma scoring systems: a systematic review and survey of UK practice. J Am Coll Emerg Physicians Open 2020; 1:1000-1008. [PMID: 33145551 PMCID: PMC7593416 DOI: 10.1002/emp2.12083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/30/2020] [Accepted: 04/08/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Acute exacerbations of asthma are common in children. Multiple asthma severity scores exist, but current emergency department (ED) use of severity scores is not known. METHODS A systematic review was undertaken to identify the parameters collected in pediatric asthma severity scores. A survey of Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI) sites was undertaken to ascertain routinely collected asthma data and information about severity scores. Included studies examined severity of asthma exacerbation in children 5-18 years of age with extractable severity parameters. RESULTS Sixteen articles were eligible, containing 17 asthma severity scores. The severity scores assessed combinations of 15 different parameters (median, 6; range, 2-8). The most common parameters considered were expiratory wheeze (15/17), inspiratory wheeze (13/17), respiratory rate (10/17), and general accessory muscle use (9/17). Fifty-nine PERUKI centers responded to the questionnaire. Twenty centers (33.1%) currently assess severity, but few use a published score. The most commonly recorded routine data required for severity scores were oxygen saturations (59/59, 100%), heart rate, and respiratory rate (58/59, 98.3% for both). Among well-validated scores like the Pulmonary Index Score (PIS), Pediatric Asthma Severity Score (PASS), Childhood Asthma Score (CAS), and the Pediatric Respiratory Assessment Measure (PRAM), only 6/59 (10.2%), 3/59 (5.1%), 1/59 (1.7%), and 0 (0%) of units respectively routinely collect the data required to calculate them. CONCLUSION Standardized published pediatric asthma severity scores are infrequently used. Improved routine data collection focusing on the key parameters common to multiple scores could improve this, facilitating research and audit of pediatric acute asthma.
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Affiliation(s)
- Jerry Chacko
- School of MedicineUniversity of LiverpoolLiverpoolUK
- Department of Women's and Children's HealthUniversity of LiverpoolLiverpoolUK
| | - Charlotte King
- Royal Liverpool and Broadgreen University Hospital TrustLiverpoolUK
| | - David Harkness
- National Institute for Health Research Alder Hey Clinical Research FacilityAlder Hey Children's HospitalLiverpoolUK
| | - Shrouk Messahel
- Emergency DepartmentAlder Hey Children's HospitalLiverpoolUK
| | - Julie Grice
- Emergency DepartmentAlder Hey Children's HospitalLiverpoolUK
| | - John Roe
- Darwin Emergency DepartmentDarwinNorthern TerritoryAustralia
| | - Niall Mullen
- Paediatric Emergency MedicineSunderland Royal HospitalSunderlandUK
| | - Ian P. Sinha
- Department of Respiratory MedicineAlder Hey Children's HospitalLiverpoolUK
| | - Daniel B. Hawcutt
- Department of Women's and Children's HealthUniversity of LiverpoolLiverpoolUK
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21
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Nurse-driven Clinical Pathway Based on an Innovative Asthma Score Reduces Admission Time for Children. Pediatr Qual Saf 2020; 5:e344. [PMID: 32984742 PMCID: PMC7480997 DOI: 10.1097/pq9.0000000000000344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 07/09/2020] [Indexed: 11/26/2022] Open
Abstract
We recently demonstrated that an innovative asthma score independent of auscultation could accurately predict the requirement for bronchodilator nebulization compared to the physician's routine clinical judgment to administer bronchodilators. We aimed to standardize inpatient care for children with acute asthma by implementing a clinical pathway based on this innovative asthma score. Methods We designed a nurse-driven clinical pathway. This pathway included standardized respiratory assessments and a protocol for the nursing staff to administer bronchodilators without a specific order from the physician. We compared the length of stay and the number of readmissions to a historical cohort. Results Seventy-nine patients with moderate acute asthma completed the pathway. We obtained a total of 858 Childhood asthma scores in these patients, with a median of 11 scores per patient (interquartile range 8-17). Patients treated according to the nurse-driven protocol were 3.3 times more likely to be discharged earlier (hazard ratio, 3.29; 95% confidence interval, 2.33-4.66; P < 0.05), and length of stay was significantly reduced (median 28 versus 53 h) compared to the historical standard practice. On request, the attending physician assessed the patient's respiratory status 42 times (4.9% of all childhood asthma score assessments). Patient safety was not compromised, and none of the patients were removed from the pathway. In each group, we readmitted two (2.5%) patients within 1 week after discharge. Conclusion This nurse-driven clinical pathway for children with acute asthma based on an asthma score independent of auscultation findings significantly decreased length of stay without compromising patient safety.
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Lung Ultrasound and Clinical Progression of Acute Bronchiolitis: A Prospective Observational Single-Center Study. MEDICINA-LITHUANIA 2020; 56:medicina56060314. [PMID: 32604769 PMCID: PMC7353897 DOI: 10.3390/medicina56060314] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 06/19/2020] [Accepted: 06/24/2020] [Indexed: 12/05/2022]
Abstract
Background and Objectives: Recent literature suggests that lung ultrasound might have a role in the diagnosis and management of bronchiolitis. The aim of the study is to evaluate the relationship between an ultrasound score and the clinical progression of bronchiolitis: need for supplemental oxygen, duration of oxygen therapy and hospital stay. Materials and Methods: This was a prospective observational single-center study, conducted in a pediatric unit during the 2017–2018 epidemic periods. All consecutive patients admitted with clinical signs of acute bronchiolitis, but without the need for supplemental oxygen, underwent a lung ultrasound in the first 24 h of hospital care. The lung involvement was graded based on the ultrasound score. During clinical progression, need for supplemental oxygen, duration of oxygen therapy and duration of hospital stay were recorded. Results: The final analysis included 83 patients, with a mean age of 4.5 ± 4.1 months. The lung ultrasound score in patients that required supplemental oxygen during hospitalization was 4.5 ± 1.7 (range: 2.0–8.0), different from the one of the not supplemented infants (2.5 ± 1.8; range: 0.0–6.0; p < 0.001). Ultrasound score was associated with the need for supplemental oxygen (OR = 2.2; 95% CI = 1.5–3.3; p < 0.0001). Duration of oxygen therapy was not associated with LUS score (p > 0.05). Length of hospital stay (coef. = 0.5; 95% CI = 0.2–0.7; p < 0.0001) correlates with LUS score. Conclusion: Lung ultrasound score correlates with the need of supplemental oxygen and length of hospital stay in infants with acute bronchiolitis.
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Jagodich TA, Bersenas AME, Bateman SW, Kerr CL. High-flow nasal cannula oxygen therapy in acute hypoxemic respiratory failure in 22 dogs requiring oxygen support escalation. J Vet Emerg Crit Care (San Antonio) 2020; 30:364-375. [PMID: 32583614 DOI: 10.1111/vec.12970] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 10/07/2018] [Accepted: 10/31/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To determine the effect of high-flow nasal cannula (HFNC) oxygen therapy on cardiorespiratory variables and outcome in dogs with acute hypoxemic respiratory failure. DESIGN Prospective, sequential clinical trial. SETTING University veterinary teaching hospital. ANIMALS Twenty-two client-owned dogs that failed to respond to traditional oxygen support. INTERVENTIONS Initiation of HFNC therapy after traditional oxygen supplementation failed to increase Spo2 > 96% and Pao2 > 75 mm Hg or improve respiratory rate/effort. MEASUREMENTS AND MAIN RESULTS Physiological variables, blood gas analyses, and dyspnea/sedation/tolerance scores were collected prior to HFNC initiation (on traditional oxygen support [time 0 or T0]), and subsequently during HFNC oxygen administration at time 30 minutes, 60 minutes, and 7 ± 1 hours. Relative to T0, use of HFNC resulted in a decreased respiratory rate at 1 hour (P = 0.022) and 7 hours (P = 0.012), a decrease in dyspnea score at all times (P < 0.01), and an increase in Spo2 at all times (P < 0.01). There was no difference in arterial/venous Pco2 relative to T0, although Paco2 was correlated with flow rate. Based on respiratory assessment, 60% of dogs responded to HFNC use by 30 minutes, and 45% ultimately responded to HFNC use and survived. No clinical air-leak syndromes were observed. CONCLUSIONS HFNC use improved oxygenation and work of breathing relative to traditional oxygen therapies, without impairing ventilation. HFNC use appears to be a beneficial oxygen support modality to bridge the gap between standard oxygen supplementation and mechanical ventilation.
