Utilization of nebulized 3% saline in infants hospitalized with bronchiolitis

Antibiotic Prescription in Young Children With Respiratory Syncytial Virus-Associated Respiratory Failure and Associated Outcomes

OBJECTIVES

To describe antibiotic prescribing practices during the first 2 days of mechanical ventilation among previously healthy young children with respiratory syncytial virus-associated lower respiratory tract infection and evaluate associations between the prescription of antibiotics at onset of mechanical ventilation with clinical outcomes.

DESIGN

Retrospective cohort study.

SETTING

Forty-six children's hospitals in the United States.

PATIENTS

Children less than 2 years old discharged between 2012 and 2016 with an International Classification of Diseases diagnosis of respiratory syncytial virus-associated lower respiratory tract infection, no identified comorbid conditions, and receipt of mechanical ventilation.

INTERVENTIONS

Antibiotic prescription during the first 2 days of mechanical ventilation.

MEASUREMENTS AND MAIN RESULTS

We compared duration of mechanical ventilation and hospital length of stay between children prescribed antibiotics on both of the first 2 days of mechanical ventilation and children not prescribed antibiotics during the first 2 days of mechanical ventilation. We included 2,107 PICU children with respiratory syncytial virus-associated lower respiratory tract infection (60% male, median age of 1 mo [interquartile range, 1-4 mo]). The overall proportion of antibiotic prescription on both of the first 2 days of mechanical ventilation was 82%, decreasing over the study period (p = 0.004) and varying from 36% to 100% across centers. In the bivariate analysis, antibiotic prescription was associated with a shorter duration of mechanical ventilation (6 d [4-9 d] vs 8 d [6-11 d]; p < 0.001) and a shorter hospital length of stay (11 d [8-16 d] vs 13 d [10-18 d]; p < 0.001). After adjustment for center, demographics, and vasoactive medication prescription, antibiotic prescription was associated with a 1.21-day shorter duration of mechanical ventilation and a 2.07-day shorter length of stay. Ultimately, 95% of children were prescribed antibiotics sometime during hospitalization, but timing, duration, and antibiotic choice varied markedly.

CONCLUSIONS

Although highly variable across centers and decreasing over time, the practice of instituting antibiotics after intubation in young children with respiratory syncytial virus-associated lower respiratory tract infection was associated with a shortened clinical course after adjustment for the limited available covariates. A prudent approach to identify and optimally treat bacterial coinfection is needed.

Nebulized Normal Saline Solution for Treatment of Bronchial Asthma Exacerbations and Bronchiolitis: Not Standard of Care

Nebulized normal saline is frequently prescribed for the treatment of bronchiolitis or bronchial asthma exacerbations. We aimed to reinforce guidelines care by educating providers on the futility of saline administration. Frequency and indications for nebulized normal saline prescription were documented from November 1, 2014, to April 1, 2015, and then again, after dissemination of educational material to providers, from November 1, 2016, to April 1, 2017. A total of 263 patients had bronchiolitis and 470 had asthma. Nebulized normal saline for bronchiolitis decreased significantly in the emergency department (ED) and inpatient settings ( P < .001 and P = .027, respectively). For asthma exacerbations, the use of nebulized normal saline decreased significantly in the inpatient setting ( P = .025), while in the ED, numbers were low at baseline and remained unchanged. Nebulized normal saline administration in the hospital setting results in continued use in the community, where this leads to unnecessary ED visits, where first-line therapy should have been administered.

Quality Improvement Initiative to Increase the Use of Nasogastric Hydration in Infants With Bronchiolitis

BACKGROUND AND OBJECTIVES

Intravenous (IV) hydration is used primarily in children with bronchiolitis at our institution. Because nasogastric (NG) hydration can provide better nutrition, the goal of our quality improvement (QI) initiative was to increase the rate of NG hydration in eligible children 1 to 23 months old with bronchiolitis by 20% over 6 months.

