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Ruppel H, Bonafide CP, Beidas RS, Albanowski K, Parlar-Chun R, Rajbhandari P, Kern-Goldberger AS, Stoeck PA, Snow K, House SA, Lucey KE, Brady PW, Schondelmeyer AC. Continuous pulse oximetry monitoring in children hospitalized with bronchiolitis: A qualitative analysis of clinicians' justifications. J Hosp Med 2024. [PMID: 39120261 DOI: 10.1002/jhm.13442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 06/10/2024] [Accepted: 06/12/2024] [Indexed: 08/10/2024]
Abstract
Continuous pulse oximetry (cSpO2) monitoring use outside established guidelines is common in children hospitalized with bronchiolitis. We analyzed clinicians' real-time rationale for continuous monitoring in stable children with bronchiolitis not requiring supplemental oxygen. Data for this study were collected as part a multicenter deimplementation trial for cSpO2 in children hospitalized with bronchiolitis. We analyzed 371 clinician responses across 36 hospitals; 258 (70%) responses did not include a clinical reason for monitoring ("nonclinical"; e.g., respondent forgot to discontinue monitoring, did not know why the patient was monitored, or was following an order). The remaining 113 (30%) responses contained a clinical reason for monitoring ("clinical"; e.g., recently requiring oxygen, physical exam concerns, or concerns relating to patient condition or history). Strategies to reduce unnecessary monitoring should include changes in workflow to facilitate shared understanding of monitoring goals and timely discontinuation of monitoring.
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Affiliation(s)
- Halley Ruppel
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Clinical Futures, A Center of Emphasis Within the CHOP Research Institute, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christopher P Bonafide
- Clinical Futures, A Center of Emphasis Within the CHOP Research Institute, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Section of Pediatric Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Penn Implementation Science Center (PISCE), University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rinad S Beidas
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Kimberly Albanowski
- Section of Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Raymond Parlar-Chun
- Division of Hospital Medicine, Texas Children's Hospital, Houston, Texas, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Prabi Rajbhandari
- Division of Hospital Medicine, Akron Children's Hospital, Akron, Ohio, USA
- Department of Pediatrics, Northeast Ohio Medical Unversity (NEOMED), Akron, Ohio, USA
- Rebecca D.Considine Research Institute, Akron Children's Hospital, Akron, Ohio, USA
| | - Andrew S Kern-Goldberger
- Division of Pediatric Hospital Medicine, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio, USA
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - Patricia A Stoeck
- Department of Pediatrics, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Kathleen Snow
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Samantha A House
- Department of Pediatrics, Dartmouth Health Children's, Lebanon, New Hampshire, USA
| | - Kate E Lucey
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Hospital Based Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Center for Quality and Safety, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Patrick W Brady
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Amanda C Schondelmeyer
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
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Peters MJ, Ramnarayan P. Randomized Trials to Reduce Clinical Uncertainty: Gold Standard or Fool's Gold? Pediatr Crit Care Med 2024; 25:775-777. [PMID: 39101806 DOI: 10.1097/pcc.0000000000003533] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/06/2024]
Affiliation(s)
- Mark J Peters
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom
- Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, United Kingdom
- Children's Acute Transport Service, Great Ormond Street Hospital, London, United Kingdom
| | - Padmanabhan Ramnarayan
- Children's Acute Transport Service, Great Ormond Street Hospital, London, United Kingdom
- Section of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
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Gould DW, Peters MJ. The Oxy-PICU Conservative Versus Liberal Oxygenation Target Trial in Critically Ill Children-A Changed World or a "So What" Result? Pediatr Crit Care Med 2024; 25:e343-e346. [PMID: 38602434 DOI: 10.1097/pcc.0000000000003518] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Doug W Gould
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Mark J Peters
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, United Kingdom
- Infection, Immunity & Inflammation Department, University College London Great Ormond St Institute of Child Health, London, United Kingdom
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Walsh R, Costello L, DiCosimo A, Doyle AM, Kehoe L, Mulhall C, O'Hara S, Elnazir B, Meehan J, Isweisi E, Semova G, Branagan A, Roche E, Molloy E. Bronchiolitis: evidence-based management in high-risk infants in the intensive care setting. Pediatr Res 2024:10.1038/s41390-024-03340-y. [PMID: 38902454 DOI: 10.1038/s41390-024-03340-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/13/2024] [Accepted: 05/15/2024] [Indexed: 06/22/2024]
Abstract
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.
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Affiliation(s)
- Ruth Walsh
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland.
| | - Liam Costello
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
| | - Alexandria DiCosimo
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
| | - Anne-Marie Doyle
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
| | - Laura Kehoe
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
| | - Cormac Mulhall
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
| | - Sean O'Hara
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
| | - Basil Elnazir
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
- Respiratory Medicine, Children's Health Ireland at Tallaght, Tallaght University Hospital, Dublin, 24, Ireland
| | - Judith Meehan
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
- Trinity Research in Childhood Centre (TRiCC), Trinity College Dublin, Dublin, Ireland
| | - Eman Isweisi
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
- Trinity Research in Childhood Centre (TRiCC), Trinity College Dublin, Dublin, Ireland
| | - Gergana Semova
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
- Trinity Research in Childhood Centre (TRiCC), Trinity College Dublin, Dublin, Ireland
| | - Aoife Branagan
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
- Trinity Research in Childhood Centre (TRiCC), Trinity College Dublin, Dublin, Ireland
- Paediatrics, The Coombe Hospital, Dublin, 8, Ireland
| | - Edna Roche
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
- Trinity Research in Childhood Centre (TRiCC), Trinity College Dublin, Dublin, Ireland
- Endocrinology, Children's Health Ireland at Tallaght, Tallaght University Hospital, Dublin, 24, Ireland
| | - Eleanor Molloy
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
- Trinity Research in Childhood Centre (TRiCC), Trinity College Dublin, Dublin, Ireland
- Paediatrics, The Coombe Hospital, Dublin, 8, Ireland
- Neurodisability Children's Health Ireland at Tallaght, Tallaght University Hospital, Dublin, 24, Ireland
- Neonatology, Children's Health Ireland at Crumlin, Dublin, 12, Ireland
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Kandasamy S, Rameshkumar R, Sangaralingam T, Krishnamoorthy N, Shankar NCG, Vijayakumar V, Sridharan B. High-flow nasal oxygen in infants and children for early respiratory management of pneumonia-induced acute hypoxemic respiratory failure: the CENTURI randomized clinical trial. INTENSIVE CARE MEDICINE. PAEDIATRIC AND NEONATAL 2024; 2:15. [PMID: 38567201 PMCID: PMC10982089 DOI: 10.1007/s44253-024-00031-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 02/01/2024] [Indexed: 04/04/2024]
Abstract
Objective To compare the effectiveness of early high-flow nasal cannula (HFNC) and low-flow oxygen support (LFOS) in children under 5 years with acute hypoxemic respiratory failure (AHRF) due to severe community-acquired pneumonia in low-middle-income countries. Methods An open-label randomized clinical trial enrolled children aged 2-59 months with AHRF due to severe community-acquired pneumonia and randomized into HFNC and LFOS. In the LFOS group, the patient received cold wall oxygen humidified by bubbling through sterile water administered through simple nasal prongs at a fixed flow rate of 2 L/min. In the HFNC group, the patient received humidified, heated (37 °C), high-flow oxygen at a flow rate assigned based on weight range, with a titratable oxygen fraction. The primary outcome was treatment failure in 72 h (escalating the respiratory support method using any modality other than primary intervention). Results Data was analyzed intention-to-treat (HFNC = 124; LFOS = 120). Median (IQR) age was 12 (6-20) and 11 (6-27) months, respectively. Treatment failure occurred in a significantly lower proportion in the HFNC group (7.3%, n = 9/124) as compared to the LFOS group (20%, n = 24/120) (relative risk = 0.36, 95% CI 0.18 to 0.75; p = 0.004; adjusted hazard ratio 0.34, 95% CI 0.16 to 0.73; p = 0.006). The intubation rate was significantly lower in the HFNC group (7.3%, n = 9/124 vs. 16.7%, n = 20/120; relative risk = 0.44, 95% CI 0.21 to 0.92, p = 0.023). There were no significant differences noted in other secondary outcomes. No mortality occurred. Conclusion High-flow nasal cannula oxygen therapy used as early respiratory support in children under 5 years with acute hypoxemic respiratory failure due to severe community-acquired pneumonia was associated with significantly lower treatment failure compared with standard low-flow oxygen support. Trial registration CTRI/2016/04/006788. Registered 01 April 2016, https://ctri.nic.in/Clinicaltrials/advsearch.php. Supplementary Information The online version contains supplementary material available at 10.1007/s44253-024-00031-8.
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Affiliation(s)
- Sasidaran Kandasamy
- Advanced Pediatric Critical Care Centre, Pediatric Acute Care Education & Research (PACER) Unit, Department of Pediatrics, Mehta Multi Speciality Hospitals, Chennai, Tamil Nadu 600 031 India
| | - Ramachandran Rameshkumar
- Division of Pediatric Critical Care, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605 006 India
- Present Address: Pediatric Critical Care, Mediclinic City Hospital, Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai, United Arab Emirates
| | | | | | - N. C. Gowri Shankar
- Department of Pediatrics, Mehta Multi Speciality Hospitals, Chennai, Tamil Nadu 600 031 India
| | - Vimalraj Vijayakumar
- Advanced Pediatric Critical Care Centre, Department of Pediatrics, Mehta Multi Speciality Hospitals, Chennai, Tamil Nadu 600 031 India
| | - Balaji Sridharan
- Pediatric Acute Care Education and Research (PACER) Unit, Department of Pediatrics, Mehta Multi-Speciality Hospitals, Chennai, Tamil Nadu 600 031 India
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De Luca D, Pezza L, Vivalda L, Di Nardo M, Lepainteur M, Baraldi E, Piastra M, Ricciardi W, Conti G, Gualano MR. Critical care of severe bronchiolitis during shortage of ICU resources. EClinicalMedicine 2024; 69:102450. [PMID: 38333363 PMCID: PMC10850123 DOI: 10.1016/j.eclinm.2024.102450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 02/10/2024] Open
Abstract
Large seasonal outbreaks of bronchiolitis put pressure on healthcare systems and particularly on intensive care units (ICUs). ICU admission is necessary to provide respiratory support to the severest cases, otherwise bronchiolitis can result in substantial mortality. ICU resources are often insufficient and there is scant evidence to guide the ICU clinical management. Most available studies do not cover the ICU-admitted cases and do not consider the associated public health issues. We review this topic through a multidisciplinary approach from both the clinical and public health perspectives, with an analysis based on pathophysiology and cost-effectiveness. We suggest ways to optimise respiratory care, minimise ICU stay, "protect" ICU beds and, whenever possible, make them available for other critically ill children. We also provide guidance on how to prepare ICUs to work under stressful conditions due to outbreaks and to reduce the risk of nosocomial cross-contamination, particularly in ICUs caring for high-risk children. Funding None.
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Affiliation(s)
- Daniele De Luca
- Division of Paediatrics and Neonatal Critical Care, “A. Béclère” Hospital, APHP-Paris Saclay University, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France
| | - Lucilla Pezza
- Division of Paediatrics and Neonatal Critical Care, “A. Béclère” Hospital, APHP-Paris Saclay University, Paris, France
| | - Laura Vivalda
- Division of Paediatrics and Neonatal Critical Care, “A. Béclère” Hospital, APHP-Paris Saclay University, Paris, France
| | - Matteo Di Nardo
- Paediatric Intensive Care Unit, “Bambino Gesù” Children's Hospital-IRCCS, Rome, Italy
| | - Margaux Lepainteur
- Division of Bacteriology-Hygiene, “A. Béclère” Hospital, APHP-Paris Saclay University, Paris, France
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Padova, Padua, Italy
- Respiratory Syncytial Virus Network (RESVINET) Foundation, Zeist, the Netherlands
| | - Marco Piastra
- Paediatric Intensive Care Unit, “A. Gemelli” University Hospital Foundation-IRCCS, Rome, Italy
- Department of Biotechnological Sciences, Intensive and Perioperative Medicine, Catholic University of Sacred Heart, Rome, Italy
| | - Walter Ricciardi
- Leadership Research Centre, Catholic University of Sacred Heart, Rome, Italy
| | - Giorgio Conti
- Paediatric Intensive Care Unit, “A. Gemelli” University Hospital Foundation-IRCCS, Rome, Italy
- Department of Biotechnological Sciences, Intensive and Perioperative Medicine, Catholic University of Sacred Heart, Rome, Italy
| | - Maria Rosaria Gualano
- UniCamillus - Saint Camillus International University of Health and Medical Sciences, Rome, Italy
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Lakshminrusimha S, Abman SH. Oxygen Targets in Neonatal Pulmonary Hypertension: Individualized, "Precision-Medicine" Approach. Clin Perinatol 2024; 51:77-94. [PMID: 38325948 PMCID: PMC10857735 DOI: 10.1016/j.clp.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Oxygen is a specific pulmonary vasodilator. Hypoxemia causes pulmonary vasoconstriction, and normoxia leads to pulmonary vasodilation. However, hyperoxia does not enhance pulmonary vasodilation but causes oxidative stress. There are no clinical trials evaluating optimal oxygen saturation or Pao2 in pulmonary hypertension. Data from translational studies and case series suggest that oxygen saturation of 90% to 97% or Pao2 between 50 and 80 mm Hg is associated with the lowest pulmonary vascular resistance.
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Affiliation(s)
- Satyan Lakshminrusimha
- Department of Pediatrics, University of California, UC Davis Children's Hospital, 2516 Stockton Boulevard, Sacramento, CA 95817, USA.
| | - Steven H Abman
- Department of Pediatrics, The Pediatric Heart Lung Center, University of Colorado Anschutz Medical Campus, Mail Stop B395, 13123 East 16th Avenue, Aurora, CO 80045, USA
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Eposse Ekoube C, Heles Nsang E, Épée P, Mandeng Ma Linwa E, Djike Puepi Y, Mbono Betoko R, Noukeu Njinkui D, Enyama D, Mbonjo Bitsie D, Disso Massako J, Abba S, Ngo Linwa EE, Ida Penda C. Predictors of prolonged length of hospital stay and in-hospital mortality in patients aged 1-24 months with acute bronchiolitis in Douala, Cameroon. BMC Pediatr 2024; 24:150. [PMID: 38424505 PMCID: PMC10903055 DOI: 10.1186/s12887-024-04653-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/17/2024] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION In Cameroon, acute bronchiolitis has been reported as the third commonest lower respiratory infection and is usually associated with low mortality. Nonetheless, respiratory distress associated with non-adherence to management guidelines can prolong hospital stay. This study aimed to explore predictors of prolonged hospital stay (≥ 5 days) and mortality in patients aged < 2years hospitalised for acute bronchiolitis. METHODOLOGY We conducted a retrospective cohort study at three paediatric units in the city of Douala, Cameroon. Factors associated with prolonged hospital stay and mortality were determined using multivariable linear regression model. Threshold for significance was set at p ≤ 0.05. RESULTS A total of 215 patients with bronchiolitis were included with mean age of 6.94 ± 5.71 months and M/F sex ratio of 1.39/1. Prolonged hospital stay was reported in 46.98% and mortality in 10.70% of patients hospitalised for bronchiolitis. Factors independently associated with prolonged hospital duration were oxygen administration [b = 0.36, OR = 2.35 (95% CI:1.16-4.74), p = 0.017], abnormal respiratory rate [b = 0.38, OR = 2.13 (1.00-4.55), p = 0.050] and patients presenting with cough [b = 0.33, OR = 2.35 (95% CI: 1.22-4.51), p = 0.011], and diarrhoea [b = 0.71, OR = 6.44 (95% CI: 1.6-25.86), p = 0.009] on admission. On the other hand, factors independently associated with mortality were age of the patient [b= -0.07, OR = 0.84 (95% CI: 0.74-0.97), p = 0.014] and oxygen administration [b = 1.08, OR = 9.64 (95% CI:1.16-79.85), p = 0.036] CONCLUSION: Acute bronchiolitis represented 1.24% of admissions and was common in the rainy season, in males and 3-11-month-old patients. Management guidelines were poorly respected. Prolonged length of stay was reported in half of the patients hospitalized and mortality was high, especially in younger patients and in patients receiving oxygen.