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Affiliation(s)
- Tiffany A Jagodich
- Department of Clinical Sciences, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Alexa M E Bersenas
- Department of Clinical Sciences, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Shane W Bateman
- Department of Clinical Sciences, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Carolyn L Kerr
- Department of Clinical Sciences, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
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Jagodich TA, Bersenas AME, Bateman SW, Kerr CL. Preliminary evaluation of the use of high-flow nasal cannula oxygen therapy during recovery from general anesthesia in dogs with obstructive upper airway breathing. J Vet Emerg Crit Care (San Antonio) 2020; 30:487-492. [PMID: 32542930 DOI: 10.1111/vec.12971] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 12/10/2018] [Accepted: 12/21/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Brachycephalic airway syndrome can pose a risk of complicated recovery from anesthesia as a result of irritation to the excess pharyngeal andlaryngeal tissue present in affected dogs. High-flow nasal cannula (HFNC) oxygen therapy is a respiratory support modality that offers provision of continuous positive airway pressure via high gas flow rates. The HFNC system actively warms and humidifies inspired gases, which improves comfort and facilitates tolerance of the high flow rates in people and dogs. HFNC oxygen therapy was applied to brachycephalic dogs that developed increased work of breathing or hypoxemia in the recovery phase of anesthesia to determine if this device would be tolerable and effective for relief of upper respiratory difficulty. KEY FINDINGS The HFNC nasal prong interface is well suited to the brachycephalic facial structure. The application of HFNC was found to reduce dyspnea scores in patients with signs of upper airway obstruction after general anesthesia. Aerophagia and changes in PCO2 were noted. SIGNIFICANCE Application of HFNC in the recovery period may result in improved airflow during times of somnolent obstructive breathing, not unlike the use of continuous positive airway pressure therapy in sleep-disordered breathing in people.
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Affiliation(s)
- Tiffany A Jagodich
- Department of Clinical Sciences, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Alexa M E Bersenas
- Department of Clinical Sciences, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Shane W Bateman
- Department of Clinical Sciences, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
| | - Carolyn L Kerr
- Department of Clinical Sciences, Ontario Veterinary College, University of Guelph, Guelph, Ontario, Canada
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Hakizimana B, Saint G, van Miert C, Cartledge P. Can a Respiratory Severity Score Accurately Assess Respiratory Distress in Children with Bronchiolitis in a Resource-Limited Setting? J Trop Pediatr 2020; 66:234-243. [PMID: 32236471 DOI: 10.1093/tropej/fmz055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Boniface Hakizimana
- Department of Pediatrics, University of Rwanda, Kigali, Rwanda.,Department of Pediatrics, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Gemma Saint
- Department of Child Health, Institute of Translational Medicine, University of Liverpool, Liverpool
| | - Clare van Miert
- Liverpool John Moores University, Liverpool.,Alder Hey Children's NHS Foundation Trust, Liverpool
| | - Peter Cartledge
- Department of Pediatrics, University of Rwanda, Kigali, Rwanda.,Department of Pediatrics, Yale University, Rwanda Human Resources for Health (HRH) Program, Kigali, Rwanda
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Human bocavirus in children hospitalized for acute respiratory tract infection in Rome. World J Pediatr 2020; 16:293-298. [PMID: 31776891 PMCID: PMC7091143 DOI: 10.1007/s12519-019-00324-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 11/01/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND The role of human bocavirus (HBoV) as a respiratory pathogen has not been fulfilled yet. We aimed to describe clinical and serological characteristics of children with HBoV hospitalized for acute respiratory tract infection and to evaluate whether differences occur between HBoV alone and in co-infection. METHODS We retrospectively reviewed data from 60 children (median age of 6.2 months, range 0.6-70.9) hospitalized for acute respiratory symptoms, with HBoV detected from a respiratory sample, using a reverse transcriptase-PCR for 14 respiratory viruses (including respiratory syncytial virus (RSV), influenza virus A and B, human coronavirus OC43, 229E, NL-63 and HUK1, adenovirus, rhinovirus, parainfluenza virus1-3, and human metapneumovirus). RESULTS HBoV was detected alone in 29 (48.3%) patients, while in co-infection with other viruses in 31 patients (51.7%), with a peak between December and January. Among the 60 patients, 34 were bronchiolitis, 19 wheezing, 3 pneumonia, 2 upper respiratory tract infection, and 2 whooping cough. Seven children (11.6%) required admission to the paediatric intensive care unit (PICU) for respiratory failure. No differences was observed in age, family history for atopy and/or asthma, clinical presentations, chest X-ray, or laboratory findings in children with HBoV alone vs. multiple viral detection. RSV was the most frequently co-detected virus (61.3%). When compared with HBoV detection alone, the co-detection of RSV and HBoV was associated with male sex (P = 0.013), younger age (P = 0.01), and lower blood neutrophil count (P = 0.032). CONCLUSIONS HBoV can be detected alone and in co-infection respiratory samples of children with an acute respiratory tract infection. A cause-effect relationship between HBoV and respiratory infection is not clear, so further studies are needed to clarify this point.
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Abstract
BRIEF DESCRIPTION Family-initiated rapid response (FIRR) empowers families to express concern and seek care from specialized response teams. We studied FIRRs that occurred in a pediatric tertiary hospital over a 3-year period. The main aims were to describe the characteristics and outcomes of FIRRs and compare them with clinician-activated RRs (C-RRs). Of the 1,906 RRs events reviewed, 49 (2.6%) were FIRRs. All FIRRs had appropriate clinical triggers with the most common being uncontrolled pain. Chronic conditions and previous admissions were present in 61%. More than half of FIRRs had a vital sign change that should have qualified C-RR activation. Seventy-six percent FIRRs needed at least one or more interventions. Twenty-seven percent of FIRRs needed transfer to intensive care unit compared with 60% transfer rate for C-RRs. PURPOSE OF SUBMISSION/RELEVANCE TO HEALTHCARE QUALITY Family-initiated rapid response events were activated for legitimate concerns and frequently needed clinical interventions. Enhanced information and awareness of FIRR can improve utilization of the system and enhance family satisfaction, patient safety, and outcomes. Disseminating the information on FIRR and the importance of family involvement will improve the care of children and empower family members.
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Yurtseven A, Turan C, Elibol P, Çiçek C, Saz EU. Is multiple viral infection a predictor of severity in children with acute bronchiolitis? HONG KONG J EMERG ME 2019. [PMCID: PMC8280554 DOI: 10.1177/1024907918789279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Acute bronchiolitis is a common cause of pediatric emergency department admissions in children younger than 2. Objectives: The study aimed to compare the outcomes and the severity of bronchiolitis in young children with multiple simultaneous respiratory virus infections to those with single virus infection and no virus identified group. Methods: Patients with moderate and severe bronchiolitis who visited our emergency department between November 2016 and May 2017 had nasopharyngeal swab samples results tested by multiplex polymerase chain reaction were included in the study. Patients’ characteristics, clinical severity of illness, and outcome (pediatric emergency department discharge, admission to ward or pediatric intensive care unit) were compared with the detected viral agents. Results: A total of 241 patients were included in the study. The mean age was 7.8 ± 2.6 months and 147 (61%) were male. Respiratory syncytial virus was the most common detected viral agent in 108 (39%) cases followed by human rhinoviruses in 67 (24%). Respiratory syncytial virus was found more frequently in February and March (p = 0.002). Leukocytosis and pneumonia were more likely observed in patients with only human rhinoviruses (+) subjects (p = 0.010 and p = 0.015, respectively). Intensive care hospitalization rate (16%) was higher in patients with multiple viral agents (p = 0.004). Conclusions: Respiratory syncytial virus remains the most common detected viral agent in acute bronchiolitis patients. While the pathogens detected were seasonally different, there was a significant relationship between leukocytosis, bacterial pneumonia, and detected viral agents. The disease was more severe in patients with multiple viral agents.
