Temporal trends in emergency department visits for bronchiolitis in the United States, 2006 to 2010

Sociodemographic Factors and Trends in Bronchiolitis-Related Emergency Department Visit and Hospitalization Rates

Importance

Bronchiolitis is the most common and most cumulatively expensive condition in pediatric hospital care. Few population-based studies have examined health inequalities in bronchiolitis outcomes over time.

Objective

To examine trends in bronchiolitis-related emergency department (ED) visit and hospitalization rates by sociodemographic factors in a universally funded health care system.

Design, Setting, and Participants

This repeated cross-sectional cohort study was performed from April 1, 2004, to March 31, 2022, using population-based health administrative data from children younger than 2 years in Ontario, Canada.

Main Outcome and Measures

Bronchiolitis ED visit and hospitalization rates per 1000 person-years reported for the equity stratifiers of sex, residence location (rural vs urban), and material resources quintile. Trends in annual rates by equity stratifiers were analyzed using joinpoint regression and estimating the average annual percentage change (AAPC) with 95% CI and the absolute difference in AAPC with 95% CI from April 1, 2004, to March 31, 2020.

Results

Of 2 921 573 children included in the study, 1 422 088 (48.7%) were female and 2 619 139 (89.6%) lived in an urban location. Emergency department visit and hospitalization rates were highest for boys, those with rural residence, and those with least material resources. There were no significant between-group absolute differences in the AAPC in ED visits per 1000 person-years by sex (female vs male; 0.22; 95% CI, -0.92 to 1.35; P = .71), residence (rural vs urban; -0.31; 95% CI -1.70 to 1.09; P = .67), or material resources (quintile 5 vs 1; -1.17; 95% CI, -2.57 to 0.22; P = .10). Similarly, there were no significant between-group absolute differences in the AAPC in hospitalizations per 1000 person-years by sex (female vs male; 0.53; 95% CI, -1.11 to 2.17; P = .53), residence (rural vs urban; -0.62; 95% CI, -2.63 to 1.40; P = .55), or material resources (quintile 5 vs 1; -0.93; 95% CI -3.80 to 1.93; P = .52).

Conclusions and Relevance

In this population-based cohort study of children in a universally funded health care system, inequalities in bronchiolitis ED visit and hospitalization rates did not improve over time.

Trends in emergency department visits for bronchiolitis, 1993-2019

INTRODUCTION

Bronchiolitis is a leading indication for pediatric emergency department (ED) visits and hospitalizations. Our objective was to provide a comprehensive review of national trends and epidemiology of ED visits for bronchiolitis from 1993 to 2019 in the United States.

METHODS

We retrospectively reviewed the National Hospital Ambulatory Medical Care Survey (NHAMCS) reporting of ED visits for bronchiolitis for children age <2 years from 1993 to 2019. Bronchiolitis cases were identified using billing codes assigned at discharge. The primary outcome was bronchiolitis ED visit rates, calculated using NHAMCS-assigned patient visit weights. We then evaluated for temporal variation in patient characteristics, facility location, and hospitalizations among the bronchiolitis ED visits.

RESULTS

There were an estimated 8 million ED visits for bronchiolitis for children <2 years between 1993 and 2019. Bronchiolitis ED visits rates ranged from 28 to 36 per 1000 ED visits from 1993 to 2010 and increased significantly to 65 per 1000 ED visits in the 2017-2019 time period (p < 0.001). There was no significant change over time in patient age, sex, race and ethnicity, insurance status, hospital type, or triage level upon ED presentation. Approximately half of bronchiolitis ED visits occurred in the winter months throughout the study period.

CONCLUSION

In this analysis of 27 years of national data, we identified a recent rise in ED visit rates for bronchiolitis, which have almost doubled from 2010 to 2019 following a period of relative stability between 1993 and 2010.

Clinical epidemiology and disease burden of bronchiolitis in hospitalized children in China: a national cross-sectional study

BACKGROUND

Bronchiolitis is a common acute lower respiratory tract infection (ALRTI) and the most frequent cause of hospitalization of infants and young children with ALRTI. Respiratory syncytial virus is the main pathogen that leads to severe bronchiolitis. The disease burden is relatively high. To date, few descriptions of the clinical epidemiology and disease burden of children hospitalized for bronchiolitis are available. This study reports the general clinical epidemiological characteristics and disease burden of bronchiolitis in hospitalized children in China.

METHODS

This study included the face sheet of discharge medical records collected from 27 tertiary children's hospitals from January 2016 to December 2020 that were aggregated into the FUTang Update medical REcords (FUTURE) database. The sociodemographic variables, length of stay (LOS) and disease burden of children with bronchiolitis were analyzed and compared using appropriate statistical tests.

RESULTS

In total, 42,928 children aged 0-3 years were hospitalized due to bronchiolitis from January 2016 to December 2020, accounting for 1.5% of the total number of hospitalized children of the same age in the database during the period and 5.31% of the hospitalizations for ALRTI. The male to female ratio was 2.01:1. Meanwhile, more boys than girls were observed in different regions, age groups, years, and residences. The 1-2 year age group had the greatest number of hospitalizations for bronchiolitis, while the 29 days-6 months group had the largest proportion of the total inpatients and inpatients with ALRTI in the same age group. In terms of region, the hospitalization rate of bronchiolitis was the highest in East China. Overall, the number of hospitalizations from 2017 to 2020 showed a decreasing trend from that in 2016. Seasonally, the peak hospitalizations for bronchiolitis occurred in winter. Hospitalization rates in North China in autumn and winter were higher than those in South China, while hospitalization rates in South China were higher in spring and summer. Approximately, half of the patients with bronchiolitis had no complications. Among the complications, myocardial injury, abnormal liver function and diarrhea were more common. The median LOS was 6 days [interquartile range (IQR) = 5-8], and the median hospitalization cost was 758 United States dollars (IQR = 601.96-1029.53).

CONCLUSIONS

Bronchiolitis is a common respiratory disease in infants and young children in China, and it accounts for a higher proportion of both total hospitalizations and hospitalizations due to ALRTI in children. Among them, children aged 29 days-2 years are the main hospitalized population, and the hospitalization rate of boys is significantly higher than that of girls. The peak season for bronchiolitis is winter. Bronchiolitis causes few complications and has a low mortality rate, but the burden of this disease is heavy.

Distribution of Emergency Department Encounters and Subsequent Hospital Admissions for Children by Child Opportunity Index

OBJECTIVE

To evaluate differences in emergency department (ED) utilization and subsequent admission among children by Child Opportunity Index (COI).

METHODS

We performed a cross-sectional study of pediatric (<18 years) encounters to 194 EDs in Illinois from 2016 to 2020. Each encounter was assigned to quntiles of COI 2.0 by postal code. We described the difference in the percent of encounters between lower (Very Low and Low) and higher (Very High and High) COI overall and among diagnoses with overrepresentation from lower COI groups. We evaluated the association of diagnosis with COI in ordinal models adjusted for demographics.

RESULTS

There were 4,653,026 eligible ED encounters classified by COI as Very Low (28.6%), Low (24.8%), Moderate (20.3%), High (15.6%), and Very High (10.8%) (difference between low and high COI encounters 27.0%). Diagnoses with the greatest difference between low and high COI were eye infection, upper respiratory tract infections, and cough. The COI distribution for children admitted from the ED (n = 140,298) was 29.1% Very Low, 19.3% Low, 18.2% Moderate, 17.7% High, and 15.7% Very High (percent difference 15.1%). Diagnoses with the greatest differences between low and high COI among admitted patients were sickle cell crisis, asthma, and influenza. All ED diagnoses and 7/12 admission diagnoses were associated with lower COI in multivariable ordinal models.

CONCLUSIONS

Children from lower COI areas are overrepresented in ED and inpatient encounters overall and within certain diagnosis groups. Further research is required to examine how health outcomes may be influenced by the structural and contextual characteristics of a child's neighborhood.

Mortality Among US Infants and Children Under 5 Years of Age with Respiratory Syncytial Virus and Bronchiolitis: A Systematic Literature Review

Background

A systematic literature review was conducted to summarize the mortality (overall and by disease severity factors) of US infants and children aged <5 years with respiratory syncytial virus (RSV) or all-cause bronchiolitis (ACB).