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Affiliation(s)
- Charlotte Eposse Ekoube
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon.
- Paediatric unit, Douala Laquintinie Hospital, Douala, Cameroon.
| | - Emmanuel Heles Nsang
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
| | - Patricia Épée
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
| | | | | | - Ritha Mbono Betoko
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
| | - Diomède Noukeu Njinkui
- Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Dominique Enyama
- Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Dora Mbonjo Bitsie
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
| | | | - Soumaiyatou Abba
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
| | | | - Calixte Ida Penda
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
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9
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Lee V, Ruppel H, Schondelmeyer AC. Pulse Oximetry in Bronchiolitis: Have We Reached Saturation? Hosp Pediatr 2024; 14:e107-e109. [PMID: 38164077 DOI: 10.1542/hpeds.2023-007505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Affiliation(s)
- Vivian Lee
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Halley Ruppel
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- Clinical Futures, The Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda C Schondelmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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10
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Im JHB, Wahi G, Giglia L, Bayliss A, Kanani R, Pound CM, Sakran M, Schuh S, Gill PJ, Parkin PC, Barrowman N, Mahant S. Oxygen Saturation Targets in Infants Hospitalized With Bronchiolitis: A Multicenter Cohort Study. Hosp Pediatr 2024; 14:67-74. [PMID: 38164101 DOI: 10.1542/hpeds.2023-007301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVES To examine 2 hospital oxygen saturation target policies and clinical outcomes in infants hospitalized with bronchiolitis. METHODS This multicenter cohort study used data collected from a randomized clinical trial of infants aged 4 weeks to 24 months, hospitalized with bronchiolitis at children's and community hospitals from 2016 to 2019. We modeled the association between hospital oxygen saturation target policy, either 90% while awake and 88% while asleep (90%/88%) or 90% while awake and asleep (90%/90%), and clinical outcomes. RESULTS A total of 162 infants were enrolled at 4 hospitals using a 90%/88% oxygen saturation target and 67 infants at 2 hospitals using a 90%/90% target policy. No significant differences between the 90%/88% group and 90%/90% groups were observed for time to discharge (adjusted hazard ratio, 0.83; 95% confidence interval [CI], 0.61-1.14; P = .25), initiation of supplemental oxygen (adjusted odds ratio [aOR], 0.98; 95% CI, 0.47-2.02; P = .95), time to discontinuation of supplemental oxygen (adjusted hazard ratio, 0.75; 95% CI, 0.44-1.27; P = .28), revisits (aOR, 1.38; 95% CI, 0.52-3.71; P = .52), and parent days missed from work (aOR, 2.41; 95% CI, 0.90-6.41; P = .08). Three infants in the 90%/88% group and none in the 90%/90% group were transferred to the ICU. CONCLUSIONS Among infants hospitalized with bronchiolitis, clinical outcomes were similar between a hospital oxygen saturation target policy of 90% while awake and 88% while asleep compared with 90% while awake and asleep. These findings may inform the design of future trials of oxygen saturation targets in bronchiolitis hospital care.
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Affiliation(s)
- James H B Im
- Dalla Lana School of Public Health
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gita Wahi
- Division of General Pediatrics, Department of Pediatrics, McMaster University and McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Lucy Giglia
- Division of General Pediatrics, Department of Pediatrics, McMaster University and McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Ann Bayliss
- Children's Health Division, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Ronik Kanani
- Department of Pediatrics
- Department of Pediatrics, North York General Hospital, Toronto, Ontario, Canada
| | - Catherine M Pound
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Mahmoud Sakran
- Department of Pediatrics, Lakeridge Health, Oshawa, and Queens University, Kingston, Ontario, Canada
| | - Suzanne Schuh
- Department of Pediatrics
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Peter J Gill
- Department of Pediatrics
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Patricia C Parkin
- Department of Pediatrics
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nicholas Barrowman
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Sanjay Mahant
- Department of Pediatrics
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
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11
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Peters MJ, Gould DW, Ray S, Thomas K, Chang I, Orzol M, O'Neill L, Agbeko R, Au C, Draper E, Elliot-Major L, Giallongo E, Jones GAL, Lampro L, Lillie J, Pappachan J, Peters S, Ramnarayan P, Sadique Z, Rowan KM, Harrison DA, Mouncey PR. Conservative versus liberal oxygenation targets in critically ill children (Oxy-PICU): a UK multicentre, open, parallel-group, randomised clinical trial. Lancet 2024; 403:355-364. [PMID: 38048787 DOI: 10.1016/s0140-6736(23)01968-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 09/10/2023] [Accepted: 09/14/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND The optimal target for systemic oxygenation in critically ill children is unknown. Liberal oxygenation is widely practiced, but has been associated with harm in paediatric patients. We aimed to evaluate whether conservative oxygenation would reduce duration of organ support or incidence of death compared to standard care. METHODS Oxy-PICU was a pragmatic, multicentre, open-label, randomised controlled trial in 15 UK paediatric intensive care units (PICUs). Children admitted as an emergency, who were older than 38 weeks corrected gestational age and younger than 16 years receiving invasive ventilation and supplemental oxygen were randomly allocated in a 1:1 ratio via a concealed, central, web-based randomisation system to conservative peripheral oxygen saturations ([SpO2] 88-92%) or liberal (SpO2 >94%) targets. The primary outcome was the duration of organ support at 30 days following random allocation, a rank-based endpoint with death either on or before day 30 as the worst outcome (a score equating to 31 days of organ support), with survivors assigned a score between 1 and 30 depending on the number of calendar days of organ support received. The primary effect estimate was the probabilistic index, a value greater than 0·5 indicating more than 50% probability that conservative oxygenation is superior to liberal oxygenation for a randomly selected patient. All participants in whom consent was available were included in the intention-to-treat analysis. The completed study was registered with the ISRCTN registry (ISRCTN92103439). FINDINGS Between Sept 1, 2020, and May 15, 2022, 2040 children were randomly allocated to conservative or liberal oxygenation groups. Consent was available for 1872 (92%) of 2040 children. The conservative oxygenation group comprised 939 children (528 [57%] of 927 were female and 399 [43%] of 927 were male) and the liberal oxygenation group included 933 children (511 [56%] of 920 were female and 409 [45%] of 920 were male). Duration of organ support or death in the first 30 days was significantly lower in the conservative oxygenation group (probabilistic index 0·53, 95% CI 0·50-0·55; p=0·04 Wilcoxon rank-sum test, adjusted odds ratio 0·84 [95% CI 0·72-0·99]). Prespecified adverse events were reported in 24 (3%) of 939 patients in the conservative oxygenation group and 36 (4%) of 933 patients in the liberal oxygenation group. INTERPRETATION Among invasively ventilated children who were admitted as an emergency to a PICU receiving supplemental oxygen, a conservative oxygenation target resulted in a small, but significant, greater probability of a better outcome in terms of duration of organ support at 30 days or death when compared with a liberal oxygenation target. Widespread adoption of a conservative oxygenation saturation target (SpO2 88-92%) could help improve outcomes and reduce costs for the sickest children admitted to PICUs. FUNDING UK National Institute for Health and Care Research Health Technology Assessment Programme.
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Affiliation(s)
- Mark J Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, UK; Respiratory, Critical Care and Anaesthesia Unit, Infection, Inflammation, and Immunity Division, University College London Great Ormond Street Institute of Child Health, London, UK; Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
| | - Doug W Gould
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Samiran Ray
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, UK
| | - Karen Thomas
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Irene Chang
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Marzena Orzol
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Lauran O'Neill
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, UK
| | - Rachel Agbeko
- Department of Paediatric Intensive Care, Great North Children's Hospital, The Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Carly Au
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Elizabeth Draper
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | | | - Elisa Giallongo
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Gareth A L Jones
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, UK
| | - Lamprini Lampro
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Jon Lillie
- Paediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK; Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Jon Pappachan
- Paediatric Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sam Peters
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Padmanabhan Ramnarayan
- Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; Section of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
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12
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Zhang XL, Zhang X, Hua W, Xie ZD, Liu HM, Zhang HL, Chen BQ, Chen Y, Sun X, Xu Y, Shu SN, Zhao SY, Shang YX, Cao L, Jia YH, Lin LN, Li J, Hao CL, Dong XY, Lin DJ, Xu HM, Zhao DY, Zeng M, Chen ZM, Huang LS. Expert consensus on the diagnosis, treatment, and prevention of respiratory syncytial virus infections in children. World J Pediatr 2024; 20:11-25. [PMID: 38064012 PMCID: PMC10828005 DOI: 10.1007/s12519-023-00777-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/26/2023] [Indexed: 01/31/2024]
Abstract
BACKGROUND Respiratory syncytial virus (RSV) is the leading global cause of respiratory infections and is responsible for about 3 million hospitalizations and more than 100,000 deaths annually in children younger than 5 years, representing a major global healthcare burden. There is a great unmet need for new agents and universal strategies to prevent RSV infections in early life. A multidisciplinary consensus development group comprising experts in epidemiology, infectious diseases, respiratory medicine, and methodology aims to develop the current consensus to address clinical issues of RSV infections in children. DATA SOURCES The evidence searches and reviews were conducted using electronic databases, including PubMed, Embase, Web of Science, and the Cochrane Library, using variations in terms for "respiratory syncytial virus", "RSV", "lower respiratory tract infection", "bronchiolitis", "acute", "viral pneumonia", "neonatal", "infant" "children", and "pediatric". RESULTS Evidence-based recommendations regarding diagnosis, treatment, and prevention were proposed with a high degree of consensus. Although supportive care remains the cornerstone for the management of RSV infections, new monoclonal antibodies, vaccines, drug therapies, and viral surveillance techniques are being rolled out. CONCLUSIONS This consensus, based on international and national scientific evidence, reinforces the current recommendations and integrates the recent advances for optimal care and prevention of RSV infections. Further improvements in the management of RSV infections will require generating the highest quality of evidence through rigorously designed studies that possess little bias and sufficient capacity to identify clinically meaningful end points.
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Affiliation(s)
- Xian-Li Zhang
- Department of Infectious Disease, Children's Hospital, Zhejiang University School of Medicine, 3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China
| | - Xi Zhang
- Clinical Research Unit, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wang Hua
- Department of Infectious Disease, Children's Hospital, Zhejiang University School of Medicine, 3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China
| | - Zheng-De Xie
- Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Han-Min Liu
- Department of Pediatric Pulmonology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Hai-Lin Zhang
- Department of Pediatric Pulmonology, the Second Affiliated Hospital & Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, China
| | - Bi-Quan Chen
- Department of Infectious Disease, Anhui Provincial Children's Hospital, Hefei, China
| | - Yuan Chen
- Department of Pediatrics, the Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xin Sun
- Department of Pediatrics, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yi Xu
- Department of Infectious Disease, Guangzhou Women and Children's Medicine Center, Guangzhou Medicine University, Guangzhou, China
| | - Sai-Nan Shu
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shun-Ying Zhao
- Department of Respiratory Disease, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yun-Xiao Shang
- Department of Pediatric Respiratory, Shengjing Hospital of China Medical University, Shenyang, China
| | - Ling Cao
- Respiratory Department, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, China
| | - Yan-Hui Jia
- Department of Infectious Disease, Children's Hospital, Zhejiang University School of Medicine, 3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China
| | - Luo-Na Lin
- Department of Infectious Disease, Children's Hospital, Zhejiang University School of Medicine, 3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China
| | - Jiong Li
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Chuang-Li Hao
- Department of Respirology, Children's Hospital of Soochow University, Suzhou, China
| | - Xiao-Yan Dong
- Department of Respiratory, Children's Hospital of Shanghai, Children's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dao-Jiong Lin
- Department of Infectious Disease, Hainan Women and Children's Medical Center, Haikou, China
| | - Hong-Mei Xu
- Department of Infectious Disease, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - De-Yu Zhao
- Department of Respiratory, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Mei Zeng
- Department of Infectious Diseases, Children's Hospital of Fudan University, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China.
| | - Zhi-Min Chen
- Department of Respiratory Diseases, Children's Hospital, Zhejiang University School of Medicine, 3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China.
| | - Li-Su Huang
- Department of Infectious Disease, Children's Hospital, Zhejiang University School of Medicine, 3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China.
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13
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Gilbert Y, Shrapnel J, Lau C, Dalby-Payne J. Duration of monitoring after cessation of oxygen therapy in infants with bronchiolitis. J Paediatr Child Health 2023; 59:1223-1229. [PMID: 37654081 DOI: 10.1111/jpc.16485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 06/07/2023] [Accepted: 08/16/2023] [Indexed: 09/02/2023]
Abstract
AIM There is no evidence for how long bronchiolitis patients should be observed after coming off oxygen therapy and wide practice variation exists. We aimed to investigate whether it is safe to discharge bronchiolitis patients 4 h after cessation of oxygen therapy. METHODS A retrospective single-centre cohort study of 884 infants (n = 462 in 2018 vs. n = 422 in 2019) aged 0-24 months admitted with bronchiolitis in 2018 and 2019 was conducted after implementation of a bronchiolitis protocol recommending discharge home 4 h post-cessation of oxygen therapy in 2019. We compared the rate of readmissions and Clinical Reviews/Rapid Responses in the pre- and post-exposure cohorts. RESULTS There was a significant reduction in median (interquartile range (IQR)) time to discharge post oxygen cessation by 87 min (510 (370-1033) min versus 423 (273-904) min; P < 0.001) and in median (IQR) length of stay by 6.7 h (2.11 (1.54-2.97) days vs. 1.83 (1.17-2.71) days; P < 0.001). There was no significant difference between readmissions in 2018 compared to 2019 (0.6% vs. 1.4%; P = 0.317). In 2018, there were two Clinical Reviews and in 2019 there were two Rapid Responses post-cessation of oxygen. There were 89 patients discharged within 4 h of cessation of oxygen therapy (n = 18 in 2018 vs. n = 71 in 2019; P < 0.001) with no readmissions, Clinical Reviews or Rapid Responses in the 2019 cohort. CONCLUSIONS This study demonstrates that patients can be discharged 4 h after cessation of supplemental oxygen without increased risk of adverse events.
