1
|
Franklin D, Miller L, Pham TM, Frampton C, Moloney S, Waugh J, Fairless S, Hobbins S, Grew S, George S, Fahy R, Morel D, Schibler A. Nasal high flow therapy for bronchiolitis. J Paediatr Child Health 2024; 60:288-293. [PMID: 38775344 DOI: 10.1111/jpc.16557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 04/03/2024] [Accepted: 04/21/2024] [Indexed: 07/24/2024]
Abstract
AIM Uptake of nasal high-flow therapy in infants with bronchiolitis has grown in the last decade with some evidence suggesting a reduction in escalation of care. The effect of the implementation of recent available evidence on clinical practice remains unclear. METHODS In a prospective observational study over 6 months in six metropolitan hospitals in Australia, we investigated the clinical practice of high-flow in infants admitted with bronchiolitis and an oxygen requirement. To assess the choice by clinicians of the initial oxygen therapy (standard oxygen or high-flow) the disease severity was measured by physiological parameters obtained prior to oxygen therapy commencement. Additional secondary outcomes were hospital length of stay and transfers to intensive care. RESULTS Two hundred thirty-five infants with bronchiolitis were admitted for oxygen therapy over 6 months during the winter season. Infants who received high-flow on admission to hospital displayed significantly higher respiratory rates, higher heart rates and higher early warning tool scores with more severe work of breathing than those commenced on standard oxygen therapy as a first line of oxygen therapy. A significantly longer hospital length of stay of 0.6 days occurred in infants commenced on high-flow. A significantly greater proportion on high-flow (23.3%) were admitted to intensive care compared to infants commenced on SOT (10.4%) despite the severity of disease in both groups being similar. CONCLUSIONS Infants with bronchiolitis presenting with greater disease severity are more likely to receive high-flow therapy. Escalation of care in an intensive care unit occurred more frequently on infants on high-flow. TRIAL REGISTRATION This trial is registered in the Australian New Zealand Clinical Trial Registry ACTRN12618001206213.
Collapse
Affiliation(s)
- Donna Franklin
- Children's Emergency and Critical Care Collaborative Research Group, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Children's Critical Care, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Victoria, Australia
| | - Letitia Miller
- Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Trang Mt Pham
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Chris Frampton
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Susan Moloney
- Gold Coast University Hospital, Paediatric Department, and School of Medicine Griffith University Queensland, Gold Coast, Queensland, Australia
| | - John Waugh
- Paediatric Department, Ipswich General Hospital, Ipswich, Queensland, Australia
- Paediatric Department, Caboolture Hospital, Caboolture, Queensland, Australia
| | - Samantha Fairless
- Paediatric Department, Ipswich General Hospital, Ipswich, Queensland, Australia
| | - Sue Hobbins
- Paediatric and Emergency Departments, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Simon Grew
- Paediatric Department, Redcliffe Hospital, Redcliffe, Queensland, Australia
| | - Shane George
- Children's Emergency and Critical Care Collaborative Research Group, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Children's Critical Care, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Victoria, Australia
| | - Rose Fahy
- Paediatric and Emergency Departments, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Douglas Morel
- Emergency Department, Redcliffe Hospital, Redcliffe, Queensland, Australia
| | - Andreas Schibler
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Victoria, Australia
- St Andrew's War Memorial Hospital, Brisbane, Queensland, Australia
- Critical Care Research Group, St Andrew's War Memorial Hospital, Brisbane, Queensland, Australia
- Wesley Medical Research, Brisbane, Queensland, Australia
| |
Collapse
|
2
|
Lawrence J, Hiscock H, Bryant PA, Greig G, Sharma A, Walpola R. Potential bed-day savings and caregiver perspectives of transitioning hospital-level management of infants with bronchiolitis to the home: a mixed-methods study. Arch Dis Child 2024:archdischild-2024-327237. [PMID: 38902004 DOI: 10.1136/archdischild-2024-327237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 06/10/2024] [Indexed: 06/22/2024]
Abstract
OBJECTIVE Home management of infants admitted to hospital with bronchiolitis would alleviate pressure on hospital beds. We aim to understand the proportion of children requiring active care interventions (ie, oxygen, fluids), caregiver perspectives and potential impact of transitioning hospital-level care of infants with bronchiolitis to home. METHODS This is a mixed-methods study in an Australian tertiary paediatric hospital. Semistructured interviews with caregivers of infants with bronchiolitis focused on attitudes towards managing bronchiolitis at home. Interviews were analysed using inductive thematic analysis. Data on bronchiolitis admissions among infants aged 1-12 months were extracted from the electronic medical record from April 2016 to October 2020. Potential bed-days saved were calculated. RESULTS 18 parents were interviewed, with themes emerging of 'hospital is safe', 'hospital incurs costs' and 'knowledge is power'. During 4.5 years, 2367 infants were admitted to hospital with bronchiolitis: a total of 4557 bed-days. Of these, 40% of infants were admitted for monitoring alone, 25% for nasogastric fluid support, 17% for oxygen therapy and 7.5% for both fluids and oxygen. 11% received treatments not currently feasible at home (high-flow oxygen, intravenous fluids). Oxygen therapy accounted for the largest number of bed-days (242 bed-days/year). CONCLUSION Managing bronchiolitis at home could have a substantial impact on hospital bed demand, with an estimated 344 bed-days saved per year if all interventions were offered. Parent willingness to transfer to home balances the perceived safety of the hospital versus the financial, logistic and emotional costs. Empowering parents with knowledge was seen as a substantial facilitator of supporting transition to the home.