Methods

Comprehensive, systematic literature searches were conducted; articles were screened using prespecified eligibility criteria. A standard risk of bias tool was used to evaluate studies. Mortality was extracted as the rate per 100 000 or the case fatality ratio (CFR; proportion of deaths among RSV/ACB cases).

Results

Among 42 included studies, 36 evaluated inpatient deaths; 10 used nationally representative populations updated through 2013, and only 2 included late-preterm/full-term otherwise healthy infants and children. The RSV/ACB definition varied across studies (multiple International Classification of Diseases [ICD] codes; laboratory confirmation); no study reported systematic testing for RSV. No studies reported RSV mortality rates, while 3 studies provided ACB mortality rates (0.57–9.4 per 100 000). CFRs ranged from 0% to 1.7% for RSV (n = 15) and from 0% to 0.17% for ACB (n = 6); higher CFRs were reported among premature, intensive care unit-admitted, and publicly insured infants and children.

Conclusions

RSV mortality reported among US infants and children is variable. Current, nationally representative estimates are needed for otherwise healthy, late-preterm to full-term infants and children.

Evaluation of Bronchiolitis-Related Emergency Department Visits From 2004 to 2018: A Population-Based Cohort Study

This cohort study analyzes the patterns of emergency department use, hospitalization, revisit, and mortality rates associated with bronchiolitis in children younger than 2 years.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

AUTHORS' CONCLUSIONS

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

Comparative Fecal Microbiota Analysis of Infants With Acute Bronchiolitis Caused or Not Caused by Respiratory Syncytial Virus

Bronchiolitis due to respiratory syncytial virus (RSV) or non-RSV agents is a health-menacing lower respiratory tract (LRT) disease of infants. Whereas RSV causes more severe disease than other viral agents may, genus-dominant fecal microbiota profiles have been identified in US hospitalized infants with bronchiolitis. We investigated the fecal microbiota composition of infants admitted to an Italian hospital with acute RSV (25/37 [67.6%]; group I) or non-RSV (12/37 [32.4%]; group II) bronchiolitis, and the relationship of fecal microbiota characteristics with the clinical characteristics of infants. Group I and group II infants differed significantly (24/25 [96.0%] versus 5/12 [41.7%]; P = 0.001) regarding 90% oxygen saturation (SpO₂), which is an increased respiratory effort hallmark. Accordingly, impaired feeding in infants from group I was significantly more frequent than in infants from group II (19/25 [76.0%] versus 4/12 [33.3%]; P = 0.04). Conversely, the median (IQR) length of stay was not significantly different between the two groups (seven [3–14] for group I versus five [5–10] for group II; P = 0.11). The 16S ribosomal RNA V3–V4 region amplification of infants’ fecal samples resulted in 299 annotated amplicon sequence variants. Based on alpha- and beta-diversity microbiota downstream analyses, group I and group II infants had similar bacterial communities in their samples. Additionally, comparing infants having <90% SpO₂ (n = 29) with infants having ≥90% SpO₂ (n = 8) showed that well-known dominant genera (Bacteroides, Bifidobacterium, Escherichia/Shigella, and Enterobacter/Veillonella) were differently, but not significantly (P = 0.44, P = 0.71, P = 0.98, and P = 0.41, respectively) abundant between the two subgroups. Overall, we showed that, regardless of RSV or non-RSV bronchiolitis etiology, no fecal microbiota-composing bacteria could be associated with the severity of acute bronchiolitis in infants. Larger and longitudinally conducted studies will be necessary to confirm these findings.

Reducing Unnecessary Respiratory Viral Testing to Promote High-Value Care

BACKGROUND AND OBJECTIVES

Viral respiratory infections are common in children, and practice guidelines do not recommend routine testing for typical viral illnesses. Despite results often not impacting care, nasopharyngeal swabs for viral testing are frequently performed and are an uncomfortable procedure. The aim of this initiative was to decrease unnecessary respiratory viral testing (RVT) in the emergency department (ED) and the pediatric medicine wards (PMWs) by 50% and 25%, respectively, over 36 months.

METHODS

An expert panel reviewed published guidelines and appropriate evidence to formulate an RVT pathway using plan-do-study-act cycles. A multifaceted improvement strategy was developed that included implementing 2 newer, more effective tests when testing was deemed necessary; electronic order modifications with force functions; audit and feedback; and education. By using statistical process control charts, the outcomes analyzed were the percentage of RVT ordered in the ED and the rate of RVT ordered on the PMWs. Balancing measures included return visits leading to admission and inpatient viral nosocomial outbreaks.

RESULTS

The RVT rate decreased from a mean of 3.0% to 0.5% of ED visits and from 44.3 to 30.1 per 1000 patient days on the PMWs and was sustained throughout the study. Even when accounting for the new rapid influenza test available in the ED, a 50% decrease in overall ED RVT was still achieved without any significant impact on return visits leading to admission or inpatient nosocomial infections.

CONCLUSIONS

Through implementation of a standardized, electronically integrated RVT pathway, a decrease in unnecessary RVT was successfully achieved. Audit and feedback, reminders, and biannual education all supported long-term sustainability of this initiative.

Randomized Controlled Trial Comparing the Bulb Aspirator With a Nasal-Oral Aspirator in the Treatment of Bronchiolitis

OBJECTIVE

This study aimed to compare the traditional bulb aspirator with a nasal-oral aspirator in the treatment of bronchiolitis.

METHODS

This was a single-center, single-blind, randomized controlled trial. Patients with bronchiolitis discharged from the emergency department were randomized to receive a bulb or nasal-oral aspirator for home use.Data regarding return visits, hydration, respiratory relief, parental satisfaction, device preference, and adverse events were gathered using a predistribution questionnaire, diary, poststudy questionnaire, and chart review.

RESULTS

There was not a statistically significant difference in the rate of unscheduled return visits (bulb vs nasal-oral, 28.2% vs 20.7%; P = 0.26). No difference was seen in hydration or respiratory relief in either the diary or poststudy questionnaire. The nasal-oral aspirator had higher satisfaction rates (bulb vs nasal-oral, 68.8% vs 93.9%; P < 0.01). When asked which device was preferred with regard to all devices ever tried, 57.2% of respondents reported the nasal-oral aspirator. More adverse events were seen with the bulb compared with the nasal-oral aspirator (bulb vs nasal-oral, 50.0% vs 17.5%; P < 0.01).

CONCLUSIONS

No difference was appreciated between the bulb and nasal-oral aspirators in unscheduled return rates. The nasal-oral aspirator demonstrated higher parental satisfaction and preference rates, and fewer adverse effects compared with the bulb aspirator. Medical providers should have a cost-benefit discussion with caregivers when recommending home aspirators for the treatment of bronchiolitis.Registry ClinicalTrials.gov Identifier: NCT03288857. Comparison of the Bulb Aspirator With a Nasal-Oral Aspirator in the Treatment of Bronchiolitis.

OUP accepted manuscript

Background

Limited data are available on the economic costs of respiratory syncytial virus (RSV) infections among infants and young children in the United States.

Methods

We performed a systematic literature review of 10 key databases to identify studies published between 1 January 2014 and 2 August 2021 that reported RSV-related costs in US children aged 0–59 months. Costs were extracted and a systematic analysis was performed.

Results

Seventeen studies were included. Although an RSV hospitalization (RSVH) of an extremely premature infant costs 5.6 times that of a full-term infant ($10 214), full-term infants accounted for 82% of RSVHs and 70% of RSVH costs. Medicaid-insured infants were 91% more likely than commercially insured infants to be hospitalized for RSV treatment in their first year of life. Medicaid financed 61% of infant RSVHs. Paying 32% less per hospitalization than commercial insurance, Medicaid paid 51% of infant RSVH costs. Infants’ RSV treatment costs $709.6 million annually, representing $187 per overall birth and $227 per publicly funded birth.

Conclusions

Public sources pay for more than half of infants’ RSV medical costs, constituting the highest rate of RSVHs and the highest expenditure per birth. Full-term infants are the predominant source of infant RSVHs and costs.

