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Gracioso Martins AM, Snider DB, Popowski KD, Schuchard KG, Tenorio M, Akunuri S, Wee J, Peters KJ, Jansson A, Shirwaiker R, Cheng K, Freytes DO, Cruse GP. Low-dose intrapulmonary drug delivery device for studies on next-generation therapeutics in mice. J Control Release 2023; 359:287-301. [PMID: 37301267 PMCID: PMC10527740 DOI: 10.1016/j.jconrel.2023.05.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 05/16/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023]
Abstract
Although nebulizers have been developed for delivery of small molecules in human patients, no tunable device has been purpose-built for targeted delivery of modern large molecule and temperature-sensitive therapeutics to mice. Mice are used most of all species in biomedical research and have the highest number of induced models for human-relevant diseases and transgene models. Regulatory approval of large molecule therapeutics, including antibody therapies and modified RNA highlight the need for quantifiable dose delivery in mice to model human delivery, proof-of-concept studies, efficacy, and dose-response. To this end, we developed and characterized a tunable nebulization system composed of an ultrasonic transducer equipped with a mesh nebulizer fitted with a silicone restrictor plate modification to control the nebulization rate. We have identified the elements of design that influence the most critical factors to targeted delivery to the deep lungs of BALB/c mice. By comparing an in silico model of the mouse lung with experimental data, we were able to optimize and confirm the targeted delivery of over 99% of the initial volume to the deep portions of the mouse lung. The resulting nebulizer system provides targeted lung delivery efficiency far exceeding conventional nebulizers preventing waste of expensive biologics and large molecules during proof-of-concept and pre-clinical experiments involving mice. (Word Count =207).
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Affiliation(s)
- Ana Maria Gracioso Martins
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC, USA; Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina-Chapel Hill, NC, USA
| | - Douglas B Snider
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA; Comparative Medicine and Translational Research Training Program, North Carolina State University, Raleigh, NC, USA; Comparative Medicine Institute, North Carolina State University, Raleigh, NC, USA
| | - Kristen D Popowski
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA; Comparative Medicine Institute, North Carolina State University, Raleigh, NC, USA; Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina-Chapel Hill, NC, USA
| | - Karl G Schuchard
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC, USA; Edward P. Fitts Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC, USA
| | - Matias Tenorio
- Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina-Chapel Hill, NC, USA
| | - Sandip Akunuri
- Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina-Chapel Hill, NC, USA
| | - Junghyun Wee
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC, USA
| | - Kara J Peters
- Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC, USA
| | - Anton Jansson
- Analytical Instrumentation Facility, Monteith Research Center, North Carolina State University, Raleigh, NC, USA
| | - Rohan Shirwaiker
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC, USA; Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina-Chapel Hill, NC, USA; Edward P. Fitts Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC, USA; Department of Mechanical and Aerospace Engineering, North Carolina State University, Raleigh, NC, USA
| | - Ke Cheng
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA; Comparative Medicine Institute, North Carolina State University, Raleigh, NC, USA; Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina-Chapel Hill, NC, USA
| | - Donald O Freytes
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC, USA; Joint Department of Biomedical Engineering, North Carolina State University & University of North Carolina-Chapel Hill, NC, USA
| | - Glenn P Cruse
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA; Comparative Medicine Institute, North Carolina State University, Raleigh, NC, USA.
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Walsh P, Chaigneau FRC, Lebedev M, Mutua V, McEligot H, Lam SHF, Hwang B, Bang H, Gershwin LJ. Validating a bovine model for lung ultrasound of bronchiolitis. J Ultrasound 2022; 25:611-624. [PMID: 35067896 PMCID: PMC8784226 DOI: 10.1007/s40477-021-00635-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 10/28/2021] [Indexed: 02/06/2023] Open
Affiliation(s)
- Paul Walsh
- Pediatric Emergency Medicine, Sutter Medical Center Sacramento, 2825 Capitol Avenue, Sacramento, CA, 95816, USA.
| | - Francisco R Carvallo Chaigneau
- Department of Pathology, Microbiology and Immunology, School of Veterinary Medicine, University of California, Davis, Davis, CA, 95616, USA
- California Animal Health and Food Safety Laboratory, San Bernardino Branch, 105 W Central Ave, San Bernardino, CA, 92408, USA
- Department of Biomedical Sciences and Pathobiology, Virginia Maryland College of Veterinary Medicine, Virginia Tech, Blacksburg, VA, 24060, USA
| | - Maxim Lebedev
- Department of Pathology, Microbiology and Immunology, School of Veterinary Medicine, University of California, Davis, Davis, CA, 95616, USA
| | - Victoria Mutua
- Department of Pathology, Microbiology and Immunology, School of Veterinary Medicine, University of California, Davis, Davis, CA, 95616, USA
| | - Heather McEligot
- Department of Pathology, Microbiology and Immunology, School of Veterinary Medicine, University of California, Davis, Davis, CA, 95616, USA
| | - Samuel H F Lam
- Pediatric Emergency Medicine, Sutter Medical Center Sacramento, 2825 Capitol Avenue, Sacramento, CA, 95816, USA
| | - Benjamin Hwang
- Department of Pathology, Microbiology and Immunology, School of Veterinary Medicine, University of California, Davis, Davis, CA, 95616, USA
| | - Heejung Bang
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, Davis, CA, 95616, USA
| | - Laurel J Gershwin
- Department of Pathology, Microbiology and Immunology, School of Veterinary Medicine, University of California, Davis, Davis, CA, 95616, USA.