Collapse
Affiliation(s)
- Joanna Lawrence
- Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Harriet Hiscock
- Community Child Health, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Centre for Community Child Health, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Penelope A Bryant
- General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Genevieve Greig
- Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Anurag Sharma
- University of New South Wales, Sydney, New South Wales, Australia
| | - Ramesh Walpola
- University of New South Wales, Sydney, New South Wales, Australia
| |
Collapse
|
3
|
Walsh R, Costello L, DiCosimo A, Doyle AM, Kehoe L, Mulhall C, O'Hara S, Elnazir B, Meehan J, Isweisi E, Semova G, Branagan A, Roche E, Molloy E. Bronchiolitis: evidence-based management in high-risk infants in the intensive care setting. Pediatr Res 2024:10.1038/s41390-024-03340-y. [PMID: 38902454 DOI: 10.1038/s41390-024-03340-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/13/2024] [Accepted: 05/15/2024] [Indexed: 06/22/2024]
Abstract
AIM Systematically review the management of infants with severe bronchiolitis in a paediatric intensive care unit (PICU) setting with a focus on high-risk infants to identify gaps in evidence-based knowledge. METHODS This systematic review utilised Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) to examine the literature on the PICU management of bronchiolitis in infants <24 months old. Three databases, Embase, PubMed and Medline, were searched and higher levels of evidence I, II and III were included. RESULTS There were 455 papers reviewed and 26 met the inclusion criteria. Furthermore, 19 of these studied respiratory interventions such as positive airway pressure and oxygen delivery. The remaining 7 examined: erythropoietin, caffeine, dexamethasone, protein supplementation, ribavirin, respiratory syncytial virus immune globulin, or diuretic therapy. Of the 26 studies, 20 excluded infants with high-risk conditions. Therapies showing favourable outcomes included Heliox, prophylactic dexamethasone pre-extubation, protein supplementation, and diuretic use. CONCLUSIONS Clinical trials for bronchiolitis management frequently exclude high-risk children. Innovative study design in the future may improve access to clinical trials for the management of bronchiolitis in high-risk infants in a PICU setting. IMPACT Clinical trials for bronchiolitis management frequently exclude high-risk children. We review the evidence base for the management of an under-investigated patient demographic in the setting of acute bronchiolitis. Randomised controlled trials are needed to determine the efficacy of management strategies for bronchiolitis in high-risk infants in a paediatric intensive care setting.
Collapse
Affiliation(s)
- Ruth Walsh
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland.
| | - Liam Costello
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
| | - Alexandria DiCosimo
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
| | - Anne-Marie Doyle
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
| | - Laura Kehoe
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
| | - Cormac Mulhall
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
| | - Sean O'Hara
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
| | - Basil Elnazir
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
- Respiratory Medicine, Children's Health Ireland at Tallaght, Tallaght University Hospital, Dublin, 24, Ireland
| | - Judith Meehan
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
- Trinity Research in Childhood Centre (TRiCC), Trinity College Dublin, Dublin, Ireland
| | - Eman Isweisi
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
- Trinity Research in Childhood Centre (TRiCC), Trinity College Dublin, Dublin, Ireland
| | - Gergana Semova
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
- Trinity Research in Childhood Centre (TRiCC), Trinity College Dublin, Dublin, Ireland
| | - Aoife Branagan
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
- Trinity Research in Childhood Centre (TRiCC), Trinity College Dublin, Dublin, Ireland
- Paediatrics, The Coombe Hospital, Dublin, 8, Ireland
| | - Edna Roche
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
- Trinity Research in Childhood Centre (TRiCC), Trinity College Dublin, Dublin, Ireland
- Endocrinology, Children's Health Ireland at Tallaght, Tallaght University Hospital, Dublin, 24, Ireland
| | - Eleanor Molloy
- Discipline of Paediatrics, School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, 2, Ireland
- Trinity Research in Childhood Centre (TRiCC), Trinity College Dublin, Dublin, Ireland
- Paediatrics, The Coombe Hospital, Dublin, 8, Ireland
- Neurodisability Children's Health Ireland at Tallaght, Tallaght University Hospital, Dublin, 24, Ireland
- Neonatology, Children's Health Ireland at Crumlin, Dublin, 12, Ireland
| |
Collapse
|
4
|
Ford T, Lane J, Noelck M, Byrd C. Addressing high flow overuse in bronchiolitis - Successes and future directions. Paediatr Respir Rev 2024:S1526-0542(24)00051-4. [PMID: 38937209 DOI: 10.1016/j.prrv.2024.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 06/03/2024] [Indexed: 06/29/2024]
Abstract
The use of high flow nasal cannula (HFNC) in the treatment of bronchiolitis has markedly increased in the last decade, yet randomized controlled trials have reported little clinical benefit with early, routine use. This article provides a concise overview of the current status of HFNC therapy, discusses successful de-implementation strategies to curtail HFNC overuse, and explores future bronchiolitis and HFNC quality improvement and research considerations.