Clinico-virological Profile, Intensive Care Needs, and Outcome of Infants with Acute Viral Bronchiolitis: A Prospective Observational Study

OBJECTIVES

The objective of the study was to describe the clinico-virological profile, treatment details, intensive care needs, and outcome of infants with acute viral bronchiolitis (AVB).

METHODOLOGY

In this prospective observational study, 173 infants with AVB admitted to the pediatric emergency room and pediatric intensive care unit (PICU) of a tertiary care teaching hospital in North India during November 2019 to February 2020 were enrolled. The data collection included clinical features, viruses detected [respiratory syncytial virus (RSV), rhinovirus, influenza A virus, parainfluenza virus (PIV) 2 and 3, and human metapneumovirus (hMPV)], complications, intensive care needs, treatment, and outcomes. Multivariate analysis was performed to determine independent predictors for PICU admission.

RESULTS

Most common symptoms were rapid breathing (98.8%), cough (98.3%), and fever (74%). On examination, tachypnea (98.8%), chest retractions (93.6%), respiratory failure (84.4%), wheezing (49.7%), and crepitations (23.1%) were observed. RSV and rhinovirus were the predominant isolates. Complications were noted in 25% of cases as encephalopathy (17.3%), transaminitis (14.3%), shock (13.9%), acute kidney injury (AKI) (7.5%), myocarditis (6.4%), multiple organ dysfunction syndrome (MODS) (5.8%), and acute respiratory distress syndrome (ARDS) (4.6%). More than one-third of cases required PICU admission. The treatment details included nasal cannula oxygen (11%), continuous positive airway pressure (51.4%), high-flow nasal cannula (14.5%), mechanical ventilation (23.1%), nebulization (74%), antibiotics (35.9%), and vasoactive drugs (13.9%). The mortality was 8.1%. Underlying comorbidity, chest retractions, respiratory failure at admission, presence of shock, and need for mechanical ventilation were independent predictors of PICU admission. Isolation of virus or coinfection was not associated with disease severity, intensive care needs, and outcomes.

CONCLUSION

Among infants with AVB, RSV and rhinovirus were predominant. One-third infants with AVB needed PICU admission. The presence of comorbidity, chest retractions, respiratory failure, shock, and need for mechanical ventilation independently predicted PICU admission.

HOW TO CITE THIS ARTICLE

Angurana SK, Takia L, Sarkar S, Jangra I, Bora I, Ratho RK, et al. Clinico-virological Profile, Intensive Care Needs, and Outcome of Infants with Acute Viral Bronchiolitis: A Prospective Observational Study. Indian J Crit Care Med 2021;25(11):1301-1307.

Early Use of Bronchodilators and Outcomes in Bronchiolitis

BACKGROUND AND OBJECTIVES

There are no effective interventions to prevent hospital admissions in infants with bronchiolitis. The American Academy of Pediatrics recommends against routine bronchodilator use for bronchiolitis. The objective of this study was to characterize trends in and outcomes associated with the use of bronchodilators for bronchiolitis.

METHODS

This is a multicenter retrospective study of infants <12 months of age with bronchiolitis from 49 children's hospitals from 2010 to 2018. The primary outcomes were rates of hospital admissions, ICU admissions, emergency department (ED) return visits after initial ED discharge, noninvasive ventilation, and invasive ventilation. Multivariable logistic regression was used to evaluate the rates of outcomes among hospitals with high and low early use of bronchodilators (on day of presentation).

RESULTS

A total of 446 696 ED visits of infants with bronchiolitis were included. Bronchodilator use, hospital admissions, and ED return visits decreased between 2010 and 2018 (all P < .001). ICU admissions and invasive and noninvasive ventilation increased over the study period (all P < .001). Hospital-level early bronchodilator use (hospitals with high versus low use) was not associated with differences in patient-level hospital admissions, ICU admissions, ED return visits, noninvasive ventilation, or invasive ventilation (all P > .05).

CONCLUSIONS

In a large study of infants at children's hospitals, bronchodilator therapy decreased significantly from 2010 to 2018. Hospital-level early bronchodilator use was not associated with a reduction in any outcomes. This study supports the current American Academy of Pediatrics recommendation to limit routine use of bronchodilators in infants with bronchiolitis.

Seasonal variation of respiratory viral infections: a comparative study between children with cancer undergoing chemotherapy and children without cancer

Respiratory viral infections (RVIs) affect children year-round, with seasonal-specific patterns. Pediatric oncology patients are uniquely vulnerable to infection, but whether this predisposes them to different patterns of RVIs than healthy children is unknown. There is also limited data on the impact of RVIs on cancer patients. We conducted a retrospective study of children ages 1-21 with cancer presenting to the clinic and emergency department (ED) and a randomly selected subset of patients without cancer presenting to the ED who had positive nasopharyngeal viral polymerase chain reactions at our institution from 2014 to 2019. Sixty-seven cancer patients (206 RVI episodes) and 225 pediatric non-cancer patients (237 RVI episodes) were included. Human rhino/enterovirus (HRE) was the most common infection in both groups in the spring, summer, and fall. In the winter, the most common RVI was influenza in cancer patients verses respiratory syncytial virus in non-cancer patients. On age-adjusted analysis, the likelihood of detecting coronavirus in the winter, HRE in the spring and fall, and parainfluenza in the summer was significantly greater in cancer patients (OR = 2.60, 2.52, 5.73, 3.59 respectively). Among cancer RVI episodes, 50% received parenteral antibiotics, 22% were severely neutropenic, 22% had chemotherapy delays for a median of six days, 16% were hospitalized, and 6% received intravenous immunoglobulin. We conclude that there are differences in the seasonal patterns of RVIs between children with and without cancer. RVIs also cause significant morbidity in children with cancer.

Trends in Emergency Department Utilization Among Women With Leiomyomas in the United States

OBJECTIVE

To describe trends in emergency department (ED) visits in the United States with a primary diagnosis of leiomyomas, subsequent admissions, and associated charges.

METHODS

The Healthcare Cost and Utilization Project Nationwide Emergency Department Sample database was used to retrospectively identify all ED visits from 2006 to 2017 among women aged 18-55 years with a primary diagnosis of leiomyomas as indicated by International Classification of Diseases (ICD) diagnosis codes. Trends in ED visits and subsequent admissions were analyzed and stratified by patient and hospital characteristics. Secondary ICD codes, Current Procedural Terminology codes, and hospital charges were analyzed. A multivariate regression model was used to identify predictors of admission.

RESULTS

Although the number of ED visits for leiomyomas increased from 28,732 in 2006 to 65,685 in 2017, the admission rate decreased, from 23.9% in 2006 to 11.1% in 2017. Emergency department visits for leiomyomas were highest among women who were aged 36-45 years (44.5%), in the lowest income quartile (36.1%), privately insured (38.3%), and living in the South (46.2%). Admission was more likely at nonteaching hospitals (odds ratio [OR] 1.23, 95% CI 1.08-1.39) or those located in the Northeast (OR 1.39, 95% CI 1.15-1.68). Patient characteristics associated with admission included older age (26-35 years: OR 1.42, 95% CI 1.21-1.66; 36-45 years: OR 2.01, 95% CI 1.72-2.34; 46-55 years: OR 2.60, 95% CI 2.23-3.03) and bleeding-related complaints (OR 14.92, 95% CI 14.00-15.90). Admission was least likely in uninsured patients (Medicare: OR 1.37, 95% CI 1.21-1.54; Medicaid: OR 1.26, 95% CI 1.16-1.36; private: OR 1.44, 95% CI 1.32-1.56).

CONCLUSION

Although ED visits for leiomyomas are increasing, admission rates for these visits are decreasing. The substantial decline in admissions suggests many of these visits could potentially be addressed in a non-acute-care setting. However, when women with leiomyomas present with a bleeding-related complaint, the odds of admission increase 15-fold. There is an apparent disparity in likelihood of admission based on insurance type.

[Decrease in the use of bronchodilators in the management of bronchiolitis after applying improvement initiatives]

INTRODUCTION

In the treatment of patients with acute bronchiolitis there is great variability in clinical practice. Treatments whose efficacy has not been demonstrated are frequently used despite the recommendations contained in the Clinical Practice Guidelines.

