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Chacorowski ARP, Lima VDO, Menezes E, Teixeira JJV, Bertolini DA. Acute viral bronchiolitis phenotype in response to glucocorticoid and bronchodilator treatment. Clinics (Sao Paulo) 2024; 79:100396. [PMID: 38843677 PMCID: PMC11215958 DOI: 10.1016/j.clinsp.2024.100396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 05/02/2024] [Accepted: 05/14/2024] [Indexed: 07/04/2024] Open
Abstract
OBJECTIVE To analyze whether infants admitted to hospital with Acute Viral Bronchiolitis (AVB), who received glucocorticoids and bronchodilators, and who had an atopic phenotype, spent less time in hospital and/or less time on oxygen therapy when compared to those who did not have the phenotype. METHOD A cross-sectional, retrospective epidemiological study was developed with data from medical records of infants admitted to hospital due to AVB from 2012 to 2019 in a sentinel public hospital. It was verified that the frequency of prescription of glucocorticoids, bronchodilators and antibiotics. Length of stay and oxygen therapy duration were then compared in the group that used glucocorticoids and bronchodilators between those who had a personal or family history of atopy and those who did not. Subsequently, the length of hospital stay was compared among infants who received antibiotic therapy and those who did not. RESULTS Fifty-eight infants were included. Of these, 62.1 % received an antibiotic, 100 % a bronchodilator and 98.3 % a glucocorticoid. When comparing infants without a family history of atopy, those who received antibiotics had a longer hospital stay (p = 0.01). CONCLUSION The presence of an atopic phenotype did not interfere with the length of stay and/or oxygen therapy duration of those who received bronchodilators and glucocorticoids. Increased length of stay of infants without a family history of atopy, who used antibiotics without evidence of bacterial co-infection, and the high frequency of prescription of non-recommended drugs call attention to stricter protocol implementation and professional training in AVB diagnosis and care.
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Rodriguez-Martinez CE, Nino G, Castro-Rodriguez JA, Perez GF, Sossa-Briceño MP, Buendia JA. Cost-effectiveness analysis of phenotypic-guided versus guidelines-guided bronchodilator therapy in viral bronchiolitis. Pediatr Pulmonol 2021; 56:187-195. [PMID: 33049126 PMCID: PMC8850934 DOI: 10.1002/ppul.25114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/10/2020] [Accepted: 10/09/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Although recent evidence suggests that management of viral bronchiolitis requires something other than guidelines-guided therapy, there is a lack of evidence supporting the economic benefits of phenotypic-guided bronchodilator therapy for treating this disease. The aim of the present study was to compare the cost-effectiveness of phenotypic-guided versus guidelines-guided bronchodilator therapy in infants with viral bronchiolitis. METHODS A decision analysis model was developed to compare the cost-effectiveness of phenotypic-guided versus guidelines-guided bronchodilator therapy in infants with viral bronchiolitis. Phenotypic-guided bronchodilator therapy was defined as the administration of albuterol in infants exhibiting a profile of increased likelihood of response to bronchodilators. The effectiveness parameters and costs of the model were obtained from systematic reviews of the literature with meta-analyses and electronic medical records. The main outcome was the avoidance of hospital admission after initial care in the emergency department. RESULTS Compared to guidelines-guided strategy, treating patients with viral bronchiolitis with the phenotypic-guided bronchodilator therapy strategy was associated with lower total costs (US$250.99; 95% uncertainty interval [UI]: US$184.37 to $336.51 vs. US$263.46; 95% UI: US$189.81 to $349.19 average cost per patient) and a higher probability of avoidance of hospital admission (0.7902; 95% UI: 0.7315-0.8356 vs. 0.7638; 95% UI: 0.7062-0.8201), thus leading to dominance. Results were robust to deterministic and probabilistic sensitivity analyses. CONCLUSIONS Compared to guidelines-guided strategy, treating infants with viral bronchiolitis using the phenotypic-guided bronchodilator therapy strategy is a more cost-effective strategy, because it involves a lower probability of hospital admission at lower total treatment costs.