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Affiliation(s)
- Ali Yurtseven
- Department of Pediatrics, School of Medicine, Ege University, Izmir, Turkey
- Department of Emergency Medicine, School of Medicine, Ege University, Izmir, Turkey
| | - Caner Turan
- Department of Pediatrics, School of Medicine, Ege University, Izmir, Turkey
- Department of Emergency Medicine, School of Medicine, Ege University, Izmir, Turkey
| | - Pelin Elibol
- Department of Pediatrics, School of Medicine, Ege University, Izmir, Turkey
| | - Candan Çiçek
- Department of Medical Microbiology, School of Medicine, Ege University, Izmir, Turkey
| | - Eylem Ulas Saz
- Department of Pediatrics, School of Medicine, Ege University, Izmir, Turkey
- Department of Emergency Medicine, School of Medicine, Ege University, Izmir, Turkey
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Patel B, Khine H, Shah A, Sung D, Medar S, Singer L. Randomized clinical trial of high concentration versus titrated oxygen use in pediatric asthma. Pediatr Pulmonol 2019; 54:970-976. [PMID: 30945478 DOI: 10.1002/ppul.24329] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 01/23/2019] [Accepted: 03/13/2019] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To compare the effects of high concentration to titrated oxygen therapy (HCOT) on transcutaneous carbon dioxide (PtCO2 ) level in pediatric asthma exacerbation. Titrated oxygen therapy (TOT) in acute asthma will avoid a rise in PtCO 2 in the pediatric population. METHOD The study design is a prospective, randomized, clinical trial comparing HCOT (maintain SpO2 92-95%) while being treated for asthma exacerbation in the emergency department (ED). INCLUSION CRITERIA 2 to 18 years, previously diagnosed asthma with acute exacerbation (asthma score >5). PtCO2 and asthma scores were measured at 0, 20, 40, 60 minutes and then every 30 minutes until disposition decision. The primary outcome was a change in PtCO 2 . Secondary outcomes were admission rate and change in asthma score. RESULTS A total of 96 patients were enrolled in the study with a mean age of 8.27 years; 49 in HCOT and 47 in the TOT group. The 0 minute PtCO2 was similar (35.33 + 3.88 HCOT vs 36.66 + 4.69 TOT, P = 0.13); whereas, the 60 minutes PtCO 2 was higher in the HCOT (38.08 + 5.11 HCOT vs 35.51 + 4.57 TOT, P = 0.01). The asthma score was similar at 0 minute (7.55 + 1.34 HCOT vs 7.30 + 1.18 TOT, P = 0.33); whereas, the 60 minutes asthma score was lower in the TOT (4.71 + 1.38 HCOT vs 3.57 + 1.25 TOT, P = 0.0001). The rate of admission to the hospital was 40.5% in HCOT vs 25.5% in the TOT (P = 0.088). CONCLUSIONS HCOT in pediatric asthma exacerbation leads to significantly higher carbon dioxide levels, which increases asthma scores and trends towards the increasing rate of admission. Larger studies are needed to explore this association.
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Affiliation(s)
- Bhavi Patel
- Department of Pediatric Critical Care, The Children's Hospital at Montefiore, Bronx, New York.,Department of Pediatric Cardiac Critical Care, Nicklaus Children's Hospital, Miami, Florida
| | - Hnin Khine
- Department of Pediatric Critical Care, The Children's Hospital at Montefiore, Bronx, New York
| | - Ami Shah
- Department of Pediatric Critical Care, The Children's Hospital at Montefiore, Bronx, New York
| | - Deborah Sung
- Department of Pediatric Critical Care, The Children's Hospital at Montefiore, Bronx, New York
| | - Shivanand Medar
- Department of Pediatric Critical Care, The Children's Hospital at Montefiore, Bronx, New York
| | - Lewis Singer
- Department of Pediatric Critical Care, The Children's Hospital at Montefiore, Bronx, New York
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30
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Yurtseven A, Turan C, Erseven E, Saz EU. Comparison of heated humidified high-flow nasal cannula flow rates (1-L·kg·min -1 vs 2-L·kg·min -1 ) in the management of acute bronchiolitis. Pediatr Pulmonol 2019; 54:894-900. [PMID: 30887731 PMCID: PMC7167921 DOI: 10.1002/ppul.24318] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 02/28/2019] [Accepted: 03/04/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We aimed to compare the heated humidified high-flow nasal cannula (HHHFNC) flow rate of 1-L·kg·min-1 (1 L) with 2-L·kg·min -1 (2 L) in patients with severe bronchiolitis presenting to the pediatric emergency department. STUDY DESIGN We performed a study in which all patients were allocated to receive these two flow rates. The primary outcome was admitted as treatment failure, which was defined as a clinical escalation in respiratory status. Secondary outcomes covered a decrease of respiratory rate (RR), heart rate (HR), the clinical respiratory score (CRS), rise of peripheral capillary oxygen saturation (SpO2 ), and rates of weaning, intubation, and intensive care unit (ICU) admission. RESULTS One hundred and sixty-eight cases (88 received the 1-L flow rate and 80, the 2-L flow rate) were included in the analyses. Treatment failure was 11.4% (10 of 88) in the 1-L group, and 10% (8 of 80) in the 2-L group (P = .775). Significant variation in the intubation rate or the ICU admission rate was not determined. At the 2nd hour, the rate of weaning (53.4% vs 35%; P = .017), the falling down of the CRS (-2.1 vs -1.5; P < .001), RR (-15.2 vs -11.8; P < .001), and HR (- 24.8 vs - 21.2; P < .001), and the increase of SpO 2 (4.8 vs 3.6; P < .001) were significantly more evident in the 1-L group. CONCLUSION HHHFNC with the 1-L·kg·min-1 flow rate, which provides a more frequent earlier effect, reached therapy success as high as the 2-L·kg·min -1 flow rate in patients with severe acute bronchiolitis.
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Affiliation(s)
- Ali Yurtseven
- Department of Pediatrics, Division of Emergency Medicine, School of Medicine, Ege University, Izmir, Turkey
| | - Caner Turan
- Department of Pediatrics, Division of Emergency Medicine, School of Medicine, Ege University, Izmir, Turkey
| | - Eren Erseven
- Department of Pediatrics, Division of Emergency Medicine, School of Medicine, Ege University, Izmir, Turkey
| | - Eylem Ulas Saz
- Department of Pediatrics, Division of Emergency Medicine, School of Medicine, Ege University, Izmir, Turkey
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Abdel-Kader A, Nassar MF, Qabazard Z, Disawi M. Imaging In Acute Bronchiolitis: Evaluation of The Current Practice In a Kuwaiti Governmental Hospital and Its Possible Impact on Hospitalization Period. Open Respir Med J 2019; 12:75-80. [PMID: 30988829 PMCID: PMC6425066 DOI: 10.2174/1874306401812010075] [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: 01/01/2018] [Revised: 06/24/2018] [Accepted: 10/18/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Guidelines for acute bronchiolitis recommend primarily supportive care, but unnecessary treatment measures remain well documented. This study was designed to assess the Al-Adan Hospital pediatricians` attitude towards imaging of inpatients with bronchiolitis aiming to evaluate its utilization and possible impact on patients` management and length of hospital stay. SUBJECTS AND METHODS This study included 194 cases of acute bronchiolitis admitted to Al-Adan Hospital. Number of X-Rays done following admission and reasons stated in the files were recorded. Bronchiolitis severity was estimated from the data obtained. RESULTS Chest X-Rays were ordered in 52.1% of our inpatients with acute bronchiolitis. In nearly half of those cases, the reason for X-Ray request is a clinical severity factor, namely desaturations and apneas, and in rest of the cases, no specific reason for ordering X-Rays was documented. Significantly more patients who had two or more X-Rays were prescribed antibiotics and had statistically longer hospital stay. The number of X-Rays performed during admission was not a significant contributor to the need for PICU care, however, it was a significant factor affecting the length of hospital stay. CONCLUSION The implementation of acute bronchiolitis guidelines regarding imaging in admitted cases with acute bronchiolitis is highly recommended in Al-Adan hospital. Clear documentation for the reasons behind ordering X-Rays is needed for those cases. A decrease in the X-Ray utilization and subsequent unnecessary antibiotic use can help in decreasing the costs and hazards of hospitalization for patients with acute bronchiolitis.
