Recent evidence on the management of bronchiolitis

Respiratory Syncytial Virus is the Most Common Causative Agent of Viral Bronchiolitis in Young Children: An Updated Review

BACKGROUND

Viral bronchiolitis is a common condition and a leading cause of hospitalization in young children.

OBJECTIVE

This article provides readers with an update on the evaluation, diagnosis, and treatment of viral bronchiolitis, primarily due to RSV.

METHODS

A PubMed search was conducted in December 2021 in Clinical Queries using the key terms "acute bronchiolitis" OR "respiratory syncytial virus infection". The search included clinical trials, randomized controlled trials, case control studies, cohort studies, meta-analyses, observational studies, clinical guidelines, case reports, case series, and reviews. The search was restricted to children and English literature. The information retrieved from the above search was used in the compilation of this article.

RESULTS

Respiratory syncytial virus (RSV) is the most common viral bronchiolitis in young children. Other viruses such as human rhinovirus and coronavirus could be etiological agents. Diagnosis is based on clinical manifestation. Viral testing is useful only for cohort and quarantine purposes. Cochrane evidence-based reviews have been performed on most treatment modalities for RSV and viral bronchiolitis. Treatment for viral bronchiolitis is mainly symptomatic support. Beta-agonists are frequently used despite the lack of evidence that they reduce hospital admissions or length of stay. Nebulized racemic epinephrine, hypertonic saline and corticosteroids are generally not effective. Passive immunoprophylaxis with a monoclonal antibody against RSV, when given intramuscularly and monthly during winter, is effective in preventing severe RSV bronchiolitis in high-risk children who are born prematurely and in children under 2 years with chronic lung disease or hemodynamically significant congenital heart disease. Vaccines for RSV bronchiolitis are being developed. Children with viral bronchiolitis in early life are at increased risk of developing asthma later in childhood.

CONCLUSION

Viral bronchiolitis is common. No current pharmacologic treatment or novel therapy has been proven to improve outcomes compared to supportive treatment. Viral bronchiolitis in early life predisposes asthma development later in childhood.

Predicting the severity of viral bronchiolitis in children

Acute viral bronchiolitis is one of the common causes of hospitalization and mortality, especially among children in the first year of life who have risk factors (prematurity, congenital heart defects, bronchopulmonary dysplasia, immunosuppression). As factors associated with the severe course of bronchiolitis, along with the traditional ones, single nucleotide polymorphisms of the genes of the immune response molecules can be considered.The aim. Based on the analysis of clinical, laboratory and molecular genetic parameters, to identify prognostic criteria for the severe course of acute viral bronchiolitis in children.Materials and methods. The study included 106 children with acute viral bronchiolitis (severe course – 34, mild course – 72), the etiology of which in 67.9 % was respiratory syncytial virus. Forty-seven anamnestic, clinical, traditional laboratory and molecular genetic parameters were assessed as prognostic criteria. Determination of SNP genes of cytokines IL-4 (C-589T), IL-10 (G-1082A), IL-10 (C-592A), IL-10 (C-819T), TNF-α (G-308A), IL-17A (G197A), IL-17F (His161Arg), TLR2-753ArgGln, TLR6-Ser249Pro in venous blood was carried out by the polymerase chain reaction method.Results. An additional criterion for the risk of developing a severe course of bronchiolitis can be the mutant genotype (AA) SNP of the IL-10 gene (C-592A), which was detected exclusively in the group of patients with severe bronchiolitis, increasing the risk of developing a severe disease by 16.11 times (OR = 16.11; 95 % CI: 0.81–121.22, p = 0.02) in conjunction with already established modifying factors: the presence of congenital heart disease, bronchopulmonary dysplasia, prematurity, birth weight < 1500 g. Based on a comprehensive assessment of the established risk factors, a method has been developed that allows calculate the likelihood of developing a severe course of acute viral bronchiolitis. Conclusion. The use of the developed prediction method will not only increase the likelihood of developing severe acute viral bronchiolitis in children, but also determine the priority group among children with predictors of severe viral bronchiolitis for priority immunoprophylaxis against RS-virus infection.

Do the Guidelines Apply?-A Multisite, Combined Stakeholder Qualitative Case Study to Understand Care Decisions in Bronchiolitis

BACKGROUND

Clinical practice guidelines for bronchiolitis recommend against tests and treatments that do not improve outcomes, yet most children admitted with bronchiolitis continue to receive them. An improved understanding of factors that influence care decisions across multiple stakeholders and diverse settings is needed to develop effective strategies to de-implement (or reduce) unnecessary testing and treatment.

