Use of continuous positive airway pressure (CPAP) in acute viral bronchiolitis: a systematic review

High-flow nasal cannula therapy for infants with bronchiolitis

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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

BACKGROUND

Acute bronchiolitis is one of the most frequent causes of emergency department visits and hospitalisation in children up to three years of age. There is no specific treatment for bronchiolitis except for supportive treatment, which includes ensuring adequate hydration and oxygen supplementation. Continuous positive airway pressure (CPAP) aims to widen the lungs' peripheral airways, enabling deflation of overdistended lungs in bronchiolitis. Increased airway pressure also prevents the collapse of poorly supported peripheral small airways during expiration. Observational studies report that CPAP is beneficial for children with acute bronchiolitis. This is an update of a review first published in 2015 and updated in 2019.

OBJECTIVES

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

SEARCH METHODS

We conducted searches of CENTRAL (2021, Issue 7), which includes the Cochrane Acute Respiratory Infections Group Specialised Register, MEDLINE (1946 to August 2021), Embase (1974 to August 2021), CINAHL (1981 to August 2021), and LILACS (1982 to August 2021) in August 2021. We also searched the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) for completed and ongoing trials on 26 October 2021.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data using a structured pro forma, analysed data, and performed meta-analyses. We used the Cochrane risk of bias tool to assess risk of bias in the included studies. We created a summary of the findings table employing GRADEpro GDT software.  MAIN RESULTS: We included three studies with a total of 122 children (62/60 in intervention/control arms) aged up to 12 months investigating nasal CPAP compared with supportive (or 'standard') therapy. We included one new trial (72 children) in the 2019 update that contributed data to the assessment of respiratory rate and the need for mechanical ventilation for this update. We did not identify any new trials for inclusion in the current update. The included studies were single-centre trials conducted in France, the UK, and India. Two studies were parallel-group RCTs, and one study was a cross-over RCT. The evidence provided by the included studies was of low certainty; we made an assessment of high risk of bias for blinding, incomplete outcome data, and selective reporting, and confidence intervals were wide. The effect of CPAP on the need for mechanical ventilation in children with acute bronchiolitis was uncertain due to risk of bias and imprecision around the effect estimate (risk difference -0.01, 95% confidence interval (CI) -0.09 to 0.08; 3 RCTs, 122 children; low certainty evidence). None of the trials measured time to recovery. Limited, low certainty evidence indicated that CPAP decreased respiratory rate (decreased respiratory rate is better) (mean difference (MD) -3.81, 95% CI -5.78 to -1.84; 2 RCTs, 91 children; low certainty evidence). Only one trial measured change in arterial oxygen saturation (increased oxygen saturation is better), and the results were imprecise (MD -1.70%, 95% CI -3.76 to 0.36; 1 RCT, 19 children; low certainty evidence). The effect of CPAP on change in arterial partial carbon dioxide pressure (pCO₂) (decrease in pCO₂ is better) was imprecise (MD -2.62 mmHg, 95% CI -5.29 to 0.05; 2 RCTs, 50 children; low certainty evidence). Duration of hospital stay was similar in both the CPAP and supportive care groups (MD 0.07 days, 95% CI -0.36 to 0.50; 2 RCTs, 50 children; low certainty evidence). Two studies did not report pneumothorax, but pneumothorax did not occur in one study. No studies reported occurrences of deaths. Several outcomes (change in partial oxygen pressure, hospital admission rate (from the emergency department to hospital), duration of emergency department stay, and need for intensive care unit admission) were not reported in the included studies.

AUTHORS' CONCLUSIONS

The use of CPAP did not reduce the need for mechanical ventilation in children with bronchiolitis, although the evidence was of low certainty. Limited, low certainty evidence suggests that breathing improved (a decreased respiratory rate) in children with bronchiolitis who received CPAP; this finding is unchanged from the 2015 review and 2019 update. Due to the limited available evidence, the effect of CPAP in children with acute bronchiolitis is uncertain for our other outcomes. Larger, adequately powered trials are needed to evaluate the effect of CPAP for children with acute bronchiolitis.

Comparison of high flow nasal cannula and non-invasive positive pressure ventilation in children with bronchiolitis: A meta-analysis of randomized controlled trials

BACKGROUND

The effects of high-flow nasal cannula (HFNC) compared to non-invasive positive pressure ventilation (NIPPV) on children with bronchiolitis remain unclear.

METHODS

This meta-analysis was performed following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement. Randomized controlled trials (RCTs) were identified from a comprehensive search in PubMed, EMBASE, Cochrane Library, and Web of Science without time and language limitations. Primary endpoints include the rate of treatment failure, the rate of need for intubation, and the pediatric intensive care unit (PICU) length of stay.

RESULTS

Five RCTs including 541 children of less than 24 months were enrolled in the meta-analysis. Compared to the NIPPV group, the rate of treatment failure was significantly higher in the HFNC treatment group (I ² = 0.0%, P = 0.574; RR 1.523, 95% CI 1.205 to 1.924, P < 0.001). No significant difference was noted in the need for intubation (I ² = 0.0%, P = 0.431; RR 0.874, 95% CI 0.598 to 1.276, P = 0.485) and the PICU length of stay (I ² = 0.0%, P = 0.568; WMD = -0.097, 95% CI = -0.480 to 0.285, P = 0.618) between the HFNC group and the NIPPV treatment.

CONCLUSION

Compared to the NIPPV group, HFNC therapy was associated with a significantly higher treatment failure rate in children suffering from bronchiolitis. The intubation rate and the PICU length of stay were comparable between the two approaches.

High flow nasal cannula therapy versus continuous positive airway pressure and nasal positive pressure ventilation in infants with severe bronchiolitis: a randomized controlled trial

Introduction

non-invasive ventilation is widely used in the respiratory management of severe bronchiolitis.

Methods

a randomized controlled trial was carried out in a tertiary pediatric university hospital´s PICU over 3 years to compare between continuous positive airway pressure/nasal positive pressure ventilation (CPAP/NPPV) and high flow nasal cannula (HFNC) devices for severe bronchiolitis. The trial was recorded in the national library of medicine registry (NCT04650230). Patients aged from 7 days to 6 months, admitted for severe bronchiolitis were enrolled. Eligible patients were randomly chosen to receive either HFNC or CPAP/NPPV. If HFNC failed, the switch to CPAP/NPPV was allowed. Mechanical ventilation was the last resort in case of CPAP/NPPV device failure. The primary outcome was the success of the treatment defined by no need of care escalation. The secondary outcomes were failure predictors, intubation rate, stay length, serious adverse events, and mortality.

Results

a total of 268 patients were enrolled. The data of 255 participants were analyzed. The mean age was 51.13 ± 34.43 days. Participants were randomized into two groups; HFNC group (n=130) and CPAP/NPPV group (n=125). The success of the treatment was significantly higher in the CPAP/NPPV group (70.4% [61.6%- 78.2%) comparing to HFNC group (50.7% [41.9%- 59.6%])- (p=0.001). For secondary outcomes, lower baseline pH was the only significant failure predictor in the CPAP/NPPV group (p=0.035). There were no differences in intubation rate or serious adverse events between the groups.