Collapse
Affiliation(s)
- Taylor Ford
- Emory University School of Medicine, Pediatric Hospital Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, 1405 Clifton Road, Atlanta, GA 30322, United States
| | - Jennifer Lane
- Oregon Health and Science University, Pediatric Hospital Medicine, Department of Pediatrics, Oregon Health & Science University, 707 SW Gaines Street, mail code CDRCP, Portland, OR 97239, United States
| | - Michelle Noelck
- Oregon Health and Science University, Pediatric Hospital Medicine, Department of Pediatrics, Oregon Health & Science University, 707 SW Gaines Street, mail code CDRCP, Portland, OR 97239, United States
| | - Courtney Byrd
- Emory University School of Medicine, Pediatric Hospital Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, 1405 Clifton Road, Atlanta, GA 30322, United States.
| |
Collapse
|
5
|
Fitzgerald DA. Go slow with high flow initiation in bronchiolitis. Paediatr Respir Rev 2024:S1526-0542(24)00049-6. [PMID: 38876819 DOI: 10.1016/j.prrv.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 05/31/2024] [Indexed: 06/16/2024]
Affiliation(s)
- Dominic A Fitzgerald
- The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, NSW, Australia.
| |
Collapse
|
6
|
Robertson T, Borland ML, O'Brien S, Haskell L, Babl FE, Dalziel SR, Tavender E. Understanding the uptake and adaption of targeted implementation interventions for reducing bronchiolitis investigations and therapies. Acta Paediatr 2024; 113:802-811. [PMID: 38189212 DOI: 10.1111/apa.17090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/10/2023] [Accepted: 12/22/2023] [Indexed: 01/09/2024]
Abstract
AIM To understand and evaluate the uptake and local adaptations of proven targeted implementation interventions that have effectively reduced unnecessary investigations and therapies in infants with bronchiolitis within emergency departments. METHODS A multi-centred, mixed-methods quality improvement study in four Australian hospitals that provide paediatric emergency and inpatient care from May to December 2021. All hospitals were provided with the same implementation intervention package and training. Real-time tracking logs of adaptions were completed followed by semi-structured interviews. Interviews were recorded, transcribed and subsequently coded using FRAME-IS to further describe the adaptions made. RESULTS Tracking logs were summarised and data from 12 interviews were compared from participating sites. The intervention resulted in 116 education sessions and a total of 23 adaptations made to educational materials, both content and contextual. Shortening education presentations, addition of bronchiolitis definitions, formatting of materials and novel interventions were the most common modifications. Audit and feedback were completed across all sites with varying utilisation. Targeted teaching was noted to dictate adaptions prior to and during implementation. CONCLUSION Quantitative and qualitative analysis of clinical 'real-world' adaptations to proven targeted implementation interventions allows invaluable insight for future de-implementation initiatives and national roll-out of implementation packages in the ED setting.