METHODS

We explored health care provider, care team, and parent perspectives on testing and treatment in bronchiolitis to develop a combined stakeholder account of care decisions. We conducted a qualitative case study across 2 geographically distinct university affiliated children's hospitals representing a generally low and high test/treatment utilizing hospital respectively from March 2019 to May 2020. We conducted 46 semistructured interviews and 3 focus groups with a total of 74 participants. Data were analyzed using applied thematic analysis and findings were triangulated across participant group and data collection method.

RESULTS

Three themes emerged around care decisions: 1) awareness and perceptions of the guidelines or evidence; 2) perceptions of expected tests or treatments, and 3) organizational culture and existing care processes. Provider and care team participants commonly described parent expectations as drivers of utilization. Conversely, parents generally reported a lack of expectations for tests/treatments and that tests/treatments did not improve their experience of care.

CONCLUSIONS

This study illuminated factors associated with the differential adoption of evidence and targets for future de-implementation strategies. Importantly, incongruent with provider and care team perceptions, parents reported that they desire an evidence-based, less-is-more approach to bronchiolitis care.

Bronchiolitis Management and Unnecessary Antibiotic Use Across 3 Canadian PICUs

OBJECTIVES

To describe the patient characteristics, clinical management, and infectious etiology in critically ill children with bronchiolitis. The secondary objective was to determine the association between antibiotic use and hospital length of stay among patients without concomitant bacterial infections.

METHODS

Retrospective cohort study including patients ≤2 years old with bronchiolitis admitted to 3 Canadian pediatric intensive care units between 2016 and 2018.

RESULTS

We included 372 patients with a median age of 2.1 months (interquartile range 1.2-6.6) and Pediatric Risk of Mortality III score 3.0 (interquartile range 0-3.0). Initial ventilatory management included high flow nasal cannula (28.2%) and noninvasive positive pressure ventilation (53.7%), of which 41.9% and 87.5%, respectively, did not require escalation of ventilatory support. Chest radiographs (81.7%) and respiratory virus testing (95.4%) were performed in most patients; 14.0% received systemic steroids. Respiratory syncytial virus was detected in 61.3% patients, and 7.5% had a culture-positive concomitant bacterial infection. Of 258 (69.4%) patients with a viral infection, only 45.3% received antibiotics. In this group, antibiotic use beyond 72 hours was not associated with hospital length of stay (ratio 1.14, 95% confidence interval 0.97-1.34).

CONCLUSIONS

High flow nasal canulae and noninvasive ventilation are commonly used in severe bronchiolitis. Despite contrary evidence, steroids and antibiotics were also frequently used. Evidence-based guidelines specific to children with severe bronchiolitis are needed to improve the care delivered to this patient population.

Management of Hospitalized Respiratory Syncytial Virus Bronchiolitis in the Pediatric Ward in Spain: Assessing the Impact of a New Clinical Practice Protocol

BACKGROUND

Bronchiolitis caused by the respiratory syncytial virus (RSV) is the main reason for hospitalization in infants. Supportive care is the mainstay of treatment, and tests are restricted to a few indications. During 2015, our hospital bronchiolitis protocol (2015 HBP) was updated according to the latest practice guidelines.

OBJECTIVE

The objective of this study was to assess implementation of the 2015 HBP and the clinical outcome of children aged ≤ 24 months with RSV bronchiolitis admitted to a pediatric ward.

METHODS

We compared the use of treatments and tests, hospital length of stay (LOS), and oxygen requirements before implementation of the 2015 HBP (2014-2015 and 2015-2016 seasons) and after implementation (2016-2017 and 2017-2018 seasons).

RESULTS

The study population comprised 251 children (44.90%) in the first period and 308 (55.10%) in the second (median age 99 days, interquartile range 44-233). After implementation of the 2015 HBP, a statistically significant reduction was found in the percentage of patients undergoing the following treatments or diagnostic tests: salbutamol, from 57.77 to 31.17% (p < 0.001); epinephrine, from 61.75 to 1.30% (p < 0.001); 3% hypertonic saline, from 70.12 to 6.82% (p < 0.001); antibiotics, from 33.07 to 23.05% (p = 0.008); and chest X-ray, from 43.82 to 31.17% (p = 0.001). No statistically significant reductions were observed in the use of corticosteroids and blood tests. Hospital LOS and oxygen requirements were similar in each period.

CONCLUSIONS

Appropriate implementation of the 2015 HBP in the pediatric ward improves the use of medication and chest X-ray without modifying clinical outcomes. However, further efforts are needed to reduce the use of salbutamol, corticosteroids, and blood tests.

A Cost Analysis of Pulse Oximetry as a Determinant in the Decision to Admit Infants With Mild to Moderate Bronchiolitis

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.

Nine Seasons of a Bronchiolitis Observation Unit and Home Oxygen Therapy Protocol

BACKGROUND

We implemented an observation unit and home oxygen therapy (OU-HOT) protocol at our children's hospital during the 2010-2011 winter season to facilitate earlier discharge of children hospitalized with bronchiolitis. An earlier study demonstrated substantial reductions in inpatient length of stay and costs in the first year after implementation.