Conclusion

high flow nasal cannula was safe and efficient, but CPAP/ NPPV was better in preventing treatment failure. The switch to CPAP/NPPV if HFNC failed, avoided intubation in 54% of the cases.

Noninvasive Ventilation and Outcomes in Bronchiolitis

OBJECTIVES

Evaluation of potential benefits of noninvasive ventilation for bronchiolitis has been precluded in part by the absence of large, adequately powered studies. The objectives of this study were to characterize temporal trends in and associations between the use of noninvasive ventilation in bronchiolitis and two clinical outcomes, invasive ventilation, and cardiac arrest.

DESIGN

Multicenter retrospective cross-sectional study.

SETTING

Forty-nine U.S. children's hospitals participating in the Pediatric Health Information System database.

PATIENTS

Infants under 12 months old who were admitted from the emergency department with bronchiolitis between January 1, 2010, and December 31, 2018.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were rates of noninvasive ventilation, invasive ventilation, and cardiac arrest. Trends over time were assessed with univariate logistic regression. In the main analysis, hospital-level multivariable logistic regression evaluated rates of outcomes including invasive ventilation and cardiac arrest among hospitals with high and low utilization of noninvasive ventilation. The study included 147,288 hospitalizations of infants with bronchiolitis. Across the entire study population, noninvasive and invasive ventilation increased between 2010 and 2018 (2.9-8.7%, 2.1-4.0%, respectively; p < 0·001). After adjustment for markers of severity of illness, hospital-level noninvasive ventilation (high vs low utilization) was not associated with differences in invasive ventilation (5.0%, 1.8%, respectively, adjusted odds ratio, 1.8; 95% CI, 0·7-4·6) but was associated with increased cardiac arrest (0.36%, 0.02%, respectively, adjusted odds ratio, 25.4; 95% CI, 4.9-131.0).

CONCLUSIONS

In a large cohort of infants at children's hospitals, noninvasive and invasive ventilation increased significantly from 2010 to 2018. Hospital-level noninvasive ventilation utilization was not associated with a reduction in invasive ventilation but was associated with higher rates of cardiac arrest even after controlling for severity. Noninvasive ventilation in bronchiolitis may incur an unintended higher risk of cardiac arrest, and this requires further investigation.

Summary of recommendations and key points of the consensus of Spanish scientific societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the use of non-invasive ventilation and high-flow oxygen therapy with nasal cannulas in adult, pediatric, and neonatal patients with severe acute respiratory failure

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

Summary of Recommendations and Key Points of the Consensus of Spanish Scientific Societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the Use of Non-Invasive Ventilation and High-Flow Oxygen Therapy with Nasal Cannulas in Adult, Pediatric, and Neonatal Patients With Severe Acute Respiratory Failure

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analog classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

Summary of Recommendations and Key Points of the Consensus of Spanish Scientific Societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the Use of Non-Invasive Ventilation and High-Flow Oxygen Therapy with Nasal Cannulas in Adult, Pediatric, and Neonatal Patients with Severe Acute Respiratory Failure

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

Summary of recommendations and key points of the consensus of Spanish scientific societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the use of non-invasive ventilation and high-flow oxygen therapy with nasal cannulas in adult, pediatric, and neonatal patients with severe acute respiratory failure

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

Progression of Respiratory Support Following Pediatric Extubation

OBJECTIVES

High-flow nasal cannula and noninvasive positive pressure ventilation have become ubiquitous in contemporary PICUs. Practice patterns associated with the use of these modalities have not been well described. In this study, we aimed to describe the use of high-flow nasal cannula and noninvasive positive pressure ventilation in children after extubation and analyze the progression of usage in association with patient factors. Our secondary aim was to describe interventions used for postextubation stridor.

DESIGN

Single-center retrospective cohort study.

SETTING

A 36-bed quaternary medical-surgical PICU.

PATIENTS

Mechanically ventilated pediatric patients admitted between April 2017 and March 2018. Exclusions were patients in the cardiac ICU, patients requiring a tracheostomy or chronic ventilatory support, and patients with limited resuscitation status.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data regarding respiratory modality use was collected for the first 72 hours after extubation. There were 427 patients included in the analysis; 51 patients (11.9%) were extubated to room air, 221 (51.8%) to nasal cannula, 132 (30.9%) to high-flow nasal cannula, and 23 (5.4%) to noninvasive positive pressure ventilation. By 72 hours, 314 patients (73.5%) were on room air, 52 (12.2%) on nasal cannula, 29 (6.8%) on high-flow nasal cannula, eight (1.9%) on noninvasive positive pressure ventilation, and 24 (5.6%) were reintubated. High-flow nasal cannula was the most used respiratory modality for postextubation stridor. Multivariate analysis demonstrated that longer duration of invasive mechanical ventilation increased the odds of initial high-flow nasal cannula and noninvasive positive pressure ventilation use, and a diagnosis of cerebral palsy increased the odds of escalating from high-flow nasal cannula to noninvasive positive pressure ventilation in the first 24 hours post extubation.

CONCLUSIONS

High-flow nasal cannula is commonly used immediately after pediatric extubation and the development of postextubation stridor; however, its usage sharply declines over the following 72 hours. Larger multicenter trials are needed to identify high-risk patients for extubation failure that might benefit the most from prophylactic use of high-flow nasal cannula and noninvasive positive pressure ventilation after extubation.

Weaning from noninvasive ventilation and high flow nasal cannula in bronchiolitis: A survey of practice

RATIONAL

This study aims to describe the current weaning practices from any type of noninvasive support in infants with bronchiolitis, in terms of weaning procedures, weaning initiation and weaning failure criteria.

WORKING HYPOTHESIS

No information regarding the weaning practices is currently available and there may be a wide variability of strategies.

STUDY DESIGN

A cross-sectional electronic survey.

METHODOLOGY

The survey was distributed to physicians from five French-speaking countries with key roles in pediatric intensive care units (PICUs).

RESULTS

Responses were obtained from 29 PICUs from five French-speaking countries. A written weaning protocol was available in three pediatric centers (10%) and nurses had a key role in the weaning process in 72% of centers. The sudden weaning was the most commonly used procedure, no matter the type of noninvasive ventilatory (NIV) support. The most commonly used criteria for weaning initiation and weaning failure were the degree of respiratory distress, the occurrence of apneas and the fraction of inspired oxygen (FiO₂ ). The thresholds commonly used for weaning initiation criteria were (a) none or a slight use of accessory muscles; (b) FiO₂ less than equal to 40%, (c) respiratory rate less than 60 per minute, (d) no apnea, (e) blood pH more than 7.30, and (f) partial pressure of venous carbon dioxide less than equal to 50 mm Hg.

CONCLUSION

In infants with bronchiolitis requiring NIV support, the sudden weaning procedure was the most commonly used strategy. We observed a certain consensus on criteria for weaning initiation. These findings should help in building nurse-driven weaning protocols, but prospective studies remain needed to assess the best weaning strategy in infants with bronchiolitis-related acute respiratory failure.