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Affiliation(s)
- Yasmin Gilbert
- Department of General Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Jane Shrapnel
- Department of General Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
- The Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Christine Lau
- Department of General Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Jacqueline Dalby-Payne
- Department of General Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
- The Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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14
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Sebastian A, Borkhoff CM, Wahi G, Giglia L, Bayliss A, Kanani R, Pound CM, Sakran M, Breen-Reid K, Gill PJ, Parkin PC, Mahant S. A Feeding Adequacy Scale for Children With Bronchiolitis: Prospective Multicenter Study. Hosp Pediatr 2023; 13:895-903. [PMID: 37712130 DOI: 10.1542/hpeds.2023-007339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
OBJECTIVES To determine the measurement properties of the Feeding Adequacy Scale (FAS) in young children hospitalized with bronchiolitis. METHODS Multicenter cohort study of infants hospitalized with bronchiolitis at children's and community hospitals in Ontario, Canada. Caregivers and nurses completed the FAS, a 10-cm visual analog scale anchored by "not feeding at all" (score 0) and "feeding as when healthy" (score 10). The main outcome measures were feasibility, reliability, validity, and responsiveness of the FAS. RESULTS A total of 228 children were included with an average (SD) age of 6.3 (5.4) months. Completing the FAS was feasible for caregivers and nurses, with no floor or ceiling effects. Test-retest reliability was moderate for caregivers (intraclass correlation coefficient [ICC] 2,1 0.73; 95% confidence interval [CI] 0.63-0.80) and good for nurses (ICC 2,1 0.75; 95% CI 0.62-0.83). Interrater reliability between 1 caregiver and 1 nurse was moderate (ICC 1,1 0.55; 95% CI 0.45-0.64). For construct validity, the FAS was negatively associated with length of hospital stay and positively associated with both caregiver and nurse readiness for discharge scores (P values <.0001). The FAS demonstrated clinical improvement from the first FAS score at admission to the last FAS score at discharge, with significant differences between scores for both caregivers and nurses (P values for paired t test <.0001). CONCLUSIONS These results provide evidence of the feasibility, reliability, validity, and responsiveness of caregiver-completed and nurse-completed FAS as a measure of feeding adequacy in children hospitalized with bronchiolitis.
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Affiliation(s)
- Agnes Sebastian
- Temerty Faculty of Medicine
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cornelia M Borkhoff
- Division of Paediatric Medicine, Department of Pediatrics
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gita Wahi
- Division of General Pediatrics, Department of Pediatrics, McMaster University and McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Lucy Giglia
- Division of General Pediatrics, Department of Pediatrics, McMaster University and McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Ann Bayliss
- Children's Health Division, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Ronik Kanani
- Department of Pediatrics, North York General Hospital, Toronto, Ontario, Canada
| | - Catherine M Pound
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Mahmoud Sakran
- Department of Pediatrics, Lakeridge Health, Oshawa, and Queens University, Kingston, Ontario, Canada
| | - Karen Breen-Reid
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Peter J Gill
- Temerty Faculty of Medicine
- Division of Paediatric Medicine, Department of Pediatrics
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Patricia C Parkin
- Temerty Faculty of Medicine
- Division of Paediatric Medicine, Department of Pediatrics
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sanjay Mahant
- Temerty Faculty of Medicine
- Division of Paediatric Medicine, Department of Pediatrics
- Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
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15
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Ruppel H, O'Byrne ML, Foglia EE. Mitigating Risks for Racial Bias in Pulse Oximetry on Children-Reply. JAMA Pediatr 2023; 177:982-983. [PMID: 37459108 DOI: 10.1001/jamapediatrics.2023.2295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Affiliation(s)
- Halley Ruppel
- School of Nursing, Department of Family and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael L O'Byrne
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elizabeth E Foglia
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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16
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McCollum ED, Ahmed S, Roy AD, Islam AA, Schuh HB, King C, Hooli S, Quaiyum MA, Ginsburg AS, Checkley W, Baqui AH, Colbourn T. Risk and accuracy of outpatient-identified hypoxaemia for death among suspected child pneumonia cases in rural Bangladesh: a multifacility prospective cohort study. THE LANCET. RESPIRATORY MEDICINE 2023; 11:769-781. [PMID: 37037207 PMCID: PMC10469265 DOI: 10.1016/s2213-2600(23)00098-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 02/02/2023] [Accepted: 02/08/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Hypoxaemic pneumonia mortality risk in low-income and middle-income countries is high in children who have been hospitalised, but unknown among outpatient children. We sought to establish the outpatient burden, mortality risk, and prognostic accuracy of death from hypoxaemia in children with suspected pneumonia in Bangladesh. METHODS We conducted a prospective community-based cohort study encompassing three upazila (subdistrict) health complex catchment areas in Sylhet, Bangladesh. Children aged 3-35 months participating in a community surveillance programme and presenting to one of three upazila health complex Integrated Management of Childhood Illness (IMCI) outpatient clinics with an acute illness and signs of difficult breathing (defined as suspected pneumonia) were enrolled in the study; because lower respiratory tract infection mortality mainly occurs in children younger than 1 year, the primary study population comprised children aged 3-11 months. Study physicians recorded WHO IMCI pneumonia guideline clinical signs and peripheral arterial oxyhaemoglobin saturations (SpO2) in room air. They treated children with pneumonia with antibiotics (oral amoxicillin [40 mg/kg per dose twice per day for 5-7 days, as per local practice]), and recommended oxygen, parenteral antibiotics, and hospitalisation for those with an SpO2 of less than 90%, WHO IMCI danger signs, or severe malnutrition. Community health workers documented the children's vital status and the date of any vital status changes during routine household surveillance (one visit to each household every 2 months). The primary outcome was death at 2 weeks after enrolment in children aged 3-11 months (primary study population) and 12-35 months (secondary study population). Primary analyses included estimating the outpatient prevalence, mortality risk, and prognostic accuracy of hypoxaemia for death in children aged 3-11 months with suspected pneumonia. Risk ratios were produced by fitting a multivariable model that regressed predefined SpO2 ranges (<90%, 90-93%, and 94-100%) on the primary 2-week mortality outcome (binary outcome) using Poisson models with robust variance estimation. We established the prognostic accuracy of WHO IMCI guidelines for death with and without varying SpO2 thresholds. FINDINGS Participants were recruited between Sept 1, 2015, to Aug 31, 2017. During the study period, a total of 7440 children aged 3-35 months with the first suspected pneumonia episode were enrolled, of whom 3848 (54·3%) with an attempted pulse oximeter measurement and 2-week outcome were included in our primary study population of children aged 3-11-months. Among children aged 3-11 months, an SpO2 of less than 90% occurred in 102 (2·7%) of 3848 children, an SpO2 of 90-93% occurred in 306 (8·0%) children, a failed SpO2 measurement occurred in 67 (1·7%) children, and 24 (0·6%) children with suspected pneumonia died. Compared with an SpO2 of 94-100% (3373 [87·7%] of 3848), the adjusted risk ratio for death was 10·3 (95% CI 3·2-32·3; p<0·001) for an SpO2 of less than 90%, 4·3 (1·5-11·8; p=0·005) for an SpO2 of 90-93%, and 11·4 (3·1-41·4; p<0·001) for a failed measurement. When not considering pulse oximetry, of the children who died, WHO IMCI guidelines identified only 25·0% (95% CI 9·7-46·7; six of 24 children) as eligible for referral to hospital. For identifying deaths, in children with an SpO2 of less than 90% WHO IMCI guidelines had a 41·7% sensitivity (95% CI 22·1-63·4) and 89·7% specificity (88·7-90·7); for children with an SpO2 of less than 90% or measurement failure the guidelines had a 54·2% sensitivity (32·8-74·4) and 88·3% specificity (87·2-89·3); and for children with an SpO2 of less than 94% or measurement failure the guidelines had a 62·5% sensitivity (40·6-81·2) and 81·3% specificity (80·0-82·5). INTERPRETATION These findings support pulse oximeter use during the outpatient care of young children with suspected pneumonia in Bangladesh as well as the re-evaluation of the WHO IMCI currently recommended threshold of an SpO2 less than 90% for hospital referral. FUNDING Fogarty International Center of the National Institutes of Health (K01TW009988), The Bill & Melinda Gates Foundation (OPP1084286 and OPP1117483), and GlaxoSmithKline (90063241).
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Affiliation(s)
- Eric D McCollum
- Global Program in Pediatric Respiratory Sciences, Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of International Health, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | | | | | | | - Holly B Schuh
- Department of Epidemiology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Shubhada Hooli
- Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Mohammad Abdul Quaiyum
- Projahnmo Research Foundation, Dhaka, Bangladesh; International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | - William Checkley
- Department of International Health, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Bloomberg School of Public Health, and Division of Pulmonary and Critical Care, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Center for Global Non-Communicable Disease Research and Training, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Abdullah H Baqui
- Department of International Health, International Center for Maternal and Newborn Health, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
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17
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Marlow JA, Kalburgi S, Gupta V, Shadman K, Webb NE, Chang PW, Ben Wang X, Frost PA, Flesher SL, Le MK, Shankar LG, Schroeder AR. Perspectives of Health Care Personnel on the Benefits of Bronchiolitis Interventions. Pediatrics 2023; 151:e2022059939. [PMID: 37183614 PMCID: PMC10233737 DOI: 10.1542/peds.2022-059939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 05/16/2023] Open
Abstract
OBJECTIVES Many interventions in bronchiolitis are low-value or poorly studied. Inpatient bronchiolitis management is multidisciplinary, with varying degrees of registered nurse (RN) and respiratory therapist (RT) autonomy. Understanding the perceived benefit of interventions for frontline health care personnel may facilitate deimplementation efforts. Our objective was to examine perceptions surrounding the benefit of common inpatient bronchiolitis interventions. METHODS We conducted a cross-sectional survey of inpatient pediatric RNs, RTs, and physicians/licensed practitioners (P/LPs) (eg, advanced-practice practitioners) from May to December of 2021 at 9 university-affiliated and 2 community hospitals. A clinical vignette preceded a series of inpatient bronchiolitis management questions. RESULTS A total of 331 surveys were analyzed with a completion rate of 71.9%: 76.5% for RNs, 57.4% for RTs, and 71.2% for P/LPs. Approximately 54% of RNs and 45% of RTs compared with 2% of P/LPs believe albuterol would be "extremely or somewhat likely" to improve work of breathing (P < .001). Similarly, 52% of RNs, 32% of RTs, and 23% of P/LPs thought initiating or escalating oxygen in the absence of hypoxemia was likely to improve work of breathing (P < .001). Similar differences in perceived benefit were observed for steroids, nebulized hypertonic saline, and deep suctioning, but not superficial nasal suctioning. Hospital type (community versus university-affiliated) did not impact the magnitude of these differences. CONCLUSIONS Variation exists in the perceived benefit of several low-value or poorly studied bronchiolitis interventions among health care personnel, with RNs/RTs generally perceiving higher benefit. Deimplementation, educational, and quality improvement efforts should be designed with an interprofessional framework.
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Affiliation(s)
- Julia A. Marlow
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford School of Medicine, Palo Alto, California
| | - Sonal Kalburgi
- Division of Hospital Medicine, Children’s National Hospital, the George Washington School of Medicine and Health Sciences, Washington, District of Columbia
| | - Vedant Gupta
- Division of Pediatric Hospital Medicine, Phoenix Children’s Hospital, Phoenix, Arizona
| | - Kristin Shadman
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Wisconsin, School of Medicine and Public Health, Madison, Wisconsin
| | - Nicole E. Webb
- Division of Hospital Medicine, Valley Children’s Healthcare, Madera, California
| | - Pearl W. Chang
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Seattle Children’s Hospital, Seattle, Washington
| | - Xiao Ben Wang
- Division of Pediatric Hospital Medicine, Department of Pediatrics, UCLA Mattel Children’s Hospital, Los Angeles, California
| | - Patricia A. Frost
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Susan L. Flesher
- Department of Pediatrics, Joan C. Edwards Marshall University School of Medicine, Huntington, West Virginia
| | - Matthew K. Le
- Pediatric Hospital Medicine, Department of Pediatrics, Oklahoma Children’s Hospital, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Lavanya G Shankar
- Division of Hospital Medicine Outreach, Ann & Robert Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Alan R. Schroeder
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford School of Medicine, Palo Alto, California
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18
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Rodriguez-Martinez CE, Sossa-Briceño MP, Nino G. Oxygen saturation thresholds for bronchiolitis at high altitudes: a cost-effectiveness analysis. Expert Rev Pharmacoecon Outcomes Res 2023; 23:527-533. [PMID: 36922366 DOI: 10.1080/14737167.2023.2192482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND There is evidence suggesting that exaggerated reliance on pulse oximetry (SpO2) and the use of arbitrary/inadequate thresholds of SpO2 might drive unnecessary hospitalizations for viral bronchiolitis, especially among high-altitude residents. The aim of the present study was to compare the cost-effectiveness of two oxygen SpO2 thresholds for deciding whether infants with viral bronchiolitis living at high altitudes need hospital admission or can be discharged home. METHODS A cost-effectiveness study was performed to compare the cost and clinical outcomes of two oxygen SpO2 thresholds, adjusted or not, to an altitude above the sea level of Bogota, Colombia (2640 m), for deciding whether infants with viral bronchiolitis need hospitalization or can be discharged home. The principal outcome was avoidance of hospital admission. RESULTS Compared to the use of an SpO2 threshold of 90%, using an SpO2 threshold of 85% in infants with viral bronchiolitis was associated with lower overall costs (US$130.4 vs. US$194.0 average cost per patient) and a higher probability of hospitalization avoided (0.7500 vs. 0.5900), thus leading to dominance. CONCLUSIONS The use of an SpO2 threshold below 90% for deciding on hospitalization in infants with viral bronchiolitis living at high altitudes appears to be logical, secure, and cost-effective.
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Affiliation(s)
- Carlos E Rodriguez-Martinez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia
- Department of Pediatric Pulmonology, School of Medicine, Universidad El Bosque, Bogota, Colombia
| | - Monica P Sossa-Briceño
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Gustavo Nino
- Division of Pediatric Pulmonary, Sleep Medicine and Integrative Systems Biology. Center for Genetic Research, Children's National Medical Center, George Washington University, Washington, United States
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19
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Sharma KP. Temporary hypoxemia at high altitude in an intensive care unit physician. SAGE Open Med Case Rep 2023; 11:2050313X231153526. [PMID: 36776206 PMCID: PMC9909067 DOI: 10.1177/2050313x231153526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/11/2023] [Indexed: 02/10/2023] Open
Abstract
A 42-year-old pediatric intensive care unit physician traveled to Nepal and took a helicopter trip to Everest Base Camp. The helicopter reached an altitude of 5500 m during flight and descended at different destinations with varying altitudes. At Hotel Everest View at 3820 m, his oxygen saturation was 79%. He had mild tachypnea and deep breathing but was able to walk around, jump, and take photographs. He returned to Kathmandu (altitude, 1324 m) without using any supplemental oxygen during the entire trip. Based on calculations with the alveolar gas equation, he observed that he and his fellow passengers probably had hypoxemia during the trip. In summary, temporary hypoxemia associated with high altitude in healthy individuals without cardiorespiratory compromise may not require oxygen therapy. In contrast, intensive care unit patients who have respiratory failure may have similar oxygen saturation levels but may require oxygen therapy and mechanical ventilation. The oxygen saturation level must be interpreted in consideration of the clinical scenario before deciding about the need for oxygen therapy.
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Affiliation(s)
- Kamal P Sharma
- Kamal P Sharma, Children & Women’s Hospital, University of South Alabama College of Medicine, 1700 Center Street, Mobile, AL 36604, USA.