OBJECTIVE

Evaluate long-term reductions in length of stay and cost.

DESIGN, SETTING, AND PARTICIPANTS

Interrupted time-series analysis, adjusting for patient demographic factors and disease severity. Participants were children aged 3 to 24 months and hospitalized with bronchiolitis from 2007 to 2019.

INTERVENTION

OU-HOT protocol implementation.

MAIN OUTCOME AND MEASURES

Hospital length of stay. Process measures were the percentage of patients discharged from the OU; percentage of patients discharged with HOT. Balancing measures were 7-day hospital revisit rates; annual per-population bronchiolitis admission rates. Secondary outcomes were inflation-adjusted cost per episode of care and discharges within 24 hours.

RESULTS

A total of 7,116 patients met inclusion criteria. The OU-HOT protocol was associated with immediate decreases in mean length of stay (-30.6 hours; 95% CI, -37.1 to -24.2 hours) and mean cost per episode of care (-$4,181; 95% CI, -$4,829 to -$3,533). These findings were sustained for 9 years after implementation. Hospital revisit rates did not increase immediately (-1.1% immediate change; 95% CI, -1.8% to -0.4%), but a small increase in revisits was observed over time (change in slope 0.4% per season, 95% CI, 0.1%-0.8%).

CONCLUSION

The OU-HOT protocol was associated with sustained reductions in length of stay and cost, representing a promising strategy to reduce the inpatient burden of bronchiolitis.

Variability of Care of Infants With Severe Respiratory Syncytial Virus Bronchiolitis: A Multicenter Study

BACKGROUND

Viral bronchiolitis caused by respiratory syncytial virus (RSV) is a common childhood disease accounting for many hospitalizations worldwide. Some infants may clinically deteriorate, requiring admission to an intensive care unit. We aimed to describe diagnostic and therapeutic measures of bronchiolitis in Israeli pediatric intensive care units (PICUs) and evaluate intercenter variability of care.

METHODS

Medical records of all RSV-infected infants admitted to 5 Israeli PICUs over 4 RSV seasons were retrospectively reviewed.

RESULTS

Data on 276 infants with RSV-positive bronchiolitis, admitted to the participating PICUs were analyzed. Most of the infants were males with a mean admission age of 4.7 months. Approximately half of the infants had pre-existing conditions such as prematurity, cardiac disease or chronic lung disease. Respiratory distress was the most common symptom at presentation followed by hypoxemia and fever. There was significant variation in the methods used for RSV diagnosis, medical management and respiratory support of the infants. Furthermore, utilization of inhalational therapy and transfusion of blood products differed significantly between the centers. Although a bacterial pathogen was isolated in only 13.4% of the infants, 82.6% of the cohort was treated with antibiotics.

CONCLUSIONS

Significant variation was found between the different PICUs regarding RSV bronchiolitis diagnosis, medical management and respiratory support, which may not be accounted for by the differences in baseline and clinical characteristics of the infants. Some of these differences may be explained by uneven resource allocations. This diversity and the documented routine use of medications with weak evidence of efficacy calls for national guidelines for bronchiolitis management.

Bronchiolitis in children - do we choose wisely?

OBJECTIVE

Aim: The aim of our study was to evaluate the adherence to the 2014 American Academy of Pediatrics guidelines for bronchiolitis.

PATIENTS AND METHODS

Material and methods: The study measured the utility of diagnostic and therapeutic procedures in children with the first episode of bronchiolitis in their lives hospitalized at the University Children's Hospital in Krakow, Poland, between September 2014 and March 2015. The results were compared with the achievable benchmarks of care (ABCs) for hospitalized children with bronchiolitis. Hospital performance was measured by five clinical indicators: chest X-ray utilization, viral testing implementation, steroids, antibiotics and bronchodilator prescriptions. Odds ratios (OR) with 95% confidence intervals (95%CI) were calculated for comparisons between hospital performance and ABCs.

RESULTS

Results: There were 214 children in the study group (56% were boys). Chest X-ray was performed in 95% of the children, while ABCs indicate 32.4% (OR=42; 95%CI [30-58]); viral testing in 67.9% children, whereas ABCs indicate 0.6% (OR=350; 95%CI [155-790]). Steroids were prescribed in 62% of the patients (ABCs=6.4%; OR=24; 95%CI [18-31]), similarly antibiotics in 62% (ABCs=18.5%; OR=20; 95%CI [15-25]), bronchodilators were administered in 86% patients (ABCs=18.9%; OR=27; 95%CI [21-34]). All the analyzed procedures were used dozens of times more often than suggested by ABCs (the difference is highly statistically significant).