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Hirai K, Nukaga M, Tabata H, Enseki M, Furuya H, Niimura F, Yamaguchi K, Mochizuki H. Objective measurement of nocturnal cough in infants with acute bronchiolitis. Respir Investig 2019; 57:605-610. [PMID: 31327680 DOI: 10.1016/j.resinv.2019.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/10/2019] [Accepted: 06/10/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The objective measurement of the cough severity and the assessment of the pattern of nocturnal coughing could be useful in the treatment of respiratory diseases in children. STUDY DESIGN In children with respiratory syncytial virus (RSV)-induced acute bronchiolitis, coughs were recorded using our original system with a microphone and accelerometer, and analyzed using our customized software program. The number of coughs in every 30-minute interval was measured in patients with acute bronchiolitis (n = 20), and their results were compared with those of infants with asthma exacerbation (n = 16). RESULTS The cough count in children with acute bronchiolitis (median: 108.0/night) was almost as high as that in children with asthma exacerbation (median: 119/night). However, the time-dependent pattern of overnight cough was different in infants with acute bronchiolitis and those with asthma exacerbation. In the infants with asthma exacerbation, cough frequency significantly increased while falling asleep and waking up as compared to midnight (p < 0.001 and p < 0.001, respectively). However, these differences were not found in infants with acute bronchiolitis. CONCLUSIONS Our data demonstrated that the number of coughing events due to acute bronchiolitis was similar to that of acute asthma exacerbation, although the acute bronchiolitis did not show a characteristic overnight cough pattern.
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Affiliation(s)
- Kota Hirai
- Department of Pediatrics, Tokai University Hachioji Hospital, 1838, Ishikawa, Hachioji, Tokyo, 192-0032 Japan.
| | - Mariko Nukaga
- Department of Pediatrics, Tokai University School of Medicine, 143, Shimokasuya, Isehara, Kanagawa, 259-1193 Japan.
| | - Hideyuki Tabata
- Department of Pediatrics, Tokai University School of Medicine, 143, Shimokasuya, Isehara, Kanagawa, 259-1193 Japan.
| | - Mayumi Enseki
- Department of Pediatrics, Tokai University School of Medicine, 143, Shimokasuya, Isehara, Kanagawa, 259-1193 Japan.
| | - Hiroyuki Furuya
- Department of Basic Clinical Science and Public Health, Tokai University School of Medicine, 143, Shimokasuya, Isehara, Kanagawa, 259-1193 Japan.
| | - Fumio Niimura
- Department of Pediatrics, Tokai University School of Medicine, 143, Shimokasuya, Isehara, Kanagawa, 259-1193 Japan.
| | - Koichi Yamaguchi
- Department of Pediatrics, Tokai University Hachioji Hospital, 1838, Ishikawa, Hachioji, Tokyo, 192-0032 Japan.
| | - Hiroyuki Mochizuki
- Department of Pediatrics, Tokai University School of Medicine, 143, Shimokasuya, Isehara, Kanagawa, 259-1193 Japan.
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Which ICD-9-CM codes should be used for bronchiolitis research? BMC Med Res Methodol 2018; 18:149. [PMID: 30466396 PMCID: PMC6249877 DOI: 10.1186/s12874-018-0589-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 10/29/2018] [Indexed: 11/10/2022] Open
Abstract
Background Bronchiolitis is a common respiratory disorder in children. Although there are specific ICD-9-CM diagnosis codes for bronchiolitis, the illness is often coded using broader diagnosis codes. This creates the potential for subject misclassification if researchers rely on specific diagnosis codes when assembling retrospective cohorts. Here we challenge the common research practice of relying on specific diagnosis codes for bronchiolitis. Methods We examined the use of diagnosis codes for the first episode of bronchiolitis, bronchitis, acute asthma, and bronchospasm and wheezing, in children younger than six and 24 months in the State of California Medic-Aid database. We categorized codes as narrow or broad diagnosis codes. We compared patient, geographic, and temporal characteristics of the different diagnoses codes. Results We identified visits from 48,732 children for first episode of wheezing illness. We retained 48,269 who had the diagnosis codes and data of interest. Diagnosis codes for acute asthma were widely used, even in children younger than six months in whom a diagnosis code for bronchiolitis would have been anticipated. The temporal pattern was similar across all diagnoses. Antipyretics were prescribed more often in those with diagnosis codes for bronchiolitis and bronchitis. Other statistically significant differences were too small to usefully distinguish the groups. There was substantial geographic variability in the diagnosis codes selected. Conclusion Users of Medic-Aid administrative data should generally favor broad rather than narrow definitions of bronchiolitis and should perform sensitivity analysis comparing broad and narrow definitions. Electronic supplementary material The online version of this article (10.1186/s12874-018-0589-4) contains supplementary material, which is available to authorized users.
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Walsh P. Even the Thinnest Salami Contains Some Meat. West J Emerg Med 2018; 19:484-486. [PMID: 29760844 PMCID: PMC5942013 DOI: 10.5811/westjem.2018.4.38408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 04/04/2018] [Accepted: 04/05/2018] [Indexed: 12/02/2022] Open
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Bronchiolitis. PRINCIPLES AND PRACTICE OF PEDIATRIC INFECTIOUS DISEASES 2018. [PMCID: PMC7173594 DOI: 10.1016/b978-0-323-40181-4.00033-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Prospective Multicentre Study on the Epidemiology and Current Therapeutic Management of Severe Bronchiolitis in Spain. BIOMED RESEARCH INTERNATIONAL 2017; 2017:2565397. [PMID: 28421191 PMCID: PMC5380832 DOI: 10.1155/2017/2565397] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 02/14/2017] [Accepted: 02/27/2017] [Indexed: 12/04/2022]
Abstract
Objective. To determine the epidemiology and therapeutic management of patients with severe acute bronchiolitis (AB) admitted to paediatric intensive care units (PICUs) in Spain. Design. Descriptive, prospective, multicentre study. Setting. Sixteen Spanish PICUs. Patients. Patients with severe AB who required admission to any of the participating PICUs over 1 year. Interventions. Both epidemiological variables and medical treatment received were recorded. Results. A total of 262 patients were recruited; 143 were male (54.6%), with median age of 1 month (0–23). Median stay in the PICU was 7 days (1–46). Sixty patients (23%) received no nebuliser treatment, while the rest received a combination of inhalation therapies. One-quarter of patients (24.8%) received corticosteroids and 56.5% antibiotic therapy. High-flow oxygen therapy was used in 14.3% and noninvasive ventilation (NIV) was used in 75.6%. Endotracheal intubation was required in 24.4% of patients. Younger age, antibiotic therapy, and invasive mechanical ventilation (IMV) were risk factors that significantly increased the stay in the PICU. Conclusions. Spanish PICUs continue to routinely use nebulised bronchodilator treatment and corticosteroid therapy. Despite NIV being widely used in this condition, intubation was required in one-quarter of cases. Younger age, antibiotic therapy, and IMV were associated with a longer stay in the PICU.