Acute Viral Bronchiolitis: A Narrative Review

Acute viral bronchiolitis (AVB) is the leading cause of hospital admissions among infants in developed and developing countries and associated with increased morbidity and cost of treatment. This review was performed to guide the clinicians managing AVB in light of evidence accumulated in the last decade. We searched published English literature in last decade regarding etiology, diagnosis, treatment, and prevention of AVB using PubMed and Cochrane Database of Systematic Reviews. Respiratory syncytial virus is the most common causative agent. The diagnosis is mainly clinical with limited role of diagnostic investigations and chest radiographs are not routinely indicated. The management of AVB remains a challenge, as the role of various interventions is not clear. Supportive care in from of provision of heated and humidified oxygen and maintaining hydration are main interventions. The use of pulse oximetry helps to guide the administration of oxygen. Trials and systematic reviews evaluated various interventions like nebulized adrenaline, bronchodilators and hypertonic saline, corticosteroids, different modes of noninvasive ventilation (high-flow nasal cannula [HFNC], continuous positive airway pressure [CPAP], and noninvasive positive pressure ventilation [NPPV]), surfactant, heliox, chest physiotherapy, and antiviral drugs. The interventions which showed some benefits in infants and children with AVB are adrenaline and hypertonic saline nebulization, HFNC, CPAP, NIV, and surfactant. The routine administration of antibiotics, bronchodilators, corticosteroids, steam inhalation, chest physiotherapy, heliox, and antiviral drugs are not recommended.

FIRST-line support for assistance in breathing in children (FIRST-ABC): a master protocol of two randomised trials to evaluate the non-inferiority of high-flow nasal cannula (HFNC) versus continuous positive airway pressure (CPAP) for non-invasive respiratory support in paediatric critical care

INTRODUCTION

Even though respiratory support is a common intervention in paediatric critical care, there is no randomised controlled trial (RCT) evidence regarding the effectiveness of two commonly used modes of non-invasive respiratory support (NRS), continuous positive airway pressure (CPAP) and high-flow nasal cannula therapy (HFNC). FIRST-line support for assistance in breathing in children is a master protocol of two pragmatic non-inferiority RCTs to evaluate the clinical and cost-effectiveness of HFNC (compared with CPAP) as the first-line mode of support in critically ill children.

METHODS AND ANALYSIS

We will recruit participants over a 30-month period at 25 UK paediatric critical care units (paediatric intensive care units/high-dependency units). Patients are eligible if admitted/accepted for admission, aged >36 weeks corrected gestational age and <16 years, and assessed by the treating clinician to require NRS for an acute illness (step-up RCT) or within 72 hours of extubation following a period of invasive ventilation (step-down RCT). Due to the emergency nature of the treatment, written informed consent will be deferred to after randomisation. Randomisation will occur 1:1 to CPAP or HFNC, stratified by site and age (<12 vs ≥12 months). The primary outcome is time to liberation from respiratory support for a continuous period of 48 hours. A total sample size of 600 patients in each RCT will provide 90% power with a type I error rate of 2.5% (one sided) to exclude the prespecified non-inferiority margin of HR of 0.75. Primary analyses will be undertaken separately in each RCT in both the intention-to-treat and per-protocol populations.

ETHICS AND DISSEMINATION

This master protocol received favourable ethical opinion from National Health Service East of England-Cambridge South Research Ethics Committee (reference: 19/EE/0185) and approval from the Health Research Authority (reference: 260536). Results will be disseminated via publications in peer-reviewed medical journals and presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

ISRCTN60048867.

Bronchiolitis: an update on management and prophylaxis

Bronchiolitis is an acute respiratory illness that is the leading cause of hospitalization in young children less than 2 years of age in the UK. Respiratory syncytial virus is the most common virus associated with bronchiolitis and has the highest disease severity, mortality and cost. Bronchiolitis is generally a self-limiting condition, but can have serious consequences in infants who are very young, premature, or have underlying comorbidities. Management of bronchiolitis in the UK is guided by the National Institute for Health and Care Excellence (2015) guidance. The mainstays of management are largely supportive, consisting of fluid management and respiratory support. Pharmacological interventions including nebulized bronchodilators, steroids and antibiotics generally have limited or no evidence of efficacy and are not advised by National Institute of Health and Care Excellence. Antiviral therapeutics remain in development. As treatments are limited, there have been extensive efforts to develop vaccines, mainly targeting respiratory syncytial virus. At present, the only licensed product is a monoclonal antibody for passive immunisation. Its cost restricts its use to those at highest risk. Vaccines for active immunisation of pregnant women and young infants are also being developed.

Caffeine treatment for bronchiolitis-related apnea in the pediatric intensive care unit

INTRODUCTION

Apnea is commonly encountered in children with bronchiolitis. Despite the lack of recommendations regarding bronchiolitis-related apnea (BRA) management, some pediatric intensive care unit (PICU) practitioners use caffeine treatment based on extrapolation from the recommendations for prematurity-related apnea management. The objectives of this study were to describe the management of BRA in our PICU, evaluate the caffeine prescription rate for this indication, and explore its potential effects on clinical outcomes.

METHODS

This was a retrospective study in a university hospital PICU between January 1st, 2009 and December 31st, 2016. All children under 1 year of age admitted to the PICU with a diagnosis of BRA were included. Patients were allocated to a control group or a caffeine group depending on the administration of caffeine.

RESULTS

In total, 54 infants were included and caffeine treatment was administered to 49 (91%) of them. Patient characteristics were similar between the two groups. Ventilatory support was initiated for 50 patients (93%). Supportive care and length of PICU stay were similar between the two groups. Caffeine was not associated with adverse events.

CONCLUSION

Caffeine treatment in BRA could be considered as a local standard practice. This retrospective study was underpowered to show any benefit of caffeine treatment on clinical outcomes. This treatment was not associated with significant adverse effects. We raised the question of the appropriate caffeine dosing regimen for BRA in this postterm population. Further studies on this topic are warranted.

Respiratory Support during Bronchiolitis Due to One Virus versus More Than One Virus: An Observational Study

Bronchiolitis is common during infancy and frequently leads to pediatric intensive care unit (PICU) admission. This study aimed to determine if there is a difference in the duration of respiratory support when bronchiolitis is due to one virus or more than one virus. This is a retrospective, observational study of cases admitted to PICU with confirmed bronchiolitis. There were 306 cases analyzed, 70% (215/306) were infected by a single virus and 30% (91/306) were infected with more than one virus. Both groups had similar duration of respiratory support and PICU length of stay (LOS). Hospital LOS was longer for the group with more than one virus.

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

BACKGROUND

Acute bronchiolitis is one of the most frequent causes of emergency department visits and hospitalisation in children. There is no specific treatment for bronchiolitis except for supportive treatment, which includes ensuring adequate hydration and oxygen supplementation. Continuous positive airway pressure (CPAP) aims to widen the lungs' peripheral airways, enabling deflation of overdistended lungs in bronchiolitis. Increased airway pressure also prevents the collapse of poorly supported peripheral small airways during expiration. Observational studies report that CPAP is beneficial for children with acute bronchiolitis. This is an update of a review first published in 2015.