CONCLUSION

Conclusions: Overuse of ineffective procedures and therapies in bronchiolitis remains common, with overuse of chest X-rays, viral testing, prescriptions of bronchodilators, corticosteroids and antibiotics. We should focus our efforts on strategies aimed at decreasing the procedures that have no benefit for children with bronchiolitis.

Bronchiolitis in children - do we choose wisely?

OBJECTIVE

Aim: The aim of our study was to evaluate the adherence to the 2014 American Academy of Pediatrics guidelines for bronchiolitis.

PATIENTS AND METHODS

Material and methods: The study measured the utility of diagnostic and therapeutic procedures in children with the first episode of bronchiolitis in their lives hospitalized at the University Children's Hospital in Krakow, Poland, between September 2014 and March 2015. The results were compared with the achievable benchmarks of care (ABCs) for hospitalized children with bronchiolitis. Hospital performance was measured by five clinical indicators: chest X-ray utilization, viral testing implementation, steroids, antibiotics and bronchodilator prescriptions. Odds ratios (OR) with 95% confidence intervals (95%CI) were calculated for comparisons between hospital performance and ABCs.

RESULTS

Results: There were 214 children in the study group (56% were boys). Chest X-ray was performed in 95% of the children, while ABCs indicate 32.4% (OR=42; 95%CI [30-58]); viral testing in 67.9% children, whereas ABCs indicate 0.6% (OR=350; 95%CI [155-790]). Steroids were prescribed in 62% of the patients (ABCs=6.4%; OR=24; 95%CI [18-31]), similarly antibiotics in 62% (ABCs=18.5%; OR=20; 95%CI [15-25]), bronchodilators were administered in 86% patients (ABCs=18.9%; OR=27; 95%CI [21-34]). All the analyzed procedures were used dozens of times more often than suggested by ABCs (the difference is highly statistically significant).

CONCLUSION

Conclusions: Overuse of ineffective procedures and therapies in bronchiolitis remains common, with overuse of chest X-rays, viral testing, prescriptions of bronchodilators, corticosteroids and antibiotics. We should focus our efforts on strategies aimed at decreasing the procedures that have no benefit for children with bronchiolitis.

Overview of prevention and management of acute bronchiolitis due to respiratory syncytial virus

INTRODUCTION

Respiratory Syncytial Virus (RSV) is the most common cause of Acute Bronchiolitis (AVB) in infants. AVB causes significant morbidity and mortality worldwide, most deaths occurring in the developing world. AVB causes respiratory distress in infants, leading to respiratory failure in some cases. Disease is more severe in infants with risk factors, such as prematurity, chronic cardiac and lung disease and immunodeficiency. Areas covered: Despite major advances in supportive care in the developed world, which has led to a significant reduction in mortality, treatment remains symptomatic and supportive. No specific antiviral treatment has yet proven to be effective. Prevention of disease with monoclonal antibodies has proven to reduce illness severity in those with risk factors, however, this is prohibitively expensive, particularly for the developing world. Prospects for vaccine development are improving. However, because most disease is in young infants, maternal immunization is necessary. However, due to the transient nature of RSV immunity and the circulation of multiple subtypes, vaccines proven to be effective in adult challenge models have yet to be translated to protection in infants. Expert commentary: Despite advances in preventative treatments, adherence to evidence-based guidelines provides the best prospect for successful reduction in morbidity and mortality.

Hyponatremia in children with respiratory infections: a cross-sectional analysis of a cohort of 3938 patients

Hyponatremia can be a life-threatening illness among hospitalized children. The aims of this study were to evaluate the incidence and risk factors of hyponatremia in 3938 children who were admitted to the Cheil General Hospital and Women’s Health Care Center with respiratory infections. Clinical data were collected, and multiplex RT-PCR analyses were done for various microorganisms. Hyponatremia was observed in 531 (13.5%) patients. The incidence of hyponatremia differed according to the respiratory tract infection (P < 0.0001) and microorganism (P = 0.001). In children with hyponatremia, the age at admission was significantly older (P < 0.0001), male gender was more frequent (P = 0.019), CRP was higher (P < 0.0001), and coinfection with multiple organisms was more common (P = 0.001) than in children without hyponatremia. In multivariate analyses, an older age at admission (P = 0.006), male gender (P = 0.004), and increased CRP (P < 0.0001) were independent risk factors. Sodium levels correlated negatively with WBC (P = 0.037), CRP (P < 0.0001), and number of hospital days (P = 0.020). The AUC values of age (0.586, P < 0.0001), CRP (0.599, P < 0.0001), and blood urea nitrogen (0.559, P < 0.0001) were all significant predictors of hyponatremia. This study is the first to show that the incidence of hyponatremia differs according to infecting microorganism and radiological findings.