METHODS

We used Plan-Do-Study-Act cycles to increase the use of NG hydration in eligible children. Interventions included educational and system-based changes and sharing parental feedback with providers. Chart reviews were performed to identify the rates of NG hydration, which were plotted over time in a statistical process control p chart. The balancing measure was the rate of complications in children with NG versus IV hydration.

RESULTS

Two hundred and ninety-three children who were hospitalized with bronchiolitis needed supplemental hydration during the QI initiative (January 2016-April 2016). Ninety-one children were candidates for NG hydration, and 53 (58%) received NG hydration. The rates of NG hydration increased from a baseline of 0% pre-QI bronchiolitis season (January 2015-April 2015) to 58% during the initiative. There was no aspiration and no accidental placement of the NG tube into a child's airway. Nine patients (17%) in the NG group had a progression of disease requiring nil per os status, and 6 of these were transferred to the PICU whereas none of those in the IV group were transferred to the PICU. Post-QI initiative, the majority of nurses (63%) and physicians (95%) stated that they are more likely to consider NG hydration in children with bronchiolitis.

CONCLUSIONS

We successfully increased the rates of NG hydration in eligible children with bronchiolitis by using educational and system-based interventions.

Corticosteroid Therapy During Acute Bronchiolitis in Patients Who Later Develop Asthma

BACKGROUND AND OBJECTIVE

Meta-analyses show that corticosteroids are not effective in patients with bronchiolitis. However, risk factors for asthma such as eczema or familial atopy prompt some practitioners to prescribe corticosteroids for bronchiolitis. We assessed if corticosteroid prescription is associated with shorter hospitalization for bronchiolitis among patients who later develop asthma.

METHODS

The Pediatric Health Information System database was interrogated for patients with bronchiolitis aged <2 years hospitalized between 2006 and 2015. Only patients who also later had a hospitalization for asthma and prescription of inhaled corticosteroids were included. For the initial bronchiolitis admission, use of mechanical ventilation defined "severe illness," and ICU admission without mechanical ventilation defined "moderate illness"; all other patients were deemed to have "mild illness." Variables associated (P < .10) with length of stay (LOS) in bivariate analysis were included in linear regression analysis.

RESULTS

During the bronchiolitis admission of 2479 children who were later hospitalized for asthma, corticosteroid prescription (n = 857) was associated with longer LOS in bivariate analysis (3 [2-4] vs 2 [2-4] days; P < .01) but not the multivariate model (P = .18) that included age, sex, comorbid conditions, bacterial pneumonia, and illness severity. Corticosteroid prescription was associated with shorter LOS among previously healthy children with moderate illness (4 [2-6] vs 5 [3-7] days; P = .02) but not those with mild or severe illness.

CONCLUSIONS

Corticosteroids were not associated with improved outcome in patients with bronchiolitis who were later hospitalized with asthma. Moderately ill patients with no comorbidities may warrant further study.

A regional cohort study of the treatment of critically ill children with bronchiolitis

OBJECTIVE

To describe the treatment practices in critically ill children with RSV bronchiolitis across four regional PICUs in the northeastern United States, and to determine the factors associated with increased ICU length of stay in this population.

METHODS

We conducted a retrospective cohort study of children who were admitted with RSV bronchiolitis between July 2009 and July 2011 to the PICUs of Connecticut Children's Medical Center, Yale-New Haven Children's Hospital, Maria Fareri Children's Hospital, and Baystate Children's Hospital. Data were collected regarding clinical characteristics and intensive care course among these hospitals.

RESULTS

During the study period, 323 children were admitted to one of the four ICUs with RSV bronchiolitis. Despite similar mortality risk scores among ICUs, there was considerable variation in the use of therapies, particularly intubation and mechanical ventilation, in which there was greater than a 3.5-fold increased risk of intubation between sites with the highest and lowest frequency of intubation (odds ratio: 3.8; 95% confidence interval: 2.2-6.4). Albuterol was the most commonly used respiratory treatment, followed by chest physiotherapy, high-flow nasal cannula, and hypertonic saline. Longer stays in the ICU were associated with more frequent use of therapies, specifically invasive mechanical ventilation, inhaled corticosteroids, intrapulmonary percussive ventilation, and chest physiotherapy.