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Affiliation(s)
- Alaa Abdel-Kader
- Pediatric Department, Al-Adan Hospital, MOH, Kuwait.,Pediatric Department, Faculty of Medicine, Mansoura University, Dakahlia, Egypt
| | - May Fouad Nassar
- Pediatric Department, Al-Adan Hospital, MOH, Kuwait.,Pediatric Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Jagodich TA, Bersenas AME, Bateman SW, Kerr CL. Comparison of high flow nasal cannula oxygen administration to traditional nasal cannula oxygen therapy in healthy dogs. J Vet Emerg Crit Care (San Antonio) 2019; 29:246-255. [PMID: 30861261 DOI: 10.1111/vec.12817] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 03/20/2017] [Accepted: 04/23/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine the feasibility, degree of respiratory support, and safety of high flow nasal cannula (HFNC) oxygen therapy in sedated and awake healthy dogs, when compared to traditional nasal cannula (TNC) oxygen administration. DESIGN Randomized experimental crossover study. SETTING University research facility. ANIMALS Eight healthy dogs. INTERVENTIONS Variable flow rates (L/kg/min) were assessed, TNC: 0.1, 0.2, and 0.4 and HFNC: 0.4, 1.0, 2.0, and 2.5. HFNC was assessed in sedated and awake dogs. MEASUREMENTS Variables measured included: inspiratory/expiratory airway pressures, fraction of inspired oxygen (FiO2 ), end-tidal oxygen (ETO2 ), end-tidal carbon dioxide (ETCO2 ), partial pressure of oxygen (PaO2 ), partial pressure of carbon dioxide (PaCO2 ), temperature, heart/respiratory rate, arterial blood pressure, and pulse oximetry. Sedation status, complications, and predefined tolerance and respiratory scores were recorded. MAIN RESULTS Using HFNC, continuous positive airway pressure (CPAP) was achieved at 1 and 2 L/kg/min. CPAP was not higher at 2.5 than 2 L/kg/min, with worse tolerance scores. Expiratory airway pressures were increased when sedated (P = 0.006). FiO2 at 0.4 L/kg/min for both methods was 72%. FiO2 with TNC 0.1 L/kg/min was 27% and not different from room air. The FiO2 at all HFNC flow rates ≥1 L/kg/min was 95%. PaO2 for HFNC 0.4 L/kg/min was lower than at other flow rates (P = 0.005). The only noted complication was aerophagia. PaCO2 was increased with sedation and use of HFNC when compared to baseline (P = 0.006; P < 0.01). CONCLUSIONS Use of HFNC in dogs is feasible and safe, provides predictable oxygen support and provides CPAP, but may cause a mild increase in PaCO2 . Flow rates of 1-2 L/kg/min are recommended. If using TNC, flow rates above 0.1 L/kg/min may attain higher FiO2 .
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Affiliation(s)
- Tiffany A Jagodich
- Department of Clinical Sciences, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Alexa M E Bersenas
- Department of Clinical Sciences, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Shane W Bateman
- Department of Clinical Sciences, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Carolyn L Kerr
- Department of Clinical Sciences, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
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Elphick HE, Alkali AH, Kingshott RK, Burke D, Saatchi R. Exploratory Study to Evaluate Respiratory Rate Using a Thermal Imaging Camera. Respiration 2019; 97:205-212. [PMID: 30605906 DOI: 10.1159/000490546] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 05/29/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Respiratory rate is a vital physiological measurement used in the immediate assessment of unwell children and adults. Convenient electronic devices exist for the measurement of pulse, blood pressure, oxygen saturation, and temperature. Although devices which measure respiratory rate exist, none have entered everyday clinical practice for acute assessment of children and adults. An accurate and practical device which has no physical contact with the patient is important to ensure readings are not affected by distress caused by the assessment method. OBJECTIVE The aim of this study was to evaluate the use of a thermal imaging method to monitor the respiratory rate in children and adults. METHODS Facial thermal images of adult volunteers and children undergoing elective polysomnography were included. Respiration was recorded for at least 2 min with the camera positioned 1 m from the subject's face. Values obtained using the thermal imaging camera were compared with those obtained from contact methods such as the nasal thermistor, respiratory inductance plethysmography, nasal airflow, and end tidal CO2. RESULTS A total of 61 subjects, including 41 adults (age range 27-46 years) and 20 children (age range 0.5-18 years) were enrolled. The correlation between the respiratory rate measured using thermal imaging and the contact method was r = 0.94. Sequential refinements to the thermal imaging algorithms resulted in the ability to perform real-time measurements and an improvement of the correlation to r = 0.995. CONCLUSION This exploratory study shows that thermal imaging-derived respiratory rates in children and adults correlate closely with the best performing standard method. With further refinements, this method could be implemented in both acute and chronic care in children and adults.
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Affiliation(s)
- Heather E Elphick
- Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom,
| | | | - Ruth K Kingshott
- Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
| | - Derek Burke
- Sheffield Children's NHS Foundation Trust, Sheffield, United Kingdom
| | - Reza Saatchi
- Faculty of ACES, Sheffield Hallam University, Sheffield, United Kingdom
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Doğruel D, Altıntaş DU, Yılmaz M. Astımlı çocuklarda fiziksel egzersizin klinik ve fonksiyonel parametrelere etkisi. CUKUROVA MEDICAL JOURNAL 2018. [DOI: 10.17826/cumj.366166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Migita R, Yoshida H, Rutman L, Woodward GA. Quality Improvement Methodologies: Principles and Applications in the Pediatric Emergency Department. Pediatr Clin North Am 2018; 65:1283-1296. [PMID: 30446063 DOI: 10.1016/j.pcl.2018.07.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The origins of quality improvement in health care trace back to industry. Lessons learned from the "flow production" system of the Ford Model-T assembly line in Michigan and the Toyota Production System led to direct applications of Lean and Six Sigma to improve health care systems. Emergency medicine is well suited as a testing and proving ground for quality improvement methodologies because of high patient volume and rapid turnover. This article reviews the history of quality improvement in health care, describes Lean principles in detail, and provides illustrative examples of applications of Lean and quality improvement methodologies in the pediatric emergency department.
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Affiliation(s)
- Russell Migita
- Department of Pediatrics, Division of Emergency Medicine and Emergency Department, Seattle Children's Hospital, University of Washington School of Medicine, MB.7.520, PO Box 5371, Seattle, WA 98145-5005, USA; UW Medicine Center for Scholarship in Patient Care Quality and Safety, UWMC Health Sciences, BB1240, Campus Box #356526, 1959 NE Pacific Street, Seattle, WA 98195, USA.
| | - Hiromi Yoshida
- Department of Pediatrics, Division of Emergency Medicine and Emergency Department, Seattle Children's Hospital, University of Washington School of Medicine, MB.7.520, PO Box 5371, Seattle, WA 98145-5005, USA
| | - Lori Rutman
- Department of Pediatrics, Division of Emergency Medicine and Emergency Department, Seattle Children's Hospital, University of Washington School of Medicine, MB.7.520, PO Box 5371, Seattle, WA 98145-5005, USA
| | - George A Woodward
- Department of Pediatrics, Division of Emergency Medicine and Emergency Department, Seattle Children's Hospital, University of Washington School of Medicine, MB.7.520, PO Box 5371, Seattle, WA 98145-5005, USA
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Nayani K, Naeem R, Munir O, Naseer N, Feroze A, Brown N, Mian AI. The clinical respiratory score predicts paediatric critical care disposition in children with respiratory distress presenting to the emergency department. BMC Pediatr 2018; 18:339. [PMID: 30376827 PMCID: PMC6208017 DOI: 10.1186/s12887-018-1317-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 10/22/2018] [Indexed: 01/03/2023] Open
Abstract
Background Respiratory distress is a common presenting complaint in children brought to the Emergency Department (ED). The Clinical Respiratory Score (CRS) has shown promise as a screen for severe illness in High Income Countries. We aimed to validate the admission CRS in children presenting to the ED of a Low-to Middle Income Country. Methods Children (1 month to 16 years) presenting with respiratory distress to the ED of the Aga Khan University Hospital, Karachi, Pakistan, between November 2015 to March 2016, were enrolled. The CRS was measured at initial presentation, prior to any management and 2 h after treatment was started. The predictive value for admission to the paediatric critical care units for a variety of cut offs for CRS at presentation were derived. Results A total of 112 children (70% male) of median age 12 months (IQR 2, 34.5 months) were enrolled. Patients with severe CRS (score 8–12) at presentation were more likely to be admitted to paediatric critical care (90% vs. 23% with mild-moderate CRS; OR: 5.7; 95% CI: 2.2–15.3, p < 0.001). The sensitivity and specificity of CRS > 3 in predicting outcome were 94% (95% CI 79.8–99.3) and 40% (95% CI 35–45), respectively, with a positive likelihood ratio of 1.6 (95% CI 1.31–1.98) and negative predictive value of 94% (95% CI 81–98). Conclusion An admission CRS of > 3 in the ED of a Low-to Middle Income Country had excellent predictive value for disease severity, and it should be considered for incorporation into ED triage protocols.