The ABCs of RSV

Respiratory syncytial virus (RSV) is a common viral infection affecting many children in the United States. This seasonal virus is the leading cause of hospitalization of infants and neonates. This article reviews the current recommendations for diagnostic testing, treatment options, and prevention of RSV.

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.

The cost-effectiveness of hypertonic saline inhalations for infant bronchiolitis: a decision analysis

BACKGROUND

This study evaluated the cost-effectiveness of hypertonic saline (HS) inhalations for infant bronchiolitis, compared to normal saline inhalations or standard treatment without inhalations as controls.

METHODS

The decision tree in the decision analysis was used to calculate the expected costs. Actual cost data were obtained from our retrospective case-control study on bronchiolitis treatment. The effectiveness of treatment, based on the hospitalization rate of those admitted to the emergency department and the length of stay (LOS) of those who were hospitalized, was collected from previous studies. For the effectiveness estimations, we made a meta-analysis summarizing the results of the meta-analysis of the Cochrane review in 2013 and the results of 10 studies published after it.

RESULTS

The mean hospitalization rate was 24.7% in the HS inhalation group and 32.6% in the control group [risk ratio: 0.80, 95% confidence interval (CI) 0.67-0.96] and the mean LOS was 3.736 (HS group) and 4.292 (controls) days (mean difference: - 0.55 days, 95% CI - 0.96 to - 0.15), respectively. The expected costs per patient, when both inpatients and outpatients were included, were €816 ($1111) in the HS inhalation group and €962 ($1310) in the control group. The expected costs per hospitalization, when only inpatients were included, were €2600 ($3540) in the HS inhalation group and €2890 ($3935) in the control group.

CONCLUSIONS

HS inhalations slightly reduced the expected hospitalization costs of infant bronchiolitis. However, the low effectiveness, rather than the cost, is the factor that will limit the use of HS inhalations in infant bronchiolitis.

[Expression of vascular intercellular adhesion molecule-1 and its significance in children with bronchiolitis]

OBJECTIVE

To investigate the expression of intercellular adhesion molecule-1 (ICAM-1) in serum and induced sputum supernatant in children with bronchiolitis, as well as its role in the pathogenesis of bronchiolitis in children.

METHODS

A total of 67 children with bronchiolitis who were diagnosed and hospitalized between July 2015 and January 2017 were enrolled. According to the diagnostic criteria, these children were divided into mild group with 22 children, moderate group with 24 children, and severe group with 21 children. A total of 20 children who underwent physical examination were enrolled as healthy control group. ELISA was used to measure the level of ICAM-1 in serum and induced sputum supernatant in the children with bronchiolitis in the acute stage and recovery stage and the children in the healthy control group.

RESULTS

Compared with the healthy control group, the mild, moderate, and severe bronchiolitis groups had a significant increase in the level of ICAM-1 in serum and sputum (P<0.01). Compared with the mild group, the moderate and severe groups had a significant increase in the level of ICAM-1 in serum and sputum (P<0.01). Compared with the moderate group, the severe group had a significant increase in the level of ICAM-1 in serum and sputum (P<0.01). Compared with the children with bronchiolitis in the acute stage, the children in the recovery stage had a significant reduction in the level of ICAM-1 in serum and sputum (P<0.01). The correlation analysis showed that in the acute stage, the level of ICAM-1 in serum was positively correlated with that in sputum in children with bronchiolitis (r=0.875, P<0.001).

CONCLUSIONS

ICAM-1 is involved in the pathogenesis of bronchiolitis and is associated with disease severity.

Variability of Care in Infants with Severe Bronchiolitis: Less-Invasive Respiratory Management Leads to Similar Outcomes

OBJECTIVE

To compare the management of children with severe bronchiolitis requiring intensive care (based on duration of ventilatory support and duration of pediatric intensive care unit [PICU] stay) in 2 countries with differing pediatric transport and PICU organizations.

STUDY DESIGN

This was a prospective observational care study in 2 PICUs of tertiary care university hospitals, 1 in France and 1 in Canada. All children with bronchiolitis who required admission to the PICU between November 1, 2013, and March 31, 2014, were included.

RESULTS

A total of 194 children were included. Baseline characteristics and illness severity were similar at the 2 sites. There was a significant difference between centers in the use of invasive ventilation (3% in France vs 26% in Canada; P < .0001). The number of investigations performed from admission to emergency department presentation and during the PICU stay was significantly higher in Canada for both chest radiographs and blood tests (P < .001). The use of antibiotics was significantly higher in Canada both before (60% vs 28%; P < .001) and during (72% vs 33%; P < .0001) the PICU stay. The duration of ventilatory support, median length of stay, and rate of PICU readmission were similar in the 2 centers.

CONCLUSION

Important differences in the management of children with severe bronchiolitis were observed during both prehospital transport and PICU treatment. Less invasive management resulted in similar outcomes with in fewer complications.