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Abstract
OBJECTIVE To identify publishing trends within the field of pediatric emergency medicine between 2004 and 2013. METHODS We conducted a MEDLINE search of pediatric emergency medicine articles, filtered by clinical trial, published between 2004 and 2013 in ten journals from the fields of pediatrics, emergency medicine, general medicine, and pediatric emergency medicine. Each article was classified by journal type, study design, results (positive or negative/equivocal), age/type of subjects, and major topic (based on the objective of the study). Articles were stratified by publication period (2004-2008 or 2009-2013) to analyze trends. RESULTS A total of 464 articles were analyzed. The majority of articles were described as randomized-controlled trials (47%) with negative/equivocal findings (70%). The most common major topics were pain management, asthma, sedation, bronchiolitis, resuscitation, simulation, and ultrasound. Over time, the percentage of articles published in pediatrics and pediatric emergency medicine journals increased (P = 0.0499) and the percentage for all study designs increased except for randomized controlled trials (P = 0.0089). There were no differences between the 2 publication periods when stratified by results, age/type of subjects, and major topic. CONCLUSIONS By identifying these trends, we hope to encourage researchers to perform studies in the field of pediatric emergency medicine where deficiencies lie and to guide pediatric health care professionals to where published, evidence-based studies can be found in the medical literature.
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Walsh P, Behrens N, Carvallo Chaigneau FR, McEligot H, Agrawal K, Newman JW, Anderson M, Gershwin LJ. A Randomized Placebo Controlled Trial of Ibuprofen for Respiratory Syncytial Virus Infection in a Bovine Model. PLoS One 2016; 11:e0152913. [PMID: 27073858 PMCID: PMC4830518 DOI: 10.1371/journal.pone.0152913] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 03/21/2016] [Indexed: 01/05/2023] Open
Abstract
Background Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis and hospital admission in infants. An analogous disease occurs in cattle and costs US agriculture a billion dollars a year. RSV causes much of its morbidity indirectly via adverse effects of the host response to the virus. RSV is accompanied by elevated prostaglandin E2 (PGE2) which is followed by neutrophil led inflammation in the lung. Ibuprofen is a prototypical non-steroidal anti-inflammatory drug that decreases PGE2 levels by inhibiting cyclooxygenase. Hypotheses We hypothesized that treatment of RSV with ibuprofen would decrease PGE2 levels, modulate the immune response, decrease clinical illness, and decrease the histopathological lung changes in a bovine model of RSV. We further hypothesized that viral replication would be unaffected. Methods We performed a randomized placebo controlled trial of ibuprofen in 16 outbred Holstein calves that we infected with RSV. We measured clinical scores, cyclooxygenase, lipoxygenase and endocannabinoid products in plasma and mediastinal lymph nodes and interleukin (Il)-4, Il-13, Il-17 and interferon-γ in mediastinal lymph nodes. RSV shedding was measured daily and nasal Il-6, Il-8 and Il-17 every other day. The calves were necropsied on Day 10 post inoculation and histology performed. Results One calf in the ibuprofen group required euthanasia on Day 8 of infection for respiratory distress. Clinical scores (p<0.01) and weight gain (p = 0.08) seemed better in the ibuprofen group. Ibuprofen decreased cyclooxygenase, lipoxygenase, and cytochrome P450 products, and increased monoacylglycerols in lung lymph nodes. Ibuprofen modulated the immune response as measured by narrowed range of observed Il-13, Il-17 and IFN-γ gene expression in mediastinal lymph nodes. Lung histology was not different between groups, and viral shedding was increased in calves randomized to ibuprofen. Conclusions Ibuprofen decreased PGE2, modulated the immune response, and improved clinical outcomes. However lung histopathology was not affected and viral shedding was increased.
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Affiliation(s)
- Paul Walsh
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Sutter Medical Center Sacramento, Sacramento, California, United States of America
- * E-mail:
| | - Nicole Behrens
- Department of Pathology, Microbiology, and Immunology, School of Veterinary Medicine, University of California Davis, 1 Shields Ave, Davis, California, United States of America
| | - Francisco R. Carvallo Chaigneau
- California Animal Health and Food Safety Laboratory, San Bernardino branch, 105 W Central Ave, San Bernardino, California, United States of America
| | - Heather McEligot
- Department of Pathology, Microbiology, and Immunology, School of Veterinary Medicine, University of California Davis, 1 Shields Ave, Davis, California, United States of America
| | - Karan Agrawal
- Department of Nutrition, University of California Davis, Davis, 95616 California, United States of America
- NIH West Coast Metabolomics Center, University of California Davis, Davis, California, United States of America
| | - John W. Newman
- Obesity and Metabolism Research Unit, United States Department of Agriculture, Agricultural Research Service, Western Human Nutrition Research Center, Davis, California, United States of America
- Department of Nutrition, University of California Davis, Davis, 95616 California, United States of America
- NIH West Coast Metabolomics Center, University of California Davis, Davis, California, United States of America
| | - Mark Anderson
- California Animal Health and Food Safety Laboratory, 620 W. Health Sciences Drive, Davis, California, United States of America
| | - Laurel J. Gershwin
- Department of Pathology, Microbiology, and Immunology, School of Veterinary Medicine, University of California Davis, 1 Shields Ave, Davis, California, United States of America
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Walsh P, Cunningham P, Merchant S, Walker N, Heffner J, Shanholtzer L, Rothenberg SJ. Derivation of Candidate Clinical Decision Rules to Identify Infants at Risk for Central Apnea. Pediatrics 2015; 136:e1228-36. [PMID: 26482666 PMCID: PMC4621801 DOI: 10.1542/peds.2015-1825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/18/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Central apnea complicates, and may be the presenting complaint in, bronchiolitis. Our objective was to prospectively derive candidate clinical decision rules (CDRs) to identify infants in the emergency department (ED) who are at risk for central apnea. METHODS We conducted a prospective observational study over 8 years. The primary outcome was central apnea subsequent to the initial ED visit. Infants were enrolled if they presented with central apnea or bronchiolitis. We excluded infants with obstructive apnea, neonatal jaundice, trauma, or suspected sepsis. We developed 3 candidate CDRs by using 3 techniques: (1) Poisson regression clustered on the individual, (2) classification and regression tree analysis (CART), and (3) a random forest (RF). RESULTS We analyzed 990 ED visits for 892 infants. Central apnea subsequently occurred in the hospital in 41 (5%) patients. Parental report of apnea, previous history of apnea, congenital heart disease, birth weight ≤2.5 kg, lower weight, and age ≤6 weeks all identified a group at high risk for subsequent central apnea. All CDRs and RFs were 100% sensitive (95% confidence interval [CI] 91%-100%) and had a negative predictive value of 100% (95% CI 99%-100%) for the subsequent apnea. Specificity ranged from 61% to 65% (95% CI 58%-68%) for CDRs based on Poisson models; 65% to 77% (95% CI 62%-90%) for CART; and 81% to 91% (95% CI 78%-92%) for RF models. CONCLUSIONS All candidate CDRs had a negative predictive value of 100% for subsequent central apnea.