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Affiliation(s)
- Kanwal Nayani
- Department of Paediatrics and Child Health, AKU, Karachi, Pakistan
| | - Rubaba Naeem
- Department of Emergency Medicine, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Owais Munir
- Department of Emergency Medicine, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Naureen Naseer
- Department of Emergency Medicine, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Asher Feroze
- Department of Emergency Medicine, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Nick Brown
- Department of Paediatrics and Child Health, AKU, Karachi, Pakistan.,International Maternal and Child Health (IMCH), Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Department of Paediatrics, Länssjukhuset Gävle-Sandviken, 801 87, Gävle, Sweden
| | - Asad I Mian
- Department of Emergency Medicine, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan.
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Savage TJ, Kuypers J, Chu HY, Bradford MC, Buccat AM, Qin X, Klein EJ, Jerome KR, Englund JA, Waghmare A. Enterovirus D-68 in children presenting for acute care in the hospital setting. Influenza Other Respir Viruses 2018; 12:522-528. [PMID: 29498483 PMCID: PMC6005627 DOI: 10.1111/irv.12551] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Severe respiratory disease associated with enterovirus D68 (EV-D68) has been reported in hospitalized pediatric patients. Virologic and clinical characteristics of EV-D68 infections exclusively in patients presenting to a hospital Emergency Department (ED) or urgent care have not been well defined. METHODS Mid-nasal swabs from pediatric patients with respiratory symptoms presenting to the ED or urgent care were evaluated using a commercial multiplex PCR platform. Specimens positive for rhinovirus/enterovirus (HRV/EV) were subsequently tested using real-time reverse-transcriptase PCR for EV-D68. The PCR cycle threshold (CT) was used as a viral load proxy. Clinical outcomes were compared between patients with EV-D68 and patients without EV-D68 who tested positive for HRV/EV. RESULTS From August to December 2014, 511 swabs from patients with HRV/EV were available. EV-D68 was detected in 170 (33%) HRV/EV-positive samples. In multivariable models adjusted for age and underlying asthma, patients with EV-D68 were more likely to require hospitalization for respiratory reasons (odds ratio (OR): 3.11, CI: 1.85-5.25), require respiratory support (OR: 1.69, CI: 1.09-2.62), have confirmed/probable lower respiratory tract infection (LRTI; OR: 3.78, CI: 2.03-7.04), and require continuous albuterol or steroids (OR: 3.91, CI: 2.22-6.88 and OR: 4.73, CI: 2.65-8.46, respectively). Higher EV-D68 viral load was associated with need for respiratory support and LRTI in multivariate models. CONCLUSIONS Among pediatric patients presenting to the ED or urgent care, EV-D68 causes more severe disease than non-EV-D68 HRV/EV independent of underlying asthma. High viral load was associated with worse clinical outcomes. Rapid and quantitative viral testing may help identify and risk stratify patients.
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Affiliation(s)
- Timothy J. Savage
- Seattle Children's HospitalSeattleWAUSA
- University of WashingtonSeattleWAUSA
| | | | | | | | | | - Xuan Qin
- Seattle Children's HospitalSeattleWAUSA
| | - Eileen J. Klein
- Seattle Children's HospitalSeattleWAUSA
- University of WashingtonSeattleWAUSA
- Seattle Children's Research InstituteSeattleWAUSA
| | - Keith R. Jerome
- University of WashingtonSeattleWAUSA
- Fred Hutchinson Cancer Research CenterSeattleWAUSA
| | - Janet A. Englund
- Seattle Children's HospitalSeattleWAUSA
- University of WashingtonSeattleWAUSA
- Seattle Children's Research InstituteSeattleWAUSA
| | - Alpana Waghmare
- Seattle Children's HospitalSeattleWAUSA
- University of WashingtonSeattleWAUSA
- Seattle Children's Research InstituteSeattleWAUSA
- Fred Hutchinson Cancer Research CenterSeattleWAUSA
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Implementing a Standardized Clinical Pathway Leads to Reduced Asthma Admissions and Health Care Costs. Pediatr Qual Saf 2018; 3:e091. [PMID: 30229202 PMCID: PMC6135551 DOI: 10.1097/pq9.0000000000000091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 05/23/2018] [Indexed: 11/27/2022] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: Asthma exacerbations are 1 of the leading causes of hospital admissions in children in the United States. High volumes in the emergency department can lead to delayed treatment. Several studies have shown that implementation of a standardized clinical pathway can improve adherence to evidence-based standards. The purpose of our quality improvement project was to develop a standardized pathway of care for children with asthma exacerbations to improve time to treatment and reduce admissions. Methods: The team used process mapping to review the current process of care for patients with asthma exacerbations presenting to the Emergency Department. After identification of several barriers, the team used plan-do-study-act cycles to develop a standardized clinical pathway of care for children based on their respiratory clinical score. Further interventions occurred after data collection and analyzation through run charts. Results: Implementation of a standardized clinical pathway for children with asthma presenting to the Emergency Department resulted in treatment with steroids in less than 60 minutes. Overall admissions were decreased from an average of 24% to 17% throughout the intervention period. We estimated cost savings for the institution at over $230,000 for the 2 years after implementation of the pathway. Conclusions: Using a multidisciplinary team approach to develop a standardized clinical pathway for a common childhood illness like asthma can result in reduced time to treatment and admissions.
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Golan-Tripto I, Goldbart A, Akel K, Dizitzer Y, Novack V, Tal A. Modified Tal Score: Validated score for prediction of bronchiolitis severity. Pediatr Pulmonol 2018; 53:796-801. [PMID: 29655288 DOI: 10.1002/ppul.24007] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 03/14/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To further validate the use of the Modified Tal Score (MTS), a clinical tool for assessing bronchiolitis severity, by physicians with varying experience and training levels, and to determine the ability of the MTS to predict bronchiolitis severity. METHODS This prospective cohort study included infants of <12 months of age who were diagnosed with bronchiolitis and assessed via MTS. We calculated the intra-class correlation coefficient (ICC) among four groups of raters: group 1, board-certified pediatric pulmonologists; group 2, board-certified pediatricians; group 3, senior pediatric residents; and group 4, junior pediatric residents. Clinical outcomes were determined as length of oxygen support and length of stay (LOS). We assessed MTS's prediction of these outcomes. Relative risk (RR) for clinical severity was calculated via a Generalized Linear Model. RESULTS Twenty-four physicians recorded a total of 600 scores for 50 infants (average age 5 ± 3 months; 56% male). The ICC values with group 1 as a reference were 0.92, 0.87, and 0.83, for groups 2, 3, and 4, respectively (P < 0.001). RR for oxygen support required was; 1.33 (CI 1.12-1.57), 1.26 (1.1-1.46), 1.26 (1.06-1.5), and 1.21 (0.93-1.58) for groups 1, 2, 3, and 4, respectively. RR for LOS was; 1.15 (CI 0.97-1.37), 1.19 (1.03-1.38), 1.18 (1.0-1.39), and 1.18 (0.93-1.51) for groups 1, 2, 3, and 4, respectively. CONCLUSION The MTS is a simple and valid scoring system for evaluating infants with acute bronchiolitis, among different physician groups. The first score upon admission is a fair predictor of oxygen requirement at 48 h, and LOS at 72 h.