Marked variability observed in inpatient management of bronchiolitis in three Finnish hospitals

AIM

Infants hospitalised for bronchiolitis undergo examinations and treatments not supported by current research evidence and we investigated practice variations with regard to Finnish children under the age of two.

METHODS

This prospective, multicentre cohort study was conducted in paediatric units in three university hospitals in Finland from 2008 to 2010. Hospital medical records were reviewed to collect data on clinical course, testing and treatment. Data were analysed separately for children meeting our strict definition of bronchiolitis, aged under 12 months without a history of wheezing, and a loose definition, aged 12-23 months or with a history of wheezing.

RESULTS

The median age of the 408 children was 8.1 months. Clinical management varied between the three hospitals when stratified by strict and loose bronchiolitis subgroup definitions: complete blood counts ranged from 15-95% vs 16-94%, respectively, and the other measures were chest x-ray (16-91% vs 14-72%), intravenous fluids (2-47% vs 2-41%), use of nebulised epinephrine (10-84% vs 7-50%), use of salbutamol (18-21% vs 13-84%) and use of corticosteroids (6-23% vs 60-76%).

CONCLUSION

The clinical management of bronchiolitis varied considerably with regard to the three hospitals and the two definitions of bronchiolitis. A stronger commitment to evidence-based bronchiolitis guidelines is needed in Finland.

High-flow oxygen therapy is more cost-effective for bronchiolitis than standard treatment-A decision-tree analysis

We evaluated the cost-effectiveness of high-flow nasal cannula (HFNC) to provide additional oxygen for infants with bronchiolitis, compared to standard low-flow therapy. The cost-effectiveness was evaluated by decision analyses, using decision tree modeling, and was based on real costs from our recently published retrospective case-control study. The data on the effectiveness of HFNC treatment were collected from earlier published retrospective studies, using admission rates to pediatric intensive care units (PICU). The analyses in the study showed that the expected treatment costs of each episode of infant bronchiolitis varied between €1,312-2,644 ($1,786-3,600) in the HFNC group and €1,598-3,764 ($2,175-5,125) in the standard treatment group. The PICU admission rates and consequential costs were lower for HFNC than for standard treatment. HFNC treatment proved more cost-effective than standard treatment in all the baseline analyses and was also more cost-effective in the sensitivity analyses, except for in the worst-case scenario analysis. In conclusion, our modeling demonstrated that HFNC was strongly cost-effective for infant bronchiolitis, compared to standard treatment because it was both more effective and less expensive. Thus, if children hospitalized for bronchiolitis need oxygen, it should be delivered as HFNC treatment. Pediatr Pulmonol. 2016;51:1393-1402. © 2016 Wiley Periodicals, Inc.

A clustering approach to identify severe bronchiolitis profiles in children

OBJECTIVE

Although bronchiolitis is generally considered a single disease, recent studies suggest heterogeneity. We aimed to identify severe bronchiolitis profiles using a clustering approach.

METHODS

We analysed data from two prospective, multicentre cohorts of children younger than 2 years hospitalised with bronchiolitis, one in the USA (2007-2010 winter seasons, n=2207) and one in Finland (2008-2010 winter seasons, n=408). Severe bronchiolitis profiles were determined by latent class analysis, classifying children based on clinical factors and viral aetiology.

RESULTS

In the US study, four profiles were identified. Profile A (12%) was characterised by history of wheezing and eczema, wheezing at the emergency department (ED) presentation and rhinovirus infection. Profile B (36%) included children with wheezing at the ED presentation, but, in contrast to profile A, most did not have history of wheezing or eczema; this profile had the largest probability of respiratory syncytial virus infection. Profile C (34%) was the most severely ill group, with longer hospital stay and moderate-to-severe retractions. Profile D (17%) had the least severe illness, including non-wheezing children with shorter length of stay. Two of these profiles (A and D) were replicated in the Finnish cohort; a third group ('BC') included Finnish children with characteristics of profiles B and/or C in the US population.

CONCLUSIONS

Several distinct clinical profiles (phenotypes) were identified by a clustering approach in two multicentre studies of children hospitalised for bronchiolitis. The observed heterogeneity has important implications for future research on the aetiology, management and long-term outcomes of bronchiolitis, such as future risk of childhood asthma.

Hypertonic saline (HS) for acute bronchiolitis: Systematic review and meta-analysis

BACKGROUND

Acute bronchiolitis is the commonest cause of hospitalisation in infancy. Currently management consists of supportive care and oxygen. A Cochrane review concluded that, "nebulised 3 % saline may significantly reduce the length of hospital stay". We conducted a systematic review of controlled trials of nebulised hypertonic saline (HS) for infants hospitalised with primary acute bronchiolitis.