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Affiliation(s)
- Carlos E Rodriguez-Martinez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia.,Department of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Bogota, Colombia
| | - Gustavo Nino
- Division of Pediatric Pulmonary and Sleep Medicine, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Jose A Castro-Rodriguez
- Division of Pediatrics, Department of Pediatric Pulmonology and Cardiology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Geovanny F Perez
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, Oishei Children's Hospital, University at Buffalo, Buffalo, New York, USA
| | | | - Jefferson A Buendia
- Department of Pharmacology and Toxicology, School of Medicine, Research Group in Pharmacology and Toxicology (INFARTO), Universidad de Antioquia, Medellín, Colombia
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Nino G, Rodríguez-Martínez CE, Castro-Rodriguez JA. The use of β 2-adrenoreceptor agonists in viral bronchiolitis: scientific rationale beyond evidence-based guidelines. ERJ Open Res 2020; 6:00135-2020. [PMID: 33083437 PMCID: PMC7553108 DOI: 10.1183/23120541.00135-2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 06/10/2020] [Indexed: 12/25/2022] Open
Abstract
Despite scientific evidence proving that inhaled β2-adrenergic receptor (β2-AR) agonists can reverse bronchoconstriction in all ages, current guidelines advocate against the use of β2-AR bronchodilators in infants with viral bronchiolitis because clinical trials have not demonstrated an overall clinical benefit. However, there are many different types of viral bronchiolitis, with variations occurring at an individual and viral level. To discard a potentially helpful treatment from all children regardless of their clinical features may be unwarranted. Unfortunately, the clinical criteria to identify the infants that may benefit from bronchodilators from those who do not are not clear. Thus, we summarised the current understanding of the individual factors that may help clinicians determine the highest probability of response to β2-AR bronchodilators during viral bronchiolitis, based on the individual immunobiology, viral pathogen, host factors and clinical presentation. There are several factors that may help clinicians determine the highest probability of response to β2-AR bronchodilators during viral bronchiolitis, based on the individual immunobiology, viral pathogen, host factors and clinical presentationhttps://bit.ly/30CoHcH
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Affiliation(s)
- Gustavo Nino
- Division of Pediatric Pulmonary and Sleep Medicine, Center for Genetic Research, Children's National Medical Center, George Washington University, Washington, DC, USA
| | - Carlos E Rodríguez-Martínez
- Dept of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia.,Dept of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Bogota, Colombia
| | - Jose A Castro-Rodriguez
- Dept of Pediatric Pulmonology, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
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Gultekingil A, Gocer E, Anil M, Agin H, Anil AB, Işguder R, Kurt F, Incekoy-Girgin F, Erkek N, Durak F, Akca H, Berksoy E, Goktug A, Gunay I, Derinoz O, Yalindag-Ozturk N, Azapagasi E, Besli GE, Odek C, Tekin D, Dursun O, Kendirli T, Teksam O. Pediatricians' Attitude in Management of Acute Bronchiolitis: Did Guidelines Overcome Practices? PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2020; 33:57-62. [PMID: 35863042 PMCID: PMC8443258 DOI: 10.1089/ped.2020.1141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 04/11/2020] [Indexed: 06/15/2023]
Abstract
Background: Acute bronchiolitis is one of the most common diseases of early childhood. There are many recent changes in the treatment of acute bronchiolitis. The aim of this study is to evaluate treatment approaches to acute bronchiolitis among clinicians and to observe compliance with clinical guidelines. Materials and Methods: Our study was designed as a multicenter cross-sectional descriptive study. A cohort of pediatric residents, fellows, and attendants were surveyed with a questionnaire including general and occupational characteristics of pediatricians and treatment choices in acute bronchiolitis. Results: A total of 713 questionnaires were collected. Most commonly applied treatment among pediatricians was inhaled salbutamol, followed by intravenous hydration, hypertonic saline, and inhaled steroid. Most commonly preferred treatment in the management of mild bronchiolitis was oral hydration and inhaled salbutamol in severe bronchiolitis. Conclusion: Although recent guidelines for the treatment of acute bronchiolitis does not support the use of many different therapies, pediatricians still tend to use them, especially bronchodilators, corticosteroids, and antibiotics.