MATERIAL AND METHODS

A quality improvement strategy is implemented in the care of patients with acute bronchiolitis in the Emergency Department, which is maintained for five years and is periodically updated to be increasingly restrictive regarding the use of bronchodilators. To evaluate the impact of the intervention, a retrospective study of the rates of prescription of bronchodilators in children diagnosed with acute bronchiolitis in the month of December of four epidemic periods (2012, 2014, 2016 and 2018) was carried out.

RESULTS

1767 children are included. There were no differences regarding age, respiratory rate, oxygen saturation or the estimated severity in each of the study seasons. The use of salbutamol in the Emergency Department decreased from 51.2% (95% CI: 46.6%-55.8%) in 2012 to 7.8% (95% CI: 5.7%-10.5%) in 2018 (P<.001) and epinephrine prescription rates fell from 12.9% (95% CI: 10.1%-16.3%) to 0.2% (95% CI: 0-1.1%) (P<.001). At the same time, there was a decrease in the median time of attendance in the Emergency Department and in the admission rate without changing the readmission rate in 72h.

CONCLUSIONS

The systematic and continuous deployment over time of actions aimed at reducing the use of salbutamol and epinephrine in the treatment of bronchiolitis, prior to the epidemic period, seems an effective strategy to reduce the use of bronchodilators in the Emergency Department.

Measured CPAP in a Noninvasive Pediatric Airway and Lung Model

BACKGROUND

Bronchiolitis is the most common cause of admission in children < 2 y of age in the United States. The standard of care involves supportive measures, including noninvasive interventions such as CPAP. CPAP is traditionally delivered through a full face mask; however, pediatric ICUs have been exploring the use of the RAM cannula by Neotech as a mode of CPAP delivery. The level of CPAP delivered via the RAM cannula is uncertain. We performed an in vitro study to determine the level of CPAP delivered via the RAM cannula utilizing a pediatric lung model.

METHODS

Models of 7 sizes of pediatric upper airways, produced with a 3-dimensional printer, were connected to a breathing simulator. We applied each size of RAM cannula to weight-appropriate airway and lung compliance parameters, delivering pressures of 5, 7, and 10 cm H₂O using a ventilator in the CPAP mode. Leaks of 0%, 20%, 40%, and 60% were generated to emulate a complete seal, a poor fit, and open-mouth breathing. The outcome measure was the difference in CPAP, referred to as "%leak effect," measured by the lung simulator relative to the CPAP set on the ventilator.

RESULTS

We found that set CPAP of 5-10 cm H₂O generated measured CPAP ranging from 2.6 to 9.7 cm H₂O. For the set CPAP levels of 5, 7, and 10 cm H₂O, the mean %leak effect values of measured CPAP from the set CPAP were -25%, -26%, and -25.7%, respectively. For each specific cannula-airway combination, increasing the set pressure and decreasing the air leak resulted in higher levels of CPAP delivered.

CONCLUSIONS

The RAM cannula delivered varying amounts of CPAP, with a percent loss of approximately -25% depending on the level of leak in the system. With minimal leak, it is conceivable that the RAM cannula can be used to deliver clinically meaningful CPAP.

Magnesium sulphate for treating acute bronchiolitis in children up to two years of age

BACKGROUND

Acute bronchiolitis is a significant burden on children, their families and healthcare facilities. It mostly affects children younger than two years of age. Treatment involves adequate hydration, humidified oxygen supplementation, and nebulisation of medications, such as salbutamol, epinephrine, and hypertonic saline. The effectiveness of magnesium sulphate for acute bronchiolitis is unclear.

OBJECTIVES

To assess the effects of magnesium sulphate in acute bronchiolitis in children up to two years of age.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS, CINAHL, and two trials registries to 30 April 2020. We contacted trial authors to identify additional studies. We searched conference proceedings and reference lists of retrieved articles. Unpublished and published studies were eligible for inclusion.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs, comparing magnesium sulphate, alone or with another treatment, with placebo or another treatment, in children up to two years old with acute bronchiolitis. Primary outcomes were time to recovery, mortality, and adverse events. Secondary outcomes were duration of hospital stay, clinical severity score at 0 to 24 hours and 25 to 48 hours after treatment, pulmonary function test, hospital readmission within 30 days, duration of mechanical ventilation, and duration of intensive care unit stay.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We used GRADE methods to assess the certainty of the evidence.

MAIN RESULTS

We included four RCTs (564 children). One study received funding from a hospital and one from a university; two studies did not report funding sources. Comparator interventions differed among all four trials. Studies were conducted in Qatar, Turkey, Iran, and India. We assessed two studies to be at an overall low risk of bias, and two to be at unclear risk of bias, overall. The certainty of the evidence for all outcomes and comparisons was very low except for one: hospital re-admission rate within 30 days of discharge for magnesium sulphate versus placebo. None of the studies measured time to recovery, duration of mechanical ventilation, duration of intensive care unit stay, or pulmonary function. There were no events of mortality or adverse effects for magnesium sulphate compared with placebo (1 RCT, 160 children). The effects of magnesium sulphate on clinical severity are uncertain (at 0 to 24 hours: mean difference (MD) on the Wang score 0.13, 95% confidence interval (CI) -0.28 to 0.54; and at 25 to 48 hours: MD on the Wang score -0.42, 95% CI -0.84 to -0.00). Magnesium sulphate may increase hospital re-admission rate within 30 days of discharge (risk ratio (RR) 3.16, 95% CI 1.20 to 8.27; 158 children; low-certainty evidence). None of our primary outcomes were measured for magnesium sulphate compared with hypertonic saline (1 RCT, 220 children). Effects were uncertain on the duration of hospital stay in days (MD 0.00, 95% CI -0.28 to 0.28), and on clinical severity on the Respiratory Distress Assessment Instrument (RDAI) score at 25 to 48 hours (MD 0.10, 95% CI -0.39 to 0.59). There were no events of mortality or adverse effects for magnesium sulphate, with or without salbutamol, compared with salbutamol (1 RCT, 57 children). Effects on the duration of hospital stay were uncertain (magnesium sulphate: 24 hours (95% CI 25.8 to 47.4), magnesium sulphate + salbutamol: 20 hours (95% CI 15.3 to 39.0), and salbutamol: 24 hours (95% CI 23.4 to 76.9)). None of our primary outcomes were measured for magnesium sulphate + epinephrine compared with no treatment or normal saline + epinephrine (1 RCT,120 children). Effects were uncertain for the duration of hospital stay in hours (MD -0.40, 95% CI -3.94 to 3.14), and for RDAI scores (0 to 24 hours: MD -0.20, 95% CI -1.06 to 0.66; and 25 to 48 hours: MD -0.90, 95% CI -1.75 to -0.05).

AUTHORS' CONCLUSIONS

There is insufficient evidence to establish the efficacy and safety of magnesium sulphate for treating children up to two years of age with acute bronchiolitis. No evidence was available for time to recovery, duration of mechanical ventilation and intensive care unit stay, or pulmonary function. There was no information about adverse events for some comparisons. Well-designed RCTs to assess the effects of magnesium sulphate for children with acute bronchiolitis are needed. Important outcomes, such as time to recovery and adverse events should be measured.

Acute Viral Bronchiolitis: A Narrative Review

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

Identifying and managing bronchiolitis

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

Non-gradient and genotype-dependent patterns of RSV gene expression

Respiratory syncytial virus (RSV) is a nonsegmented negative-strand RNA virus (NSV) and a leading cause of severe lower respiratory tract illness in infants and the elderly. Transcription of the ten RSV genes proceeds sequentially from the 3’ promoter and requires conserved gene start (GS) and gene end (GE) signals. Previous studies using the prototypical GA1 genotype Long and A2 strains have indicated a gradient of gene transcription extending across the genome, with the highest level of mRNA coming from the most promoter-proximal gene, the first nonstructural (NS1) gene, and mRNA levels from subsequent genes dropping until reaching a minimum at the most promoter-distal gene, the polymerase (L) gene. However, recent reports show non-gradient levels of mRNA, with higher than expected levels from the attachment (G) gene. It is unknown to what extent different transcript stabilities might shape measured mRNA levels. It is also unclear whether patterns of RSV gene expression vary, or show strain- or genotype-dependence. To address this, mRNA abundances from five RSV genes were measured by quantitative real-time PCR (qPCR) in three cell lines and in cotton rats infected with RSV isolates belonging to four genotypes (GA1, ON, GB1, BA). Relative mRNA levels reached steady-state between four and 24 hours post-infection. Steady-state patterns were non-gradient and genotype-specific, where mRNA levels from the G gene exceeded those from the more promoter-proximal nucleocapsid (N) gene across isolates. Transcript stabilities could not account for the non-gradient patterns observed, indicating that relative mRNA levels more strongly reflect transcription than decay. Our results indicate that gene expression from a small but diverse set of RSV genotypes is non-gradient and genotype-dependent. We propose novel models of RSV transcription that can account for non-gradient transcription.