METHODS

Searches to January 2015 involved: Cochrane Central Register of Controlled Trials; Ovid MEDLINE; Embase; Google Scholar; Web of Science; and, a variety of trials registers. We hand searched Chest, Paediatrics and Journal of Paediatrics on 14 January 2015. Reference lists of eligible trial publications were checked. Randomised or quasi-randomised trials which compared HS versus either normal saline (+/- adjunct treatment) or no treatment were included. Eligible studies involved children less than 2 years old hospitalised due to the first episode of acute bronchiolitis. Two reviewers extracted data to calculate mean differences (MD) and 95 % Confidence Intervals (CIs) for length of hospital stay (LoS-primary outcome), Clinical Severity Score (CSS) and Serious Adverse Events (SAEs). Meta-analysis was undertaken using a fixed effect model, supplemented with additional sensitivity analyses. We investigated statistical heterogeneity using I(2). Risk of bias, within and between studies, was assessed using the Cochrane tool, an outcome reporting bias checklist and a funnel plot.

RESULTS

Fifteen trials were included in the systematic review (n = 1922), HS reduced mean LoS by 0.36, (95 % CI 0.50 to 0.22) days, but with considerable heterogeneity (I(2) = 78 %) and sensitivity to alternative analysis methods. A reduction in CSS was observed where assessed [n = 516; MD -1.36, CI -1.52, -1.20]. One trial reported one possible intervention related SAE, no other studies described intervention related SAEs.

CONCLUSIONS

There is disparity between the overall combined effect on LoS as compared with the negative results from the largest and most precise trials. Together with high levels of heterogeneity, this means that neither individual trials nor pooled estimates provide a firm evidence-base for routine use of HS in inpatient acute bronchiolitis.

Virus Type and Genomic Load in Acute Bronchiolitis: Severity and Treatment Response With Inhaled Adrenaline

Background. Acute bronchiolitis frequently causes infant hospitalization. Studies on different viruses or viral genomic load and disease severity or treatment effect have had conflicting results. We aimed to investigate whether the presence or concentration of individual or multiple viruses were associated with disease severity in acute bronchiolitis and to evaluate whether detected viruses modified the response to inhaled racemic adrenaline.

Methods. Nasopharyngeal aspirates were collected from 363 infants with acute bronchiolitis in a randomized, controlled trial that compared inhaled racemic adrenaline versus saline. Virus genome was identified and quantified by polymerase chain reaction analyses. Severity was assessed on the basis of the length of stay and the use of supportive care.

Results. Respiratory syncytial virus (83%) and human rhinovirus (34%) were most commonly detected. Seven other viruses were present in 8%–15% of the patients. Two or more viruses (maximum, 7) were detected in 61% of the infants. Virus type or coinfection was not associated with disease severity. A high genomic load of respiratory syncytial virus was associated with a longer length of stay and with an increased frequency of oxygen and ventilatory support use. Treatment effect of inhaled adrenaline was not modified by virus type, load or coinfection.

Discussion. In infants hospitalized with acute bronchiolitis, disease severity was not associated with specific viruses or the total number of viruses detected. A high RSV genomic load was associated with more-severe disease.

Clinical Trials Registration. NCT00817466 and EudraCT 2009-012667-34.

Clinical Endpoints for Respiratory Syncytial Virus Prophylaxis Trials in Infants and Children in High-income and Middle-income Countries

Respiratory syncytial virus (RSV) continues to cause significant clinical and economic burden around the world. Historically, RSV-associated hospitalization was used as a primary endpoint for RSV prophylaxis trials in infants. However, because of the changing epidemiology and healthcare system landscape, this endpoint has become a critical bottleneck on the pathway to licensure for new therapeutics. A panel of 7 RSV experts was convened (Chicago, IL, May 22, 2014) to evaluate the challenges of defining RSV prevention endpoints for clinical trials and to develop endpoints that are clinically meaningful while minimizing subjectivity and bias to achieve sufficient consistency of response for regulatory approval. Particular consideration was given to the ability to collect data systematically and consistently in countries with different healthcare practices and systems, while capturing the greatest proportion of disease impact. The group consensus was that a clinically meaningful primary endpoint could include medically attended RSV illness in settings beyond RSV-associated hospitalizations alone, in particular, a composite reduction in hospitalization, emergency room or urgent care center visits because of an RSV respiratory infection. Relevant secondary endpoints included reductions in RSV lower respiratory tract infection, RSV-related intensive care unit rates, subsequent recurrent wheezing or asthma and direct and indirect costs.

Allergic diseases and the effect of inhaled epinephrine in children with acute bronchiolitis: follow-up from the randomised, controlled, double-blind, Bronchiolitis ALL trial

BACKGROUND

Although use of inhaled bronchodilators in infants with acute bronchiolitis is not supported by evidence-based guidelines, it is often justified by the belief in a subgroup effect in individuals developing atopic disease. We aimed to assess if inhaled epinephrine during acute bronchiolitis in infancy would benefit patients with later recurrent bronchial obstruction, atopic eczema, or allergic sensitisation.