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20
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The Local and Systemic Exposure to Oxygen in Children With Severe Bronchiolitis on Invasive Mechanical Ventilation: A Retrospective Cohort Study. Pediatr Crit Care Med 2023; 24:e115-e120. [PMID: 36661429 PMCID: PMC9848215 DOI: 10.1097/pcc.0000000000003130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Oxygen supplementation is a cornerstone treatment in critically ill children with bronchiolitis in the PICU. However, potential deleterious effects of high-dose oxygen are well-known. In this study, we aim to describe the pulmonary (local) and arterial (systemic) oxygen exposure over the duration of invasive mechanical ventilation (IMV) in children with severe bronchiolitis. Our secondary aim was to estimate potentially avoidable exposure to high-dose oxygen in these patients. DESIGN Retrospective cohort study. SETTING Single-center, tertiary-care PICU. PATIENTS Children younger than 2 years old admitted to the PICU for severe bronchiolitis receiving IMV. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Hourly measurements of Fio2 and peripheral oxygen saturation (Spo2), and arterial blood gas data were collected up to day 10 of IMV. A total of 24,451 hours of IMV were observed in 176 patients (median age of 1.0 mo [interquartile range (IQR), 1.0-2.3 mo]). The pulmonary exposure to oxygen was highest during the first day of IMV (median time-weighted average [TWA]-Fio2 0.46 [IQR, 0.39-0.53]), which significantly decreased over subsequent days. The systemic exposure to oxygen was relatively low, as severe hyperoxemia (TWA-Pao2 > 248 Torr [> 33 kPa]) was not observed. However, overuse of oxygen was common with 52.3% of patients (n = 92) having at least 1 day of possible excessive oxygen exposure and 14.8% (n = 26) with severe exposure. Furthermore, higher oxygen dosages correlated with increasing overuse of oxygen (rrepeated measures, 0.59; 95% CI, 0.54-0.63). Additionally, caregivers were likely to keep Fio2 greater than or equal to 0.50 when Spo2 greater than or equal to 97%. CONCLUSIONS Moderate to high-dose pulmonary oxygen exposure and potential overuse of oxygen were common in this cohort of severe bronchiolitis patients requiring IMV; however, this was not accompanied by a high systemic oxygen burden. Further studies are needed to determine optimal oxygenation targets to prevent overzealous use of oxygen in this vulnerable population.
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21
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Rodriguez-Martinez CE, Sossa-Briceño MP, Antonio Buendia J. Comparison of two oxygen saturation targets to decide on hospital discharge of infants with viral bronchiolitis living at high altitudes: a cost-effectiveness analysis. Curr Med Res Opin 2022; 38:2047-2053. [PMID: 35993483 DOI: 10.1080/03007995.2022.2115774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES The objective of the current study was to evaluate the cost-effectiveness of two pulse oximetry (SpO2) thresholds to decide on hospital discharge when all other discharge criteria are met, in infants with viral bronchiolitis living at high altitudes. METHODS A decision analysis model was developed to estimate the cost-effectiveness of the use of an SpO2 threshold of 90% versus one of 85% for deciding whether infants hospitalized for viral bronchiolitis can be safely discharged to home, from a third-party payer's perspective. The main outcome was discharge to home at day 4 of the initial hospitalization. The time horizon was 28 days after discharge from hospital. We performed deterministic sensitivity analyses and probabilistic sensitivity analyses. RESULTS Compared to the use of an SpO2 threshold of 90%, treating infants with viral bronchiolitis with the use of an SpO2 threshold of 85% resulted in lower total costs (US$119.39 vs. US$188.357 mean cost per patient) and a greater probability of discharge to home at day 4 of the initial hospitalization (0.8400 vs. 0.7600), therefore being a dominant strategy. Sensitivity analyses were in line with base case results. CONCLUSIONS In Bogota, a high-altitude city, in infants admitted for viral bronchiolitis, the use of an SpO2 threshold of 85% to decide on hospital discharge when all other discharge criteria are met is dominant because it entails a greater probability of discharge to home at day 4 of the initial hospitalization and generates fewer costs than the use of an SpO2 threshold of 90%.
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Affiliation(s)
- Carlos E Rodriguez-Martinez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia
- Department of Pediatric Pulmonology, School of Medicine, Universidad El Bosque, Bogota, Colombia
| | - Monica P Sossa-Briceño
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia
| | - Jefferson Antonio Buendia
- Department of Pharmacology and Toxicology, School of Medicine, Research Group in Pharmacology and Toxicology (INFARTO), Universidad de Antioquia, Medellín, Colombia
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22
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Roland D, Williams T, Lyttle MD, Marlow R, Hardelid P, Sinha I, Swann O, Maxwell-Hodkinson A, Cunningham S. Features of the transposed seasonality of the 2021 RSV epidemic in the UK and Ireland: analysis of the first 10 000 patients. Arch Dis Child 2022; 107:1062-1063. [PMID: 36261149 DOI: 10.1136/archdischild-2022-324241] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Damian Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester Royal Infirmary, Leicester, UK
- SAPPHIRE Group, Health Sciences, University of Leicester, Leicester, UK
| | - Thomas Williams
- Child Life and Health, University of Edinburgh, Edinburgh, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Robin Marlow
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
| | - Pia Hardelid
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Ian Sinha
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- Division of Child Health, University of Liverpool, Liverpool, UK
| | - Olivia Swann
- Child Life and Health, University of Edinburgh, Edinburgh, UK
- Department of Paediatric Infectious Diseases and Immunology, Royal Hospital for Children, Glasgow, UK
| | | | - Steve Cunningham
- Department of Paediatric Respiratory and Sleep Medicine, Royal Hospital for Sick Children, Edinburgh, UK
- Centre for Inflammation Research, The University of Edinburgh, Edinburgh, UK
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23
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Elks M, Young J, Kearney L, Bernard A. The impact of an autonomous nurse-led high-flow nasal cannula oxygen protocol on clinical outcomes of infants with bronchiolitis. J Clin Nurs 2022. [PMID: 36164265 DOI: 10.1111/jocn.16525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 08/01/2022] [Accepted: 08/14/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the relationship of the implementation of a nurse-led high-flow nasal cannula oxygen protocol on the clinical outcomes of infants with bronchiolitis in a regional paediatric unit. BACKGROUND Bronchiolitis is a common lower respiratory illness and is the leading cause for hospitalisation of infants globally. Standard care involves the provision of supportive measures. Historically, supplemental oxygen was provided by low-flow nasal cannula. High-flow nasal cannula oxygen has been increasingly adopted despite limited evidence of its efficacy. METHODS This study employed non-equivalent, post-implementation only design to explore clinical outcomes of infants with bronchiolitis admitted for high-flow nasal cannula oxygen therapy. The study compared infants in the 24 months before and after the initiation of a high-flow nasal cannula protocol. The primary clinical outcome was length of stay, secondary outcomes included time on high flow, weaning time, escalation of care and time outside of physiological parameters. Implementation strategy evaluation was measured by compliance with applying the protocol, reported as episodes of variance, and duration of variance. The StaRI checklist was selected as the most appropriate reporting guideline. RESULTS A total of 80 patients were admitted with bronchiolitis and received high-flow nasal cannula oxygen therapy during a 48-month period; 37 patients were prior, and 43 after, the introduction of a nurse-led high-flow nasal cannula protocol. Length of stay was significantly reduced in the post-implementation group compared to the historical control group (83.8 vs. 61.3 h). Time on high flow and weaning time was decreased in the post-implementation group compared to the control group (33.5 vs. 26.7 h and 26 vs.12.25 h, respectively); however, these did not reach statistical significance. There was varied application of the HFNC protocol. CONCLUSIONS The implementation of a nurse-led high-flow nasal cannula protocol was associated with a reduced length of stay. RELEVANCE TO CLINICAL PRACTICE This study demonstrated that infants with bronchiolitis that were treated with a nurse-led high-flow nasal cannula (HFNC) therapy protocol had positive effects on clinical outcomes including a shorter length of stay than compared with those with physician-directed care in a regional paediatric unit. A weight-based (2 L/kg) HFNC therapy was safely administered to infants with bronchiolitis in a regional hospital paediatric ward with no paediatric intensive care unit (PICU).
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Affiliation(s)
- Michelle Elks
- Sunshine Coast Hospital and Health Service, University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
| | - Jeanine Young
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
| | - Lauren Kearney
- School of Nursing, Midwifery & Paramedicine University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
| | - Anne Bernard
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia
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24
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Chang I, Thomas K, O'Neill Gutierrez L, Peters S, Agbeko R, Au C, Draper E, Jones GAL, Major LE, Orzol M, Pappachan J, Ramnarayan P, Ray S, Sadique Z, Gould DW, Harrison DA, Rowan KM, Mouncey PR, Peters MJ. Protocol for a Randomized Multiple Center Trial of Conservative Versus Liberal Oxygenation Targets in Critically Ill Children (Oxy-PICU): Oxygen in Pediatric Intensive Care. Pediatr Crit Care Med 2022; 23:736-744. [PMID: 35699737 PMCID: PMC9426735 DOI: 10.1097/pcc.0000000000003008] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Oxygen administration is a fundamental part of pediatric critical care, with supplemental oxygen offered to nearly every acutely unwell child. However, optimal targets for systemic oxygenation are unknown. Oxy-PICU aims to evaluate the clinical effectiveness and cost-effectiveness of a conservative peripheral oxygen saturation (Sp o2 ) target of 88-92% compared with a liberal target of more than 94%. DESIGN Pragmatic, open, multiple-center, parallel group randomized control trial with integrated economic evaluation. SETTING Fifteen PICUs across England, Wales, and Scotland. PATIENTS Infants and children age more than 38 week-corrected gestational age to 16 years who are accepted to a participating PICU as an unplanned admission and receiving invasive mechanical ventilation with supplemental oxygen for abnormal gas exchange. INTERVENTION Adjustment of ventilation and inspired oxygen settings to achieve an Sp o2 target of 88-92% during invasive mechanical ventilation. MEASUREMENTS AND MAIN RESULTS Randomization is 1:1 to a liberal Sp o2 target of more than 94% or a conservative Sp o2 target of 88-92% (inclusive), using minimization with a random component. Minimization will be performed on: age, site, primary reason for admission, and severity of abnormality of gas exchange. Due to the emergency nature of the treatment, approaching patients for written informed consent will be deferred to after randomization. The primary clinical outcome is a composite of death and days of organ support at 30 days. Baseline demographics and clinical status will be recorded as well as daily measures of oxygenation and organ support, and discharge outcomes. This trial received Health Research Authority approval on December 23, 2019 (reference: 272768), including a favorable ethical opinion from the East of England-Cambridge South Research Ethics Committee (reference number: 19/EE/0362). Trial findings will be disseminated in national and international conferences and peer-reviewed journals.
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Affiliation(s)
- Irene Chang
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Karen Thomas
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Lauran O'Neill Gutierrez
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Sam Peters
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Rachel Agbeko
- Department of Paediatric Intensive Care, Great North Children's Hospital, The Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Carly Au
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Elizabeth Draper
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Gareth A L Jones
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- Respiratory Critical Care and Anaesthesia Unit, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | | | - Marzena Orzol
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - John Pappachan
- Paediatric Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Padmanabhan Ramnarayan
- Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, United Kingdom
| | - Samiran Ray
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- Respiratory Critical Care and Anaesthesia Unit, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Doug W Gould
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Mark J Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- Respiratory Critical Care and Anaesthesia Unit, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
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25
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Dalziel SR, Haskell L, O'Brien S, Borland ML, Plint AC, Babl FE, Oakley E. Bronchiolitis. Lancet 2022; 400:392-406. [PMID: 35785792 DOI: 10.1016/s0140-6736(22)01016-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 03/27/2022] [Accepted: 05/26/2022] [Indexed: 02/06/2023]
Abstract
Viral bronchiolitis is the most common cause of admission to hospital for infants in high-income countries. Respiratory syncytial virus accounts for 60-80% of bronchiolitis presentations. Bronchiolitis is diagnosed clinically without the need for viral testing. Management recommendations, based predominantly on high-quality evidence, advise clinicians to support hydration and oxygenation only. Evidence suggests no benefit with use of glucocorticoids or bronchodilators, with further evidence required to support use of hypertonic saline in bronchiolitis. Evidence is scarce in the intensive care unit. Evidence suggests use of high-flow therapy in bronchiolitis is limited to rescue therapy after failure of standard subnasal oxygen only in infants who are hypoxic and does not decrease rates of intensive care unit admission or intubation. Despite systematic reviews and international clinical practice guidelines promoting supportive rather than interventional therapy, universal de-implementation of interventional care in bronchiolitis has not occurred and remains a major challenge.
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Affiliation(s)
- Stuart R Dalziel
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand; Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.
| | - Libby Haskell
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand; Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
| | - Sharon O'Brien
- Emergency Department, Perth Children's Hospital, Perth, WA, Australia; School of Nursing, Curtin University, Perth, WA, Australia
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, WA, Australia; Division of Paediatrics, School of Medicine, University of Western Australia, Perth, WA, Australia; Division of Emergency Medicine, School of Medicine, University of Western Australia, Perth, WA, Australia
| | - Amy C Plint
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada; Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Emergency Department, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Franz E Babl
- Department of Emergency Medicine, Royal Children's Hospital, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Ed Oakley
- Department of Emergency Medicine, Royal Children's Hospital, Melbourne, VIC, Australia; Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia
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26
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Gourishankar A, Evangelista M, Ellsworth M, Hsu J. Utility and Impact Analysis of Inpatient Pediatric Physiologic Monitoring. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1749679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
AbstractThis study aimed to study the practice and effect of monitoring hospitalized pediatric patients in terms the length of stay (LOS). We have performed a prospective, observational study of pediatric patients in the general ward from October to December 2016. We have recorded the use of cardiac monitor, pulse oximeter, or both, and as per physician order at patient admission. We have studied the proportions of monitoring in different patient groups. We have applied a linear regression model to investigate the relationship between LOS and cardiopulmonary monitoring, orders, and medical complexity. Among 399 patients, patients with cardiac and pulse oximeter monitoring with orders were 68 and 82%, respectively. The pulmonary group had more monitoring than the neurology group of patients. LOS was shorter in patients without monitoring; the median difference for the cardiac monitoring was one day (interquartile range [IQR] = 1), and the pulse oximeter was 0.5 days (IQR = 1). Cardiac monitoring order increased LOS by 22% (95% confidence interval [CI]: 0.5, 48%) and complex past medical history increased it by 25% (95% CI: 4, 51%). Our study highlights the variable practice in using monitors, emphasizing a standardized approach. The judicious use of monitoring may reduce prolonged hospitalization. Selective use of physiologic monitoring of ill-appearing or at risk of hypoxemia or cardiac dysrhythmia will reduce overuse.
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Affiliation(s)
- Anand Gourishankar
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, United States
| | - Monaliza Evangelista
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Texas Health, McGovern Medical School at Houston, Texas, United States
| | - Misti Ellsworth
- Division of Pediatric Infectious Disease, Department of Pediatrics, University of Texas Health, McGovern Medical School at Houston, Texas, United States
| | - Jean Hsu
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, United States
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27
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Hartog K, Ardura-Garcia C, Hammer J, Kuehni CE, Barben J. Acute bronchiolitis in Switzerland - Current management and comparison over the last two decades. Pediatr Pulmonol 2022; 57:734-743. [PMID: 34889073 DOI: 10.1002/ppul.25786] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 11/02/2021] [Accepted: 12/07/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Although international guidelines and Cochrane reviews emphasize that therapies do not alter the natural course of acute viral bronchiolitis (AVB), they are still prescribed frequently. This survey evaluated self-reported management of AVB by Swiss pediatricians in 2019 and compared it with previous surveys. METHODS We performed a cross-sectional online survey of all board-certified pediatricians in Switzerland in November 2019 and compared the reported use of therapies with that reported in the 2001 and 2006 surveys. We used multivariable ordered logistic regression to assess factors associated with reported prescription of bronchodilators, corticosteroids, antibiotics, and physiotherapy. RESULTS Among 1618 contacted board-certified pediatricians, 884 returned the questionnaires (55% response rate). After exclusions were applied, 679 were included in the final analysis. Pediatricians working in primary care reported using therapeutics more frequently than those working in a hospital setting, either always or sometimes: bronchodilators 53% versus 38%, corticosteroids 37% versus 23%, and antibiotics 39% versus 22%. The opposite occurred with physiotherapy: 53% reported prescribing it in hospital and 44% in primary care. There was an overall decrease in the prescription of therapeutics and interventions for AVB from 2001 to 2019. The proportion who reported "always" prescribing corticosteroids decreased from 71% to 2% in primary care, and of those "always" prescribing bronchodilators from 55% to 1% in hospitals. CONCLUSION Although we observed a significant decrease since 2001, more effort is required to reduce the use of unnecessary therapies in children with AVB.