OBJECTIVES

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

SEARCH METHODS

We conducted searches of CENTRAL (2017, Issue 12), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1946 to December, 2017), Embase (1974 to December 2017), CINAHL (1981 to December 2017), and LILACS (1982 to December 2017) in January 2018.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We included three studies with a total of 122 children (62/60 in intervention/control arms) aged up to 12 months that investigated nasal CPAP compared with supportive (or "standard") therapy. We included one new trial (72 children) that contributed data to the assessment of respiratory rate and need for mechanical ventilation for this update. The included studies were single-centre trials conducted in France, the UK, and India. Two studies were parallel-group RCTs and one was a cross-over RCT. The evidence provided by the included studies was low quality; we assessed high risk of bias for blinding, incomplete outcome data, and selective reporting, and confidence intervals were wide.The effect of CPAP on the need for mechanical ventilation in children with acute bronchiolitis was uncertain due to imprecision around the effect estimate (3 RCTs, 122 children; risk ratio (RR) 0.69, 95% confidence interval (CI) 0.14 to 3.36; low-quality evidence). None of the trials measured time to recovery. Limited, low-quality evidence indicated that CPAP decreased respiratory rate (2 RCTs, 91 children; mean difference (MD) -3.81, 95% CI -5.78 to -1.84). Only one trial measured change in arterial oxygen saturation, and the results were imprecise (19 children; MD -1.70%, 95% CI -3.76 to 0.36). The effect of CPAP on change in arterial partial carbon dioxide pressure (pCO₂) was imprecise (2 RCTs, 50 children; MD -2.62 mmHg, 95% CI -5.29 to 0.05; low-quality evidence). Duration of hospital stay was similar in both CPAP and supportive care groups (2 RCTs, 50 children; MD 0.07 days, 95% CI -0.36 to 0.50; low-quality evidence). Two studies did not report about pneumothorax, but pneumothorax did not occur in one study. No studies reported occurrences of deaths. Several outcomes (change in partial oxygen pressure, hospital admission rate (from emergency department to hospital), duration of emergency department stay, and need for intensive care unit admission) were not reported in the included studies.

AUTHORS' CONCLUSIONS

Limited, low-quality evidence suggests that breathing improved (a decreased respiratory rate) in children with bronchiolitis who received CPAP; this finding is unchanged from the 2015 review. Further evidence for this outcome was provided by the inclusion of a low-quality study for the 2018 update. Due to the limited available evidence, the effect of CPAP in children with acute bronchiolitis is uncertain for other outcomes. Larger, adequately powered trials are needed to evaluate the effect of CPAP for children with acute bronchiolitis.

Parental severity assessment predicts supportive care in infant bronchiolitis

AIM

In infants with acute bronchiolitis, the precision of parental disease severity assessment is unclear. We aimed to determine if parental assessment at the time of hospitalisation predicted the use of supportive care, and subsequently determine the likelihood that the infant with acute bronchiolitis would receive supportive care.

METHODS

From the Bronchiolitis ALL south-east Norway study, we included all 267, 0-12 month old, infants with acute bronchiolitis whose parents at the time of hospitalisation completed a three-item visual analogue scale (VAS) concerning Activity, Feeding and Illness. Respiratory rate, oxygen saturation (SpO₂ ) and use of supportive care were recorded daily. By multivariate logistic regression analyses we included significant predictors available at hospital admission to predict the use of supportive care.

RESULTS

The parental Activity, Feeding and Illness VAS scores significantly predicted supportive care with odds ratios of 1.23, 1.26 and 1.36, respectively. The prediction algorithm included parental Feeding and Illness scores, SpO₂ , gender and age, with an area under the curve of 0.76 (95% CI 0.69, 0.81). A positive likelihood ratio of 2.1 gave the highest combined sensitivity of 81% and specificity of 61%.

CONCLUSION

Parental assessment at hospital admission moderately predicted supportive care treatment in infants with acute bronchiolitis.

The change in management of bronchiolitis in the intensive care unit between 2000 and 2015

This case-control study evaluated interventions for bronchiolitis in relation to time in the pediatric intensive care unit (PICU) during a 16-year surveillance period. Together, 105 infants aged < 12 months were treated for bronchiolitis in the PICU, and for them, we selected 210 controls admitted for bronchiolitis closest to cases. We collected data on treatments in the PICU, at the ward and in the emergency department for three periods: years 2000-2005, 2006-2010, and 2011-2015. Median hospital length of stay for PICU patients were 7 days (interquartile range 5-12), 5 days (4-8) and 8 days (4-12.5, p = 0.127), respectively. By time, the use of inhaled beta-agonist (68 vs. 44 vs. 38%, p = 0.019) and systemic corticosteroids (29 vs. 15 vs. 5%, p = 0.019) decreased, but that of racemic adrenaline (59 vs. 78 vs. 84%, p = 0.035) and hypertonic saline (0 vs. 0 vs. 54%, p < 0.001) inhalations increased in the PICU. Similar changes were seen at the ward. In the PICU, non-invasive ventilation therapies increased significantly, but intubation rates did not decline.Conclusion: Beta-agonists and systemic corticosteroids were used less by time in intensive care for infant bronchiolitis, but the use of hypertonic saline and racemic adrenaline increased, though their effectiveness has been questioned. What is Known: • Until now, studies have shown which treatments do not work in bronchiolitis, and so, there is no consensus how infants with bronchiolitis should be treated. In particular, there is no consensus on different interventions in intensive care for bronchiolitis. What is New: • During 2000-2015, treatments with inhaled beta-agonists and systemic corticosteroids decreased but treatments with racemic adrenaline and hypertonic saline inhalations increased in intensive care for bronchiolitis. Similar changes were seen at the ward. Though non-invasive ventilation therapies increased, the intubation rate did not decline.

FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): a multicentre pilot randomised controlled trial of high-flow nasal cannula therapy versus continuous positive airway pressure in paediatric critical care

BACKGROUND

Although high-flow nasal cannula therapy (HFNC) has become a popular mode of non-invasive respiratory support (NRS) in critically ill children, there are no randomised controlled trials (RCTs) comparing it with continuous positive airway pressure (CPAP). We performed a pilot RCT to explore the feasibility, and inform the design and conduct, of a future large pragmatic RCT comparing HFNC and CPAP in paediatric critical care.

METHODS

In this multi-centre pilot RCT, eligible patients were recruited to either Group A (step-up NRS) or Group B (step-down NRS). Participants were randomised (1:1) using sealed opaque envelopes to either CPAP or HFNC as their first-line mode of NRS. Consent was sought after randomisation in emergency situations. The primary study outcomes were related to feasibility (number of eligible patients in each group, proportion of eligible patients randomised, consent rate, and measures of adherence to study algorithms). Data were collected on safety and a range of patient outcomes in order to inform the choice of a primary outcome measure for the future RCT.