CONCLUSIONS

Even within a close geographic region, there is significant variation in the treatment provided to critically ill children with RSV bronchiolitis. None of these treatments were associated with shorter durations of hospitalization in this population and some, such as mechanical ventilation, were associated with longer ICU lengths of stay.

A randomized trial of nebulized 3% hypertonic saline with salbutamol in the treatment of acute bronchiolitis in hospitalized infants

OBJECTIVE

Acute bronchiolitis is a common disorder of infants that often results in hospitalization. Apart from supportive care, no therapy has been shown to influence the course of the disease, except for a possible effect of nebulized hypertonic saline (HS). To determine whether this does have beneficial effects on length of stay in hospital or on severity scores, we undertook a double-blind, randomized, controlled trial in a pediatric department of a Portuguese hospital.

METHODS

Previously healthy infants, younger than 12 months, hospitalized with mild-to-moderate acute viral bronchiolitis were randomized to receive either nebulized 3% (hypertonic, HS) or 0.9% (normal, NS) saline during their entire hospital stay. Primary endpoints were: length of hospital stay and severity scores on each day of hospitalization. Need for supplemental oxygen, further add-on medications and adverse effects were also analyzed.

RESULTS

Sixty-eight patients completed the study (HS: 33; NS: 35). The median length of hospital stay did not differ between groups: HS: 5.6 ± 2.3 days; NS: 5.4 ± 2.1 days (P = 0.747). We found no difference between groups in severity scores from day 1 to day 4. There were no differences in need for supplemental oxygen or add-on medications. Patients in HS group had significantly more cough (46% vs. 20%, P = 0.025) and rhinorrhoe (58% vs. 31%, P = 0.30).

CONCLUSION

This study does not support the use of nebulized HS over NS in therapy of hospitalized children with mild-to-moderate acute viral bronchiolitis.

Hypertonic Saline for the Treatment of Bronchiolitis in Infants and Young Children: A Critical Review of the Literature

Bronchiolitis, an infection of the lower respiratory tract, is the leading cause of infant and child hospitalization in the United States. Therapeutic options for management of bronchiolitis are limited. Hypertonic saline inhalation therapy has been studied in numerous clinical trials with mixed results. In 2014, the American Academy of Pediatrics (AAP) published updated guidelines on the diagnosis and management of bronchiolitis, which include new recommendations on the use of hypertonic saline. We reviewed all published clinical trials mentioned in the 2014 AAP guidelines, as well as additional trials published since the guidelines, and critically evaluated each trial to determine efficacy, safety, and expectations of hypertonic saline inhalation therapy. A total of 2682 infants were studied over the course of 22 clinical trials. Nine trials were carried out in the outpatient/clinic/emergency department and 13 in the inpatient setting. We agree with the AAP guidelines regarding the recommendation to use nebulized hypertonic saline for infants hospitalized with bronchiolitis, with the expectation of reducing bronchiolitis scores and length of stay when it is expected to last more than 72 hours. However, we also believe there might be an advantage for hypertonic saline in reducing admission rates from the emergency department, based on close examination of the results of recent trials. This review also highlights important gaps in the available literature that need to be addressed in order to define the role of inhaled hypertonic saline therapy.

Latest options for treatment of bronchiolitis in infants

Bronchiolitis is the most frequent pathology associated with lower respiratory tract infection in newborns and young infants. The treatment of bronchiolitis is essentially supportive therapy for respiratory distress, hypoxia and dehydration. To date, no specific antiviral drug is used on a routine basis for the treatment of RSV infections. Currently, the only antiviral drug approved for the infection is ribavirin; however, its use is limited due to adverse side effects and the risks it poses to healthcare providers. Moreover, several drugs have been routinely administered for years in infants with acute RSV bronchiolitis, even if their efficacy is often not confirmed by clinical evidence, and studies on emerging antiviral drugs are still ongoing. In the present paper we review the recent literature about the drugs used during acute bronchiolitis and we summarize the main recommendations of national and international guidelines and the latest options for the treatment of bronchiolitis.