Update on 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.

Medication use in infants admitted with bronchiolitis

BACKGROUND

There are no medications known that improve the outcome of infants with bronchiolitis. Studies have shown the management of bronchiolitis to be varied.

OBJECTIVES

To describe medication use at the seven study hospitals from a recent multi-centre randomised controlled trial on hydration in bronchiolitis (comparative rehydration in bronchiolitis [CRIB]).

METHODS

A retrospective analysis of extant data of infants between 2 months (corrected for prematurity) and 12 months of age admitted with bronchiolitis identified through the CRIB trial. CRIB study records, medical records, pathology and radiology databases were used to collect data using a standardised form and entered in a single site database. Medications investigated included salbutamol, adrenaline, steroids, ipratropium bromide, normal saline, hypertonic saline, steroids and antibiotics.

RESULTS

There were 3456 infants available for analysis, of which 42.0% received at least one medication during hospitalisation. Medication use varied by site between 27.0 and 48.7%. The most frequently used medication was salbutamol (25.5%). Medication use in general, and salbutamol use in particular, increased by 8.2 and 9.3%, respectively, per month after 4 months of age; from 22.9 and 3.6% at 4 months to 81.4 and 68.8% at 11 months. In infants admitted to the intensive care unit (ICU) compared with those not admitted to ICU 81.6 and 39.5%, respectively, received medication at one point during the hospital stay.

CONCLUSIONS

Medication was used for infants with bronchiolitis frequently and variably in Australia and New Zealand. Medication use increased with age. Better strategies for translating evidence into practice are needed.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Factors associated with disease severity in children with bronchiolitis

OBJECTIVE

Bronchiolitis is one of the top causes of hospitalization of infants in the United States. Several clinical factors have been associated with hospitalization; however, few studies have examined factors related to severe disease. Our goal was to describe the clinical characteristics and hospital course of children admitted with bronchiolitis and to identify factors related to intensive care unit (ICU) admission in this population.

METHODS

We conducted a retrospective review of all children less than 2 years of age admitted to a children's hospital with bronchiolitis between July 2008 and July 2011. Demographic and clinical data were collected including information regarding hospital course, treatments received and respiratory pathogens.

RESULTS

During the study period, 734 children were admitted to the hospital with bronchiolitis, 22% of whom were admitted to the ICU and 10% of whom were intubated and mechanically ventilated. Admission to the ICU was associated with younger age [110 (45-210) days versus 69 (35-149) days, p < 0.001] and history of premature birth (OR 1.7, 95% CI 1.1-2.4, p = 0.01), but not with race or ethnicity. The use of respiratory treatments was common in the children admitted to the ICU but was not associated with shortened durations of hospitalization. In addition, neither prematurity nor young age were associated with either increased duration of hospitalization or with increased likelihood of mechanical ventilation.

CONCLUSIONS

During acute bronchiolitis infections, younger children and those with a history of prematurity were more likely to be admitted to the ICU with severe disease.

Diagnosis and treatment of bronchiolitis in Finnish and Swedish children's hospitals

AIM

There is no widely accepted consensus on the diagnosis and treatment of bronchiolitis. This study describes current practices in Finnish and Swedish hospitals.

METHODS

A questionnaire on the diagnosis and treatment of bronchiolitis in children below 2 years of age was sent to all Finnish and Swedish hospitals providing inpatient care for children. All 22 Finnish hospitals answered, covering 100% of the <12-month-old population and 21 of the 37 Swedish hospitals responded, covering 74%.

RESULTS

The mean upper age limit for bronchiolitis was 12.7 months in Finnish hospitals and 12.5 months in Swedish hospitals. In both, laboured breathing, chest retractions and fine crackles were highlighted as the main clinical findings, followed by prolonged expiration. The mean value for the lowest acceptable saturation in room air was 94% in Finnish hospitals and 93% in Swedish hospitals. The most important factors influencing hospitalisation were young age, desaturation and inability to take oral fluids. Finnish doctors preferred intravenous routes, and Swedish doctors preferred nasogastric tubes for supplementary feeding. The first-line drug therapy was inhaled racemic adrenaline in Finland and inhaled levo-adrenaline in Sweden.

CONCLUSION

The diagnosis and treatment of bronchiolitis is fairly similar in Finnish and Swedish hospitals.

Strategies for reducing the risk of respiratory syncytial virus infection in infants and young children: a Canadian nurses' perspective

Respiratory syncytial virus (RSV) infections are prevalent globally and can cause substantial morbidity in infants and young children. The virus is easily transmitted by direct hand-to-hand contact and can lead to serious respiratory disease and hospitalization, particularly in premature infants and children with certain medical conditions. Educating families with young children, especially those in remote rural regions, regarding the potential adverse health outcomes of RSV infection and measures to reduce the risk of transmitting or acquiring RSV has been a key focus of the health care system in Canada. Geographic, cultural, and socioeconomic factors present formidable challenges to the execution of this endeavor. Therefore, it is critical to develop and systematically implement effective educational programs for both families and health care providers. In Canada, nurses play a critical role in education and counseling. In this review, we share our perspectives and suggest empirical practices that may be applicable worldwide.