Collapse
Affiliation(s)
- Tim Robertson
- Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Meredith L Borland
- Perth Children's Hospital, Nedlands, Western Australia, Australia
- School of Medicine, Divisions of Emergency Medicine and Paediatrics, University of Western Australia, Perth, Western Australia, Australia
| | - Sharon O'Brien
- Perth Children's Hospital, Nedlands, Western Australia, Australia
- School of Nursing, Faculty of Health Sciences, Curtin University, Bentley, Western Australia, Australia
| | - Libby Haskell
- Starship Children's Hospital, Auckland, New Zealand
- Departments Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Franz E Babl
- Royal Children's Hospital, Parkville, Victoria, Australia
- Departments of Paediatrics and Critical Care, Murdoch Children's Research Institute, University of Melbourne, Parkville, Victoria, Australia
| | - Stuart R Dalziel
- Starship Children's Hospital, Auckland, New Zealand
- Cure Kids Chair of Child Health Research, Departments of Surgery and Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Emma Tavender
- Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Departments of Paediatrics and Critical Care, The University of Melbourne, Parkville, Victoria, Australia
| |
Collapse
|
7
|
Lawrence J, Hiscock H, Voskoboynik A, Walpola R, Sharma A. Reducing unwarranted chest x-rays in bronchiolitis: Importance of a robust analysis. J Paediatr Child Health 2024; 60:100-106. [PMID: 38597355 DOI: 10.1111/jpc.16539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 10/25/2023] [Accepted: 03/18/2024] [Indexed: 04/11/2024]
Abstract
AIM Bronchiolitis is the commonest reason for hospitalisation amongst infants and is often a target for low-value care (LVC) reduction. We aimed to assess the impact of a multifaceted intervention (clinician education, parent engagement, audit-feedback) on rates of chest x-rays (CXR) in bronchiolitis. METHODS Longitudinal study of CXRs ordered in infants (1-12 months) diagnosed with bronchiolitis in the Emergency Department (ED) of an Australian paediatric hospital between May 2016 and February 2023. We used logistic regression to measure the impact of the intervention on unwarranted CXR orders, controlling for other potential impacting variables such as time, patient characteristics (age/sex), clinical variables (fever, hypoxia, tachypnoea), seasonal factors (month, day of the week, business hours) and time passed since intervention. RESULTS Ten thousand one hundred and nine infants were diagnosed with bronchiolitis in the ED over the study period, with 939 (9.3%) receiving a CXR, of which 69% (n = 651) were considered unwarranted. Rates of unwarranted CXRs reduced from 7.9% to 5.4% post-intervention (P < 0.0001). Logistic regression showed the intervention had no significant effect (OR 0.89, 95% CI 0.65-1.23) once other variables and underlying time-based trends were accounted for. CONCLUSIONS Although pre-post rates appeared significantly improved, a robust analysis demonstrated that our multi-faceted intervention was not effective in reducing CXRs in bronchiolitis. The decision to order CXR was associated with clinical features that overlap with pneumonia suggesting ongoing misconceptions regarding the role of CXR for this indication. Our study highlights the value of large electronic medical record datasets and robust methodology to avoid falsely attributing underlying trends to the LVC intervention.
Collapse
Affiliation(s)
- Joanna Lawrence
- Hospital in the Home, Royal Children's Hospital, Melbourne, Victoria, Australia
- Health Services Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- School of Population Health, Faculty of Medicine UNSW, Sydney, New South Wales, Australia
| | - Harriet Hiscock
- Health Services Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Alice Voskoboynik
- Centre for Health Analytics, Melbourne Children's Campus, Melbourne, Victoria, Australia
| | - Ramesh Walpola
- School of Population Health, Faculty of Medicine UNSW, Sydney, New South Wales, Australia
| | - Anurag Sharma
- School of Population Health, Faculty of Medicine UNSW, Sydney, New South Wales, Australia
| |
Collapse
|
8
|
Hak SF, Venekamp RP, Wildenbeest JG, Bont LJ. Outpatient respiratory syncytial virus infections and novel preventive interventions. Curr Opin Pediatr 2024; 36:171-181. [PMID: 38085019 PMCID: PMC10919273 DOI: 10.1097/mop.0000000000001323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
PURPOSE OF REVIEW With interventions to prevent respiratory syncytial virus (RSV) infection within reach, this review aims to provide healthcare professionals with the latest information necessary to inform parents and assess the potential impact of RSV prevention on everyday practice. We address frequently asked questions for parental counseling. RECENT FINDINGS Numerous studies emphasize the major burden of RSV on young children, parents, healthcare and society. In the first year of life, about 14% of healthy term infants visit a doctor and 2% require hospitalization due to RSV. In older children (1--5 years), RSV infections and associated morbidity (wheeze, acute otitis media) are major drivers of outpatient visits. A novel maternal RSV vaccine and long-acting mAb can provide protection during infants' first months of life. This maternal vaccine showed 70.9% efficacy against severe RSV infection within 150 days after birth; the mAb nirsevimab reduces medically attended RSV infections by 79.5% within 150 days after administration. Both gained regulatory approval in the USA (FDA) and Europe (EMA). SUMMARY Novel RSV immunizations hold promise to reduce the RSV burden in infants, with substantial impact on everyday practice. Tailored parental guidance will be instrumental for successful implementation. Awaiting pediatric vaccines, RSV infections beyond infancy will still pose a significant outpatient burden.