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Affiliation(s)
- Inbal Golan-Tripto
- Department of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel.,Pediatric Pulmonary Unit, Soroka University Medical Center, Beer Sheva, Israel
| | - Aviv Goldbart
- Department of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel.,Pediatric Pulmonary Unit, Soroka University Medical Center, Beer Sheva, Israel
| | - Khaled Akel
- Department of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
| | - Yotam Dizitzer
- Clinical Research Center, Soroka University Medical Center, Beer Sheva, Israel
| | - Victor Novack
- Clinical Research Center, Soroka University Medical Center, Beer Sheva, Israel.,Department of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Asher Tal
- Department of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel.,Pediatric Pulmonary Unit, Soroka University Medical Center, Beer Sheva, Israel
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A Randomized Trial Comparing Metered Dose Inhalers and Breath Actuated Nebulizers. J Emerg Med 2018; 55:7-14. [PMID: 29716819 DOI: 10.1016/j.jemermed.2018.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 02/19/2018] [Accepted: 03/03/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite little evidence for its effectiveness, the breath-actuated nebulizer (BAN) is the default albuterol delivery method in our pediatric emergency department. OBJECTIVE We compared the clinical efficacy of BAN and the metered-dose inhaler (MDI) in treating subjects patients 2 to 17 years of age who presented with mild to moderate asthma exacerbations. METHODS This is a randomized, nonblinded, noninferiority study conducted at a single pediatric tertiary care emergency department. Subjects presenting with a Pediatric Asthma Score ranging from 5 to 11 received albuterol by BAN or MDI via standard weight-based and symptom severity dosing protocols. Aerosolized ipratropium (via BAN) and intravenous magnesium sulfate were given when clinically indicated. The primary outcome was patient disposition. The noninferiority margin for the primary outcome was an admission rate difference ≤10%. Analyses were adjusted for confounders that were significant at p ≤ 0.10. RESULTS We enrolled 890 subjects between October 2014 and April 2015. BAN and MDI groups were comparable for age, gender, and race but not for pretreatment symptom severity; 51% in the MDI group had a Pediatric Asthma Score of moderate severity (8-11) vs. 63% in the BAN group (p < 0.003). Unadjusted admission rates were 11.9% for MDI and 12.8% for BAN, for an unadjusted risk difference of -0.9% (95% confidence interval -5% to 3%). After adjusting for baseline confounder severity, the risk difference was 2% (95% confidence interval -4% to 7%), which met the criteria for noninferiority. CONCLUSIONS Albuterol therapy by MDI is noninferior to BAN for the treatment of mild to moderate asthma exacerbations in children 2 to 17 years of age.
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Abstract
OBJECTIVE We describe the characteristics and outcomes of pediatric repeat rapid response events within a single hospitalization. We hypothesized that triggers for repeat rapid response and initial rapid response events are similar, and repeat rapid response events are associated with high prevalence of medical complexity and worse outcomes. DESIGN A 3-year retrospective study. SETTING High-volume tertiary academic pediatric hospital. PATIENTS All rapid response events were reviewed to identify repeat rapid response events. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Patient demographics, rapid response triggers, primary clinical diagnoses, illness acuity scores, medical interventions, transfers to ICU, occurrence of critical deterioration, and mortality were reviewed. We reviewed 146 patients with 309 rapid response events (146 initial rapid response and 163 repeat rapid response: 36% < 24 hr, 38% 24 hr to 7 d, and 26% > 7 d after initial rapid response). Median age was 3 years, and 60% were males. Eighty-five percentage of repeat rapid response occurred in medical complexity patients. The triggers for 71% of all repeat rapid response matched with those of initial rapid response. Transfer to ICU occurred in 69 (47%) of initial rapid response and 124 (76%) of repeat rapid response (p < 0.01). The median hospital stay was 11 and 30 days for previously healthy and medical complexity patients, respectively (p = 0.16). ICU readmission at repeat rapid response was associated with longer hospital stay (p < 0.01). Mortality during hospitalization occurred in 14% (all medically complex) of patients after repeat rapid response. Hospital mortality after rapid response is 4.4% per our center's administrative data and 6.7% according to published multicenter data. CONCLUSIONS Prevalence of medical complexity was high in patients with repeat rapid response compared with that reported for pediatric hospitalizations. Triggers between initial and repeat rapid response events correlated. Transfer to ICU was more likely after repeat rapid response and among repeat rapid response, events with ICU readmissions had a longer length of ICU and hospital stay. Mortality for the repeat rapid response cohort was higher than that for overall rapid responses in our center and per published reports from other centers.
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Maitland K, Kiguli S, Opoka RO, Olupot-Olupot P, Engoru C, Njuguna P, Bandika V, Mpoya A, Bush A, Williams TN, Grieve R, Sadique Z, Fraser J, Harrison D, Rowan K. Children's Oxygen Administration Strategies Trial (COAST): A randomised controlled trial of high flow versus oxygen versus control in African children with severe pneumonia. Wellcome Open Res 2018; 2:100. [PMID: 29383331 PMCID: PMC5771148 DOI: 10.12688/wellcomeopenres.12747.2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2018] [Indexed: 01/16/2023] Open
Abstract
Background: In Africa, the clinical syndrome of pneumonia remains the leading cause of morbidity and mortality in children in the post-neonatal period. This represents a significant burden on in-patient services. The targeted use of oxygen and simple, non-invasive methods of respiratory support may be a highly cost-effective means of improving outcome, but the optimal oxygen saturation threshold that results in benefit and the best strategy for delivery are yet to be tested in adequately powered randomised controlled trials. There is, however, an accumulating literature about the harms of oxygen therapy across a range of acute and emergency situations that have stimulated a number of trials investigating permissive hypoxia. Methods: In 4200 African children, aged 2 months to 12 years, presenting to 5 hospitals in East Africa with respiratory distress and hypoxia (oxygen saturation < 92%), the COAST trial will simultaneously evaluate two related interventions (targeted use of oxygen with respect to the optimal oxygen saturation threshold for treatment and mode of delivery) to reduce shorter-term mortality at 48-hours (primary endpoint), and longer-term morbidity and mortality to 28 days in a fractional factorial design, that compares: Liberal oxygenation (recommended care) compared with a strategy that permits hypoxia to SpO 2 > or = 80% (permissive hypoxia); andHigh flow using AIrVO 2 TM compared with low flow delivery (routine care). Discussion: The overarching objective is to address the key research gaps in the therapeutic use of oxygen in resource-limited setting in order to provide a better evidence base for future management guidelines. The trial has been designed to address the poor outcomes of children in sub-Saharan Africa, which are associated with high rates of in-hospital mortality, 9-10% (for those with oxygen saturations of 80-92%) and 26-30% case fatality for those with oxygen saturations <80%. Clinical trial registration: ISRCTN15622505 Trial status: Recruiting.
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Affiliation(s)
- Kathryn Maitland
- Department of Paediatrics, Faculty of Medicine, Imperial College London, London, W2 1PG, UK
- Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, UK
| | - Sarah Kiguli
- Department of Paediatrics, Mulago Hospital, Makerere College of Health Sciences, Kampala, Uganda
| | - Robert O. Opoka
- Department of Paediatrics, Mulago Hospital, Makerere College of Health Sciences, Kampala, Uganda
| | - Peter Olupot-Olupot
- Mbale Clinical Research Institute, Mbale, Uganda
- Department of Paediatrics, Mbale Regional Referral Hospital, Mbale, Uganda
| | - Charles Engoru
- Department of Paediatrics, Soroti Regional Referral Hospital, Soroti, Uganda
| | - Patricia Njuguna
- Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, UK
| | - Victor Bandika
- Department of Paediatrics, Coast Provincial General Hospital, Mombasa, Kenya
| | - Ayub Mpoya
- Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, UK
| | - Andrew Bush
- Department of Paediatrics, Faculty of Medicine, Imperial College London, London, W2 1PG, UK
- Department of Paediatric Respirology, National Heart and Lung Institute, Royal Brompton & Harefield NHS Foundation Trust, Imperial College, London, SW3 6NP, UK
| | - Thomas N. Williams
- Department of Paediatrics, Faculty of Medicine, Imperial College London, London, W2 1PG, UK
- Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, UK
| | - Richard Grieve
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - John Fraser
- The Critical Care Research Group, University of Queensland The Prince Charles Hospital and St Andrews Hospital, Clinical Science Building Rode Road, Chermside, QLD, 4032, Australia
| | - David Harrison
- Intensive Care National Audit & Research Centre (ICNARC), London, WC1V 6AZ, UK
| | - Kathy Rowan
- Intensive Care National Audit & Research Centre (ICNARC), London, WC1V 6AZ, UK
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Rivas-Juesas C, Rius Peris J, García A, Madramany A, Peris M, Álvarez L, Primo J. A comparison of two clinical scores for bronchiolitis. A multicentre and prospective study conducted in hospitalised infants. Allergol Immunopathol (Madr) 2018. [PMID: 28629673 DOI: 10.1016/j.aller.2017.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND There are a number of clinical scores for bronchiolitis but none of them are firmly recommended in the guidelines. METHOD We designed a study to compare two scales of bronchiolitis (ESBA and Wood Downes Ferres) and determine which of them better predicts the severity. A multicentre prospective study with patients <12 months with acute bronchiolitis was conducted. Each patient was assessed with the two scales when admission was decided. We created a new variable "severe condition" to determine whether one scale afforded better discrimination of severity. A diagnostic test analysis of sensitivity and specificity was made, with a comparison of the AUC. Based on the optimum cut-off points of the ROC curves for classifying bronchiolitis as severe we calculated new Se, Sp, LR+ and LR- for each scale in our sample. RESULTS 201 patients were included, 66.7% males and median age 2.3 months (IQR=1.3-4.4). Thirteen patients suffered bronchiolitis considered to be severe, according to the variable severe condition. ESBA showed a Se=3.6%, Sp=98.1%, and WDF showed Se=46.2% and Sp=91.5%. The difference between the two AUC for each scale was 0.02 (95%CI: 0.01-0.15), p=0.72. With new cut-off points we could increase Se and Sp for ESBA: Se=84.6%, Sp=78.7%, and WDF showed Se=92.3% and Sp=54.8%; with higher LR. CONCLUSIONS None of the scales studied was considered optimum for assessing our patients. With new cut-off points, the scales increased the ability to classify severe infants. New validation studies are needed to prove these new cut-off points.
