A Randomized Controlled Trial of a Single Dose Furosemide to Improve Respiratory Distress in Moderate to Severe Bronchiolitis

Efficacies of different treatment strategies for infants hospitalized with acute bronchiolitis

BACKGROUND

Acute bronchiolitis is a common cause of hospitalization during infancy that carries significant morbidity and mortality rates.

PURPOSE

This study compared the efficacy of different treatment modalities for infants with bronchiolitis in terms of hospital stay and clinical severity scores.

METHODS

The PubMed database was searched for relevant studies. Eligibility criteria included double-blind randomized controlled trial design, assessment of the effect of treatment on bronchiolitis in infants under 2 years of age, and publication in English from inception through July 31, 2020. The primary efficacy outcome was the length of hospital stay, while the secondary outcome was the clinical severity score. The standardized treatment effect and standard error of the effect size were calculated.

RESULTS

We identified 45 randomized controlled trials of 24 pairwise comparisons. These 45 trials included 5,061 participants and investigated 13 types of interventions (12 active, 1 placebo). Inhalation therapy with epinephrine (standard mean difference [SMD], -0.41; 95% confidence interval [CI], -0.8 to -0.03) and hypertonic saline (SMD, -0.29; 95% CI, -0.55 to -0.03) reduced the length of hospital stay compared with normal saline. Hypertonic saline was the most effective at improving the clinical severity score (SMD, -0.52; 95% CI, -0.95 to -0.10).

CONCLUSION

Inhalation therapy with epinephrine and hypertonic saline reduced the length of hospital stay and the clinical severity of bronchiolitis among infants under 2 years of age.

Bronchiolitis: evidence-based management in high-risk infants in the intensive care setting

AIM

Systematically review the management of infants with severe bronchiolitis in a paediatric intensive care unit (PICU) setting with a focus on high-risk infants to identify gaps in evidence-based knowledge.

METHODS

This systematic review utilised Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) to examine the literature on the PICU management of bronchiolitis in infants <24 months old. Three databases, Embase, PubMed and Medline, were searched and higher levels of evidence I, II and III were included.

RESULTS

There were 455 papers reviewed and 26 met the inclusion criteria. Furthermore, 19 of these studied respiratory interventions such as positive airway pressure and oxygen delivery. The remaining 7 examined: erythropoietin, caffeine, dexamethasone, protein supplementation, ribavirin, respiratory syncytial virus immune globulin, or diuretic therapy. Of the 26 studies, 20 excluded infants with high-risk conditions. Therapies showing favourable outcomes included Heliox, prophylactic dexamethasone pre-extubation, protein supplementation, and diuretic use.

CONCLUSIONS

Clinical trials for bronchiolitis management frequently exclude high-risk children. Innovative study design in the future may improve access to clinical trials for the management of bronchiolitis in high-risk infants in a PICU setting.

IMPACT

Clinical trials for bronchiolitis management frequently exclude high-risk children. We review the evidence base for the management of an under-investigated patient demographic in the setting of acute bronchiolitis. Randomised controlled trials are needed to determine the efficacy of management strategies for bronchiolitis in high-risk infants in a paediatric intensive care setting.

The Use of Diuretic in Mechanically Ventilated Children with Viral Bronchiolitis: a Cohort Study

Introduction

Viral bronchiolitis is a leading cause of admissions to pediatric intensive care unit (PICU). A literature review indicates that there is limited information on fluid overload and the use of diuretics in mechanically ventilated children with viral bronchiolitis. This study was conducted to understand diuretic use concerning fluid overload in this population.

Material and methods

A retrospective cohort study performed at a quaternary children’s hospital. The study population consisted of mechanically ventilated children with bronchiolitis, with a confirmed viral diagnosis on polymerase chain reaction (PCR) testing. Children with co-morbidities were excluded. Data collected included demographics, fluid status, diuretic use, morbidity and outcomes. The data were compared between groups that received or did not receive diuretics.

Result

Of the 224 mechanically ventilated children with confirmed bronchiolitis, 179 (79%) received furosemide on Day 2 of invasive ventilation. Out of these, 72% of the patients received intermittent intravenous furosemide, whereas 28% received continuous infusion. It was used more commonly in patients who had a higher fluid overload. Initial fluid overload was associated with longer duration of mechanical ventilation (median days 6 vs 4, p<0.001) and length of stay (median days 10 vs 6, p<0.001) even with the use of furosemide. Superimposed bacterial pneumonia was seen in 60% of cases and was associated with a higher per cent fluid overload at 24 hours (9.1 vs 6.3, p = 0.003).

Conclusion

Diuretics are frequently used in mechanically ventilated children with bronchiolitis and fluid overload, with intermittent dosing of furosemide being the commonest treatment. There is a potential benefit of improved oxygenation in these children, though further research is needed to quantify this benefit and any potential harm. Due to potential harm with fluid overload, restrictive fluid strategies may have a potential benefit.

Identifying and managing bronchiolitis

Bronchiolitis is a common viral illness that affects the lower respiratory tract of infants and young children. The disease is characterized by wheezing and increased mucus production and can range from mild to severe in terms of respiratory distress. This article reviews the epidemiology, clinical presentation, and treatment of bronchiolitis.

The Effects of Furosemide on Oxygenation in Mechanically Ventilated Children with Bronchiolitis

Fluid balance management, including diuretic administration, may influence outcomes among mechanically ventilated children. We retrospectively compared oxygenation saturation index (OSI) before and after the initial furosemide bolus among 65 mechanically ventilated children. Furosemide was not associated with a significant change in median OSI (6.25 [interquartile range: 5.01-7.92] vs. 6.06 [4.73-7.54], p  = 0.48), but was associated with expected changes in fluid balance and urine output. Secondary analysis suggested more favorable effects of furosemide in children with worse baseline OSI. The reported common use of furosemide by pediatric intensivists obligates further study to better establish its efficacy, or lack thereof, in mechanically ventilated children.