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Affiliation(s)
- Paul Walsh
- Pediatric Emergency Medicine, Sutter Medical Center, Sacramento, California; Department of Emergency Medicine, University of California Davis, Sacramento, California; Department of Emergency Medicine, Kern Medical Center, Bakersfield, California;
| | - Pádraig Cunningham
- School of Computer Science, University College Dublin, Belfield, Dublin, Ireland; and
| | - Sabrina Merchant
- Department of Emergency Medicine, Kern Medical Center, Bakersfield, California
| | - Nicholas Walker
- Department of Emergency Medicine, Kern Medical Center, Bakersfield, California
| | - Jacquelyn Heffner
- Department of Emergency Medicine, Kern Medical Center, Bakersfield, California
| | - Lucas Shanholtzer
- Department of Emergency Medicine, Kern Medical Center, Bakersfield, California
| | - Stephen J. Rothenberg
- Instituto Nacional de Salud Pública, Centro de Investigación en Salud Poblacional, Cuernavaca, Morelos, Mexico
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Walsh P, Rothenberg SJ. The recommendation to not use bronchodilators is not supported by the evidence. Pediatrics 2015; 135:e556. [PMID: 25645858 DOI: 10.1542/peds.2014-3676a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Walsh P, Rothenberg SJ. American Academy of Pediatrics 2014 bronchiolitis guidelines: bonfire of the evidence. West J Emerg Med 2015; 16:85-8. [PMID: 25671015 PMCID: PMC4307733 DOI: 10.5811/westjem.2015.1.24930] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 01/06/2015] [Indexed: 11/11/2022] Open
Affiliation(s)
- Paul Walsh
- University of California, Davis, Department of Emergency Medicine, Davis, California ; Sutter Medical Centers of Sacramento, Pediatric Emergency Medicine, Sacramento, California
| | - Stephen J Rothenberg
- Instituto Nacional de Salud Pública, Centro de Investigación en Salud Poblacional, Cuernavaca, Morelos, Mexico
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Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM, Johnson DW, Light MJ, Maraqa NF, Mendonca EA, Phelan KJ, Zorc JJ, Stanko-Lopp D, Brown MA, Nathanson I, Rosenblum E, Sayles S, Hernandez-Cancio S. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics 2014; 134:e1474-502. [PMID: 25349312 DOI: 10.1542/peds.2014-2742] [Citation(s) in RCA: 1076] [Impact Index Per Article: 107.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
This guideline is a revision of the clinical practice guideline, "Diagnosis and Management of Bronchiolitis," published by the American Academy of Pediatrics in 2006. The guideline applies to children from 1 through 23 months of age. Other exclusions are noted. Each key action statement indicates level of evidence, benefit-harm relationship, and level of recommendation. Key action statements are as follows:
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Abstract
BACKGROUND Bronchiolitis is an acute, viral lower respiratory tract infection affecting infants and is sometimes treated with bronchodilators. OBJECTIVES To assess the effects of bronchodilators on clinical outcomes in infants (0 to 12 months) with acute bronchiolitis. SEARCH METHODS We searched CENTRAL 2013, Issue 12, MEDLINE (1966 to January Week 2, 2014) and EMBASE (1998 to January 2014). SELECTION CRITERIA Randomized controlled trials (RCTs) comparing bronchodilators (other than epinephrine) with placebo for bronchiolitis. DATA COLLECTION AND ANALYSIS Two authors assessed trial quality and extracted data. We obtained unpublished data from trial authors. MAIN RESULTS We included 30 trials (35 data sets) representing 1992 infants with bronchiolitis. In 11 inpatient and 10 outpatient studies, oxygen saturation did not improve with bronchodilators (mean difference (MD) -0.43, 95% confidence interval (CI) -0.92 to 0.06, n = 1242). Outpatient bronchodilator treatment did not reduce the rate of hospitalization (11.9% in bronchodilator group versus 15.9% in placebo group, odds ratio (OR) 0.75, 95% CI 0.46 to 1.21, n = 710). Inpatient bronchodilator treatment did not reduce the duration of hospitalization (MD 0.06, 95% CI -0.27 to 0.39, n = 349).Effect estimates for inpatients (MD -0.62, 95% CI -1.40 to 0.16) were slightly larger than for outpatients (MD -0.25, 95% CI -0.61 to 0.11) for oximetry. Oximetry outcomes showed significant heterogeneity (I(2) statistic = 81%). Including only studies with low risk of bias had little impact on the overall effect size of oximetry (MD -0.38, 95% CI -0.75 to 0.00) but results were close to statistical significance.In eight inpatient studies, there was no change in average clinical score (standardized MD (SMD) -0.14, 95% CI -0.41 to 0.12) with bronchodilators. In nine outpatient studies, the average clinical score decreased slightly with bronchodilators (SMD -0.42, 95% CI -0.79 to -0.06), a statistically significant finding of questionable clinical importance. The clinical score outcome showed significant heterogeneity (I(2) statistic = 73%). Including only studies with low risk of bias reduced the heterogeneity but had little impact on the overall effect size of average clinical score (SMD -0.22, 95% CI -0.41 to -0.03).Sub-analyses limited to nebulized albuterol or salbutamol among outpatients (nine studies) showed no effect on oxygen saturation (MD -0.19, 95% CI -0.59 to 0.21, n = 572), average clinical score (SMD -0.36, 95% CI -0.83 to 0.11, n = 532) or hospital admission after treatment (OR 0.77, 95% CI 0.44 to 1.33, n = 404).Adverse effects included tachycardia, oxygen desaturation and tremors. AUTHORS' CONCLUSIONS Bronchodilators such as albuterol or salbutamol do not improve oxygen saturation, do not reduce hospital admission after outpatient treatment, do not shorten the duration of hospitalization and do not reduce the time to resolution of illness at home. Given the adverse side effects and the expense associated with these treatments, bronchodilators are not effective in the routine management of bronchiolitis. This meta-analysis continues to be limited by the small sample sizes and the lack of standardized study design and validated outcomes across the studies. Future trials with large sample sizes, standardized methodology across clinical sites and consistent assessment methods are needed to answer completely the question of efficacy.