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Rodríguez-Martínez CE, Sossa-Briceño MP, Nino G. Systematic review of instruments aimed at evaluating the severity of bronchiolitis. Paediatr Respir Rev 2018; 25:43-57. [PMID: 28258885 PMCID: PMC5557708 DOI: 10.1016/j.prrv.2016.12.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 11/27/2016] [Accepted: 12/13/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE No recent studies have performed a systematic review of all available instruments aimed at evaluating the severity of bronchiolitis. The objective of the present study was to perform a systematic review of instruments aimed at evaluating the severity of bronchiolitis and to evaluate their measurement properties. METHODS A systematic search of the literature was performed in order to identify studies in which an instrument for evaluating the severity of bronchiolitis was described. Instruments were evaluated based on their reliability, validity, utility, endorsement frequency, restrictions in range, comprehension, and lack of ambiguity. RESULTS A total of 77 articles, describing a total of 32 different instruments were included in the review. The number of items included in the instruments ranged from 2 to 26. Upon analyzing their content, respiratory rate turned out to be the most frequently used item (in 26/32, 81.3% of the instruments), followed by wheezing (in 25/32, 78.1% of the instruments). In 18 (56.3%) instruments, there was a report of at least one of their measurement properties, mainly reliability and utility. Taking into consideration the information contained in the instruments, as well as their measurement properties, one was considered to be the best one available. CONCLUSIONS Among the 32 instruments aimed at evaluating the severity of bronchiolitis that were identified and systematically examined, one was considered to be the best one available. However, there is an urgent need to develop better instruments and to validate them in a more comprehensive and proper way.
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Affiliation(s)
- Carlos E. Rodríguez-Martínez
- 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
| | - Gustavo Nino
- Division of Pediatric Pulmonary, Sleep Medicine and Integrative Systems Biology. Center for Genetic Research, Children’s National Medical Center, George Washington University, Washington, D.C
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Abstract
OBJECTIVES We aimed to evaluate the seasonal variations of acute asthma presentation in children and the utility of the pediatric asthma score (PAS) and its components in early admission prediction. METHODS As part of a randomized controlled trial addressing the clinical efficacy of budesonide nebulization in the treatment of acute asthma in children, the PAS was measured at baseline, 1st, 2nd, 3rd, and 4th h from the start of medications. Decision of admission was taken at or beyond the 2nd h. RESULTS Out of a total 906 emergency department (ED) visits with moderate-to-severe acute asthma, 157 children were admitted. June to September had the lowest number of visits. The admission-to-discharge ratio varied throughout the year. During the ED stay, between baseline and 3rd h, admission predictability of the total score improved progressively with a small difference between the 2nd and 3rd h. The total score remained the strongest predictor of admission at every time point compared to its individual components. The drop of PAS from baseline to the 2nd h was not a good predictor of admission. Oxygen saturation (OS) and respiratory rate (RR) had relatively higher predictability than other components. CONCLUSIONS Decision of admission could be made to many children with moderate-to-severe acute asthma at the 2nd h of ED stay based on their total PAS. OS and RR should be part of any scoring system to evaluate acute asthma in children.
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Affiliation(s)
- Maan Alherbish
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Khalid F Mobaireek
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah A Alangari
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Abstract
Vital signs are the simplest, cheapest and probably the most important information gathered on patients in hospital. In this narrative review we present a large amount of evidence that vital signs are currently little valued, not regularly or accurately recorded, and frequently not acted on appropriately. It is probable that few hospitals would keep their accreditation with regulatory bodies if they collected and acted on their laboratory results in the same way that they collect and act on vital signs. Professional societies and regulatory bodies need to address this issue: if vital signs were more accurately and frequently measured, and acted on promptly and appropriately hospital care would be safer, better and cheaper.
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Affiliation(s)
- John Kellett
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark.
| | - Frank Sebat
- Faculty Internal Medicine, Mercy Medical Center, Redding, CA, USA
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Justicia-Grande AJ, Pardo Seco J, Rivero Calle I, Martinón-Torres F. Clinical respiratory scales: which one should we use? Expert Rev Respir Med 2017; 11:925-943. [PMID: 28974118 DOI: 10.1080/17476348.2017.1387052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION There are countless clinical respiratory scales for acute dyspnoea. Most healthcare professionals choose one based on previous personal experience or following local practice, unaware of the implications of their choice. The lack of critical comparisons between those different tools has been a widespread problem that only recently has begun to be addressed via score validation studies. Here we try to assess and compare the quality criteria of measurement properties of acute dyspnoea scores. Areas covered: A literature review was conducted by searching the PubMed database. Forty-five documents were deemed eligible as they reported the use or building of clinical scales, using at least two parameters, and applied these to an acute episode of respiratory dyspnoea. Our primary focus was the description of the validity, reliability and utility of 41 suitable scoring instruments. Differences in sample selection, study design, rater profiles and potential methodological shortcomings were also addressed. Expert commentary: All acute dyspnoea scores lack complete validation. In particular, the areas of measurement error and interpretability have not been addressed correctly by any of the tools reviewed. Frequent modification of pre-existing scores (in items composition and/or name), differences in study design and discrepancies in reviewed sources also hinder the search for an adequate tool.
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Affiliation(s)
- Antonio José Justicia-Grande
- a Translational Pediatrics and Infectious Diseases, Department of Pediatrics , Hospital Clínico Universitario de Santiago de Compostela , A Coruña , Spain.,b Healthcare Research Institute , Instituto de Investigación Sanitaria de Santiago, GENVIP group , Santiago de Compostela, A Coruña , Spain
| | - Jacobo Pardo Seco
- b Healthcare Research Institute , Instituto de Investigación Sanitaria de Santiago, GENVIP group , Santiago de Compostela, A Coruña , Spain
| | - Irene Rivero Calle
- a Translational Pediatrics and Infectious Diseases, Department of Pediatrics , Hospital Clínico Universitario de Santiago de Compostela , A Coruña , Spain.,b Healthcare Research Institute , Instituto de Investigación Sanitaria de Santiago, GENVIP group , Santiago de Compostela, A Coruña , Spain
| | - Federico Martinón-Torres
- a Translational Pediatrics and Infectious Diseases, Department of Pediatrics , Hospital Clínico Universitario de Santiago de Compostela , A Coruña , Spain.,b Healthcare Research Institute , Instituto de Investigación Sanitaria de Santiago, GENVIP group , Santiago de Compostela, A Coruña , Spain
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48
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Maitland K, Kiguli S, Opoka RO, Olupot-Olupot P, Engoru C, Njuguna P, Bandika V, Mpoya A, Bush A, Williams TN, Grieve R, Sadique Z, Fraser J, Harrison D, Rowan K. Children's Oxygen Administration Strategies Trial (COAST): A randomised controlled trial of high flow versus oxygen versus control in African children with severe pneumonia. Wellcome Open Res 2017; 2:100. [PMID: 29383331 PMCID: PMC5771148 DOI: 10.12688/wellcomeopenres.12747.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2017] [Indexed: 12/27/2022] Open
Abstract
Background: In Africa, the clinical syndrome of pneumonia remains the leading cause of morbidity and mortality in children in the post-neonatal period. This represents a significant burden on in-patient services. The targeted use of oxygen and simple, non-invasive methods of respiratory support may be a highly cost-effective means of improving outcome, but the optimal oxygen saturation threshold that results in benefit and the best strategy for delivery are yet to be tested in adequately powered randomised controlled trials. There is, however, an accumulating literature about the harms of oxygen therapy across a range of acute and emergency situations that have stimulated a number of trials investigating permissive hypoxia. Methods: In 4200 African children, aged 2 months to 12 years, presenting to 5 hospitals in East Africa with respiratory distress and hypoxia (oxygen saturation < 92%), the COAST trial will simultaneously evaluate two related interventions (targeted use of oxygen with respect to the optimal oxygen saturation threshold for treatment and mode of delivery) to reduce shorter-term mortality at 48-hours (primary endpoint), and longer-term morbidity and mortality to 28 days in a fractional factorial design, that compares: Liberal oxygenation (recommended care) compared with a strategy that permits hypoxia to SpO 2 > or = 80% (permissive hypoxia); andHigh flow using AIrVO 2TM compared with low flow delivery (routine care). Discussion: The overarching objective is to address the key research gaps in the therapeutic use of oxygen in resource-limited setting in order to provide a better evidence base for future management guidelines. The trial has been designed to address the poor outcomes of children in sub-Saharan Africa, which are associated with high rates of in-hospital mortality, 9-10% (for those with oxygen saturations of 80-92%) and 26-30% case fatality for those with oxygen saturations <80%. Clinical trial registration: ISRCTN15622505 Trial status: Recruiting.