METHODS

In the randomised, double-blind, multicentre Bronchiolitis ALL trial, 404 infants with moderate-to-severe acute bronchiolitis were recruited from eight hospitals in Norway to receive either inhaled epinephrine or saline up to every second hour throughout the hospital stay. Randomisation was done centrally, and the two study medications (20 mg/mL racemic epinephrine or 0.9% saline) were prepared in identical bottles. The dose given depended on the infant's weight: 0.10 mL, less than 5 kg; 0.15 mL, 5-6.9 kg; 0.2 mL, 7-9.9 kg; and 0.25 mL, 10 kg or more; all dissolved in 2 mL of 0.9% saline before nebulisation. The primary outcome was the length of hospital stay. In this follow-up study, 294 children were reinvestigated at 2 years of age with an interview, a clinical examination, and a skin prick test for 17 allergens, determining bronchial obstruction, atopic eczema, and allergic sensitisation, on which subgroup analyses were done. Analyses were done by intention to treat. The trial has been completed and is registered at ClinicalTrials.gov (number NCT00817466) and EUDRACT (number 2009-012667-34).

FINDINGS

Length of stay did not differ between patients who received inhaled epinephrine versus saline in the subgroup of infants who developed recurrent bronchial obstruction by age 2 years (143 [48.6%] of 294 patients; p(interaction)=0.40). However, the presence of atopic eczema or allergic sensitisation by the age of 2 years (n=77) significantly interacted with the treatment effect of inhaled epinephrine (p(interaction)=0.02); the length of stay (mean 80.3 h, 95% CI 72.8-87.9) was significantly shorter in patients receiving inhaled epinephrine versus saline in patients without allergic sensitisation or atopic eczema by 2 years (-19.9 h, -33.1 to -6.3; p=0.003). No significant differences were found in length of hospital stay in response to epinephrine or saline in children with atopic eczema or allergic sensitisation by 2 years (+16.2 h, -11.0 to 43.3; p=0.24).

INTERPRETATION

Contrary to our hypothesis, hospital length of stay for bronchiolitis was not reduced by administration of inhaled epinephrine in infants who subsequently developed atopic eczema, allergic sensitisation, or recurrent bronchial obstruction. The present study does not support an individual trial of inhaled epinephrine in acute bronchiolitis in children with increased risk of allergic diseases.

FUNDING

Medicines for Children Network, Norway.

Three-weekly doses of azithromycin for indigenous infants hospitalized with bronchiolitis: a multicentre, randomized, placebo-controlled trial

BACKGROUND

Bronchiolitis is a major health burden in infants globally, particularly among Indigenous populations. It is unknown if 3 weeks of azithromycin improve clinical outcomes beyond the hospitalization period. In an international, double-blind randomized controlled trial, we determined if 3 weeks of azithromycin improved clinical outcomes in Indigenous infants hospitalized with bronchiolitis.

METHODS

Infants aged ≤24 months were enrolled from three centers and randomized to receive three once-weekly doses of either azithromycin (30 mg/kg) or placebo. Nasopharyngeal swabs were collected at baseline and 48 h later. Primary endpoints were hospital length of stay (LOS) and duration of oxygen supplementation monitored every 12 h until judged ready for discharge. Secondary outcomes were: day-21 symptom/signs, respiratory rehospitalizations within 6 months post-discharge and impact upon nasopharyngeal bacteria and virus shedding at 48 h.

RESULTS

Two hundred nineteen infants were randomized (n = 106 azithromycin, n = 113 placebo). No significant between-group differences were found for LOS (median 54 h for each group, difference = 0 h, 95% CI: -6, 8; p = 0.8), time receiving oxygen (azithromycin = 40 h, placebo = 35 h, group difference = 5 h, 95% CI: -8, 11; p = 0.7), day-21 symptom/signs, or rehospitalization within 6 months (azithromycin n = 31, placebo n = 25 infants, p = 0.2). Azithromycin reduced nasopharyngeal bacterial carriage (between-group difference 0.4 bacteria/child, 95% CI: 0.2, 0.6; p < 0.001), but had no significant effect upon virus detection rates.

CONCLUSION

Despite reducing nasopharyngeal bacterial carriage, three large once-weekly doses of azithromycin did not confer any benefit over placebo during the bronchiolitis illness or 6 months post hospitalization. Azithromycin should not be used routinely to treat infants hospitalized with bronchiolitis.

CLINICAL TRIAL REGISTRATION

The trial was registered with the Australian and New Zealand Clinical Trials Register: Clinical trials number: ACTRN1261000036099.

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

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