Trends in Bronchiolitis Hospitalizations in the United States: 2000-2016

OBJECTIVES

To investigate the temporal trend in the national incidence of bronchiolitis hospitalizations, their characteristics, inpatient resource use, and hospital cost from 2000 through 2016.

METHODS

We performed a serial, cross-sectional analysis of nationally representative samples (the 2000, 2003, 2006, 2009, 2012, and 2016 Kids' Inpatient Databases) of children (age <2 years) hospitalized for bronchiolitis. We identified all children hospitalized with bronchiolitis by using International Classification of Diseases, Ninth Revision, Clinical Modification 466.1 and International Classification of Diseases, 10th Revision, Clinical Modification J21. Complex chronic conditions were defined by the pediatric complex chronic conditions classification by using inpatient data. The primary outcomes were the incidence of bronchiolitis hospitalizations, mechanical ventilation use, and hospital direct cost. We examined the trends accounting for sampling weights.

RESULTS

From 2000 to 2016, the incidence of bronchiolitis hospitalization decreased from 17.9 to 13.5 per 1000 person-years in US children (25% decrease; P _trend < .001). In contrast, the proportion of bronchiolitis hospitalizations among overall hospitalizations increased from 16% to 18% (P _trend < .001). There was an increase in the proportion of children with a complex chronic condition (6%-13%; 117% increase), hospitalization to children's hospital (15%-29%; 93% increase), and mechanical ventilation use (2%-5%; 184% increase; all P _trend < .001). Likewise, the hospital cost increased from $449 million to $734 million (63% increase) nationally (with an increase in geometric mean of cost per hospitalization [from $3267 to $4086; 25% increase; P _trend < .001] adjusted for inflation) from 2003 to 2016.

CONCLUSIONS

From 2000 through 2016, the incidence of bronchiolitis hospitalizations among US children declined. In contrast, mechanical ventilation use and nationwide hospital direct cost substantially increased.

Targeted Education Across Clinical Settings Improves Adherence to Evidence-Based Interventions for Bronchiolitis

Bronchiolitis remains a leading cause of hospitalization of infants. Despite evidence-based recommendations, wide variation in practice remains. A pre-post educational intervention was implemented to improve adherence to bronchiolitis guidelines in emergency and inpatient settings. Among children meeting inclusion criteria (136 pre-intervention, 185 post-intervention), emergency department (ED) bronchodilator use decreased by 64% (P < .001). Steroid use decreased by 71% (P = .002). There was no difference in viral testing, antibiotic use, or chest radiograph acquisition. No differences were seen in the inpatient setting. There was no difference in rate of intensive care unit transfer or length of stay. Post-intervention, children were less likely to receive a bronchodilator in the ED (odds ratio [OR] = 0.15, P < .001). Children with a family history of asthma were more likely to receive a bronchodilator in the ED (OR = 4.25, P < .001). Targeted education across settings contributed to reducing bronchodilator use in the ED. Family history appeared to influence medical decision making.

The Problematic 2014 American Academy of Pediatrics Bronchiolitis Guidelines

The 2014 American Academy of Pediatrics bronchiolitis guidelines do not adequately serve the needs and clinical realities of front-line clinicians caring for undifferentiated wheezing infants and children. This article describes the clinical challenges of evaluating and managing a heterogeneous disease syndrome presenting as undifferentiated patients to the emergency department. Although the 2014 American Academy of Pediatrics bronchiolitis guidelines and the multiple international guidelines that they closely mirror have made a good faith attempt to provide clinicians with the best evidence-based recommendations possible, they have all failed to address practical, front-line clinical challenges. The therapeutic nihilism of the guidelines and the dissonance between many of the recommendations and frontline realities have had wide-ranging consequences. Nevertheless, newer evidence of therapeutic options is emerging and forecasts hope for more therapeutically optimistic recommendations with the next revision of the guidelines.

Comparison of heated humidified high-flow nasal cannula flow rates (1-L·kg·min-1 vs 2-L·kg·min -1 ) in the management of acute bronchiolitis

OBJECTIVE

We aimed to compare the heated humidified high-flow nasal cannula (HHHFNC) flow rate of 1-L·kg·min^-1 (1 L) with 2-L·kg·min ^-1 (2 L) in patients with severe bronchiolitis presenting to the pediatric emergency department.

STUDY DESIGN

We performed a study in which all patients were allocated to receive these two flow rates. The primary outcome was admitted as treatment failure, which was defined as a clinical escalation in respiratory status. Secondary outcomes covered a decrease of respiratory rate (RR), heart rate (HR), the clinical respiratory score (CRS), rise of peripheral capillary oxygen saturation (SpO₂ ), and rates of weaning, intubation, and intensive care unit (ICU) admission.

RESULTS

One hundred and sixty-eight cases (88 received the 1-L flow rate and 80, the 2-L flow rate) were included in the analyses. Treatment failure was 11.4% (10 of 88) in the 1-L group, and 10% (8 of 80) in the 2-L group (P = .775). Significant variation in the intubation rate or the ICU admission rate was not determined. At the 2nd hour, the rate of weaning (53.4% vs 35%; P = .017), the falling down of the CRS (-2.1 vs -1.5; P < .001), RR (-15.2 vs -11.8; P < .001), and HR (- 24.8 vs - 21.2; P < .001), and the increase of SpO ₂ (4.8 vs 3.6; P < .001) were significantly more evident in the 1-L group.

CONCLUSION

HHHFNC with the 1-L·kg·min^-1 flow rate, which provides a more frequent earlier effect, reached therapy success as high as the 2-L·kg·min ^-1 flow rate in patients with severe acute bronchiolitis.

Factors Predicting Asthma in Children With Acute Bronchiolitis

OBJECTIVE

The aim of this study was to determine if there is an association between bronchiolitis and future development of asthma in children younger than 2 years.

METHODS

We reviewed the medical records of 1991 patients younger than 2 years presenting to the emergency department from January 2000 to December 2010 who received a clinical diagnosis of acute bronchiolitis. Their demographic information, the number of bronchiolitis episodes, and family history of asthma were recorded. The primary care clinic records of these children were reviewed for a period of 1 year following their presentation to the emergency department to determine if they had received a diagnosis of asthma. A stepwise logistic regression was performed to determine what factors were associated with future asthma development.

RESULTS

We reviewed the medical record of 1991 children with the diagnosis of bronchiolitis for subsequent development of asthma. The following variables were identified as predictors of subsequent asthma: male sex (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.05-1.55), family history of asthma (OR, 1.6; 95% CI, 1.33-1.95), atopy (OR, 1.4; 95% CI, 1.12-1.83), age older than 5 months (OR, 1.4 95% CI, 1.13-1.66), more than 2 episodes of bronchiolitis (OR, 2.4; 95% CI, 1.79-3.07), and allergies (OR1.6; 95% CI, 1.14-2.14).

CONCLUSIONS

In this limited sample, the predictor variables for asthma were male sex, age older than 5 months, more than 2 episodes of bronchiolitis, a history of atopy, and allergies.