Collapse
Affiliation(s)
- Sarah F. Hak
- Department of Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital/University Medical Center Utrecht
| | - Roderick P. Venekamp
- Department of General Practice & Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht
| | - Joanne G. Wildenbeest
- Department of Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital/University Medical Center Utrecht
| | - Louis J. Bont
- Department of Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital/University Medical Center Utrecht
- Respiratory Syncytial Virus NETwork (ReSViNET) Foundation, Zeist, The Netherlands
| |
Collapse
|
9
|
Ramanathan A, Lee W, Peplinski J, Mace AO, Foley DA. Head-to-Head Comparison Between Respiratory Syncytial Virus and Human Metapneumovirus Bronchiolitis in the Setting of Increased Viral Testing. Pediatr Infect Dis J 2024; 43:e139-e141. [PMID: 38100724 DOI: 10.1097/inf.0000000000004217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
We compared the epidemiology, severity and management of hospitalized respiratory syncytial virus (n = 305) and human metapneumovirus (n = 39) bronchiolitis in a setting with high respiratory virus testing (95% of admissions tested). Respiratory syncytial virus-positive infants were younger and tended to require more hydration support and longer hospital stays compared to human metapneumovirus-positive infants. Respiratory support requirements were similar between groups despite significant age differences.
Collapse
Affiliation(s)
- Ashwin Ramanathan
- From the Department of General Paediatrics, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Weihao Lee
- From the Department of General Paediatrics, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Joseph Peplinski
- From the Department of General Paediatrics, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Ariel O Mace
- From the Department of General Paediatrics, Perth Children's Hospital, Nedlands, Western Australia, Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
| | - David A Foley
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, The University of Western Australia, Perth, Western Australia, Australia
- Department of Clinical Microbiology, PathWest Laboratory Medicine, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| |
Collapse
|
10
|
Ambrożej D, Orzołek I, Makrinioti H, Castro-Rodriguez JA, Camargo CA, Hasegawa K, Papadopoulos NG, Gern JE, Nino G, Vicente Ribeiro Ferreira da Silva Filho L, Takeyama A, Üzüm Ö, Adamiec A, Ruszczyński M, Jartti T, Feleszko W. Association of respiratory virus types with clinical features in bronchiolitis: Implications for virus testing strategies. A systematic review and meta-analysis. Paediatr Respir Rev 2024; 49:34-42. [PMID: 37743159 DOI: 10.1016/j.prrv.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/04/2023] [Accepted: 09/11/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Bronchiolitis is a leading cause of infant hospitalization, linked to respiratory syncytial virus (RSV) and rhinovirus (RV). Guidelines lack specific viral testing for bronchiolitis management. To establish effective management strategies, it is crucial to assess whether specific respiratory virus types are correlated with distinct examination features. METHODS Through a systematic search of three databases, 21 studies were qualitatively analyzed, with 18 used for meta-analysis. Various outcomes like wheezing on auscultation, fever, atopic traits, and infection severity were evaluated. RESULTS RSV-positive bronchiolitis was associated with a higher need for oxygen supplementation (OR 1.78, 95% CI 1.04-3.02) in 5 studies, while RV-positive bronchiolitis was more frequently linked to personal history of eczema (OR 0.60, 95% CI 0.41-0.88) in 6 studies. No significant differences were observed in the other outcomes examined. CONCLUSIONS Bronchiolitis caused by RSV or RV presents with similar clinical features. Despite the associations between RSV-positive bronchiolitis and need for oxygen supplementation, and RV-positive bronchiolitis and a history of eczema, our study shows that viral etiology of bronchiolitis cannot be determined solely based on clinical presentation. Tailored management strategies, informed by accurate viral testing, seem crucial in clinical practice for enhancing patient outcomes in severe bronchiolitis.
Collapse
Affiliation(s)
- Dominika Ambrożej
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Warsaw, Poland; Doctoral School, Medical University of Warsaw, Warsaw, Poland
| | - Izabela Orzołek
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Heidi Makrinioti
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jose A Castro-Rodriguez
- Department of Pediatric Pulmonology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Medicine, Channing Division of Network Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nikolaos G Papadopoulos
- Allergy and Clinical Immunology Unit, 2nd Paediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece; Division of Evolution and Genomic Sciences, University of Manchester, Manchester, United Kingdom
| | - James E Gern
- Department of Paediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Wisconsin, WI, USA
| | - Gustavo Nino
- Division of Pediatric Pulmonary and Sleep Medicine, Children's National Hospital, Washington, District of Columbia, USA; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | | | - Aya Takeyama
- Department of Pediatrics, Soma General Hospital, Fukushima, Japan
| | - Özlem Üzüm
- Department of Pediatric Diseases, Tepecik Training and Research Hospital, University of Health Sciences, Izmir, Turkey
| | - Aleksander Adamiec
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Warsaw, Poland; Doctoral School, Medical University of Warsaw, Warsaw, Poland
| | - Marek Ruszczyński
- Department of Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Tuomas Jartti
- Department of Pediatrics, Turku University Hospital and University of Turku, Turku, Finland; Department of Pediatrics, University of Oulu, Oulu, Finland
| | - Wojciech Feleszko
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Warsaw, Poland.