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Affiliation(s)
- Anne M Gadomski
- Bassett Medical CenterResearch Institute1 Atwell RoadCooperstownNew YorkUSA13326
| | - Melissa B Scribani
- Bassett Medical CenterComputing Center1 Atwell RoadCooperstownNew YorkUSA13326
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Johnson LW, Robles J, Hudgins A, Osburn S, Martin D, Thompson A. Management of bronchiolitis in the emergency department: impact of evidence-based guidelines? Pediatrics 2013; 131 Suppl 1:S103-9. [PMID: 23457145 DOI: 10.1542/peds.2012-1427m] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Lara W Johnson
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA.
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Nasopharyngeal airway pressures in bronchiolitis patients treated with high-flow nasal cannula oxygen therapy. Pediatr Emerg Care 2012; 28:1179-84. [PMID: 23114244 DOI: 10.1097/pec.0b013e318271a671] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Heated, humidified, high-flow nasal cannula oxygen therapy (HHHFNC) has been used to improve ventilation in preterm infants. There are no data on airway pressures generated and efficacy in bronchiolitis. OBJECTIVE The objective of this study was to determine nasopharyngeal (NP) pressures generated with HHHFNC therapy in bronchiolitis. METHODS We conducted a prospective, observational study to measure NP pressures at varying flow rates of HHHFNC therapy in moderate to severe bronchiolitis. Vital signs, bronchiolitis severity scores, and oxygen saturation were also noted. RESULTS Twenty-five patients were enrolled (mean, 78.1 [SD, 30.9] days; weight, 5.3 [SD, 1.1] kg). Nasopharyngeal pressures increased linearly with flow rates up to 6 L/min. Beyond 6 L/min, pressure increase was linear but less accelerated. On average, NP pressure increased by 0.45 cm H2O for each 1-L/min increase in flow rate. There were significant differences between pressures in open- and closed-mouth states for flow rates up to 6 L/min. At 6 L/min, the pressure in open-mouth state was 2.47 cm H2O and that in closed-mouth state was 2.74 cm H2O (P < 0.001). Linear regression analysis revealed that only flow (not weight or gender) had an effect on generated pressure. Bronchiolitis severity scores improved significantly with HHHFNC therapy (pre: 14.5 [SD, 1.4], post: 10.4 [SD, 1.2]; P < 0.001). CONCLUSIONS Increasing flow rates of HHHFNC therapy are associated with linear increases in NP pressures in bronchiolitis patients. Larger studies are needed to assess the clinical efficacy of HHHFNC therapy in bronchiolitis.
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Modaressi MR, Asadian A, Faghihinia J, Arashpour M, Mousavinasab F. Comparison of epinephrine to salbutamol in acute bronchiolitis. IRANIAN JOURNAL OF PEDIATRICS 2012; 22:241-4. [PMID: 23056893 PMCID: PMC3446067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/12/2010] [Revised: 04/13/2011] [Accepted: 06/20/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVE An appropriate treatment of acute viral bronchiolitis can reduce the symptoms, hospitalization duration and exorbitant costs which is imposed on the families and insurance organizations. This study was conducted to determine the efficacy of epinephrine in comparison with salbutamol in the treatment of the disease. METHODS Forty infants aged one month to 2 years with acute bronchiolitis in Amin and Al-Zahra hospitals, during 2008, were enrolled in this study. The participants were randomized in two treatment groups to receive epinephrine 0.1 ml/kg or salbutamol 0.15 mg/kg. Three doses of each medication were prescribed at intervals of 20 minutes and continued every 10 minutes after the third dose. The patients in both groups were monitored and rated by RDAI, number of the hospitalized days in the hospital, level of oxygen saturation and vital signs. FINDINGS Mean hospitalization duration was 3.3±1.1 and 3±0.9 in the patients receiving salbutamol and epinephrine, respectively (P=0.03). There was a significant difference in assessing RDAI index between the two groups (P=0.03). There were no differences in SPO2, PR, or RR variables in the studied intervals in both groups (P>0.05). CONCLUSION Regarding the effect of epinephrine on reduction of hospitalization duration and the RDAI index in patients with acute bronchiolitis, it seems that using epinephrine instead of salbutamol could be more effective in the management of the disease.