RESULTS

Overall, 121/254 eligible patients (47.6%) were randomised (Group A 60%, Group B 44.2%) over a 10-month period (recruitment rate for Group A, 1 patient/site/month; Group B, 2.8 patients/site/month). In Group A, consent was obtained in 29/33 parents/guardians approached (87.9%), while in Group B 84/118 consented (71.2%). Intention-to-treat analysis included 113 patients (HFNC 59, CPAP 54). Most reported adverse events were mild/moderate (HFNC 8/59, CPAP 9/54). More patients switched treatment from HFNC to CPAP (Group A: 7/16, 44%; Group B: 9/43, 21%) than from CPAP to HFNC (Group A: 3/13, 23%; Group B: 5/41, 12%). Intubation occurred within 72 h in 15/59 (25.4%) of HFNC patients and 10/54 (18.5%) of CPAP patients (p = 0.38). HFNC patients experienced fewer ventilator-free days at day 28 (Group A: 19.6 vs. 23.5; Group B: 21.8 vs. 22.2).

CONCLUSIONS

Our pilot trial confirms that, following minor changes to consent procedures and treatment algorithms, it is feasible to conduct a large national RCT of non-invasive respiratory support in the paediatric critical care setting in both step-up and step-down NRS patients.

TRIAL REGISTRATION

clinicaltrials.gov, NCT02612415 . Registered on 23 November 2015.

Treatment of severe bronchiolitis: A survey of Canadian pediatric intensivists

OBJECTIVE

To describe management practices and the factors guiding admission and treatment decisions for viral bronchiolitis across Canadian pediatric intensive care units (PICUs).

DESIGN

Cross-sectional survey.

SETTING

Canadian PICUs.

SUBJECTS

Pediatric intensivists.

MEASUREMENTS AND MAIN RESULTS

A survey using two case scenarios (non-intubated vs intubated patients) was developed using focus groups and a literature review. We analyzed our results using descriptive statistics and multivariate logistic regression. Our response rate was 55% (57/103). Regarding bronchiolitis management, 75% (42/56) of respondents would use inhaled therapies, with nebulized epinephrine (33/56, 59%) and salbutamol (20/56, 36%) being the most common. Antibiotic use within the first hour of admission to PICU almost doubled in frequency (36% vs 71%) in patients who required mechanical ventilation (p 0.0004). High flow nasal cannula (HFNC; 32/56, 57%) and continuous positive airway pressure (CPAP; 16/56, 29%) were the preferred modes of non-invasive ventilation (NIV).

CONCLUSION

The management of severe viral bronchiolitis is similar across Canadian PICUs. The use of NIV, inhaled treatments, and antibiotics is frequent, which differs from the recommendations made by published guidelines. Canadian pediatric intensivists use homogeneous PICU admission criteria based on patients' characteristics and severity of the clinical picture. Clinical practice guidelines for children with viral bronchiolitis should address the management of patients with severe clinical disease.

[Anemia, a new severity factor in young infants with acute viral bronchiolitis?]

INTRODUCTION

The role of anemia is raised as a risk of low respiratory infection of the child, but there are no data on anemia as a severity factor in acute viral bronchiolitis (AVB) in infants.

METHODS

All infants less than 16 weeks old admitted to Montpellier University Hospital from 2015/10/01 to 2016/04/01 for AVB were included in a retrospective observational study. The primary objective was to determine whether the hemoglobin (Hb) concentration on admission was an independent factor of clinical severity, judged by the modified Wood's clinical asthma score (m-WCAS). The secondary objective was to assess the impact of Hb level on the characteristics of hospitalization, including the type and duration of respiratory support.

RESULTS

The m-WCAS was used at least once during hospitalization in 180 out of 220 patients (82%), making it possible to distinguish patients with mild AVB (maximum m-WCAS<2, n=81) from patients with severe AVB (maximum m-WCAS>2, n=99). A logistic regression model indicated that the Hb concentration, for every 1g/dL decrement, was an independent factor of AVB severity (OR 1.16 [1.03-1.29], P=0.026). A level under 10g/dL on admission was associated with a higher use of continuous positive airway pressure (P<0.001), as well as a longer duration of respiratory support (P=0.01).

CONCLUSION

This study suggested that anemia may influence the clinical expression of AVB in young infants.

Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC)

Purpose

Much of the common practice in paediatric mechanical ventilation is based on personal experiences and what paediatric critical care practitioners have adopted from adult and neonatal experience. This presents a barrier to planning and interpretation of clinical trials on the use of specific and targeted interventions. We aim to establish a European consensus guideline on mechanical ventilation of critically children.

Methods

The European Society for Paediatric and Neonatal Intensive Care initiated a consensus conference of international European experts in paediatric mechanical ventilation to provide recommendations using the Research and Development/University of California, Los Angeles, appropriateness method. An electronic literature search in PubMed and EMBASE was performed using a combination of medical subject heading terms and text words related to mechanical ventilation and disease-specific terms.

Results

The Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) consisted of a panel of 15 experts who developed and voted on 152 recommendations related to the following topics: (1) general recommendations, (2) monitoring, (3) targets of oxygenation and ventilation, (4) supportive measures, (5) weaning and extubation readiness, (6) normal lungs, (7) obstructive diseases, (8) restrictive diseases, (9) mixed diseases, (10) chronically ventilated patients, (11) cardiac patients and (12) lung hypoplasia syndromes. There were 142 (93.4%) recommendations with “strong agreement”. The final iteration of the recommendations had none with equipoise or disagreement.

Conclusions

These recommendations should help to harmonise the approach to paediatric mechanical ventilation and can be proposed as a standard-of-care applicable in daily clinical practice and clinical research.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-017-4920-z) contains supplementary material, which is available to authorized users.

FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): protocol for a multicentre randomised feasibility trial of non-invasive respiratory support in critically ill children

INTRODUCTION

Over 18 000 children are admitted annually to UK paediatric intensive care units (PICUs), of whom nearly 75% receive respiratory support (invasive and/or non-invasive). Continuous positive airway pressure (CPAP) has traditionally been used to provide first-line non-invasive respiratory support (NRS) in PICUs; however, high-flow nasal cannula therapy (HFNC), a novel mode of NRS, has recently gained popularity despite the lack of high-quality trial evidence to support its effectiveness. This feasibility study aims to inform the design and conduct of a future definitive randomised clinical trial (RCT) comparing the two modes of respiratory support.

METHODS AND ANALYSIS

We will conduct a three-centre randomised feasibility study over 12 months. Patients admitted to participating PICUs who satisfy eligibility criteria will be recruited to either group A (primary respiratory failure) or group B (postextubation). Consent will be obtained from parents/guardians prior to randomisation in 'planned' group B, and deferred in emergency situations (group A and 'rescue' group B). Participants will be randomised (1:1) to either CPAP or HFNC using sealed, opaque envelopes, from a computer-generated randomisation sequence with variable block sizes. The study protocol specifies algorithms for the initiation, maintenance and weaning of HFNC and CPAP. The primary outcomes are related to feasibility, including the number of eligible patients in each group, feasibility of randomising >50% of eligible patients and measures of adherence to the treatment protocols. Data will also be collected on patient outcomes (eg, mortality and length of PICU stay) to inform the selection of an appropriate outcome measure in a future RCT. We aim to recruit 120 patients to the study.