| |
Collapse
|
11
|
Yang S, Lu S, Wang Y, Guo Y, Zhang Z, Wang W, Wang L. Respiratory syncytial virus subtypes in children with bronchiolitis: does it correlate with clinical severity? BMC Infect Dis 2024; 24:263. [PMID: 38408969 PMCID: PMC10898063 DOI: 10.1186/s12879-024-09129-y] [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: 11/14/2023] [Accepted: 02/12/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND In this retrospective study, we aimed to evaluate the factors associated with the severity of respiratory syncytial virus (RSV) bronchiolitis in children aged under 2 years who were admitted to the Children's Hospital of Hebei between June 2018 and January 2019. METHODS Sputum samples positive for RSV via multiplex PCR were subtyped using real-time PCR. Data collected included risk factors for disease severity, demographics, microbiology, and outcomes. RESULTS Of the 82 children with RSV bronchiolitis, 79 were treated and discharged with improvement, while 3 died. All three patients had underlying medical conditions, including complex congenital heart disease and severe combined immunodeficiency. Further, disease severity was associated with preexisting underlying disease, fever duration, and bacterial co-infection, but not with the RSV subtype. CONCLUSIONS Our findings suggest that an appropriate therapeutic regimen should include the detection of bacterial co-infections and the identification of underlying diseases for the effective management of severe RSV bronchiolitis.
Collapse
Affiliation(s)
- Shuo Yang
- Institute of Pediatric Research, Children's Hospital of Hebei, 133 Jianhua South Street, 050031, Shijiazhuang, Hebei Province, China
| | - Sukun Lu
- Institute of Pediatric Research, Children's Hospital of Hebei, 133 Jianhua South Street, 050031, Shijiazhuang, Hebei Province, China
| | - Yakun Wang
- Institute of Pediatric Research, Children's Hospital of Hebei, 133 Jianhua South Street, 050031, Shijiazhuang, Hebei Province, China
| | - Yinghui Guo
- Institute of Pediatric Research, Children's Hospital of Hebei, 133 Jianhua South Street, 050031, Shijiazhuang, Hebei Province, China
| | - Zhuang Zhang
- Ningbo HEALTH Gene Technologies Co., Ltd, 315000, Ningbo, China
| | - Weijian Wang
- Ningbo HEALTH Gene Technologies Co., Ltd, 315000, Ningbo, China
| | - Le Wang
- Institute of Pediatric Research, Children's Hospital of Hebei, 133 Jianhua South Street, 050031, Shijiazhuang, Hebei Province, China.
| |
Collapse
|
12
|
Lawrence J, South M, Hiscock H, Capurro D, Sharma A, Ride J. Retrospective analysis of the impact of electronic medical record alerts on low value care in a pediatric hospital. J Am Med Inform Assoc 2024; 31:600-610. [PMID: 38078841 PMCID: PMC10873857 DOI: 10.1093/jamia/ocad239] [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: 08/08/2023] [Revised: 11/08/2023] [Accepted: 12/05/2023] [Indexed: 02/18/2024] Open
Abstract
OBJECTIVES Hospital costs continue to rise unsustainably. Up to 20% of care is wasteful including low value care (LVC). This study aimed to understand whether electronic medical record (EMR) alerts are effective at reducing pediatric LVC and measure the impact on hospital costs. MATERIALS AND METHODS Using EMR data over a 76-month period, we evaluated changes in 4 LVC practices following the implementation of EMR alerts, using time series analysis to control for underlying time-based trends, in a large pediatric hospital in Australia. The main outcome measure was the change in rate of each LVC practice. Balancing measures included the rate of alert adherence as a proxy measure for risk of alert fatigue. Hospital costs were calculated by the volume of LVC avoided multiplied by the unit costs. Costs of the intervention were calculated from clinician and analyst time required. RESULTS All 4 LVC practices showed a statistically significant reduction following alert implementation. Two LVC practices (blood tests) showed an abrupt change, associated with high rates of alert adherence. The other 2 LVC practices (bronchodilator use in bronchiolitis and electrocardiogram ordering for sleeping bradycardia) showed an accelerated rate of improvement compared to baseline trends with lower rates of alert adherence. Hospital savings were $325 to $180 000 per alert. DISCUSSION AND CONCLUSION EMR alerts are effective in reducing pediatric LVC practices and offer a cost-saving opportunity to the hospital. Further efforts to leverage EMR alerts in pediatric settings to reduce LVC are likely to support future sustainable healthcare delivery.