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Affiliation(s)
- Mohammad-Reza Modaressi
- Child Health Promotion Research Center, Isfahan University of Medical Sciences, Isfahan, Iran,Pediatric Infectious Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran,Corresponding Author:Address: Children's Medical Center; Dr Gharib St, Tehran, Iran. E-mail:
| | - Asadola Asadian
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Jamal Faghihinia
- Child Health Promotion Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehrshad Arashpour
- Child Health Promotion Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Firoozeh Mousavinasab
- Child Health Promotion Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Hartling L, Bialy LM, Vandermeer B, Tjosvold L, Johnson DW, Plint AC, Klassen TP, Patel H, Fernandes RM. Epinephrine for bronchiolitis. Cochrane Database Syst Rev 2011:CD003123. [PMID: 21678340 DOI: 10.1002/14651858.cd003123.pub3] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Bronchodilators are commonly used for acute bronchiolitis, despite uncertain effectiveness. OBJECTIVES To examine the efficacy and safety of epinephrine in children less than two with acute viral bronchiolitis. SEARCH STRATEGY We searched CENTRAL (2010, Issue 3) which contains the Acute Respiratory Infections Group's Specialized Register, MEDLINE (1950 to September Week 2, 2010), EMBASE (1980 to September 2010), Scopus (1823 to September 2010), PubMed (March 2010), LILACS (1985 to September 2010) and Iran MedEx (1998 to September 2010). SELECTION CRITERIA We included randomized controlled trials comparing epinephrine to placebo or another intervention involving children less than two years with acute viral bronchiolitis. Studies were included if the trials presented data for at least one quantitative outcome of interest.We selected primary outcomes a priori, based on clinical relevance: rate of admission by days one and seven of presentation for outpatients, and length of stay (LOS) for inpatients. Secondary outcomes included clinical severity scores, pulmonary function, symptoms, quality of life and adverse events. DATA COLLECTION AND ANALYSIS Two review authors independently screened the searches, applied inclusion criteria, assessed risk of bias and graded the evidence. We conducted separate analyses for different comparison groups (placebo, non-epinephrine bronchodilators, glucocorticoids) and for clinical setting (inpatient, outpatient). MAIN RESULTS We included 19 studies (2256 participants). Epinephrine versus placebo among outpatients showed a significant reduction in admissions at Day 1 (risk ratio (RR) 0.67; 95% confidence interval (CI) 0.50 to 0.89) but not at Day 7 post-emergency department visit. There was no difference in LOS for inpatients. Epinephrine versus salbutamol showed no differences among outpatients for admissions at Day 1 or 7. Inpatients receiving epinephrine had a significantly shorter LOS compared to salbutamol (mean difference -0.28; 95% CI -0.46 to -0.09). One large RCT showed a significantly shorter admission rate at Day 7 for epinephrine and steroid combined versus placebo (RR 0.65; 95% CI 0.44 to 0.95). There were no important differences in adverse events. AUTHORS' CONCLUSIONS This review demonstrates the superiority of epinephrine compared to placebo for short-term outcomes for outpatients, particularly in the first 24 hours of care. Exploratory evidence from a single study suggests benefits of epinephrine and steroid combined for later time points. More research is required to confirm the benefits of combined epinephrine and steroids among outpatients. There is no evidence of effectiveness for repeated dose or prolonged use of epinephrine or epinephrine and dexamethasone combined among inpatients.
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Affiliation(s)
- Lisa Hartling
- Department of Pediatrics, University of Alberta, Aberhart Centre One, Room 9424, 11402 University Avenue, Edmonton, Alberta, Canada, T6G 2J3
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Bourke T, Shields M. Bronchiolitis. BMJ CLINICAL EVIDENCE 2011; 2011:0308. [PMID: 21486501 PMCID: PMC3275170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Bronchiolitis is the most common lower respiratory tract infection in infants, occurring in a seasonal pattern, with highest incidence in the winter in temperate climates and in the rainy season in warmer countries. Bronchiolitis is a common reason for attendance at and admission to hospital. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of prophylactic interventions for bronchiolitis in high-risk children? What are the effects of measures to prevent transmission of bronchiolitis in hospital? What are the effects of treatments for children with bronchiolitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to July 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 59 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotics, bronchodilators (oral, inhaled salbutamol, inhaled adrenaline [epinephrine], hypertonic saline), chest physiotherapy, continuous positive airway pressure, corticosteroids, fluid management, heliox, montelukast, nasal decongestants, nursing interventions (cohort segregation, hand washing, gowns, masks, gloves, and goggles), oxygen, respiratory syncytial virus immunoglobulins, pooled immunoglobulins, or palivizumab (monoclonal antibody), ribavirin, or surfactants.
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Affiliation(s)
- Thomas Bourke
- Emergency Department, Royal Belfast Hospital for Sick Children, Belfast, UK
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Abstract
PURPOSE OF REVIEW Bronchiolitis impacts millions of infants worldwide. Although several therapeutic options stem from highly plausible theoretical rationales for success and some may even offer modest short-term symptom relief, none has been conclusively shown to alter the course of the disease or its major outcomes. However, several recent papers shed light on which treatments show promising preliminary evidence and offer insight into future research endeavors on this topic. This review will summarize bronchiolitis therapy in view of this recent evidence. RECENT FINDINGS The agents in which theory promises but treatment does not deliver include systemic corticosteroids alone, inhaled bronchodilators alone and antileukotrienes. The most promising combination to date appears to be that of oral dexamethasone and inhaled epinephrine but numerous related issues need to be clarified further. Caretakers need to be counselled about the usual protracted clinical course of bronchiolitis. SUMMARY Because bronchiolitis is a highly heterogeneous entity, future research challenges should include detailed characterization of infants most likely to benefit from given interventions. In the meantime, stick with the good old time-honored supportive route!
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Affiliation(s)
- Suzanne Schuh
- Research Institute, The Hospital for Sick Children, Canada.
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Chéron G, Patteau G, Nouyrigat V. Bronchiolite del lattante. EMC - URGENZE 2011. [PMCID: PMC7149004 DOI: 10.1016/s1286-9341(11)70664-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
La bronchiolite è un’infezione virale stagionale delle vie respiratorie basse del lattante. Il suo agente causale principale è il virus respiratorio sinciziale. La comparsa di un distress respiratorio è legata all’intensità della risposta infiammatoria delle vie aeree. Benché si tratti di una malattia frequente, le cause della suscettibilità dei lattanti a questa infezione non sono conosciute. La diagnosi è clinica. Il trattamento è sintomatico in assenza di misure specifiche. I rapporti a medio e a lungo termine di un primo episodio di bronchiolite con le recidive e con l’asma non sono spiegati. Essi potrebbero dipendere dalla natura del virus in causa al momento del primo episodio e da fattori genetici individuali.