ETHICS AND DISSEMINATION

Ethical approval was granted by the National Research Ethics Service Committee North East-Tyne&Wear South (15/NE/0296). Study findings will be disseminated through peer-reviewed journals, national and international conferences.

TRIALS REGISTRATION NUMBER

NCT02612415; pre-results.

Comparison of CPAP and HFNC in Management of Bronchiolitis in Infants and Young Children

Continuous positive airway pressure (CPAP) has been used in infants with bronchiolitis for decades. Recently, high flow nasal cannula (HFNC) therapy was introduced We conducted a retrospective study of treatment with CPAP vs. HFNC between 2013 and 2015, comparing the development in respiratory rate, fraction of inspired oxygen (FiO2) and heart rate, treatment failure, duration of treatment, and length of hospital stay. A sample size of 49 children were included. Median age was 1.9 months. Median baseline pCO₂ was 7.4 kPa in both groups, respiratory rate per minute was 57 vs. 58 (CPAP vs. HFNC). Respiratory rate decreased faster in the CPAP group (p < 0.05). FiO2 decreased in the CPAP group and increased in the HFNC group during the first 12 h, whereafter it decreased in both groups. (p < 0.01). Heart rate development was similar in both groups. Twelve children (55%) changed systems from HFNC to CPAP due to disease progression. There was no difference in length of treatment, hospital stay, or transmission to intensive care unit between the groups. CPAP was more effective than HFNC in decreasing respiratory rate (RR) and FiO2. No differences were observed in length of treatment or complications. Further studies should be conducted to compare the efficacy of the two treatments of bronchiolitis, preferably through prospective randomized trials.

Prospective Multicentre Study on the Epidemiology and Current Therapeutic Management of Severe Bronchiolitis in Spain

Objective. To determine the epidemiology and therapeutic management of patients with severe acute bronchiolitis (AB) admitted to paediatric intensive care units (PICUs) in Spain. Design. Descriptive, prospective, multicentre study. Setting. Sixteen Spanish PICUs. Patients. Patients with severe AB who required admission to any of the participating PICUs over 1 year. Interventions. Both epidemiological variables and medical treatment received were recorded. Results. A total of 262 patients were recruited; 143 were male (54.6%), with median age of 1 month (0–23). Median stay in the PICU was 7 days (1–46). Sixty patients (23%) received no nebuliser treatment, while the rest received a combination of inhalation therapies. One-quarter of patients (24.8%) received corticosteroids and 56.5% antibiotic therapy. High-flow oxygen therapy was used in 14.3% and noninvasive ventilation (NIV) was used in 75.6%. Endotracheal intubation was required in 24.4% of patients. Younger age, antibiotic therapy, and invasive mechanical ventilation (IMV) were risk factors that significantly increased the stay in the PICU. Conclusions. Spanish PICUs continue to routinely use nebulised bronchodilator treatment and corticosteroid therapy. Despite NIV being widely used in this condition, intubation was required in one-quarter of cases. Younger age, antibiotic therapy, and IMV were associated with a longer stay in the PICU.

High flow nasal cannula (HFNC) versus nasal continuous positive airway pressure (nCPAP) for the initial respiratory management of acute viral bronchiolitis in young infants: a multicenter randomized controlled trial (TRAMONTANE study)

PURPOSE

Nasal continuous positive airway pressure (nCPAP) is currently the gold standard for respiratory support for moderate to severe acute viral bronchiolitis (AVB). Although oxygen delivery via high flow nasal cannula (HFNC) is increasingly used, evidence of its efficacy and safety is lacking in infants.

METHODS

A randomized controlled trial was performed in five pediatric intensive care units (PICUs) to compare 7 cmH₂O nCPAP with 2 L/kg/min oxygen therapy administered with HFNC in infants up to 6 months old with moderate to severe AVB. The primary endpoint was the percentage of failure within 24 h of randomization using prespecified criteria. To satisfy noninferiority, the failure rate of HFNC had to lie within 15% of the failure rate of nCPAP. Secondary outcomes included success rate after crossover, intubation rate, length of stay, and serious adverse events.

RESULTS

From November 2014 to March 2015, 142 infants were included and equally distributed into groups. The risk difference of -19% (95% CI -35 to -3%) did not allow the conclusion of HFNC noninferiority (p = 0.707). Superiority analysis suggested a relative risk of success 1.63 (95% CI 1.02-2.63) higher with nCPAP. The success rate with the alternative respiratory support, intubation rate, durations of noninvasive and invasive ventilation, skin lesions, and length of PICU stay were comparable between groups. No patient had air leak syndrome or died.

CONCLUSION

In young infants with moderate to severe AVB, initial management with HFNC did not have a failure rate similar to that of nCPAP. This clinical trial was recorded in the National Library of Medicine registry (NCT 02457013).

Non-invasive respiratory support for infants with bronchiolitis: a national survey of practice

Background

Bronchiolitis is a common respiratory illness of early childhood. For most children it is a mild self-limiting disease but a small number of children develop respiratory failure. Nasal continuous positive airway pressure (nCPAP) has traditionally been used to provide non-invasive respiratory support in these children, but there is little clinical trial evidence to support its use. More recently, high-flow nasal cannula therapy (HFNC) has emerged as a novel respiratory support modality. Our study aims to describe current national practice and clinician preferences relating to use of non-invasive respiratory support (nCPAP and HFNC) in the management of infants (<12 months old) with acute bronchiolitis.

Methods

We performed a cross-sectional web-based survey of hospitals with inpatient paediatric facilities in England and Wales. Responses were elicited from one senior doctor and one senior nurse at each hospital. We analysed the proportion of hospitals using HFNC and nCPAP; clinical thresholds for their initiation; and clinician preferences regarding first-line support modality and future research.

Results

The survey was distributed to 117 of 171 eligible hospitals; 97 hospitals provided responses (response rate: 83%). The majority of hospitals were able to provide nCPAP (89/97, 91.7%) or HFNC (71/97, 73.2%); both were available at 65 hospitals (67%). nCPAP was more likely to be delivered in a ward setting in a general hospital, and in a high dependency setting in a tertiary centre. There were differences in the oxygenation and acidosis thresholds, and clinical triggers such as recurrent apnoeas or work of breathing that influenced clinical decisions, regarding when to start nCPAP or HFNC. More individual respondents with access to both modalities (74/106, 69.8%) would choose HFNC over nCPAP as their first-line treatment option in a deteriorating child with bronchiolitis.

Conclusions

Despite lack of randomised trial evidence, nCPAP and HFNC are commonly used in British hospitals to support infants with acute bronchiolitis. HFNC appears to be currently the preferred first-line modality for non-invasive respiratory support due to perceived ease of use.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-017-0785-0) contains supplementary material, which is available to authorized users.

[Non-invasive ventilation in children: Do we need more evidence?]