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Affiliation(s)
- Katharina Hartog
- Division of Pediatric Pulmonology, Children's Hospital of Eastern Switzerland, St Gallen, Switzerland
| | | | - Jürg Hammer
- Division of Respiratory and Critical Care, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Claudia E Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Division of Respiratory Medicine, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jürg Barben
- Division of Pediatric Pulmonology, Children's Hospital of Eastern Switzerland, St Gallen, Switzerland
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28
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Ranganathan P, Pramesh CS, Aggarwal R. Equivalence trials. Perspect Clin Res 2022; 13:114-117. [PMID: 35573452 PMCID: PMC9106130 DOI: 10.4103/picr.picr_55_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 02/24/2022] [Indexed: 11/24/2022] Open
Abstract
In an equivalence trial, researchers aim to show that a new intervention is more or less similar to an existing standard of care, i.e., the two are “equivalent”. In this article, we discuss some aspects of the design, analysis, interpretation and reporting of equivalence trials.
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29
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Nagakura A, Morikawa Y, Takasugi N, Funakoshi H, Miura Y, Ota T, Shimizu A, Shimizu K, Shirane S, Hataya H. Oxygen saturation targets in pediatric respiratory disease. Pediatr Int 2022; 64:e15129. [PMID: 35616158 DOI: 10.1111/ped.15129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 12/09/2021] [Accepted: 01/11/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The present study aimed to assess the appropriate oxygen saturation target in patients with pediatric respiratory diseases by lowering the oxygen saturation target from SpO2 94% to 90%. No previous study has explored appropriate oxygen saturation targets in respiratory diseases other than bronchiolitis. METHODS The present, prospective, single-arm intervention trial enrolled pediatric inpatients with bronchiolitis, bronchitis, pneumonia, and asthma. The oxygen saturation target was lowered from SpO2 94% to 90% after the patients' general condition improved. The patients continued to be observed for 12 h after achieving SpO2 94%. The duration from the first cut-off point (SpO2 90% for 12 h without oxygen) to the second cut-off point (SpO2 94% for 12 h) was then evaluated. RESULTS In total, 248 patients completed the study. Patients with bronchiolitis, bronchitis, pneumonia, and asthma had an interval between the two cut-off points of 23.9, 15.5, 19.1, and 13.8 h, respectively, (mean 17.2 h; 95% confidence interval 15.0-19.5). CONCLUSIONS In generally healthy children, setting the oxygen saturation target at SpO2 90% after confirming improvement in their general condition was safe. The time required for increasing SpO2 from 90% to 94% was longest in the patients with bronchiolitis.
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Affiliation(s)
- Akito Nagakura
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yoshihiko Morikawa
- Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Nao Takasugi
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hanako Funakoshi
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yoko Miura
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Tomomi Ota
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Ayumi Shimizu
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Keisuke Shimizu
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Shoichiro Shirane
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hiroshi Hataya
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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Bottau P, Liotti L, Laderchi E, Palpacelli A, Calamelli E, Colombo C, Serra L, Cazzato S. Something Is Changing in Viral Infant Bronchiolitis Approach. Front Pediatr 2022; 10:865977. [PMID: 35498813 PMCID: PMC9047867 DOI: 10.3389/fped.2022.865977] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/23/2022] [Indexed: 11/13/2022] Open
Abstract
Acute Viral Bronchiolitis is one of the leading causes of hospitalization in the first 12-24 months of life. International guidelines on the management of bronchiolitis broadly agree in recommending a minimal therapeutic approach, not recommending the use of bronchodilators. Guidelines, generally, consider bronchiolitis as a "unique disease" and this runs the risk of not administering therapy in some patients who could benefit from the use of bronchodilators, for instance, in those who will develop asthma later in their life and face first episode in the age of bronchiolitis. Today, there is growing evidence that bronchiolitis is not a single illness but can have different "endotypes" and "phenotypes," based on age, personal or family history of atopy, etiology, and pathophysiological mechanism. There is evidence that some phenotypes of bronchiolitis are more strongly associated with asthma features and are linked to higher risk for asthma development. In these populations, possible use of bronchodilators might have a better impact. Age seems to be the main feature to suggest a good response to a bronchodilator-trial, because, among children > 6 months old with bronchiolitis, the presence of a subset of patients with virus-induced wheezing or the first episode of asthma is more likely. While waiting for new research to define the relationship between therapeutic options and different phenotypes, a bronchodilator-trial (using short-acting β2 agonists with metered-dose inhalers and valved holding chambers) seems appropriate in every child with bronchiolitis and age > 6 months.
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Affiliation(s)
- Paolo Bottau
- Pediatric and Neonatology Unit, Imola Hospital, Imola, Italy
| | - Lucia Liotti
- Pediatric Unit, Department of Mother and Child Health, Salesi Children's Hospital, Ancona, Italy
| | - Eleonora Laderchi
- Postgraduate School of Pediatrics, University of Bologna, Bologna, Italy
| | - Alessandra Palpacelli
- Pediatric Unit, Department of Mother and Child Health, Salesi Children's Hospital, Ancona, Italy
| | | | - Carlotta Colombo
- Postgraduate School of Pediatrics, University of Bologna, Bologna, Italy
| | - Laura Serra
- Pediatric and Neonatology Unit, Imola Hospital, Imola, Italy
| | - Salvatore Cazzato
- Pediatric Unit, Department of Mother and Child Health, Salesi Children's Hospital, Ancona, Italy
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Manti S, Licari A, Brambilla I, Caffarelli C, Calvani M, Cardinale F, Ciprandi G, Cravidi C, Duse M, Martelli A, Minasi D, Miraglia Del Giudice M, Pajno GB, Tosca MA, Chiappini E, Baraldi E, Marseglia G. Agreements and controversies of national guidelines for bronchiolitis: Results from an Italian survey. Immun Inflamm Dis 2021; 9:1229-1236. [PMID: 34677899 PMCID: PMC8589388 DOI: 10.1002/iid3.451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/01/2021] [Accepted: 04/26/2021] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Significant variations in the management of bronchiolitis are often recorded, and, in parallel, to recommend a univocal clinical approach is challenging and still questioned. This study is aimed to evaluate the diagnostic and therapeutic management of bronchiolitis in children adopted by Italian pediatricians following the national guidelines. MATERIAL AND METHODS A survey study was designed and carried out by sending an email an open-ended questionnaire developed by an expert panel of the Scientific Board of the Italian Society of Pediatric Allergology and Immunology (SIAIP). Questions were designed according to the national intersociety consensus document on treatment and prevention of bronchiolitis in newborns and infants. RESULTS Overall, 234 pediatricians were taking part in the study. When diagnosing bronchiolitis, only 44.01% (103/234) of participants correctly followed the national guidelines. All participants (100%) would perform laboratory tests and/or radiological exams. 44.01% administered oxygen (O2 ) when O2 saturation was minor than 92%. About the therapeutic regimen, marked discrepancies between national guidelines and recorded answers were reported. Indications for hospital admission and discharge criteria were in line with the national guidelines. CONCLUSIONS There is a significant practice variation in the management of acute bronchiolitis among Italian physicians. Some wrong attitudes need to be further discouraged, such use of diagnostic procedures and therapeutic approaches. Further research is urgently required to define the best management of patients with bronchiolitis and implement strategies to standardize care and improve the quality of care.
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Affiliation(s)
- Sara Manti
- Dipartimento di Medicina Clinica e SperimentaleUnità di Broncopneumologia Pediatrica, Università di CataniaCataniaItaly
| | - Amelia Licari
- Clinica Pediatrica, Fondazione IRCCS Policlinico “S. Matteo,” Università di PaviaPaviaItaly
| | - Ilaria Brambilla
- Clinica Pediatrica, Fondazione IRCCS Policlinico “S. Matteo,” Università di PaviaPaviaItaly
| | - Carlo Caffarelli
- Clinica Pediatrica, Dipartimento di Medicina e ChirurgiaUniversità di ParmaParmaItaly
| | - Mauro Calvani
- Dipartimento di PediatriaOspedale S. Camillo‐ForlaniniRomaItaly
| | - Fabio Cardinale
- UOC Pediatria, Servizio di Allergologia e Pneumologia Pediatrica, Azienda Ospedaliera‐Universitaria “Consorziale‐Policlinico,” Ospedale Pediatrico Giovanni XXIIIBariItaly
| | | | | | - Marzia Duse
- Dipartimento di Pediatria, Policlinico Umberto I, Università Sapienza di RomaRomaItaly
| | - Alberto Martelli
- UOC Pediatria, Azienda Ospedaliera G. Salvini, Ospedali di Garbagnate Milanese e BollateMilanoItaly
| | - Domenico Minasi
- UOC Pediatria, Grande Ospedale MetropolitanoReggio CalabriaItaly
| | - Michele Miraglia Del Giudice
- Dipartimento della Donna, del Bambino e di Chirurgia Generale e Specialistica, Università della Campania Luigi VanvitelliNapoliItaly
| | - Giovan B. Pajno
- Dipartimento di Pediatria, Unità di Allergologia, Università di MessinaMessinaItaly
| | - Maria A. Tosca
- Allergologia Pediatrica, Istituto Giannina GasliniGenovaItaly
| | - Elena Chiappini
- SODc Malattie Infettive AOU Meyer, Dipartimento di Scienze della SaluteUniversità di FirenzeFirenzeItaly
| | - Eugenio Baraldi
- Dipartimento della Donna e del BambinoUniversità di PadovaPadovaItaly
| | - Gianluigi Marseglia
- Clinica Pediatrica, Fondazione IRCCS Policlinico “S. Matteo,” Università di PaviaPaviaItaly
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Schondelmeyer AC, Bettencourt AP, Xiao R, Beidas RS, Wolk CB, Landrigan CP, Brady PW, Brent CR, Parthasarathy P, Kern-Goldberger AS, Sergay N, Lee V, Russell CJ, Prasto J, Zaman S, McQuistion K, Lucey K, Solomon C, Garcia M, Bonafide CP. Evaluation of an Educational Outreach and Audit and Feedback Program to Reduce Continuous Pulse Oximetry Use in Hospitalized Infants With Stable Bronchiolitis: A Nonrandomized Clinical Trial. JAMA Netw Open 2021; 4:e2122826. [PMID: 34473258 PMCID: PMC8414187 DOI: 10.1001/jamanetworkopen.2021.22826] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE National guidelines recommend against continuous pulse oximetry use for hospitalized children with bronchiolitis who are not receiving supplemental oxygen, yet guideline-discordant use remains high. OBJECTIVES To evaluate deimplementation outcomes of educational outreach and audit and feedback strategies aiming to reduce guideline-discordant continuous pulse oximetry use in children hospitalized with bronchiolitis who are not receiving supplemental oxygen. DESIGN, SETTING, AND PARTICIPANTS A nonrandomized clinical single-group deimplementation trial was conducted in 14 non-intensive care units in 5 freestanding children's hospitals and 1 community hospital from December 1, 2019, through March 14, 2020, among 847 nurses and physicians caring for hospitalized children with bronchiolitis who were not receiving supplemental oxygen. INTERVENTIONS Educational outreach focused on communicating details of the existing guidelines and evidence. Audit and feedback strategies included 2 formats: (1) weekly aggregate data feedback to multidisciplinary teams with review of unit-level and hospital-level use of continuous pulse oximetry, and (2) real-time 1:1 feedback to clinicians when guideline-discordant continuous pulse oximetry use was discovered during in-person data audits. MAIN OUTCOMES AND MEASURES Clinician ratings of acceptability, appropriateness, feasibility, and perceived safety were assessed using a questionnaire. Guideline-discordant continuous pulse oximetry use in hospitalized children was measured using direct observation of a convenience sample of patients with bronchiolitis who were not receiving supplemental oxygen. RESULTS A total of 847 of 1193 eligible clinicians (695 women [82.1%]) responded to a Likert scale-based questionnaire (71% response rate). Most respondents rated the deimplementation strategies of education and audit and feedback as acceptable (education, 435 of 474 [92%]; audit and feedback, 615 of 664 [93%]), appropriate (education, 457 of 474 [96%]; audit and feedback, 622 of 664 [94%]), feasible (education, 424 of 474 [89%]; audit and feedback, 557 of 664 [84%]), and safe (803 of 847 [95%]). Sites collected 1051 audit observations (range, 47-403 per site) on 709 unique patient admissions (range, 31-251 per site) during a 3.5-month period of continuous pulse oximetry use in children with bronchiolitis not receiving supplemental oxygen, which were compared with 579 observations (range, 57-154 per site) from the same hospitals during the baseline 4-month period (prior season) to determine whether the strategies were associated with a reduction in use. Sites conducted 148 in-person educational outreach and aggregate data feedback sessions and provided real-time 1:1 feedback 171 of 236 times (72% of the time when guideline-discordant monitoring was identified). Adjusted for age, gestational age, time since weaning from supplemental oxygen, and other characteristics, guideline-discordant continuous pulse oximetry use decreased from 53% (95% CI, 49%-57%) to 23% (95% CI, 20%-25%) (P < .001) during the intervention period. There were no adverse events attributable to reduced monitoring. CONCLUSIONS AND RELEVANCE In this nonrandomized clinical trial, educational outreach and audit and feedback deimplementation strategies for guideline-discordant continuous pulse oximetry use among hospitalized children with bronchiolitis who were not receiving supplemental oxygen were positively associated with clinician perceptions of feasibility, acceptability, appropriateness, and safety. Evaluating the sustainability of deimplementation beyond the intervention period is an essential next step. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04178941.
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Affiliation(s)
- Amanda C. Schondelmeyer
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Amanda P. Bettencourt
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor
| | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Rinad S. Beidas
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia
| | - Courtney Benjamin Wolk
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia
| | - Christopher P. Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Departments of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Patrick W. Brady
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Canita R. Brent
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Padmavathy Parthasarathy
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Andrew S. Kern-Goldberger
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nathaniel Sergay
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Pediatric Residency Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Vivian Lee
- Division of Hospital Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles
| | - Christopher J. Russell
- Division of Hospital Medicine, Children’s Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles
| | - Julianne Prasto
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Division of Pediatrics, Children’s Hospital of Philadelphia Pediatric Care and Penn Medicine Princeton Medical Center, Philadelphia, Pennsylvania
| | - Sarah Zaman
- Department of Pediatrics, University of Washington School of Medicine, Seattle
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington
| | - Kaitlyn McQuistion
- University of Washington Pediatric Residency Program, Department of Pediatrics, University of Washington, Seattle
| | - Kate Lucey
- Division of Hospital Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Courtney Solomon
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas
- Division of Pediatric Hospital Medicine, Children’s Health Dallas, Texas
| | - Mayra Garcia
- Division of General and Thoracic Surgery, Children’s Health Dallas, Dallas, Texas
| | - Christopher P. Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Mendlowitz AB, Widjaja E, Phan C, Sun Z, Moretti ME, Schuh S, Coyte PC, Hancock-Howard R, Freedman SB, Ungar WJ. A Cost Analysis of Pulse Oximetry as a Determinant in the Decision to Admit Infants With Mild to Moderate Bronchiolitis. Pediatr Emerg Care 2021; 37:e443-e448. [PMID: 30601347 DOI: 10.1097/pec.0000000000001664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES A previous randomized controlled trial showed that artificially elevating the pulse oximetry display resulted in fewer hospitalizations with no worse outcomes. This suggests that management decisions based mainly on pulse oximetry may unnecessarily increase health care costs. This study assessed the incremental cost of altered relative to true oximetry in infants with mild to moderate bronchiolitis. METHODS A cost analysis was undertaken from the health care system and societal perspectives using patient-level data from the randomized controlled trial, with a 5-day time horizon after emergency department visit. Infants aged 4 weeks to 12 months with mild to moderate bronchiolitis were randomized to pulse oximetry measurements with true or altered saturation values displayed by artificially increasing saturation 3% points above true values. Direct and indirect health care costs were measured. Sensitivity analyses were performed to assess parameter uncertainty. RESULTS From the health care system perspective, the average cost per patient was Can $1155 for altered oximetry and $1967 for true oximetry, with a net savings of $812. From a societal perspective, the average cost per patient was $1559 for altered oximetry and $2473 for true oximetry, with a net savings of $914. Probabilistic analyses demonstrated that altered oximetry remained the less costly study group, with an average savings of $810 (95% confidence interval, $748-$872) from the health care system perspective and $910 (95% confidence interval, $848-$973) from the societal system perspective. CONCLUSIONS Reliance on oximetry as a major determinant in the decision to hospitalize infants with mild to moderate bronchiolitis is associated with significantly greater costs.