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Gadomski AM, Brower M. Bronchodilators for bronchiolitis. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2010. [DOI: 10.1002/14651858.cd001266.pub3] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Viral bronchiolitis is the most common cause of hospitalization among infants. Despite its prevalence, no consistently effective therapy has been found to date, providing the driving force behind much of the ongoing research into this illness. In this review, we present a summary of the most recent published trials of interventions for bronchiolitis. Included are studies evaluating bronchodilators, corticosteroids, positive pressure ventilation, as well as 3 newer therapies for bronchiolitis: heliox, mucolytics, and leukotriene receptor antagonists.
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Chee C, Walsh P, Kuan S, Cabangangan J, Azimian K, Dong C, Tobias J, Rothenberg SJ. Emergency Department Septic Screening in Respiratory Syncytial Virus (RSV) and Non-RSV Bronchiolitis. West J Emerg Med 2010; 11:60-7. [PMID: 20411078 PMCID: PMC2850856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2009] [Revised: 06/23/2009] [Accepted: 07/13/2009] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To identify factors associated with culture-proven serious bacterial infection (SBI) and positive emergency department septic screening (EDSS) tests in children with bronchiolitis and to identify factors associated with the performance of EDSS. METHODS We reviewed an existing study database of patients with bronchiolitis. We defined a positive EDSS as urine with >/=10 WBC per high power field or cerebrospinal fluid (CSF) with >/=10 WBC per high power field (>25 WBC in neonates), or if organisms were identified on gram stain. We defined SBI as significant growth of an accepted pathogen in blood, urine or CSF. Our composite endpoint was positive if either of these was positive. The decision to perform testing was modeled using modified Poisson regression; the presence of the combined outcome was modeled using logistic regression modified for rare events. RESULTS We studied 640 children. Testing was performed in 199/640 (31.1%). These tended to be younger than two months RR 2.69 (95% CI 2.11, 3.44), febrile RR 2.01 (95% CI 1.58, 2.55), more dehydrated RR 1.50 (95% CI 1.28, 1.75) and had more severe chest wall retractions RR 1.54 (95% CI 1.22, 1.94). Only 11/640(1.7%) had a positive EDSS or SBI. Younger age (OR 0.67 per month; 95% CI 0.45, 0.99) and a negative RSV antigen test (OR 6.22; 95% CI 1.30, 29.85) were associated with the composite endpoint. CONCLUSION Testing was more likely to be performed in children younger than two months of age, and in those who were febrile, dehydrated, and had more severe chest wall retractions. A positive EDSS or SBI was rare occurring in younger infants with non-RSV bronchiolitis.
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Affiliation(s)
- Chris Chee
- Kern Medical Center, Department of Emergency Medicine, Bakersfield, CA
| | - Paul Walsh
- Kern Medical Center and Department of Internal Medicine, University of California, Los Angeles, CA,Address for Correspondence: Paul Walsh MB, BCh, Department of Emergency Medicine, 1830 Flower St.., Bakersfield, CA 93305.
| | - Sam Kuan
- Kern Medical Center, Department of Emergency Medicine, Bakersfield, CA
| | | | - Kian Azimian
- Kern Medical Center, Department of Emergency Medicine, Bakersfield, CA
| | - Christopher Dong
- Kern Medical Center, Department of Emergency Medicine, Bakersfield, CA
| | - Joshua Tobias
- Kern Medical Center, Department of Emergency Medicine, Bakersfield, CA
| | - Stephen J. Rothenberg
- Departamento de Ecología Humana, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional (I.P.N), México
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Abstract
Viral bronchiolitis is a leading cause of acute illness and hospitalization of young children. Research into the variation in treatment and outcomes for bronchiolitis across different settings has led to evidence-based clinical practice guidelines. Ongoing investigation continues to expand this body of evidence. Authors of recent surveillance studies have defined the presence of coinfections with multiple viruses in some cases of bronchiolitis. Underlying comorbidities and young age remain the most important predictors for severe bronchiolitis. Pulse oximetry plays an important role in driving use of health care resources. Evidence-based reviews have suggested a limited role for diagnostic laboratory or radiographic tests in typical cases of bronchiolitis. Several large, recent trials have revealed a lack of efficacy for routine use of either bronchodilators or corticosteroids for treatment of bronchiolitis. Preliminary evidence suggests a potential future role for a combination of these therapies and other novel treatments such as nebulized hypertonic saline.
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Affiliation(s)
- Joseph J Zorc
- MSCE, Children's Hospital of Philadelphia, Division of Emergency Medicine, Main AS01, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104-4399, USA.
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Anil AB, Anil M, Saglam AB, Cetin N, Bal A, Aksu N. High volume normal saline alone is as effective as nebulized salbutamol-normal saline, epinephrine-normal saline, and 3% saline in mild bronchiolitis. Pediatr Pulmonol 2010; 45:41-7. [PMID: 19953579 DOI: 10.1002/ppul.21108] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The objective of this study was to investigate the effectivenesses of nebulized salbutamol, epinephrin, 3% saline, and normal saline (0.9% NaCl) in the treatment of mildly affected infants with acute bronchiolitis. We enrolled 186 children (mean age 9.5 +/- 5.3 months, range 1.5-24 months, 65.1% male) with a first episode of wheezing diagnosed as mild bronchiolitis in emergency department. Patients were randomized in a double-blind fashion to receive 4 ml dose either of 1.5 mg epinephrine plus normal saline (group 1; n = 38) or 1.5 mg epinephrine plus 3% saline (group 2; n = 39) or 2.5 mg salbutamol plus normal saline (group 3; n = 36) or 2.5 mg salbutamol plus 3% saline (group 4; n = 36) or normal saline alone (group 5; n = 37) at 0 and 30 min. Thus, all treatment modalities included high amount of NaCl (72-240 mg). Clinical score, oxygen saturation and heart rate were assessed at 0, 30, 60, and 120 min. After discharge, patients were reassessed by telephone contact at 48 hr and 6 months. The baseline characteristics were similar in all groups (P > 0.05). The outcome of patients at 120 min was found significantly better than the baseline values (P < 0.05). There were no significant differences between the outcome variables of the groups (P > 0.05). No adverse effects attributable to nebulized therapy were seen. In conclusion, all treatment modalities used in this study, including a total of 8 ml normal saline inhalation at 30-min interval showed clinically significant and swift improvement in mildly affected ambulatory infants with acute bronchiolitis.