Respiratory failure is the leading cause of hospital admissions in the pediatric intensive care unit (PICU) and is associated with significant morbidity and mortality. Mechanical ventilation, preferentially delivered by a non-invasive route (NIV), is currently the first-line treatment for respiratory failure since it is associated with a reduction in the intubation rate. This ventilatory support is increasingly used in the PICU, but its wider use contrasts with the paucity of studies in this field. This review aims to describe the main indications of NIV in acute settings: (i) bronchiolitis; (ii) postextubation respiratory failure; (iii) acute respiratory distress syndrome; (iv) pneumonia; (v) status asthmaticus; (vi) acute chest syndrome; (vii) left heart failure; (viii) exacerbation of chronic respiratory failure; (ix) upper airway obstruction and (x) end-of-life care. Most of these data are based on descriptive studies and expert opinions, and few are from randomized trials. While the benefit of NIV is significant in some indications, such as bronchiolitis, it is more questionable in others. Monitoring these patients for the occurrence of NIV failure markers is crucial.

Safety of paediatric tracheal intubation after non-invasive ventilation failure

CONTEXT

Non-invasive ventilation (NIV) is increasingly used in pediatric intensive care units to limit the complications associated with intubation. However, NIV may fail, and the delay in initiating invasive ventilation may be associated with adverse outcomes. The objective of this retrospective study was to evaluate the safety of tracheal intubation after NIV failure.

METHODS

Consecutive tracheal intubation procedures were prospectively evaluated in our PICU from 01/2011 to 02/2012, as part of the National Emergency Airway Registry for Children (NEAR4KIDS) collaborative. The incidence of severe tracheal intubation associated events (TIAEs, including cardiac arrest, esophageal intubation with delayed recognition, emesis with aspiration, hypotension requiring intervention, laryngospasm, malignant hyperthermia, pneumothorax, and pneumomediastinum) and severe desaturation (below 80% when pre-intubation saturation was greater than 94%) were recorded prospectively. NIV use before intubation was retrospectively assessed.

RESULTS

100 consecutive intubation events were analyzed, 46 of which followed NIV failure. NIV exposed and non-exposed groups had different baseline characteristics, with lower weight, more frequent lower airway and lung disorder, and lower PIM2 score at admission in NIV failure patients (all P < 0.05). The nasal route for intubation was more frequent in NIV patients (P < 0.01). The incidence of severe TIAE or desaturation was 41% in the NIV failure group and 24% in primarily intubated patients (P = 0.09).

CONCLUSION

Complications occurred in 41% of intubations after NIV failure in this series. Further research is warranted to evaluate strategies to prevent these complications and to identify conditions in which intubation should not be delayed for a trial of NIV.

Neurally adjusted ventilator assist (NAVA) reduces asynchrony during non-invasive ventilation for severe bronchiolitis

BACKGROUND

To determine the prevalence of main inspiratory asynchrony events during non-invasive intermittent positive-pressure ventilation (NIV) for severe bronchiolitis. Ventilator response time and asynchrony were compared in neurally adjusted ventilator assist (NAVA) and in pressure assist/control (PAC) modes.

METHODS

This prospective physiological study was performed in a university hospital's paediatric intensive care unit and included 11 children (aged 35.2 ± 23 days) with respiratory syncytial virus bronchiolitis with failure of nCPAP. Patients received NIV for 2 hr in PAC mode followed by 2 hr in NAVA mode. Electrical activity of the diaphragm and pressure curves were recorded for 10 min. Trigger delay, main asynchronies (auto-triggering, double triggering, or non-triggered breaths) were analyzed, and the asynchrony index was calculated for each period.

RESULTS

The asynchrony index was lower during NAVA than during PAC (3 ± 3% vs. 38 ± 21%, P < 0.0001), and the trigger delay was shorter (43.9 ± 7.2 vs. 116.0 ± 38.9 ms, P < 0.0001). Ineffective efforts were significantly less frequent in NAVA mode (0.54 ± 1.5 vs. 21.8 ± 16.5 events/min, P = 0.01). Patient respiratory rates were similar, but the ventilator rate was higher in NAVA than in PAC mode (59.5 ± 17.9 vs. 49.8 ± 8.5/min, P = 0.03). The TcPCO2 baselines values (64 ± 12 mmHg vs. 62 ± 9 mmHg during NAVA, P = 0.30) were the same and their evolution over the 2 hr study period (-6 ± 10 mmHg vs. -12 ± 17 mmHg during NAVA, P = 0.36) did not differ.

CONCLUSION

Patient-ventilator inspiratory asynchronies and trigger delay were dramatically lower in NAVA mode than in PAC mode during NIV in infants with severe bronchiolitis.

Outcomes of Patients with Respiratory Distress Treated with Bubble CPAP on a Pediatric Ward in Malawi

OBJECTIVE

To describe the outcomes of infants and young children with respiratory distress when treated with a novel, low-cost, stand-alone bubble Continuous Positive Airway Pressure (bCPAP) system in a resource-limited setting.

METHODS

A non-randomized, convenience sample study in a pediatric unit in Blantyre, Malawi, 2013. Patients weighing ≤10 kg with respiratory distress were eligible. We compared outcomes for patients with bronchiolitis, pneumonia and Pneumocystis jiroveci pneumonia (PJP) after treatment with bCPAP.

RESULTS

Seventy percent of patients treated with bCPAP survived. Outcomes were best for patients with bronchiolitis and worst for those with PJP. Most survivors (80%) showed improvement within 24 h. All treating physicians found bCPAP useful, leading to a change in practice.

CONCLUSIONS

Bubble CPAP was most beneficial to patients with bronchiolitis. Children, who were going to get well, tended to get well quickly. Physicians believed the bCPAP system provided a higher level of care than nasal oxygen.

Non-invasive ventilation is useful in paediatric intensive care units if children are appropriately selected and carefully monitored

Non-invasive ventilation (NIV) is commonly used in paediatric intensive care units (PICUs) for respiratory failure. This review aims to improve paediatricians' understanding of NIV, by specifying technical or practical considerations, giving advice about selecting patients and presenting pertinent published data about NIV in different circumstances.

CONCLUSION

NIV is useful in PICUs if children are appropriately selected and carefully monitored. Technological advances and future clinical research will improve its use and success rate in PICU.

Variability of intensive care management for children with bronchiolitis

OBJECTIVE

To determine the extent of variability in testing and treatment of children with bronchiolitis requiring intensive care.

METHODS

This prospective, multicenter observational study included 16 academic children's hospitals across the United States during the 2007 to 2010 fall and winter seasons. The study included children<2 years old hospitalized with bronchiolitis who required admission to the ICU and/or continuous positive airway pressure (CPAP) within 24 hours of admission. Among the 2207 enrolled patients with bronchiolitis, 342 children met inclusion criteria. Clinical data and nasopharyngeal aspirates were collected.