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Affiliation(s)
- Ayse Gultekingil
- Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Emre Gocer
- Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Murat Anil
- Department of Pediatrics, Tepecik Research and Education Hospital, Izmir, Turkey
| | - Hasan Agin
- Department of Pediatrics, University of Health Sciences, Behcet Uz Research and Education Hospital, Izmir, Turkey
| | - Ayse B. Anil
- Department of Pediatrics, Tepecik Research and Education Hospital, Izmir, Turkey
| | - Rana Işguder
- Department of Pediatrics, University of Health Sciences, Behcet Uz Research and Education Hospital, Izmir, Turkey
| | - Funda Kurt
- Department of Pediatrics, Bilkent City Hospital, Ankara, Turkey
| | - Feyza Incekoy-Girgin
- Department of Pediatrics, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Nilgun Erkek
- Department of Pediatrics, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Fatih Durak
- Department of Pediatrics, Tepecik Research and Education Hospital, Izmir, Turkey
| | - Halise Akca
- Department of Pediatrics, Yildirim Beyazit University Faculty of Medicine, Ankara, Turkey
| | - Emel Berksoy
- Department of Pediatrics, Tepecik Research and Education Hospital, Izmir, Turkey
| | - Aytac Goktug
- Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ilker Gunay
- Department of Pediatrics, University of Health Sciences, Behcet Uz Research and Education Hospital, Izmir, Turkey
| | - Oksan Derinoz
- Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | | | - Ebru Azapagasi
- Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Gulser E. Besli
- Department of Pediatrics, Medeniyet University Faculty of Medicine, Istanbul, Turkey
| | - Caglar Odek
- Department of Pediatrics, Aydin University Faculty of Medicine, Istanbul, Turkey
| | - Deniz Tekin
- Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Oguz Dursun
- Department of Pediatrics, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Tanil Kendirli
- Department of Pediatrics, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ozlem Teksam
- Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Rodríguez-Martínez CE, Castro-Rodriguez JA, Nino G, Midulla F. The impact of viral bronchiolitis phenotyping: Is it time to consider phenotype-specific responses to individualize pharmacological management? Paediatr Respir Rev 2020; 34:53-58. [PMID: 31054799 PMCID: PMC7325448 DOI: 10.1016/j.prrv.2019.04.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 03/11/2019] [Accepted: 04/05/2019] [Indexed: 12/31/2022]
Abstract
Although recent guidelines recommend a minimalist approach to bronchiolitis, there are several issues with this posture. First, there are concerns about the definition of the disease, the quality of the guidelines, the method of administration of bronchodilators, and the availability of tools to evaluate the response to therapies. Second, for decades it has been assumed that all cases of viral bronchiolitis are the same, but recent evidence has shown that this is not the case. Distinct bronchiolitis phenotypes have been described, with heterogeneity in clinical presentation, molecular immune signatures and clinically relevant outcomes such as respiratory failure and recurrent wheezing. New research is critically needed to refine viral bronchiolitis phenotyping at the molecular and clinical levels as well as to define phenotype-specific responses to different therapeutic options.
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Affiliation(s)
- Carlos E Rodríguez-Martínez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia; Department of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Bogota, Colombia.