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Affiliation(s)
- Ayse Berna Anil
- Department of Pediatrics, Tepecik Training and Research Hospital, Izmir, Turkey.
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Abstract
PURPOSE OF REVIEW Epinephrine (adrenaline) is a medication widely used in the pediatric emergency department. This article reviews the most recent evidence and recommendations behind the many applications of epinephrine as they apply to the care of children in emergency departments. RECENT FINDINGS Recent publications address epinephrine's role in the treatment of anaphylaxis, croup, asthma, bronchiolitis and as an adjunct to local anesthesia. Additionally, authors discuss epinephrine autoinjectors and the various routes of epinephrine administration. SUMMARY Epinephrine is the recommended first-line treatment for anaphylaxis and moderate-to-severe croup. Its role in asthma and bronchiolitis is less clear. Traditional beta2-agonists are seen as first-line therapies for moderate bronchiolitis and asthma exacerbations. Epinephrine may have a role for subsets of patients with both of these illnesses. The preferred route for parenteral treatment is intramuscular. Epinephrine is well tolerated as an adjunct to local anesthesia when used in digital blocks in digits with normal perfusion. Although autoinjectors allow faster access to epinephrine for anaphylaxis, there are many issues surrounding their use and indications.
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Abstract
RSV bronchiolitis is one of the most common reasons for hospital admission and for visits to emergency departments for children, and at least half of affected infants will have subsequent episodes of respiratory illness. Despite this, there are wide variations in management. Initial assessment of respiratory status should include a measure of oxygenation and oxygen should be given when there is clinical evidence of respiratory distress even before full assessment is completed. Fluid and nutritional status should also be assessed early and decisions made about use of intravenous fluids, nasogastric feeding, or maintenance of frequent feeds orally. Given the lack of evidence on all drug therapies for bronchiolitis, clinicians should carefully evaluate treatments for their ability to reduce symptoms, decrease length of hospital stay and reduce sequelae. Furthermore, clinicians should monitor antibiotic use carefully and develop a strategy to change current physician practice.
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Walsh P, Overmeyer C, Kimmel L, Feola M, Pusavat J, Nguyen TA, Kuan S, Emery K, Rosengreen M, Mordechai E, Adelson ME. Prevalence of Bordetella pertussis and Bordetella parapertussis in Samples Submitted for RSV Screening. West J Emerg Med 2008; 9:135-40. [PMID: 19561728 PMCID: PMC2672259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2007] [Revised: 04/18/2008] [Accepted: 05/15/2008] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The clinical presentation of Bordetella pertussis can overlap with that of respiratory syncytial virus (RSV); however, management differs. HYPOTHESIS First, the prevalence of B. pertussis is less than 2% among patients screened for RSV, and second the prevalence of B. parapertussis is also less than 2% among these patients. METHODS Nasal washings submitted to a clinical laboratory for RSV screening were tested for B. pertussis and B. parapertussis, using species-specific real-time polymerase chain reaction (PCR) assays. These were optimized to target conserved regions within a complement gene and the CarB gene, respectively. A Bordetella spp. genus-specific real-time PCR assay was designed to detect the Bhur gene of B. pertussis, B. parapertussis, and B. bronchiseptica. RSV A and B subtypes were tested by reverse transcription-PCR. RESULTS Four hundred and eighty-nine clinical samples were tested. There was insufficient material to complete testing for one B. pertussis, 10 RSV subtype A, and four RSV subtype B assays. Bordetella pertussis was detected in 3/488 (0.6%) (95% CI 0.1% to 1.8%), while B. parapertussis was detected in 5/489 (1.0%) (95% CI 0.3% to 2.4%). Dual infection of B. pertussis with RSV and of B. parapertussis with RSV occurred in two and in three cases respectively. RSV was detected by PCR in 127 (26.5%). CONCLUSION The prevalence of B. pertussis in nasal washings submitted for RSV screening was less than 2%. The prevalence of parapertussis may be higher than 2%. RSV with B. pertussis and RSV with B. parapertussis coinfection do occur.
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Affiliation(s)
- Paul Walsh
- Kern Medical Center, Department of Emergency Medicine and David Geffen School of Medicine, University of California Los Angeles,Address for Correspondence: Paul Walsh, MB, BCh, BAO, MSc, Department of Emergency Medicine, Kern Medical Center, Bakersfield, CA and David Geffen School of Medicine, University of California Los Angeles. Email
| | - Christina Overmeyer
- Research and Development Department, Medical Diagnostic Laboratories, Hamilton NJ
| | - Lauren Kimmel
- Research and Development Department, Medical Diagnostic Laboratories, Hamilton NJ
| | - Melanie Feola
- Research and Development Department, Medical Diagnostic Laboratories, Hamilton NJ
| | | | - Tuan Anh Nguyen
- Kern Medical Center, Department of Emergency Medicine and David Geffen School of Medicine, University of California Los Angeles
| | - Sam Kuan
- Kern Medical Center, Department of Emergency Medicine and David Geffen School of Medicine, University of California Los Angeles
| | - Kirt Emery
- Kern Medical Center, Department of Pathology
| | - Martin Rosengreen
- Kern Medical Center, Department of Emergency Medicine and David Geffen School of Medicine, University of California Los Angeles
| | - Eli Mordechai
- Research and Development Department, Medical Diagnostic Laboratories, Hamilton NJ
| | - Martin E. Adelson
- Research and Development Department, Medical Diagnostic Laboratories, Hamilton NJ
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