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Affiliation(s)
- Andrew B Mendlowitz
- From the Institute of Health Policy, Management & Evaluation, University of Toronto
| | | | - Cathy Phan
- From the Institute of Health Policy, Management & Evaluation, University of Toronto
| | - Zhuolu Sun
- From the Institute of Health Policy, Management & Evaluation, University of Toronto
| | | | - Suzanne Schuh
- Department of Pediatric Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario
| | - Peter C Coyte
- From the Institute of Health Policy, Management & Evaluation, University of Toronto
| | | | - Stephen B Freedman
- Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta
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Shmueli E, Goldberg O, Mei-Zahav M, Stafler P, Bar-On O, Levine H, Steuer G, Mussaffi H, Gendler Y, Blau H, Prais D. Risk factors for respiratory syncytial virus bronchiolitis hospitalizations in children with chronic diseases. Pediatr Pulmonol 2021; 56:2204-2211. [PMID: 33913611 DOI: 10.1002/ppul.25435] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 04/04/2021] [Accepted: 04/14/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Respiratory syncytial virus (RSV) bronchiolitis is the most common lower respiratory tract disorder causing hospitalization in infants. Due to decreased hospitalization rates of premature infants following Palivizumab immune prophylaxis, the proportion of infants with chronic diseases not eligible for Palivizumab has increased. AIM To characterize infants hospitalized during 2014-2018 with RSV bronchiolitis, to compare between those with and without chronic conditions, and to identify risk factors for severe disease. METHODS This retrospective study analyzed demographic and clinical data of patients younger than 2 years admitted with bronchiolitis during four consecutive RSV seasons. RESULTS Of 1124 hospitalizations due to RSV bronchiolitis, 244 (22%) were in infants with chronic diseases. Although 20/1124 qualified for RSV prophylaxis, only eight received immune prophylaxis. Compared to otherwise healthy infants, children with chronic diseases had longer hospitalizations, median 4.8 days (interquartile range [IQR]: 3.4-8.3) versus 3.7 days (IQR: 2.7-5.1), p < .001; and higher pediatric intensive care unit (PICU) and readmission rates (9% vs. 4.5%, p = .007% and 3% vs. 1%, p = .055, respectively). Children with Down's syndrome comprised 2% of all hospitalizations, but 8% of PICU admissions; their median length of hospitalization was 10.7 days (IQR: 6.6-17.6). Respiratory tract malformations were present in 2% of hospitalizations, and comprised 4% of PICU admissions. CONCLUSION Among infants admitted with RSV bronchiolitis, those with chronic diseases had longer hospitalizations and higher rates of transfer to the PICU. Children with multiple comorbidities, and especially those with Down's syndrome, are at particularly high risk for severe hospitalization and may benefit from RSV immune prophylaxis.
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Affiliation(s)
- Einat Shmueli
- Pediatric Pulmonology Institute, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ori Goldberg
- Pediatric Pulmonology Institute, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Meir Mei-Zahav
- Pediatric Pulmonology Institute, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Patrick Stafler
- Pediatric Pulmonology Institute, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ophir Bar-On
- Pediatric Pulmonology Institute, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Hagit Levine
- Pediatric Pulmonology Institute, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Guy Steuer
- Pediatric Pulmonology Institute, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Huda Mussaffi
- Pediatric Pulmonology Institute, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yulia Gendler
- Department of Nursing, Ariel University, Ariel, Israel
| | - Hannah Blau
- Pediatric Pulmonology Institute, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dario Prais
- Pediatric Pulmonology Institute, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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35
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Napolitano N, Berlinski A, Walsh BK, Ginier E, Strickland SL. AARC Clinical Practice Guideline: Management of Pediatric Patients With Oxygen in the Acute Care Setting. Respir Care 2021; 66:1214-1223. [PMID: 33790048 DOI: 10.4187/respcare.09006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Oxygen therapy is one of the most important therapeutics offered in the clinical management of pediatric patients with cardiopulmonary disease. As the medical community seeks to ensure evidence-based management of clinical interventions, we conducted a systematic review with the goal of providing evidence-based clinical practice guidelines to answer questions surrounding the use of simple oxygen therapy to improve oxygenation, including a comparison of delivery devices, the efficacy of humidification, comparison of flows, and goals for use in children. Using a modification of the RAND/UCLA Appropriateness Method, we developed 4 recommendations to assist clinicians in the utilization of oxygen therapy in hospitalized children: (1) the use of an oxygen hood or tent in lieu of a low-flow oxygen device for consistent oxygen delivery is not recommended; (2) the use of high-flow nasal cannula therapy is safe and more effective than low-flow oxygen to treat infants with moderate to severe bronchiolitis; (3) the application of humidification with low-flow oxygen delivery is not recommended; (4) targeting [Formula: see text] 90-97% for infants and children with bronchiolitis is recommended; however, no specific target can be recommended for pediatric patients with respiratory diseases outside of bronchiolitis, and establishing a patient/disease oxygen therapy target upon admission is considered best practice.
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Affiliation(s)
- Natalie Napolitano
- Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Ariel Berlinski
- Division of Pediatric Pulmonary and Sleep Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences, and Arkansas Children's Hospital, Little Rock, Arkansas
| | - Brian K Walsh
- School of Health Sciences, Department of Allied Health Professions, Liberty University, Lynchburg, Virginia
| | - Emily Ginier
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan. At the time of this research
| | - Shawna L Strickland
- American Association for Respiratory Care, Irving, Texas. She is now affiliated with the American Epilepsy Society, Chicago, Illinois
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36
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Kusubae R, Hirabayashi M, Nakazaki N, Shinkoda Y. Velocity-based target flow rate for high-flow nasal cannula oxygen therapy. Pediatr Int 2021; 63:770-774. [PMID: 33190381 DOI: 10.1111/ped.14545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 10/28/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study was to assess retrospectively whether the average inspiratory flow velocity-based initial flow rate in high-flow nasal cannula (HFNC) therapy could be well tolerated and safely used for infants and children hospitalized with moderate to severe respiratory failure. METHODS Thirty-three patients without underlying diseases (22 males; 67%), hospitalized to receive HFNC therapy for infection-related respiratory failure, were analyzed. The median age was 2 months (interquartile range, 1 month to 1 year). Patients with dyspnea and carbon dioxide partial pressure (pCO2 ) >50 mmHg or venous blood pH <7.320, combined with pulse oximetry arterial oxygen saturation <92%, were included. We set target flow rates calculated from the average inspiratory flow velocity, starting at the actual initial flow rates, and these were subsequently adjusted if necessary. RESULTS One patient could not tolerate the cannula. Of the remaining 32 patients, 81% (n = 26) had an actual initial flow rate within 1 L of the target flow rate; these patients were evaluated for changes in the fraction of inspired oxygen (FITarget flow rate tableO2 ), pH, and pCO2 values after 24 h. Three patients required a higher fraction of inspired oxygen, one showed a persistent pH < 7.320, and seven exhibited pCO2 >50 mmHg. No patient required non-invasive positive-pressure ventilation, and one required intubation. Pneumothorax was not reported in any patient. CONCLUSIONS The average inspiratory flow velocity-based initial flow rate was well-tolerated without sedation, and there were no severe complications. Starting at this flow rate would improve the use of HFNC therapy in the pediatric ward, possibly reducing the need for more invasive modes of ventilation.
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Affiliation(s)
- Ryo Kusubae
- Department of Pediatrics, Kagoshima City Hospital, Kagoshima, Japan
| | | | - Naho Nakazaki
- Department of Pediatrics, Kagoshima City Hospital, Kagoshima, Japan
| | - Yuichi Shinkoda
- Department of Pediatrics, Kagoshima City Hospital, Kagoshima, Japan
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Maitland K, Kiguli S, Olupot-Olupot P, Hamaluba M, Thomas K, Alaroker F, Opoka RO, Tagoola A, Bandika V, Mpoya A, Mnjella H, Nabawanuka E, Okiror W, Nakuya M, Aromut D, Engoru C, Oguda E, Williams TN, Fraser JF, Harrison DA, Rowan K. Randomised controlled trial of oxygen therapy and high-flow nasal therapy in African children with pneumonia. Intensive Care Med 2021; 47:566-576. [PMID: 33954839 PMCID: PMC8098782 DOI: 10.1007/s00134-021-06385-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/15/2021] [Indexed: 12/27/2022]
Abstract
Purpose The life-saving role of oxygen therapy in African children with severe pneumonia is not yet established. Methods The open-label fractional-factorial COAST trial randomised eligible Ugandan and Kenyan children aged > 28 days with severe pneumonia and severe hypoxaemia stratum (SpO2 < 80%) to high-flow nasal therapy (HFNT) or low-flow oxygen (LFO: standard care) and hypoxaemia stratum (SpO2 80–91%) to HFNT or LFO (liberal strategies) or permissive hypoxaemia (ratio 1:1:2). Children with cyanotic heart disease, chronic lung disease or > 3 h receipt of oxygen were excluded. The primary endpoint was 48 h mortality; secondary endpoints included mortality or neurocognitive sequelae at 28 days. Results The trial was stopped early after enrolling 1852/4200 children, including 388 in the severe hypoxaemia stratum (median 7 months; median SpO2 75%) randomised to HFNT (n = 194) or LFO (n = 194) and 1454 in the hypoxaemia stratum (median 9 months; median SpO2 88%) randomised to HFNT (n = 363) vs LFO (n = 364) vs permissive hypoxaemia (n = 727). Per-protocol 15% of patients in the permissive hypoxaemia group received oxygen (when SpO2 < 80%). In the severe hypoxaemia stratum, 48-h mortality was 9.3% for HFNT vs. 13.4% for LFO groups. In the hypoxaemia stratum, 48-h mortality was 1.1% for HFNT vs. 2.5% LFO and 1.4% for permissive hypoxaemia. In the hypoxaemia stratum, adjusted odds ratio for 48-h mortality in liberal vs permissive comparison was 1.16 (0.49–2.74; p = 0.73); HFNT vs LFO comparison was 0.60 (0.33–1.06; p = 0.08). Strata-specific 28 day mortality rates were, respectively: 18.6, 23.4 and 3.3, 4.1, 3.9%. Neurocognitive sequelae were rare. Conclusions Respiratory support with HFNT showing potential benefit should prompt further trials. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06385-3.
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Affiliation(s)
- K Maitland
- Department of Infectious Disease and and Institute of Global Health and Innovation, Division of Medicine, Imperial College, London, UK. .,Kilifi County Hospital and Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya.
| | - S Kiguli
- School of Medicine, Makerere University and Mulago Hospital Kampala, Kampala, Uganda
| | - P Olupot-Olupot
- Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital Mbale (POO, WO), Busitema University, Mbale, Uganda
| | - M Hamaluba
- Kilifi County Hospital and Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - K Thomas
- Intensive Care National Audit and Research Centre, London, UK
| | - F Alaroker
- Soroti Regional Referral Hospital, Soroti, Uganda
| | - R O Opoka
- School of Medicine, Makerere University and Mulago Hospital Kampala, Kampala, Uganda.,Jinja Regional Referral Hospital Jinja, Jinja, Uganda
| | - A Tagoola
- Jinja Regional Referral Hospital Jinja, Jinja, Uganda
| | - V Bandika
- Coast General District Hospital, Mombasa, Kenya
| | - A Mpoya
- Kilifi County Hospital and Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - H Mnjella
- Kilifi County Hospital and Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - E Nabawanuka
- School of Medicine, Makerere University and Mulago Hospital Kampala, Kampala, Uganda
| | - W Okiror
- Faculty of Health Sciences, Mbale Campus and Mbale Regional Referral Hospital Mbale (POO, WO), Busitema University, Mbale, Uganda
| | - M Nakuya
- Soroti Regional Referral Hospital, Soroti, Uganda
| | - D Aromut
- Soroti Regional Referral Hospital, Soroti, Uganda
| | - C Engoru
- Soroti Regional Referral Hospital, Soroti, Uganda
| | - E Oguda
- Kilifi County Hospital and Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - T N Williams
- Department of Infectious Disease and and Institute of Global Health and Innovation, Division of Medicine, Imperial College, London, UK.,Kilifi County Hospital and Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme, Kilifi, Kenya
| | - J F Fraser
- Critical Care Research Group and Intensive Care Service, University of Queensland, The Prince Charles Hospital, Brisbane, Australia
| | - D A Harrison
- Intensive Care National Audit and Research Centre, London, UK
| | - K Rowan
- Intensive Care National Audit and Research Centre, London, UK
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Cheston CC, Rutledge R, Hsu HE. Should We Prioritize Deimplementation of Continuous Pulse Oximetry in Bronchiolitis Care? JAMA Pediatr 2021; 175:459-461. [PMID: 33646260 DOI: 10.1001/jamapediatrics.2020.6157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Christine C Cheston
- Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
| | - Ronnye Rutledge
- Harvard Medicine-Pediatrics Residency Program, Brigham and Women's Hospital and Boston Children's Hospital, Boston, Massachusetts
| | - Heather E Hsu
- Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
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Mahant S, Wahi G, Bayliss A, Giglia L, Kanani R, Pound CM, Sakran M, Kozlowski N, Breen-Reid K, Arafeh D, Moretti ME, Agarwal A, Barrowman N, Willan AR, Schuh S, Parkin PC. Intermittent vs Continuous Pulse Oximetry in Hospitalized Infants With Stabilized Bronchiolitis: A Randomized Clinical Trial. JAMA Pediatr 2021; 175:466-474. [PMID: 33646286 PMCID: PMC7922227 DOI: 10.1001/jamapediatrics.2020.6141] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE There is low level of evidence and substantial practice variation regarding the use of intermittent or continuous monitoring in infants hospitalized with bronchiolitis. OBJECTIVE To compare the effect of intermittent vs continuous pulse oximetry on clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS This multicenter, pragmatic randomized clinical trial included infants 4 weeks to 24 months of age who were hospitalized with bronchiolitis from November 1, 2016, to May 31, 2019, with or without supplemental oxygen after stabilization at community and children's hospitals in Ontario, Canada. INTERVENTIONS Intermittent (every 4 hours, n = 114) or continuous (n = 115) pulse oximetry, using an oxygen saturation target of 90% or higher. MAIN OUTCOMES AND MEASURES The primary outcome was length of hospital stay from randomization to discharge. Secondary outcomes included length of stay from inpatient unit admission to discharge and outcomes measured from randomization: medical interventions, safety (intensive care unit transfer and revisits), parent anxiety and workdays missed, and nursing satisfaction. RESULTS Among 229 infants enrolled (median [IQR] age, 4.0 [2.2-8.5] months; 136 [59.4%] male; 101 [44.1%] from community hospital sites), the median length of hospital stay from randomization to discharge was 27.6 hours (interquartile range [IQR], 18.8-49.6 hours) in the intermittent group and 25.4 hours (IQR, 18.3-47.6 hours) in the continuous group (difference of medians, 2.2 hours; 95% CI, -1.9 to 6.3 hours; P = .17). No significant differences were observed between the intermittent and continuous groups in the median length of stay from inpatient unit admission to discharge: 49.1 (IQR, 37.2-87.0) hours vs 46.0 (IQR, 32.5-73.8) hours (P = .13) or in frequencies or durations of hospital interventions, such as oxygen supplementation initiation: 4 of 114 (3.5%) vs. 9 of 115 (7.8%) (P = .16) and median duration of oxygen supplementation: 20.6 (IQR, 7.6-46.1) hours vs. 21.4 (11.6-52.9) hours (P = .66). Similarly, there were no significant differences in frequencies of intensive care unit transfer: 1 of 114 (0.9%) vs 2 of 115 (2.7%) (P = .76); readmission to hospital: 3 of 114 (2.6%) in the intermittent group vs 4 of 115 (3.5%) in the continuous group (P > .99); parent anxiety: mean (SD) parent anxiety score, 2.9 (0.9) in the intermittent group vs 2.8 (0.9) in the continuous group (P = .40); or parent workdays missed: median workdays missed, 1.5 (IQR, 0.5-3.0) vs 1.5 (IQR, 0.5-2.5) (P = .36). Mean (SD) nursing satisfaction with monitoring was significantly greater in the intermittent group: 8.6 (1.7) vs 7.1 (2.8) of 10 workdays; the mean difference was 1.5 (95% CI, 0.9-2.2; P < .001). CONCLUSIONS AND RELEVANCE In this randomized clinical trial, among infants hospitalized with stabilized bronchiolitis with and without hypoxia and managed using an oxygen saturation target of 90% or higher, clinical outcomes, including length of hospital stay and safety, were similar with intermittent vs continuous pulse oximetry. Nursing satisfaction was greater with intermittent monitoring. Given that other important clinical practice considerations favor less intense monitoring, these findings support the standard use of intermittent pulse oximetry in stable infants hospitalized with bronchiolitis. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02947204.