Respiratory support for infants with bronchiolitis, a narrative review of the literature

Bronchiolitis is a common viral disease that significantly affects infants less than 12 months of age. The purpose of this review is to present a review of the current knowledge of the uses of respiratory support in the management of infants with bronchiolitis presenting to hospital. We electronically searched MEDLINE, Cochrane, CINAHL and EMBASE (inception to 25th March 2018), to manually search for clinical trials that address the management strategies for respiratory support of infants with bronchiolitis. We identified 120 papers who met the inclusion criteria, of which 33 papers were relevant for this review with only nine randomized controlled trials. This review demonstrated that non-invasive respiratory support reduced the need for escalation of therapy, particularly the proportion of intubations required for infants with bronchiolitis. Additionally, clear economic benefits have been demonstrated when non-invasive ventilation has been used. The potential early use of non-invasive respiratory supports such as nasal high flow therapy and non-invasive ventilation may have an impact on health care costs and reduction in ICU admissions and intubation rates. High-grade evidence demonstrates safety and quality of high flow therapy in general ward settings.

Outcomes of Children With Bronchiolitis Treated With High-Flow Nasal Cannula or Noninvasive Positive Pressure Ventilation

OBJECTIVES

Initial respiratory support with noninvasive positive pressure ventilation or high-flow nasal cannula may prevent the need for invasive mechanical ventilation in PICU patients with bronchiolitis. However, it is not clear whether the initial choice of respiratory support modality influences the need for subsequent invasive mechanical ventilation. The purpose of this study is to compare the rate of subsequent invasive mechanical ventilation after initial support with noninvasive positive pressure ventilation or high-flow nasal cannula in children with bronchiolitis.

DESIGN

Analysis of the Virtual Pediatric Systems database.

SETTING

Ninety-two participating PICUs.

PATIENTS

Children less than 2 years old admitted to a participating PICU between 2009 and 2015 with a diagnosis of bronchiolitis who were prescribed high-flow nasal cannula or noninvasive positive pressure ventilation as the initial respiratory treatment modality.

INTERVENTIONS

None. Subsequent receipt of invasive mechanical ventilation was the primary outcome.

MEASUREMENTS AND MAIN RESULTS

We identified 6,496 subjects with a median age 3.9 months (1.7-9.5 mo). Most (59.7%) were male, and 23.4% had an identified comorbidity. After initial support with noninvasive positive pressure ventilation or high-flow nasal cannula, 12.3% of patients subsequently received invasive mechanical ventilation. Invasive mechanical ventilation was more common in patients initially supported with noninvasive positive pressure ventilation compared with high-flow nasal cannula (20.1% vs 11.0%: p < 0.001). In a multivariate logistic regression model that adjusted for age, weight, race, viral etiology, presence of a comorbid diagnosis, and Pediatric Index of Mortality score, initial support with noninvasive positive pressure ventilation was associated with a higher odds of subsequent invasive mechanical ventilation compared with high-flow nasal cannula (odds ratio, 1.53; 95% CI, 1.24-1.88).

CONCLUSIONS

In this large, multicenter database study of infants with acute bronchiolitis that received initial respiratory support with high-flow nasal cannula or noninvasive positive pressure ventilation, noninvasive positive pressure ventilation use was associated with higher rates of invasive mechanical ventilation, even after adjusting for demographics, comorbid condition, and severity of illness. A large, prospective, multicenter trial is needed to confirm these findings.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Predicting Appropriate Hospital Admission of Emergency Department Patients with Bronchiolitis: Secondary Analysis

Background

In children below the age of 2 years, bronchiolitis is the most common reason for hospitalization. Each year in the United States, bronchiolitis causes 287,000 emergency department visits, 32%-40% of which result in hospitalization. Due to a lack of evidence and objective criteria for managing bronchiolitis, clinicians often make emergency department disposition decisions on hospitalization or discharge to home subjectively, leading to large practice variation. Our recent study provided the first operational definition of appropriate hospital admission for emergency department patients with bronchiolitis and showed that 6.08% of emergency department disposition decisions for bronchiolitis were inappropriate. An accurate model for predicting appropriate hospital admission can guide emergency department disposition decisions for bronchiolitis and improve outcomes, but has not been developed thus far.

Objective

The objective of this study was to develop a reasonably accurate model for predicting appropriate hospital admission.

Methods

Using Intermountain Healthcare data from 2011-2014, we developed the first machine learning classification model to predict appropriate hospital admission for emergency department patients with bronchiolitis.

Results

Our model achieved an accuracy of 90.66% (3242/3576, 95% CI: 89.68-91.64), a sensitivity of 92.09% (1083/1176, 95% CI: 90.33-93.56), a specificity of 89.96% (2159/2400, 95% CI: 88.69-91.17), and an area under the receiver operating characteristic curve of 0.960 (95% CI: 0.954-0.966). We identified possible improvements to the model to guide future research on this topic.

Conclusions

Our model has good accuracy for predicting appropriate hospital admission for emergency department patients with bronchiolitis. With further improvement, our model could serve as a foundation for building decision-support tools to guide disposition decisions for children with bronchiolitis presenting to emergency departments.

International Registered Report Identifier (IRRID)

RR2-10.2196/resprot.5155

Appropriateness of Hospital Admission for Emergency Department Patients with Bronchiolitis: Secondary Analysis

Background

Bronchiolitis is the leading cause of hospitalization in children under 2 years of age. Each year in the United States, bronchiolitis results in 287,000 emergency department visits, 32%-40% of which end in hospitalization. Frequently, emergency department disposition decisions (to discharge or hospitalize) are made subjectively because of the lack of evidence and objective criteria for bronchiolitis management, leading to significant practice variation, wasted health care use, and suboptimal outcomes. At present, no operational definition of appropriate hospital admission for emergency department patients with bronchiolitis exists. Yet, such a definition is essential for assessing care quality and building a predictive model to guide and standardize disposition decisions. Our prior work provided a framework of such a definition using 2 concepts, one on safe versus unsafe discharge and another on necessary versus unnecessary hospitalization.

Objective

The goal of this study was to determine the 2 threshold values used in the 2 concepts, with 1 value per concept.

Methods

Using Intermountain Healthcare data from 2005-2014, we examined distributions of several relevant attributes of emergency department visits by children under 2 years of age for bronchiolitis. Via a data-driven approach, we determined the 2 threshold values.

Results

We completed the first operational definition of appropriate hospital admission for emergency department patients with bronchiolitis. Appropriate hospital admissions include actual admissions with exposure to major medical interventions for more than 6 hours, as well as actual emergency department discharges, followed by an emergency department return within 12 hours ending in admission for bronchiolitis. Based on the definition, 0.96% (221/23,125) of the emergency department discharges were deemed unsafe. Moreover, 14.36% (432/3008) of the hospital admissions from the emergency department were deemed unnecessary.

Conclusions

Our operational definition can define the prediction target for building a predictive model to guide and improve emergency department disposition decisions for bronchiolitis in the future.

Predictors of Critical Care and Mortality in Bronchiolitis after Emergency Department Discharge

OBJECTIVES

To identify the epidemiologic predictors and stratify the risk of critical care unit (CCU) admission or death in bronchiolitis following emergency department discharge. This information has not yet been explored.

STUDY DESIGN

A population-based cohort study using Ontario-wide demographic and healthcare databases linked at the individual level. We assessed all infants with bronchiolitis discharged home from all emergency departments in Ontario, Canada, 2003-2014. Targeted information included plausible demographic and clinical predictors of CCU admission/death within 14 days of emergency department discharge. Using multivariable logistic regression analyses, we identified independent predictors of this outcome and stratified the outcome risk by the type of multivariable predictor.

RESULTS

Of 34 270 study infants, 102 (0.3%) were admitted to CCU or died after discharge. Predictors of CCU admission/death were: comorbidities (OR 5.33; 95% CI 2.82-10.10), younger age [months] (OR 1.47; 95%CI 1.33-1.61), low income (OR 1.53; 95% CI 1.01-2.34), younger gestational age [weeks] (OR 1.14; 95%CI 1.06-1.22), and emergent presentation (Canadian Triage and Acuity Scale 2) at the index visit (OR 1.55, 95% CI 1.03-2.33). The absolute event risk of CCU admission/death in infants with versus without comorbidities were 1.5% versus 0.26%, respectively (P < .001). The odds of these outcomes in infants with comorbidities plus ≥2 other predictors were 25 times higher than in infants without predictors (OR 25.1, 95% CI 11.4-55.3).