| | - Jose A Castro-Rodriguez
- Department of Pediatric Pulmonology, Division of Pediatrics, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Gustavo Nino
- Division of Pediatric Pulmonary, Sleep Medicine and Integrative Systems Biology, Center for Genetic Research, Children's National Medical Center, George Washington University, Washington, D.C., United States
| | - Fabio Midulla
- Department of Pediatrics, Sapienza University, Rome, Italy
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Cano-Garcinuño A, Praena-Crespo M, Mora-Gandarillas I, Carvajal-Urueña I, Callén-Blecua MT, García-Merino Á. [Criteria heterogeneity in the diagnosis of acute bronchiolitis in Spain]. An Pediatr (Barc) 2019; 90:109-117. [PMID: 30172561 PMCID: PMC7105059 DOI: 10.1016/j.anpedi.2018.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 06/20/2018] [Accepted: 07/12/2018] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Acute viral bronchiolitis (AB) is one of the most common respiratory diseases in infants. However, diagnostic criteria for AB are heterogeneous and not very well known. OBJECTIVE To identify the diagnostic criteria for AB used by experts and clinical paediatricians in Spain. METHODS Delphi study with Spanish AB experts, looking for the points of agreement about AB diagnosis. A subsequent cross-sectional study was conducted by means of an on-line questionnaire addressed to all Spanish paediatricians, reached through electronic mail messages sent by nine paediatric scientific societies. Descriptive and factorial analyses were carried out, looking for any association of diagnostic criteria with demographic or geographic variables, or with paediatric subspecialty. RESULTS Agreement was reached by 40 experts in many issues (first episode of respiratory distress and high respiratory frequency, diagnosis in any season of the year, and usefulness of virus identification in making diagnosis), but opposite views were maintained on key characteristics such as the maximum age for diagnosis. The on-line questionnaire was completed by 1297 paediatricians. Their diagnostic criteria were heterogeneous and strongly associated with their paediatric sub-specialty. Their agreement with the Spanish expert consensus and with international standards was very poor. CONCLUSIONS Diagnostic criteria for AB in Spain are heterogeneous. These differences could cause variability in clinical practice with AB patients.
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Cano-Garcinuño A, Praena-Crespo M, Mora-Gandarillas I, Carvajal-Urueña I, Callén-Blecua MT, García-Merino Á. Criteria heterogeneity in the diagnosis of acute bronchiolitis in Spain. An Pediatr (Barc) 2019; 90:109-117. [PMID: 32289044 PMCID: PMC7146771 DOI: 10.1016/j.anpede.2018.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 07/12/2018] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Acute viral bronchiolitis (AB) is one of the most common respiratory diseases in infants. However, diagnostic criteria for AB are heterogeneous and not very well known. OBJECTIVE To identify the diagnostic criteria for AB used by experts and clinical paediatricians in Spain. METHODS Delphi study with Spanish AB experts, looking for the points of agreement about AB diagnosis. A subsequent cross-sectional study was conducted by means of an online questionnaire addressed to all Spanish paediatricians, reached through electronic mail messages sent by nine paediatric scientific societies. Descriptive and factorial analyses were carried out, looking for any association of diagnostic criteria with demographic or geographic variables, or with paediatric subspecialty. RESULTS Agreement was reached by 40 experts in many issues (first episode of respiratory distress and high respiratory frequency, diagnosis in any season of the year, and usefulness of virus identification in making diagnosis), but opposite views were maintained on key characteristics such as the maximum age for diagnosis. The online questionnaire was completed by 1297 paediatricians. Their diagnostic criteria were heterogeneous and strongly associated with their paediatric sub-specialty. Their agreement with the Spanish expert consensus and with international standards was very poor. CONCLUSIONS Diagnostic criteria for AB in Spain are heterogeneous. These differences could cause variability in clinical practice with AB patients.
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Condella A, Mansbach JM, Hasegawa K, Dayan PS, Sullivan AF, Espinola JA, Camargo CA. Multicenter Study of Albuterol Use Among Infants Hospitalized with Bronchiolitis. West J Emerg Med 2018; 19:475-483. [PMID: 29760843 PMCID: PMC5942012 DOI: 10.5811/westjem.2018.3.35837] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 02/14/2018] [Accepted: 03/05/2018] [Indexed: 01/19/2023] Open
Abstract
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.
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Affiliation(s)
- Anna Condella
- Columbia University College of Physicians and Surgeons, Division of Pediatric Emergency Medicine, Department of Pediatrics, New York, New York
| | - Jonathan M. Mansbach
- Harvard Medical School, Boston Children’s Hospital, Department of Medicine, Boston, Massachusetts
| | - Kohei Hasegawa
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Peter S. Dayan
- Columbia University College of Physicians and Surgeons, Division of Pediatric Emergency Medicine, Department of Pediatrics, New York, New York
| | - Ashley F. Sullivan
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Janice A. Espinola
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Carlos A. Camargo
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
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