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Affiliation(s)
- Sanjay Mahant
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada,Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gita Wahi
- Division of General Pediatrics, Department of Pediatrics, McMaster University and McMaster Children’s Hospital, Hamilton, Ontario, Canada
| | - Ann Bayliss
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada,Children’s Health Division, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Lucy Giglia
- Division of General Pediatrics, Department of Pediatrics, McMaster University and McMaster Children’s Hospital, Hamilton, Ontario, Canada
| | - Ronik Kanani
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada,North York General Hospital, Toronto, Ontario, Canada
| | - Catherine M. Pound
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Mahmoud Sakran
- Department of Pediatrics, Queens University, Kingston, Ontario, Canada,Department of Pediatrics, Lakeridge Health, Oshawa, Ontario, Canada
| | | | - Karen Breen-Reid
- Learning Institute, Hospital for Sick Children and Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Dana Arafeh
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Myla E. Moretti
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada,Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada,Ontario Child Health Support Unit, SickKids Research Institute, Toronto, Ontario, Canada
| | - Amisha Agarwal
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Nick Barrowman
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Andrew R. Willan
- Ontario Child Health Support Unit, SickKids Research Institute, Toronto, Ontario, Canada ,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Suzanne Schuh
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada,Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Patricia C. Parkin
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada,Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada,Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
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Barbieri E, Rossin S, Giaquinto C, Da Dalt L, Dona’ D. A Procalcitonin and C-Reactive Protein-Guided Clinical Pathway for Reducing Antibiotic Use in Children Hospitalized with Bronchiolitis. CHILDREN (BASEL, SWITZERLAND) 2021; 8:351. [PMID: 33925182 PMCID: PMC8146464 DOI: 10.3390/children8050351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/16/2021] [Accepted: 04/25/2021] [Indexed: 11/16/2022]
Abstract
Despite the lack of evidence that bronchodilators, corticosteroids, and antibiotics are useful in treating bronchiolitis, their use is still widespread. This study aimed to determine the consumption of antibiotics for bronchiolitis before and after a procalcitonin-guided clinical pathway (CP) implementation. In December 2019, a CP for lower respiratory tract infection management was implemented at the Department of Women's and Children's Health at Padua University Hospital. This was a pre-post, quasi-experimental study that assessed the changes in the treatment of bronchiolitis during two bimesters preceding the CP implementation (pre-period: January 2018-February 2018 and January 2019-February 2019) and during the bimester after CP implementation (post-period January 2020-February 2020). After the CP implementation, there was a significant reduction in antibiotic prescriptions from 36.2% to 12.5% (p = 0.036) in patients hospitalized for bronchiolitis. Co-amoxiclav treatment, the antibiotic most commonly administered, decreased from 66.6% to 33.3%. Among outpatients' bronchiolitis episodes, a statistically significant decrease in beta2-agonists' use (from 18.0% to 4.4%, pre and post periods) and a quasi-significant decrease in corticosteroid use (from 8.0% to 0% pre and post periods) were observed. An evidence-based CP supported by educational lectures was associated with significant changes in the physicians' prescribing habits.
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Affiliation(s)
- Elisa Barbieri
- Division of Paediatric Infectious Diseases, Department of Women’s and Children’s Health, University of Padova, 35100 Padova, Italy; (C.G.); (D.D.)
| | - Sara Rossin
- Pediatric Emergency Department, Department of Women’s and Children’s Health, University Hospital of Padova, 35100 Padova, Italy; (S.R.); (L.D.D.)
| | - Carlo Giaquinto
- Division of Paediatric Infectious Diseases, Department of Women’s and Children’s Health, University of Padova, 35100 Padova, Italy; (C.G.); (D.D.)
| | - Liviana Da Dalt
- Pediatric Emergency Department, Department of Women’s and Children’s Health, University Hospital of Padova, 35100 Padova, Italy; (S.R.); (L.D.D.)
| | - Daniele Dona’
- Division of Paediatric Infectious Diseases, Department of Women’s and Children’s Health, University of Padova, 35100 Padova, Italy; (C.G.); (D.D.)
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Havdal LB, Nakstad B, Fjærli HO, Ness C, Inchley C. Viral lower respiratory tract infections-strict admission guidelines for young children can safely reduce admissions. Eur J Pediatr 2021; 180:2473-2483. [PMID: 33834273 PMCID: PMC8285352 DOI: 10.1007/s00431-021-04057-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 03/13/2021] [Accepted: 03/29/2021] [Indexed: 01/11/2023]
Abstract
Viral lower respiratory tract infection (VLRTI) is the most common cause of hospital admission among small children in high-income countries. Guidelines to identify children in need of admission are lacking in the literature. In December 2012, our hospital introduced strict guidelines for admission. This study aims to retrospectively evaluate the safety and efficacy of the guidelines. We performed a single-center retrospective administrative database search and medical record review. ICD-10 codes identified children < 24 months assessed at the emergency department for VLRTI for a 10-year period. To identify adverse events related to admission guidelines implementation, we reviewed patient records for all those discharged on primary contact followed by readmission within 14 days. During the study period, 3227 children younger than 24 months old were assessed in the ED for VLRTI. The proportion of severe adverse events among children who were discharged on their initial emergency department contact was low both before (0.3%) and after the intervention (0.5%) (p=1.0). Admission rates before vs. after the intervention were for previously healthy children > 90 days 65.3% vs. 53.3% (p<0.001); for healthy children ≤ 90 days 85% vs. 68% (p<0.001); and for high-risk comorbidities 74% vs. 71% (p=0.5).Conclusion: After implementation of admission guidelines for VLRTI, there were few adverse events and a significant reduction in admissions to the hospital from the emergency department. Our admission guidelines may be a safe and helpful tool in the assessment of children with VLRTI. What is Known: • Viral lower respiratory tract infection, including bronchiolitis, is the most common cause of hospitalization for young children in the developed world. Treatment is mainly supportive, and hospitalization should be limited to the cases in need of therapeutic intervention. • Many countries have guidelines for the management of the disease, but the decision on whom to admit for inpatient treatment is often subjective and may vary even between physicians in the same hospital. What is New: • Implementation of admission criteria for viral lower respiratory tract infection may reduce the rate of hospital admissions without increasing adverse events.
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Affiliation(s)
- Lise Beier Havdal
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Sykehusveien 25, 1478, Nordbyhagen, Norway. .,Division of Paediatric and Adolescent Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Britt Nakstad
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Hans Olav Fjærli
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Sykehusveien 25, 1478, Nordbyhagen, Norway
| | - Christian Ness
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Sykehusveien 25, 1478, Nordbyhagen, Norway
| | - Christopher Inchley
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Sykehusveien 25, 1478, Nordbyhagen, Norway
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Wolk CB, Schondelmeyer AC, Barg FK, Beidas R, Bettencourt A, Brady PW, Brent C, Eriksen W, Kinkler G, Landrigan CP, Neergaard R, Bonafide CP. Barriers and Facilitators to Guideline-Adherent Pulse Oximetry Use in Bronchiolitis. J Hosp Med 2021; 16:23-30. [PMID: 33357326 PMCID: PMC7768921 DOI: 10.12788/jhm.3535] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/09/2020] [Accepted: 09/13/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Continuous pulse oximetry monitoring (cSpO2) in children with bronchiolitis does not improve clinical outcomes and has been associated with increased resource use and alarm fatigue. It is critical to understand the factors that contribute to cSpO2 overuse in order to reduce overuse and its associated harms. METHODS This multicenter qualitative study took place in the context of the Eliminating Monitor Overuse (EMO) SpO2 study, a cross-sectional study to establish rates of cSpO2 in bronchiolitis. We conducted semistructured interviews, informed by the Consolidated Framework for Implementation Research, with a purposive sample of stakeholders at sites with high and low cSpO2 use rates to identify barriers and facilitators to addressing cSpO2 overuse. Interviews were audio recorded and transcribed. Analyses were conducted using an integrated approach. RESULTS Participants (n = 56) included EMO study site principal investigators (n = 12), hospital administrators (n = 8), physicians (n = 15), nurses (n = 12), and respiratory therapists (n = 9) from 12 hospitals. Results suggest that leadership buy-in, clear authoritative guidelines for SpO2 use incorporated into electronic order sets, regular education about cSpO2 in bronchiolitis, and visual reminders may be needed to reduce cSpO2 utilization. Parental perceptions and individual clinician comfort affect cSpO2 practice. CONCLUSION We identified barriers and facilitators to deimplementation of cSpO2 for stable patients with bronchiolitis across children's hospitals with high- and low-cSpO2 use. Based on these data, future deimplementation efforts should focus on clear protocols for cSpO2, EHR changes, and education for hospital staff on bronchiolitis features and rationale for reducing cSpO2.
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Affiliation(s)
- Courtney Benjamin Wolk
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda C Schondelmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Frances K Barg
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rinad Beidas
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda Bettencourt
- Department of Systems, Populations, and Leadership, School of Nursing, University of Michigan, Ann Arbor, Michigan
| | - Patrick W Brady
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Canita Brent
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Whitney Eriksen
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Grace Kinkler
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher P Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Rebecca Neergaard
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher P Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Stollar F, Glangetas A, Luterbacher F, Gervaix A, Barazzone-Argiroffo C, Galetto-Lacour A. Frequency, Timing, Risk Factors, and Outcomes of Desaturation in Infants With Acute Bronchiolitis and Initially Normal Oxygen Saturation. JAMA Netw Open 2020; 3:e2030905. [PMID: 33355677 PMCID: PMC7758807 DOI: 10.1001/jamanetworkopen.2020.30905] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Little is known about the natural course of oxygen desaturation in acute bronchiolitis. Information on risk factors associated with desaturation as well as the time to desaturation in infants with bronchiolitis could help physicians better treat these infants before deciding whether to hospitalize them. OBJECTIVE To prospectively determine the frequency of desaturation in infants with bronchiolitis, along with the time to desaturation and risk factors associated with desaturation, and to compare infants who were hospitalized with those discharged home and evaluate risk factors for rehospitalization. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted during the 2017 to 2018 and 2018 to 2019 respiratory syncytial virus seasons in a tertiary care pediatric emergency department in Switzerland. Included individuals were 239 otherwise-healthy infants aged younger than 1 year, diagnosed with acute bronchiolitis and oxygen saturation of 90% or more on arrival. Data were analyzed from July 2019 to October 2020. EXPOSURES After receiving triage care, study participants admitted to the emergency department were equipped with a pulse oximeter to continuously record oxygen saturation (Spo2 levels), regardless of subsequent hospitalization or discharge home. MAIN OUTCOMES AND MEASURES The primary outcome was desaturation (ie, Spo2 < 90%) during the first 36 hours. RESULTS Of 239 infants enrolled, with a median (interquartile range [IQR]) age of 3.9 (1.5-6.5) months, 116 (48.5%) were boys and desaturation occurred in 165 infants (69.0%). Median (IQR) time to desaturation was 3.6 (1.8-9.4) hours. The rate of desaturation was similar between infants hospitalized and those discharged home (137 of 200 infants [68.5%] vs 28 of 39 infants [71.8%]; difference, -3.3%; 95% CI, -18.8% to 12.2%; P = .85). A more severe initial clinical presentation with moderate or severe retractions was the only independent risk factor associated with desaturation (odds ratio, 2.73; 95% CI, 1.49 to 5.02; P = .001). Of 39 infants discharged home, 22 infants (56.4%) experienced major desaturations. However, infants with desaturations, including those with major desaturations, had rates of rehospitalization similar to those of infants without desaturations (8 of 28 infants [28.5%] vs 3 of 11 infants [27.3%]; difference, 1.2%; 95% CI, -29.9% to 32.5; P > .99). CONCLUSIONS AND RELEVANCE These findings suggest that rates of desaturation in infants with acute bronchiolitis were high and similar between infants who were hospitalized and those discharged home. A more severe initial clinical presentation was the only risk factor associated with desaturation. However, for infants discharged home, desaturation was not a risk factor associated with rehospitalization.
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Affiliation(s)
- Fabiola Stollar
- General Pediatric Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Alban Glangetas
- Pediatric Emergency Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Fanny Luterbacher
- Pediatric Emergency Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Alain Gervaix
- Pediatric Emergency Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Constance Barazzone-Argiroffo
- Pediatric Pulmonology Unit, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Annick Galetto-Lacour
- Pediatric Emergency Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
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van Hasselt TJ, Singham B, Bassett E, Wacogne ID. Oxygen saturation thresholds in bronchiolitis: examining admissions. Arch Dis Child 2020; 105:1197-1199. [PMID: 31462433 DOI: 10.1136/archdischild-2019-317683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Examine admissions for bronchiolitis, comparing centres with oxygen saturation thresholds for admission of 90% versus 92%. DESIGN Prospective multi-centre service evaluation, all admissions for bronchiolitis during 4-week period, November 2018. SETTING Paediatric departments across 12 hospitals in the West Midlands, UK. PATIENTS 320 patients aged 6 weeks-1 year, diagnosis of bronchiolitis, exclusions: chronic illness or high dependency/intensive care admission. MAIN OUTCOME MEASURES Reason for admission, admission saturations and length of stay. RESULTS Inadequate feeding was the the most common reason for admission (80%). Only 20 patients were admitted solely because of low saturations. Median peripheral oxygen saturation in this group was 88%. Median length of stay in 90% centres was 41 hours, against 59 hours for 92% centres (p=0.0074). CONCLUSIONS Few patients were admitted solely due to low oxygen saturations, only one had a potentially avoidable admission if thresholds were 90%. Length of stay was significantly reduced in the 90% threshold centres.