CONCLUSIONS

Infants with comorbidities plus other predictors discharged from the emergency department with bronchiolitis are at considerable risk of subsequent CCU admission and death. These risk factors should augment current clinical and social considerations determining patient disposition.

Impact of hypertonic saline on hospitalization rate in infants with acute bronchiolitis: A meta-analysis

AIM

This meta-analysis aimed to assess the efficacy of nebulized hypertonic saline (HS) on the rate of hospitalization in infants with acute bronchiolitis in the Emergency Department (ED) setting.

METHOD

We searched PubMed, Virtual Health Library-BVS and Cochrane CENTRAL from inception until January 31, 2018. We selected randomized trials that compared nebulized HS with normal saline (NS) or standard care in children up to 24 months of age with acute bronchiolitis in the ED setting. We conducted random-effects meta-analyses to estimate the risk ratio (RR) and 95% confidence interval (CI).

RESULTS

A total of 293 records were screened and 8 trials involving 1708 patients were included. The meta-analysis showed a 16% reduction in the risk of hospitalization among patients treated with HS compared to NS (risk ratio [RR]: 0.84, 95% confidence interval [CI]: 0.71-0.98, P = 0.03). A significant effect of HS in reducing the risk of hospitalization was found only in the subgroup analyses of trials in which HS was mixed with bronchodilators, multiple doses (≥3) were given, and risk of bias was low.

CONCLUSIONS

Nebulized hypertonic saline may potentially reduce the risk of hospitalization in infants with acute bronchiolitis in the ED setting. Quality of evidence is moderate due to substantial clinical heterogeneity between studies and large multicenter trials are still warranted.

Discharge Criteria for Bronchiolitis: An Unmet Need

BACKGROUND

Admission criteria and standardized management strategies for bronchiolitis are addressed in several guidelines and have shown to be beneficial; however, guidance regarding discharge criteria is limited and widely variable. We assessed the impact on clinical outcomes of a discharge protocol for children <2 years of age hospitalized with bronchiolitis in a tertiary care pediatric hospital.

METHODS

In October 2013, a protocol to standardize the discharge of children with bronchiolitis was implemented in the infectious diseases (ID) ward but not in other pediatric units caring for these children (non-ID). The protocol included objective clinical criteria and a standardized oxygen weaning pathway. Patients were identified via International Classification of Diseases-9 codes and data manually reviewed. We compared length of stay (LOS) and readmission rates within 2 weeks of discharge according to protocol implementation (ID versus non-ID), adjusted for demographic factors, comorbidities, viral etiology and stratified by pediatric intensive care unit admission.

RESULTS

From October 2013 to May 2015, 1118 children were hospitalized in ID and 695 in non-ID units. Median age was 4.5 months, 55% were males and 28% had comorbidities. LOS was 36% longer in non-ID units (risk ratio: 1.36 [1.27-1.45]; P < 0.001) adjusted for age, gender, comorbidities and viral etiology. Difference in LOS remained significant after excluding children with comorbidities and stratifying by pediatric intensive care unit admission. Readmission rates were comparable between units (ID, 2.9% versus non-ID, 2.6%).

CONCLUSIONS

A standardized discharge protocol for bronchiolitis reduced LOS without increasing readmission rates. Unifying bronchiolitis discharge criteria and oxygen weaning pathways could positively impact hospital-based patient care for this condition.

[An initiative to reduce the use of unnecessary medication in infants with bronchiolitis in primary care]

INTRODUCTION AND OBJECTIVE

Although evidence-based guidelines for acute bronchiolitis recommend primarily supportive care unnecessary treatments remain well documented. The objective of this study was to analyse a quality improvement initiative to reduce overuse of unnecessary treatments in infants with acute bronchiolitis in primary care settings.

METHOD

To determine the number of unnecessary treatments we reviewed the charts corresponding to infants aged <24 months of age diagnosed with acute bronchiolitis in two Primary Care areas during two bronchiolitis seasons [October-Mars of 2015-2016 (pre-intervention period) and 2016-2017 (post-intervention period)]. Between those seasons we distributed an evidence-based management protocol and developed interactive sessions with on-line data collection and feed-back. Outcomes were the rate of infants receiving salbutamol, steroids or antibiotics.

RESULTS

Twenty outpatient clinics contributed with 1,277 chart reviews (619 in the pre-intervention period and 658 in the post-intervention period). Overall, the use of any medication was reduced from 72.5% (95% CI, 68.8-75.9) to 52.1% (95% CI, 48.3-55.9) (p<0.01): salbutamol from 56.0% (95% CI, 52.1-59.9) to 38.3% (95% CI, 34.6-42.0) (p<0.01), corticosteroids from 23.7% (95% CI, 20.5-27.2) to 12.9% (95% CI, 10.5-15.7) (p<0.01) and antibiotics from 36.1% (95% CI; 32.5-40.0) to 29.6% (95% CI; 26.2-33.2) (p<0.05). The number of medications per patient decreased from a mean of 1.81 (SD: 0.86) to 1.62 (SD: 0.81) (p<0.01).

CONCLUSIONS

We significantly decreased the use of unnecessary treatments in infants with acute bronchiolitis. This quality improvement initiative may be applied to the settings where the majority of infants with acute bronchiolitis are attended in western countries.

Treatment of severe bronchiolitis: A survey of Canadian pediatric intensivists

OBJECTIVE

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

DESIGN

Cross-sectional survey.

SETTING

Canadian PICUs.

SUBJECTS

Pediatric intensivists.

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSION

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

Multicenter Study of Albuterol Use Among Infants Hospitalized with Bronchiolitis

INTRODUCTION

Although bronchiolitis is a common reason for infant hospitalization, significant heterogeneity persists in its management. The American Academy of Pediatrics currently recommends that inhaled albuterol not be used in routine care of children with bronchiolitis. Our objective was to identify factors associated with pre-admission (e.g., emergency department or primary care) use of albuterol among infants hospitalized for bronchiolitis.

METHODS

We analyzed data from a 17-center observational study of 1,016 infants (age <1 year) hospitalized with bronchiolitis between 2011-2014. Pre-admission albuterol use was ascertained by chart review, and data were available for 1,008 (99%) infants. We used multivariable logistic regression to identify infant characteristics independently associated with pre-admission albuterol use.

RESULTS

Half of the infants (n=508) received at least one albuterol treatment before admission. Across the 17 hospitals, pre-admission albuterol use ranged from 23-84%. In adjusted analysis, independent predictors of albuterol use were the following: age ≥2 months (age 2.0-5.9 months [odds ratio (OR) 2.09, 95% confidence interval (CI) {1.45-3.01}] and age 6.0-11.9 months [OR 2.89, 95% CI {1.99-4.19}]); prior use of a bronchodilator (OR 1.89, 95% CI [1.24-2.90]); and presence of wheezing documented in pre-admission chart (OR 3.94, 95% CI [2.61-5.93]). By contrast, albuterol use was less likely among those with ≥7 days since the start of breathing problem (OR 0.66, 95% CI [0.44-1.00]) and parent-reported fever (OR 0.75, 95% CI [0.58-0.96]).

CONCLUSION

Variation in pre-admission albuterol use suggests that local practice had a strong influence on use, but that patient characteristics also influenced the decision. While we agree with current guidelines in recommending against albuterol for all infants with bronchiolitis, our understanding of possible subgroups of responders may improve through investigation of infants with the identified characteristics.

Multisite Emergency Department Inpatient Collaborative to Reduce Unnecessary Bronchiolitis Care

BACKGROUND AND OBJECTIVES

There is high variation in the care of acute viral bronchiolitis. We sought to promote collaboration between emergency department (ED) and inpatient (IP) units with the goal of reducing unnecessary testing and treatment.

METHODS

Multisite collaborative with improvement teams co-led by ED and IP physicians and a 1-year period of active participation. The intervention consisted of a multicomponent change package, regular webinars, and optional coaching. Data were collected by chart review for December 2014 through March 2015 (baseline) and December 2015 to March 2016 (improvement period). Patients <24 months of age with a primary diagnosis of bronchiolitis and without ICU admission, prematurity, or chronic lung or heart disease were eligible for inclusion. Control charts were used to detect improvement. Achievable benchmarks of care were calculated for each measure.