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Affiliation(s)
- Kathryn Maitland
- Department of Paediatrics, Faculty of Medicine, Imperial College London, London, W2 1PG, UK
- Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, UK
| | - Sarah Kiguli
- Department of Paediatrics, Mulago Hospital, Makerere College of Health Sciences, Kampala, Uganda
| | - Robert O. Opoka
- Department of Paediatrics, Mulago Hospital, Makerere College of Health Sciences, Kampala, Uganda
| | - Peter Olupot-Olupot
- Mbale Clinical Research Institute, Mbale, Uganda
- Department of Paediatrics, Mbale Regional Referral Hospital, Mbale, Uganda
| | - Charles Engoru
- Department of Paediatrics, Soroti Regional Referral Hospital, Soroti, Uganda
| | - Patricia Njuguna
- Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, UK
| | - Victor Bandika
- Department of Paediatrics, Coast Provincial General Hospital, Mombasa, Kenya
| | - Ayub Mpoya
- Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, UK
| | - Andrew Bush
- Department of Paediatrics, Faculty of Medicine, Imperial College London, London, W2 1PG, UK
- Department of Paediatric Respirology, National Heart and Lung Institute, Royal Brompton & Harefield NHS Foundation Trust, Imperial College, London, SW3 6NP, UK
| | - Thomas N. Williams
- Department of Paediatrics, Faculty of Medicine, Imperial College London, London, W2 1PG, UK
- Kilifi Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, UK
| | - Richard Grieve
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - John Fraser
- The Critical Care Research Group, University of Queensland The Prince Charles Hospital and St Andrews Hospital, Clinical Science Building Rode Road, Chermside, QLD, 4032, Australia
| | - David Harrison
- Intensive Care National Audit & Research Centre (ICNARC), London, WC1V 6AZ, UK
| | - Kathy Rowan
- Intensive Care National Audit & Research Centre (ICNARC), London, WC1V 6AZ, UK
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49
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Kamit Can F, Anil AB, Anil M, Zengin N, Durak F, Alparslan C, Goc Z. Predictive factors for the outcome of high flow nasal cannula therapy in a pediatric intensive care unit: Is the SpO 2/FiO 2 ratio useful? J Crit Care 2017; 44:436-444. [PMID: 28935428 DOI: 10.1016/j.jcrc.2017.09.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 08/28/2017] [Accepted: 09/03/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To determine the predictive factors for the outcome of high-flow nasal cannula (HFNC) therapy in a pediatric intensive care unit (PICU). MATERIALS AND METHODS We prospectively included all patients with acute respiratory distress/failure aged 1month to 18years who were admitted to the PICU between January 2015 and May 2016 and treated with HFNC as a primary support and for postextubation according to our pre-established protocol. HFNC failure was defined as the need for escalation to non-invasive ventilation (NIV) or invasive mechanical ventilation (MV). HFNC responders and nonresponders were compared based on clinical data obtained just before HFNC and at 30, 60, and 120min, 12, 24, and 48h, and at the end of therapy. RESULTS A total of 204 patients (median age: 16.5months) participated in the study. Twenty-six (12.7%) patients required escalation (4 to NIV and 22 to MV). Age >120months, higher PRISM-III and respiratory scores, and a lower SpO2/FiO2 (S/F) ratio at admission were predictors of HFNC failure. Achievement of the S/F>200 goal at 60min significantly predicted successful HFNC. CONCLUSION Monitoring the S/F ratio might be useful and practical to avoid delaying escalation to another ventilation support. Failure to achieve S/F>200 at 60min should be a warning for the escalation of respiratory support.
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Affiliation(s)
- Fulya Kamit Can
- Tepecik Teaching and Research Hospital, Pediatric Intensive Care Unit, Izmir, Turkey.
| | - Ayşe Berna Anil
- Izmir Katip Celebi University, Medical School, Izmir, Turkey
| | - Murat Anil
- Tepecik Teaching and Research Hospital, Pediatric Emergency Department, Izmir, Turkey
| | - Neslihan Zengin
- Tepecik Teaching and Research Hospital, Pediatric Intensive Care Unit, Izmir, Turkey
| | - Fatih Durak
- Tepecik Teaching and Research Hospital, Pediatric Intensive Care Unit, Izmir, Turkey
| | - Caner Alparslan
- Tepecik Teaching and Research Hospital, Pediatric Nephrology Department, Izmir, Turkey
| | - Zeynep Goc
- Tepecik Teaching and Research Hospital, Pediatric Emergency Department, Izmir, Turkey
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50
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Florin TA, Ambroggio L, Brokamp C, Rattan MS, Crotty EJ, Kachelmeyer A, Ruddy RM, Shah SS. Reliability of Examination Findings in Suspected Community-Acquired Pneumonia. Pediatrics 2017; 140:peds.2017-0310. [PMID: 28835381 PMCID: PMC5574720 DOI: 10.1542/peds.2017-0310] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The authors of national guidelines emphasize the use of history and examination findings to diagnose community-acquired pneumonia (CAP) in outpatient children. Little is known about the interrater reliability of the physical examination in children with suspected CAP. METHODS This was a prospective cohort study of children with suspected CAP presenting to a pediatric emergency department from July 2013 to May 2016. Children aged 3 months to 18 years with lower respiratory signs or symptoms who received a chest radiograph were included. We excluded children hospitalized ≤14 days before the study visit and those with a chronic medical condition or aspiration. Two clinicians performed independent examinations and completed identical forms reporting examination findings. Interrater reliability for each finding was reported by using Fleiss' kappa (κ) for categorical variables and intraclass correlation coefficient (ICC) for continuous variables. RESULTS No examination finding had substantial agreement (κ/ICC > 0.8). Two findings (retractions, wheezing) had moderate to substantial agreement (κ/ICC = 0.6-0.8). Nine findings (abdominal pain, pleuritic pain, nasal flaring, skin color, overall impression, cool extremities, tachypnea, respiratory rate, and crackles/rales) had fair to moderate agreement (κ/ICC = 0.4-0.6). Eight findings (capillary refill time, cough, rhonchi, head bobbing, behavior, grunting, general appearance, and decreased breath sounds) had poor to fair reliability (κ/ICC = 0-0.4). Only 3 examination findings had acceptable agreement, with the lower 95% confidence limit >0.4: wheezing, retractions, and respiratory rate. CONCLUSIONS In this study, we found fair to moderate reliability of many findings used to diagnose CAP. Only 3 findings had acceptable levels of reliability. These findings must be considered in the clinical management and research of pediatric CAP.
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Affiliation(s)
- Todd A. Florin
- Divisions of Emergency Medicine,,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Lilliam Ambroggio
- Biostatistics and Epidemiology,,Hospital Medicine, and,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Mantosh S. Rattan
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Eric J. Crotty
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Richard M. Ruddy
- Divisions of Emergency Medicine,,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Samir S. Shah
- Divisions of Emergency Medicine,,Hospital Medicine, and,Infectious Diseases, and,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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