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Affiliation(s)
- Tim J van Hasselt
- Department of General Paediatrics, Walsall Manor Hospital, Walsall, UK
| | - Bhavna Singham
- Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Eve Bassett
- Department of General Paediatrics, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Ian D Wacogne
- Department of General Paediatrics, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
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Brady PW, Schondelmeyer AC, Landrigan CP, Xiao R, Brent C, Bonafide CP. Validity of Continuous Pulse Oximetry Orders for Identification of Actual Monitoring Status in Bronchiolitis. J Hosp Med 2020; 15:665-668. [PMID: 33147128 PMCID: PMC7657657 DOI: 10.12788/jhm.3443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 04/09/2020] [Indexed: 11/20/2022]
Abstract
The accuracy of pulse oximetry monitor orders for identifying infants with bronchiolitis who are being continuously monitored is unknown. In this 56-hospital repeated cross-sectional study, investigators used direct bedside observation to determine continuous pulse oximetry monitor use and then assessed if an active continuous monitoring order was present in the electronic health record. Investigators completed 3,612 observations of infants aged 8 weeks to 23 months hospitalized with bronchiolitis and on room air. Most monitored infants did not have an active monitoring order (sensitivity 49% [95% CI, 41-57]). The positive predictive value of a monitoring order was 77% (95% CI, 72-82), and the negative predictive value was 69% (95% CI, 61-77). Teams intending to measure continuous pulse oximetry use should understand the limitations of using electronic health record orders as a stand-alone measure.
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Affiliation(s)
- Patrick W Brady
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Corresponding Author: Patrick W Brady, MD, MSc; ; Telephone: 513-636-3635; Twitter: @patrickwbrady
| | - Amanda C Schondelmeyer
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Christopher P Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Canita Brent
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christopher P Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Stoeck PA, Chieco DF, Pingree EW, Landrigan CP, Bonafide CP. Association Between Bronchiolitis Patient Volume and Continuous Pulse Oximetry Monitoring in 25 Hospitals. J Hosp Med 2020; 15:669-672. [PMID: 33147136 PMCID: PMC7657654 DOI: 10.12788/jhm.3520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 08/08/2020] [Indexed: 11/20/2022]
Abstract
Continuous pulse oximetry monitoring in stable patients with bronchiolitis is discouraged by national guidelines in order to reduce overuse, yet wide practice variation exists among hospitals. Understanding the association between monitoring overuse and hospital unit-level factors may identify areas for improvement. Conducted at 25 sites from the Pediatric Research in Inpatient Settings (PRIS) Network's Eliminating Monitoring Overuse (EMO) study, this substudy used data from 2,366 in-person observations of pulse oximetry use in patients with bronchiolitis to determine whether hospital unit-level factors were associated with variation in pulse oximetry use for patients in whom continuous monitoring is not indicated. Hospital units were classified by bronchiolitis admission burden. Monitoring rates were analyzed in a mixed-effects model that accounted for variation in baseline monitoring rates among hospitals and adjusted for covariates significantly associated with continuous pulse oximetry monitoring use in the primary study's analysis. Low burden units (<10% of total admissions) had a 2.16-fold increased odds of pulse oximetry overuse compared to high burden units (≥40% of total admissions) (95% CI, 1.27-3.69; P = .01). These results suggest that units caring for a lower percentage of patients with bronchiolitis are more likely to overuse pulse oximetry despite national guidelines.
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Affiliation(s)
- Patricia A Stoeck
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Corresponding Author: Patricia A Stoeck, MD; ; Twitter: @pattystoeck
| | - Deanna F Chieco
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Elizabeth W Pingree
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Christopher P Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Christopher P Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Roué JM, Delpeut J, d'Hennezel A, Tierrie T, Barzic A, L'Her E, Cros P. Automatic oxygen flow titration in spontaneously breathing children: An open-label randomized controlled pilot study. Pediatr Pulmonol 2020; 55:3180-3188. [PMID: 32827344 DOI: 10.1002/ppul.25035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 08/14/2020] [Indexed: 11/11/2022]
Abstract
INTRODUCTION When children require supplemental oxygen due to acute hypoxemic respiratory distress (AHRD), manual control of the oxygen flow is often difficult and time-consuming, and carries the risk of unrecognized hypoxia and hyperoxia. To date, no automatic oxygen titration system has been developed and evaluated in spontaneously breathing children. METHODS Children between 1 month and 15 years of age receiving supplemental oxygen due to AHRD were recruited within 24 hours following the onset of the O2 administration in a French University Department of Paediatrics. Patients were randomized to receive either automated oxygen administration using the FreeO2 device, or conventional manual oxygen administration over a maximum period of 6 hours. Stratification was performed to classify the patients into two age groups: 1 month to 2 years of age and 2 to 15 years of age. The primary outcome was % time spent within the SpO2 target range (92%-98%). RESULTS 60 patients (30 infants, 30 children) were randomized and 55 could be analyzed for the primary outcome (28 automated, 27 manual). The automated O2 delivery using the FreeO2 device significantly increased the time spent within the predefined SpO2 range (94.6% ± 6% vs 76.3% ± 22%, difference [95% confidence interval {CI}] 18.4 [10.1; 26.7]) with less time spent with hypoxemia (1% ± 1.1% vs 15.1% ± 21.8%, difference [95% CI] -14.4 [-22.2; -6.7]). This difference was greater among (2-15 years of age) children, compared to (1 month-2 years of age) infants. CONCLUSIONS The present randomized controlled pilot study indicates that the tested automated closed-loop O2 titration technology was safe and yielded improved oxygen parameters among spontaneously breathing children. Based on our pilot data, a full randomized controlled trial will be required to verify the potential clinical benefits.
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Affiliation(s)
- Jean-Michel Roué
- Department of Pediatrics, Brest University Hospital, Brest, France
| | - Juliette Delpeut
- Department of Pediatrics, Brest University Hospital, Brest, France
| | - Alix d'Hennezel
- Department of Pediatrics, Brest University Hospital, Brest, France
| | - Tess Tierrie
- Department of Pediatrics, Brest University Hospital, Brest, France
| | - Audrey Barzic
- Department of Pediatrics, Brest University Hospital, Brest, France
| | - Erwan L'Her
- Department of Medical Intensive Care, Brest University Hospital, Brest, France
| | - Pierrick Cros
- Department of Pediatrics, Brest University Hospital, Brest, France
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Kirolos A, Manti S, Blacow R, Tse G, Wilson T, Lister M, Cunningham S, Campbell A, Nair H, Reeves RM, Fernandes RM, Campbell H. A Systematic Review of Clinical Practice Guidelines for the Diagnosis and Management of Bronchiolitis. J Infect Dis 2020; 222:S672-S679. [PMID: 31541233 DOI: 10.1093/infdis/jiz240] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND Bronchiolitis is the leading cause of hospital admission for respiratory disease among infants aged <1 year. Clinical practice guidelines can benefit patients by reducing the performance of unnecessary tests, hospital admissions, and treatment with lack of a supportive evidence base. This review aimed to identify current clinical practice guidelines worldwide, appraise their methodological quality, and discuss variability across guidelines for the diagnosis and management of bronchiolitis. METHODS A systematic literature review of electronic databases EMBASE, Global Health, and Medline was performed. Manual searches of the gray literature, national pediatric society websites, and guideline-focused databases were performed, and select international experts were contacted to identify additional guidelines. The Appraisal of Guidelines for Research and Evaluation assessment tool was used by 2 independent reviewers to appraise each guideline. RESULTS Thirty-two clinical practice guidelines met the selection criteria. Quality assessment revealed significant shortcomings in a number of guidelines, including lack of systematic processes in formulating guidelines, failure to state conflicts of interest, and lack of consultation with families of affected children. There was widespread agreement about a number of aspects, such as avoidance of the use of unnecessary diagnostic tests, risk factors for severe disease, indicators for hospital admission, discharge criteria, and nosocomial infection control. However, there was variability, even within areas of consensus, over specific recommendations, such as variable thresholds for oxygen therapy. Guidelines showed significant variability in recommendations for the pharmacological management of bronchiolitis, with conflicting recommendations over whether use of nebulized epinephrine, hypertonic saline, or bronchodilators should be routinely trialled. CONCLUSIONS Future guidelines should aim to be compliant with international standards for clinical guidelines to improve their quality and clarity and to promote their adoption into practice. Variable recommendations between guidelines may reflect the evolving evidence base for bronchiolitis management, and platforms should be created to understand this variability and promote evidence-based recommendations.
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Affiliation(s)
- Amir Kirolos
- Usher Institute of Population Health Sciences and Informatics, Edinburgh
| | - Sara Manti
- Department of Pediatrics, University of Messina, Sicily, Italy
| | - Rachel Blacow
- Usher Institute of Population Health Sciences and Informatics, Edinburgh
| | - Gabriel Tse
- Usher Institute of Population Health Sciences and Informatics, Edinburgh
| | - Thomas Wilson
- Usher Institute of Population Health Sciences and Informatics, Edinburgh
| | | | - Steve Cunningham
- Department of Child Life and Health, Edinburgh
- Centre for Inflammation Research, University of Edinburgh, Edinburgh
| | | | - Harish Nair
- Usher Institute of Population Health Sciences and Informatics, Edinburgh
| | - Rachel M Reeves
- Usher Institute of Population Health Sciences and Informatics, Edinburgh
| | - Ricardo M Fernandes
- Clinical Pharmacology and Therapeutics, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon
| | - Harry Campbell
- Usher Institute of Population Health Sciences and Informatics, Edinburgh
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Cunningham S, Piedra PA, Martinon-Torres F, Szymanski H, Brackeva B, Dombrecht E, Detalle L, Fleurinck C. Nebulised ALX-0171 for respiratory syncytial virus lower respiratory tract infection in hospitalised children: a double-blind, randomised, placebo-controlled, phase 2b trial. THE LANCET RESPIRATORY MEDICINE 2020; 9:21-32. [PMID: 33002427 DOI: 10.1016/s2213-2600(20)30320-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 05/28/2020] [Accepted: 06/11/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Respiratory syncytial virus (RSV) is the most common cause of severe lower respiratory tract infection, with a high global health burden. There are no effective treatments available. ALX-0171 is a novel trivalent Nanobody with antiviral properties against RSV. We aimed to assess the safety and antiviral activity of nebulised ALX-0171 in children admitted to hospital with RSV lower respiratory tract infection. METHODS This double-blind, randomised, placebo-controlled, phase 2b trial was done in 50 hospital paediatric departments across 16 countries. Previously healthy children aged between 28 days to younger than 24 months who were admitted to hospital with RSV acute severe lower respiratory tract infection were randomly assigned in three sequential safety cohorts (3:1) to receive nebulised ALX-0171 (cohort 1 received 3 mg/kg, cohort 2 received 6 mg/kg, and cohort 3 received 9 mg/kg) or placebo once daily for 3 days using web-based randomisation in the sequential safety part (first block size 12, subsequently four). In a parallel part of the study, participants (cohort 4) were randomly assigned (parallel 1:1:1:1) to receive nebulised ALX-0171 3 mg/kg, 6 mg/kg, 9 mg/kg, or placebo (blocks of eight by restricted randomisation). Study drug masking was by two consecutive nebulisations (each either ALX-0171 or placebo) depending on assigned treatment group. The primary outcome was to evaluate time for the RSV viral load to drop to below quantifiable limit, measured by plaque assay on mid-turbinate nasal swabs. Safety, clinical efficacy, pharmacokinetics, viral load by RT-qPCR, and immunogenicity were secondary outcomes. Analysis, including of the primary outcome, was by modified intention to treat (participants receiving at least one dose of study drug as assigned), and safety was assessed in all children who received at least one administration of study drug, as treated. This trial is registered with EudraCT, 2016-001651-49. FINDINGS Between Jan 10, 2017, and April 26, 2018, 175 children (median age 4·8 months [IQR 2·0-10·8]), received at least one dose of study drug (45 received 3 mg/kg of ALX-0171, 43 received 6 mg/kg of ALX-0171, 45 received 9 mg/kg of ALX-0171, and 42 received placebo; the modified intention-to-treat population) commencing at a mean 3·3 days (SD 1·1) from symptom onset. Median time for the viral load to drop to below quantifiable limit on plaque assay was significantly faster for the 3 mg/kg group (median 14·2 h [IQR 5·0-28·0]), 6 mg/kg group (5·1 h [4·7-28·5]), and 9 mg/kg group (5·1 h [4·6-5·9]) than the placebo group (46·1 h [25·2-116·7]; hazard ratio [HR] all ALX-0171 groups vs placebo 2·6 [1·7-3·9]; p<0·0001). Median time for the viral load to drop below quantification limit with RT-qPCR was 95·9 h (IQR 26·7 to not estimable) for the placebo group (n=35) versus 49·4 h (25·1 to 351·4) for all ALX-0171 groups (n=118). Clinical outcomes were not improved by ALX-0171 compared with placebo, with no difference in time to clinical response (oxygen saturation >92% for 4 h in room air and adequate oral feeding) in ALX-0171 groups and the placebo group (median 43·8 h [IQR 21·7-68·5] vs 47·9 h [22·5-76·4]; HR 1·1 [95% CI 0·8-1·6]) or change in the global severity score from baseline to 5 h post-dose on day 2 (-4 [IQR -6 to -2] vs -4 [-6 to -1]; difference in least-squares mean -0·45 [95% CI -1·39 to 0·49]). Serum concentrations of ALX-0171 on day 2 exceeded the concentration estimated to give full RSV neutralisation in the lung at 6 mg/kg and 9 mg/kg doses. Treatment-emergent antidrug antibodies were detected at day 14 in 46 (34%) of 135 patients who received ALX-0171 and ten (26%) of 39 patients who received placebo. Serious adverse events were reported in five (13%) of 40 children in the placebo group and ten (7%) of 135 children in all ALX-0171 groups, leading to study drug discontinuation in three children (two in the 3 mg/kg group and one in the 6 mg/kg group). 13 of 15 serious adverse events (three of four in the 3 mg/kg group, two of three in the 6 mg/kg group, three of three in the 9 mg/kg group, and five of five in the placebo group) were related to worsening respiratory status, and none were considered to be related to the study drug. INTERPRETATION Antivirals against RSV might be unable to improve clinical course once RSV lower respiratory tract infection is established. Future studies of RSV antivirals should focus on earlier intervention and more precise measurement of objective outcomes before the onset of significant lower respiratory tract inflammation. FUNDING Ablynx, a Sanofi Company.
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Affiliation(s)
- Steve Cunningham
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK.
| | - Pedro A Piedra
- Department of Molecular Virology and Microbiology and Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Federico Martinon-Torres
- Genetics, Vaccines and Pediatric Infectious Diseases Research Group, Instituto de Investigación Sanitaria de Santiago, and Translational Pediatrics and Infectious Diseases, Department of Pediatrics, Hospital Clinico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Henryk Szymanski
- Department of Paediatrics, St Hedwig of Silesia Hospital, Trzebnica, Poland
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Abstract
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.
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Affiliation(s)
- Lauren Paluch
- At the time this article was written, Lauren Paluch was assistant fellowship director in the urgent care system of Children's Hospital of the King's Daughters in Norfolk, Va. She now is an assistant professor at Eastern Virginia Medical School in Norfolk, Va. The author has disclosed no potential conflicts of interest, financial or otherwise
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