RESULTS

Thirty-five hospitals with 5078 ED patients and 4389 IPs participated. Use of bronchodilators demonstrated special cause for the ED (mean centerline shift: 37.1%-24.5%, benchmark 5.8%) and IP (28.4%-17.7%, benchmark 9.1%). Project mean ED viral testing decreased from 42.6% to 25.4% after revealing special cause with a 3.9% benchmark, whereas chest radiography (30.9%), antibiotic use (6.2%), and steroid use (7.6%) in the ED units did not change. IP steroid use decreased from 7.2% to 4.0% after special cause with 0.0% as the benchmark. Within-site ED and IP performance was modestly correlated.

CONCLUSIONS

Collaboration between ED and IP units was associated with a decreased use of unnecessary tests and therapies in bronchiolitis; top performers used few unnecessary tests or treatments.

Pediatric respiratory tract diseases: Chronological trends and perspectives

BACKGROUND

The aim of this study was to describe the epidemiological profile of childhood respiratory tract diseases (RTD) in the region of Sfax, Tunisia, and to evaluate their trends over a 13 year period.

METHODS

We conducted a retrospective study of all children hospitalized with RTD aged under 14 years. We collected data from the regional morbidity register of the university hospital of Sfax from 2003 to 2015.

RESULTS

A total of 10 797 RTD patients were enrolled from 49 880 pediatric hospitalizations (21.7%). A male predominance was noted (60%). The median age was 8 months (IQR, 2-36 months). Acute bronchitis (AB) accounted for 53.8%, followed by asthma (15%), pneumonia (14%) and acute upper respiratory infection (AURI; 7.2%). The hospital incidence rate (HIR) of RTD was 34/10 000 inhabitants/year. It was 18.2; 5.07; 4.7 and 2.4/10 000 inhabitants for AB, asthma, pneumonia and AURI, respectively. We noted a significant increase in the HIR of RTD with an annual percentage change (APC) of 10.94% (P < 0.001); in the HIR of AB (APC, 5.27%; P < 0.001); and in asthma HIR (APC, 11.2%; P < 0.001). Otherwise, a significant decrease in AURI HIR was observed (APC, -8.8%; P < 0.001). AB lethality rate increased significantly, with an APC of 7.4% (P < 0.001). Projected trends analysis up to 2024 showed a significant rise in AB and in asthma, while AURI would significantly decrease.

CONCLUSIONS

RTD continues to be a serious health problem over time in terms of morbidity and mortality. Preventive and curative strategies are needed urgently.

Low age, low birthweight and congenital heart disease are risk factors for intensive care in infants with bronchiolitis

AIM

This study evaluated the incidence and risk factors for intensive care and respiratory support in infant bronchiolitis.

METHODS

This retrospective descriptive case-control study focused on 105 patients treated in the paediatric intensive care unit (PICU) and 210 controls treated in the emergency department or on the paediatric ward in Tampere University Hospital in Finland between 2000 and 2015. Statistically significant risk factors in nonadjusted analyses were included in the adjusted logistic regression.

RESULTS

The average age-specific annual incidence of bronchiolitis requiring PICU admission under the age of 12 months was 1.5/1000/year (range 0.18-2.59). Independently, significant risk factors for PICU admission were as follows: being less than two months old with an adjusted odds ratio (aOR) of 11.5, birthweight of <2000 g (aOR of 15.9), congenital heart disease (CHD) (aOR of 15.9), apnoea (aOR of 7.2) and the absence of wheezing (aOR of 2.2). Significant risk factors for needing respiratory support were a birthweight of <2000 g, an age of less than two months and CHD.

CONCLUSION

Less than 0.1% of infants under the age of 12 months were admitted to the PICU for bronchiolitis. Low age, low birthweight or prematurity and CHD were independently significant risk factors for both intensive care and respiratory support.

Temporal Changes in Prescription of Neuropharmacologic Drugs and Utilization of Resources Related to Neurologic Morbidity in Mechanically Ventilated Children With Bronchiolitis

OBJECTIVES

Critically ill children with bronchiolitis may require neuropharmacologic medications and support for neuro-functional sequelae, but current practices are not well described. We aimed to describe recent trends in neuropharmacology and utilization of neuro-rehabilitation resources in mechanically ventilated children with bronchiolitis.

DESIGN

Analysis of the multicenter Pediatric Health Information System database.

SETTING

Forty-seven U.S. children's hospitals.

PATIENTS

PICU patients less than 2 years old with bronchiolitis undergoing mechanical ventilation between 2006 and 2015.

INTERVENTIONS

None. Annual rates of utilization of neuropharmacologic medications (sedatives, analgesics, etc) and of neuro-rehabilitation services (physical therapy, neurologic consultation, etc) over the 10-year study period were compared.

MEASUREMENTS AND MAIN RESULTS

Neuropharmacologic medications prescribed on greater than or equal to 2 days were extracted. Utilization of MRI of the brain, neurologic consultation, swallow evaluation, occupational therapy, and physical therapy was also extracted. Among 12,508 subjects, the median age was 2.8 months, ~50% had comorbid conditions, and the median duration of mechanical ventilation was 7 days. The percentage of children prescribed greater than or equal to five drugs/drug classes increased over the study period from 36.5% to 55.8% (p < 0.001). There were significant increases over time in utilization of 10 of the 15 individual drugs/drug classes analyzed. More than half of subjects (6,294 [50.3%]) received at least one service that evaluates/treats neurologic morbidity. There were significant increases in the use of greater than or equal to one service (36.3% in 2006 to 59.6% in 2015; p < 0.001) and in the use of greater than or equal to two services (20.8% to 34.8%; p < 0.001). Utilization of each of the five individual resources increased significantly during the study period, but use of vasoactive medications and mortality did not.

CONCLUSIONS

Prescription of neuropharmacologic agents increased over time using metrics of both overall drug burden and specific drug usage. Concurrently, the utilization of services that evaluate and/or treat neurologic morbidity was common and also increased over time.

Nasal Airway Microbiota Profile and Severe Bronchiolitis in Infants: A Case-control Study

BACKGROUND

Little is known about the relationship of airway microbiota with bronchiolitis in infants. We aimed to identify nasal airway microbiota profiles and to determine their association with the likelihood of bronchiolitis in infants.

METHODS

A case-control study was conducted. As a part of a multicenter prospective study, we collected nasal airway samples from 40 infants hospitalized with bronchiolitis. We concurrently enrolled 110 age-matched healthy controls. By applying 16S ribosomal RNA gene sequencing and an unbiased clustering approach to these 150 nasal samples, we identified microbiota profiles and determined the association of microbiota profiles with likelihood of bronchiolitis.

RESULTS

Overall, the median age was 3 months and 56% were male. Unbiased clustering of airway microbiota identified 4 distinct profiles: Moraxella-dominant profile (37%), Corynebacterium/Dolosigranulum-dominant profile (27%), Staphylococcus-dominant profile (15%) and mixed profile (20%). Proportion of bronchiolitis was lowest in infants with Moraxella-dominant profile (14%) and highest in those with Staphylococcus-dominant profile (57%), corresponding to an odds ratio of 7.80 (95% confidence interval, 2.64-24.9; P < 0.001). In the multivariable model, the association between Staphylococcus-dominant profile and greater likelihood of bronchiolitis persisted (odds ratio for comparison with Moraxella-dominant profile, 5.16; 95% confidence interval, 1.26-22.9; P = 0.03). By contrast, Corynebacterium/Dolosigranulum-dominant profile group had low proportion of infants with bronchiolitis (17%); the likelihood of bronchiolitis in this group did not significantly differ from those with Moraxella-dominant profile in both unadjusted and adjusted analyses.

CONCLUSIONS

In this case-control study, we identified 4 distinct nasal airway microbiota profiles in infants. Moraxella-dominant and Corynebacterium/Dolosigranulum-dominant profiles were associated with low likelihood of bronchiolitis, while Staphylococcus-dominant profile was associated with high likelihood of bronchiolitis.