Collapse
Affiliation(s)
- Joanna Lawrence
- Electronic Medical Record Team, Royal Children’s Hospital, Melbourne 3052, Australia
- Health Services Group, Murdoch Children’s Research Institute, Melbourne 3052, Australia
- Department of Paediatrics, University of Melbourne, Melbourne 3052, Australia
- School of Population Health, Faculty of Medicine UNSW, Sydney 2052, Australia
- Centre for Digital Transformation of Health, University of Melbourne, Melbourne 3052, Australia
- Centre for Health Analytics, Melbourne Children’s Campus, Melbourne 3052, Australia
| | - Mike South
- Electronic Medical Record Team, Royal Children’s Hospital, Melbourne 3052, Australia
- Health Services Group, Murdoch Children’s Research Institute, Melbourne 3052, Australia
- Department of Paediatrics, University of Melbourne, Melbourne 3052, Australia
- Centre for Health Analytics, Melbourne Children’s Campus, Melbourne 3052, Australia
| | - Harriet Hiscock
- Health Services Group, Murdoch Children’s Research Institute, Melbourne 3052, Australia
- Department of Paediatrics, University of Melbourne, Melbourne 3052, Australia
| | - Daniel Capurro
- Centre for Digital Transformation of Health, University of Melbourne, Melbourne 3052, Australia
| | - Anurag Sharma
- School of Population Health, Faculty of Medicine UNSW, Sydney 2052, Australia
| | - Jemimah Ride
- Health Economics Group, School of Public Health and Preventive Medicine, Monash University, Melbourne 3800, Australia
| |
Collapse
|
13
|
Biondo GF, Lorentz BT, Flores JAM, Santana JCB, Amantéa SL. Measurement of the interbronchial angle in acute viral bronchiolitis. Pediatr Pulmonol 2024; 59:442-448. [PMID: 38010812 DOI: 10.1002/ppul.26771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 11/09/2023] [Accepted: 11/14/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Acute viral bronchiolitis (AVB) is the most common lower airway infection in children under 2 years. Attempts to determine disease severity based on clinical and radiological manifestations are a major challenge. Measurements of the anatomy of the trachea and main bronchi are not only limited to pure anthropometry, but are also useful for better care of critically ill patients. The purpose of the study is to verify the association between measurements of the interbronchial angle (ITB) and the severity of respiratory disease. METHODS A cross-sectional study, which included all patients admitted to the Santo Antônio Children's Hospital, over a period of 1 year, with diagnosis of AVB by respiratory syncytial virus (RSV) was designed. ITB angle was measured and clinical characteristics were analyzed. Quantitative variables were compared and correlation analysis was performed using Pearson's correlation coefficient. A receiving operator characteristic (ROC) curve was performed. P-value <0.05 was statistically significant. RESULTS A total of 425 patients with AVB due to RSV were included. Most of these patients were male and the median age was 130 days, 91.11% of them required oxygen therapy through a nasal catheter, 3.3% used noninvasive ventilation and 4% used mechanical ventilation. Those who required MV or NIV and intensive care unit support were considered severe. The mean ITB was lower for these patients than for those of lesser severity (p < 0.05). CONCLUSION The present study demonstrates that there is an association between ITB and AVB severity. The smaller the ITB, the greater the disease severity.
Collapse
Affiliation(s)
- Gabriela F Biondo
- Departament of Pediatrics, Pediatric Postgraduate Programme, Federal University of Health Science of Porto Alegre (UFCSPA), Porto Alegre, Brazil
- Pediatric Intensive Care and Emergency Medicine Department, Pediatric Emergency Division, Hospital Clinicas (HCPA), Porto Alegre, Brazil
| | - Bruna T Lorentz
- Departament of Pediatrics, Pediatric Postgraduate Programme, Federal University of Health Science of Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - José Antônio Monteiro Flores
- Department of Pediatrics, Pediatric Emergency Division, Santo Antônio Children's Hospital, Porto Alegre, Brazil
- Department of Pediatrics, Faculty of Medicine, Federal University of Health Science of Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | - João Carlos Batista Santana
- Pediatric Intensive Care and Emergency Medicine Department, Pediatric Emergency Division, Hospital Clinicas (HCPA), Porto Alegre, Brazil
| | - Sérgio L Amantéa
- Departament of Pediatrics, Pediatric Postgraduate Programme, Federal University of Health Science of Porto Alegre (UFCSPA), Porto Alegre, Brazil
- Department of Pediatrics, Pediatric Emergency Division, Santo Antônio Children's Hospital, Porto Alegre, Brazil
- Department of Pediatrics, Faculty of Medicine, Federal University of Health Science of Porto Alegre (UFCSPA), Porto Alegre, Brazil
| |
Collapse
|
14
|
