Current therapies in bronchiolitis

Intensive care unit admissions and ventilation support in infants with bronchiolitis

OBJECTIVES

To describe the rate of intensive care unit (ICU) admission, type of ventilation support provided and risk factors for ICU admission in infants with bronchiolitis.

DESIGN

Retrospective review of hospital records and Australia and New Zealand Paediatric Intensive Care (ANZPIC) registry data for infants 2-12 months old admitted with bronchiolitis.

SETTING

Seven Australian and New Zealand hospitals. These infants were prospectively identified through the comparative rehydration in bronchiolitis (CRIB) study between 2009 and 2011.

RESULTS

Of 3884 infants identified, 3589 charts were available for analysis. Of 204 (5.7%) infants with bronchiolitis admitted to ICU, 162 (79.4%) received ventilation support. Of those 133 (82.1%) received non-invasive ventilation (high flow nasal cannula [HFNC] or continuous positive airway pressure [CPAP]) 7 (4.3%) received invasive ventilation alone and 21 (13.6%) received a combination of ventilation modes. Infants with comorbidities such as chronic lung disease (OR 1.6 [95% CI 1.0-2.6]), congenital heart disease (OR 2.3 [1.5-3.5]), neurological disease (OR 2.2 [1.2-4.1]) or prematurity (OR 1.5 [1.0-2.1]), and infants 2-6 months of age (OR 1.5 [1.1-2.0]) were more likely to be admitted to ICU. Respiratory syncitial virus positivity did not increase the likelihood of being admitted to ICU (OR 1.1 [95% CI 0.8-1.4]). HFNC use changed from 13/53 (24.5% [95% CI 13.7-38.3]) patient episodes in 2009 to 39/91 (42.9% [95% CI 32.5-53.7]) patient episodes in 2011.

CONCLUSION

Admission to ICU is an uncommon occurrence in infants admitted with bronchiolitis, but more common in infants with comorbidities and prematurity. The majority are managed with non-invasive ventilation, with increasing use of HFNC.

[Variability and suitability of anti-asmathic treatment in pediatric primary health care]

OBJECTIVE

To analyse the use patterns and the characteristics of anti-asmathic prescriptions in pediatric primary health care.

DESIGN

Observational and retrospective study.

LOCATION

Pediatric primary health care, Asturias, Spain.

PARTICIPANTS

Drug prescriptions in respiratory diseases in children (<14years old) during 2011.

PRINCIPAL MEASUREMENTS

Data obtained from the billing database of the Regional Health Service of Asturias and analysed by sanitary district and primary health centres, calculating the number of DDD/1.000 children/day (DHD). Clinical records audit in 6 paediatric surgeries of sanitary district V to evaluate the suitability of the drug prescriptions to the current recommendations.

RESULTS

The main group were bronchodilators (17.14DHD) with predominance of the inhaled route (14DHD). We observe more use of inhaled corticoids (4.83DHD), with an important use of fluticasone. We considered un-suitable 94.3% oral bronchodilators, and >50% of mepiramine prescriptions. We registered off-label prescriptions, 17.8% of them were about oral salbutamol, being used in children <2years old.

CONCLUSIONS

The use of anti-asthmatic drugs in our region is high, maybe it's related to the asthma prevalence. We observed variability between sanitary districts and health centres. The prescription patterns are closed to the current recommendation, except in the case of oral bronchodilators.

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.

Infants with severe respiratory syncytial virus needed less ventilator time with nasal continuous airways pressure then invasive mechanical ventilation

AIM

Nasal continuous positive airway pressure (NCPAP) has been proposed as an early first-line support for infants with severe respiratory syncytial virus (RSV) infection. We hypothesised that infants <6 months with severe RSV would require shorter ventilator support on NCPAP than invasive mechanical ventilation (IMV).

METHODS

Retrospective cohort analysis of infants admitted to two paediatric intensive care units, one primarily using NCPAP and one exclusively using IMV, between January 2008 and February 2010.

RESULTS

We studied 133 (NCPAP n = 89, IMV n = 46) consecutively admitted infants. On admission, disease severity [i.e. Paediatric RISk of Mortality (PRISM) II score (NCPAP 5.1 ± 2.8 vs. IMV 12.2 ± 6.0, p < 0.001) and SpO2 /Fi O2 ratio (NCPAP 309 ± 81 vs. IMV 135 ± 98, p < 0.001)] was higher in the IMV group. NCPAP remained independently associated with shorter ventilatory support (hazard ratio 2.3, 95% CI 1.1-4.7, p = 0.022) after adjusting for PRISM II score, PCO2 , SpO2 /Fi O2 ratio, bronchopulmonary dysplasia and occurrence of clinically suspected secondary bacterial pneumonia.

CONCLUSION

Nasal continuous positive airway pressure was independently associated with a shorter duration of ventilatory support. Differences in baseline disease severity mandate a randomised trial before the routine use of NCPAP can be recommended.

Management of bronchiolitis in the emergency department: impact of evidence-based guidelines?

OBJECTIVE

Recent practice guidelines from the American Academy of Pediatrics recommend limiting use of bronchodilators, corticosteroids, antibiotics, and diagnostic testing for patients with bronchiolitis. We sought to determine the association of the evidence-based guidelines with bronchiolitis care in the emergency department (ED).

METHODS

We analyzed data from the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of ED visits. We compared utilization for patient visits before and after the publication of the guidelines. We used logistic regression to determine the association of the availability of the guidelines with resource utilization.

RESULTS

Bronchodilators were used in 53.8% of patient visits with no differences noted after the introduction of the guidelines (53.6% vs 54.2%, P = .91). Systemic steroids were used in 20.4% of patient visits, and antibiotics were given in 33.2% of visits. There were no changes in the frequency of corticosteroid (21.9% vs 17.8%, P = .31) or antibiotic (33.6% vs 29.7%, P = .51) use. There was an associated decrease in use of chest x-rays (65.3% vs 48.6%, P = .005). This association remained significant after adjusting for patient and hospital characteristics with an adjusted odds ratio of 0.41 (95% confidence interval 0.26-0.67).

CONCLUSIONS

For patients seen in the ED with bronchiolitis, utilization of diagnostic imaging has decreased with the availability of the American Academy of Pediatrics practice guidelines. However, there has not been an associated decrease in use of nonrecommended therapies. Targeted efforts will likely be required to change practice significantly.