Co-infections in children hospitalised for bronchiolitis: role of roomsharing

BACKGROUND

Bronchiolitis is a major cause for hospitalisation in young children during the winter season, with respiratory syncytial virus (RSV) as the main causative virus. Apart from standard hygiene measures, cohorting of RSV-infected patients separately from RSV-negative patients is frequently applied to prevent cross-infection, although evidence to support this practice is lacking. The objective is to evaluate the risk of room sharing between RSV-positive and RSV-negative patients.

METHODS

We performed a prospective observational cohort study in children < 2 years hospitalised with acute bronchiolitis. During the first day of admission, patients shared one room, pending results of virological diagnosis (PCR). When diagnostic results were available, RSV-positive and RSV-negative patients were separated. Standard hygienic measures (gowns, gloves, masks, hand washing) were used in all patients.

RESULTS

We included 48 patients (83% RSV-positive). Co-infection was found in nine patients at admission, and two during hospitalisation (23%). The two patients with acquired co-infection had been nursed in a single room during the entire admission. None of 37 patients sharing a room with other bronchiolitis patients (20 with patients with a different virus) were co-infected during admission. Disease severity in co-infection was not worse than in mono-infection.

CONCLUSION

One in five patients with bronchiolitis was co-infected, but co-infection acquired during admission was rare and was not associated with more severe disease. Room sharing between RSV-positive and RSV-negative patients (on the first day of admission) did not influence the risk of co-infection, suggesting that cohorting of RSV-infected patients separate from non-RSV-infected patients may not be indicated.

Viral bronchiolitis in children: a common condition with few therapeutic options

Even though bronchiolitis is a disease that has been recognized for many years, there are still few therapeutic strategies beyond supportive therapies. Bronchiolitis is the most frequent cause of hospital admission in children less than 1 year of age. The incidence is estimated to be about 150° million cases a year worldwide, and 2-3% of these cases require hospitalization. It is acknowledged that viruses cause bronchiolitis, but most of the studies focus on RSV. The RSV causes a more severe form of bronchiolitis in children with risk factors including prematurity, cardiovascular disease and immunodeficiency. Other viruses involved in causing bronchiolitis include RV, hMPV, hBoV and co-infections. The RV seems to be associated with a less severe acute disease, but there is a correlation between the early infection and subsequent wheezing bronchitis and asthma in later childhood and adulthood. The supportive therapies used are intravenous fluids and oxygen supplement administered by nasal cannula or CPAP in most complicated patients. Additional pharmacological therapies include epinephrine, 3% hypertonic saline and corticosteroids. The Epinephrine seems to have the greatest short-term benefits and reduces the need of hospital admission, whereas hypertonic saline and corticosteroids seem to reduce the length of hospital stay. As bronchiolitis is such a prevalent disease in children and RV seems to play an important role, perhaps more studies should center around the RV's contribution to the initial disease and following pathology.

Impact of home oxygen therapy on hospital stay for infants with acute bronchiolitis

Acute bronchiolitis has been associated with an increasing hospitalization rate over the past decades. The aim of this paper was to estimate the impact of home oxygen therapy (HOT) on hospital stay for infants with acute bronchiolitis. A retrospective cohort study was done including all children aged ≤ 12 months discharged from a pediatric tertiary-care center with a diagnosis of bronchiolitis, between November 2007 and March 2008. Oxygen was administered according to a standardized protocol. We assumed children with the following criteria could have been sent home with O(2), instead of being kept in hospital: age ≥ 2 months, distance between home and hospital <50 km, in-hospital observation ≥ 24 h, O(2) requirement ≤ 1.0 L/min, stable clinical condition, no enteral tube feeding, and intravenous fluids <50 mL/kg/day. Children with significant underlying disease were excluded. A total of 177 children were included. Median age was 2.0 months (range 0-11), and median length of stay was 3.0 days (range 0-18). Forty-eight percent of patients (85/177) received oxygen during their hospital stay. Criteria for discharge with HOT were met in 7.1 % of patients, a mean of 1.8 days (SD 1.8) prior to real discharge. The number of patient-days of hospitalization which would have been saved had HOT been available was 21, representing 3.0 % of total patient-days of hospitalization for bronchiolitis over the study period (21/701).

CONCLUSIONS

In this study setting, few children were eligible for an early discharge with HOT. Home oxygen therapy would not significantly decrease the overall burden of hospitalization for bronchiolitis.