RESULTS

Respiratory distress severity scores and intraclass correlation coefficients were calculated. The study patients' median age was 2.6 months, and 59% were male. Across the 16 sites, the median respiratory distress severity score was 5.1 (interquartile range: 4.5-5.4; P<.001). The median value of the percentages for all sites using CPAP was 15% (range: 3%-100%), intubation was 26% (range: 0%-100%), and high-flow nasal cannula (HFNC) was 24% (range: 0%-94%). Adjusting for site-specific random effects (as well as children's demographic characteristics and severity of bronchiolitis), the intraclass correlation coefficient for CPAP and/or intubation was 21% (95% confidence interval: 8-44); for HFNC, it was 44.7% (95% confidence interval: 24-67).

CONCLUSIONS

In this multicenter study of children requiring intensive care for bronchiolitis, we identified substantial institutional variability in testing and treatment, including use of CPAP, intubation, and HFNC. These differences were not explained by between-site differences in patient characteristics, including severity of illness. Further research is needed to identify best practices for intensive care interventions for this major cause of pediatric hospitalization.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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

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

Recent advances in the management of acute bronchiolitis

Acute bronchiolitis is characterized by acute wheezing in infants or children and is associated with signs or symptoms of respiratory infection; it is rarely symptomatic in adults and the most common etiologic agent is respiratory syncytial virus (RSV). Usually it does not require investigation, treatment is merely supportive and a conservative approach seems adequate in the majority of children, especially for the youngest ones (<3 months); however, clinical scoring systems have been proposed and admission in hospital should be arranged in case of severe disease or a very young age or important comorbidities. Apnea is a very important aspect of the management of young infants with bronchiolitis. This review focuses on the clinical, radiographic, and pathologic characteristics, as well as the recent advances in management of acute bronchiolitis.

Initiation de la ventilation non invasive aux urgences pédiatriques dans les bronchiolites sévères du nourrisson

Introduction

La ventilation non invasive (VNI) dans les bronchiolites sévères du nourrisson s’est développée rapidement en réanimation et au service mobile d’urgence et réanimation pédiatrique (Smur) depuis 2003. Les objectifs de cette étude sont de vérifier les indications de mise sous VNI utilisées aux urgences pédiatriques d’Ambroise-Paré en les comparant à celles utilisées en réanimation et de confirmer l’efficacité de cette technique aux urgences pédiatriques.

Méthodes et population

Étude rétrospective sur 31 nourrissons ventilés par VNI pour bronchiolite sévère aux urgences pédiatriques de l’hôpital Ambroise-Paré (92) des hivers 2009 à 2011.

Résultats

La population étudiée était composée de 16 % d’anciens prématurés sans hypotrophie ni antécédent notable et âgés d’en moyenne deux mois au moment de la bronchiolite. Le pourcentage de bronchiolites apnéisantes (seule indication de VNI selon la conférence de consensus de 2006) était de 17 %. Au moins deux indications de recours à la VNI ont été retrouvées pour chaque patient. Cinquante-huit pour cent des nourrissons étaient transférés plus de deux heures après la mise sous VNI, avec une amélioration constatée sur la fréquence respiratoire (FR), la saturation, la PCO₂ et le pH (p < 0,001) et sans complications aux urgences. La VNI a été poursuivie en réanimation dans 84 % des cas. La durée moyenne de VNI était de 2,7 jours, celle d’hospitalisation en réanimation de 4,2 jours.

Conclusion

L’utilisation de la VNI aux urgences pédiatriques est une procédure simple, permettant une prise en charge précoce, avant transfert en réanimation, des bronchiolites sévères du nourrisson et permettant une amélioration clinique et gazométrique de leur insuffisance respiratoire.

Comparison of a high-flow humidified nasal cannula to nasal continuous positive airway pressure in children with acute bronchiolitis: experience in a pediatric intensive care unit

The objective of the current study is to compare the use of a nasal continuous positive airway pressure (nCPAP) to a high-flow humidified nasal cannula (HFNC) in infants with acute bronchiolitis, who were admitted to a pediatric intensive care unit (PICU) during two consecutive seasons. We retrospectively reviewed the medical records of all infants admitted to a PICU at a tertiary care French hospital during the bronchiolitis seasons of 2010/11 and 2011/12. Infants admitted to the PICU, who required noninvasive respiratory support, were included. The first noninvasive respiratory support modality was nCPAP during the 2010/11 season, while HFNC was used during the 2011/2012 season. We compared the length of stay (LOS) in the PICU; the daily measure of PCO2 and pH; and the mean of the five higher values of heart rate (HR), respiratory rate (RR), FiO2, and SpO2 each day, during the first 5 days. Thirty-four children met the inclusion criteria: 19 during the first period (nCPAP group) and 15 during the second period (HFNC group). Parameters such as LOS in PICU and oxygenation were similar in the two groups. Oxygen weaning occurred during the same time for the two groups. There were no differences between the two groups for RR, HR, FiO2, and CO2 evolution. HFNC therapy failed in three patients, two of whom required invasive mechanical ventilation, versus one in the nCPAP group.

CONCLUSION

We did not find a difference between HFNC and nCPAP in the management of severe bronchiolitis in our PICU. Larger prospective studies are required to confirm these findings.

Recent advances in management of bronchiolitis

Background

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

Need and purpose

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

Methods

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

Results and Conclusions

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

Continuous positive airway pressure for bronchiolitis in a general paediatric ward; a feasibility study

Background

Continuous positive airway pressure (CPAP) is commonly used to relieve respiratory distress in infants with bronchiolitis, but has mostly been studied in an intensive care setting. Our prime aim was to evaluate the feasibility of CPAP for infants with bronchiolitis in a general paediatric ward, and secondary to assess capillary PCO₂ (cPCO₂) levels before and during treatment.

Methods

From May 1^st 2008 to April 30^th 2012, infants with bronchiolitis at Stavanger University Hospital were treated with CPAP in a general paediatric ward, but could be referred to an intensive care unit (ICU) when needed, according to in-house guidelines. Levels of cPCO₂ were prospectively registered before the start of CPAP and at approximately 4, 12, 24 and 48 hours of treatment as long as CPAP was given. We had a continuous updating program for the nurses and physicians caring for the infants with CPAP. The study was population based.

Results

672 infants (3.4%) were hospitalized with bronchiolitis. CPAP was initiated in 53 infants (0.3%; 7.9% of infants with bronchiolitis), and was well tolerated in all but three infants. 46 infants were included in the study, the majority of these (n = 33) were treated in the general ward only. These infants had lower cPCO₂ before treatment (8.0; 7.7, 8.6)(median; quartiles) than those treated at the ICU (n = 13) (9.3;8.5, 9.9) (p < 0.001). The level of cPCO₂ was significantly reduced after 4 h in both groups; 1.1 kPa (paediatric ward) (p < 0.001) and 1.3 kPa (ICU) (p = 0.002). Two infants on the ICU did not respond to CPAP (increasing cPCO₂ and severe apnoe) and were given mechanical ventilation, otherwise no side effects were observed in either group treated with CPAP.

Conclusion

Treatment with CPAP for infants with bronchiolitis may be feasible in a general paediatric ward, providing sufficient staffing and training, and the possibility of referral to an ICU when needed.