Walsh PS, Wendt WJ, Lipshaw MJ. Asthmalitis? Diagnostic Variability of Asthma and Bronchiolitis in Children <24 Months. Hosp Pediatr 2024; 14:59-66. [PMID: 38146264 DOI: 10.1542/hpeds.2023-007359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Bronchiolitis and asthma have similar acute clinical presentations in young children yet have opposing treatment recommendations. We aimed to assess the role of age and other factors in the diagnosis of bronchiolitis and asthma in children <24 months of age. METHODS We conducted a retrospective cross-sectional analysis of the Pediatric Health Information System database. We included children aged <2 years diagnosed with bronchiolitis, asthma, wheeze, or bronchospasm in emergency department or hospital encounters from 2017 to 2021. We described variation by age and between institutions. We used mixed-effects models to assess factors associated with a non-bronchiolitis diagnosis in children 12 to 23 months of age. RESULTS We included 554 158 encounters from 42 hospitals. Bronchiolitis made up 98% of encounters for children <3 months of age, whereas asthma diagnoses increased with age and were included in 44% of encounters at 23 months of age. Diagnosis patterns varied widely between hospitals. In children 12 to 23 months of age, the odds of a non-bronchiolitis diagnosis increased with month of age (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.12-1.13), male sex (OR 1.37, 95% CI 1.35-1.40), non-Hispanic Black race (OR 1.54, 95% CI 1.50-1.58), number of previous encounters (OR 2.73, 95% CI 2.61-2.86, for 3 or more encounters), and previous albuterol use (OR 2.24, 95% CI 2.16-2.32). CONCLUSIONS Non-bronchiolitis diagnoses and the use of inhaled bronchodilators and systemic steroids for acute wheezing respiratory illness increase with month of age in children aged 0 to 23 months. Better definitions of clinical phenotypes of bronchiolitis and asthma would allow for more appropriate treatment in acute care settings, particularly in children 12 to 23 months of age.
Collapse
Affiliation(s)
- Patrick S Walsh
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Wendi-Jo Wendt
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Matthew J Lipshaw
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
15
|
Yama B, Wahi G, Zhou K, Bayliss A, Sakran M, Breen-Reid K, Pound C, Beck C, Friedman J, Arafeh D, Kanani R, Parkin P, Mahant S. De-implementing low-value continuous pulse oximetry practice in infants hospitalized with bronchiolitis: A multicentre qualitative study. J Hosp Med 2023; 18:1092-1101. [PMID: 37932871 DOI: 10.1002/jhm.13236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/07/2023] [Accepted: 10/19/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Clinical trial evidence supports the routine use of intermittent pulse oximetry in stabilized infants hospitalized with bronchiolitis. However, continuous pulse oximetry use is common. OBJECTIVE This study aimed to understand the barriers and facilitators to de-implement continuous pulse oximetry and implement intermittent pulse oximetry in infants hospitalized with stabilized bronchiolitis. METHODS This multicentre qualitative study interviewed attending pediatricians, residents, nurses, respiratory therapists, and caregivers of infants hospitalized with bronchiolitis at hospitals in Ontario, Canada, to explore beliefs, attitudes, and experiences regarding pulse oximetry use in bronchiolitis management. Data were analyzed using thematic analysis to understand barriers and facilitators to practice change, mapped to the Consolidated Framework for Implementation Research (CFIR) domains. RESULTS Sixty-seven participants from six hospitals were interviewed using individual interviews and focus groups. Healthcare providers emphasized the importance of identifying and understanding who is responsible for bedside pulse oximetry practice (physicians vs. nurses). Clinical experience, knowledge of guidelines, importance versus competing priorities, and the tensions among team members due to practice variation in monitoring, influenced monitoring practice. Nurses believed in the advantages of intermittent monitoring (reduced alarm fatigue, facilitation of timely discharges, and reduced workload). Clinicians identified ways to clarify indications for continuous monitoring (based on patient risk factors), versus indications to transition to intermittent monitoring (established oral feeding, sleeping without desaturations). Caregivers did not express a clear preference for monitoring type; rather, they described the need for clear communication around interpreting monitor readings, management decisions, and care transitions. CONCLUSIONS Understanding professional roles, clarity around local practice standards and supporting families' understanding of pulse oximetry practice is essential for practice change. These findings may inform hospital quality improvement efforts to de-implement continuous monitoring in bronchiolitis hospital care.
Collapse
Affiliation(s)
- Brie Yama
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gita Wahi
- Department of Pediatrics, Division of General Pediatrics, McMaster University and McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Kim Zhou
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, North York General Hospital, Toronto, Ontario, Canada
| | - Ann Bayliss
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Children's Health Division, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Mahmoud Sakran
- Department of Pediatrics, Lakeridge Health, Oshawa, and Queen's University, Kingston, Ontario, Canada
| | - Karen Breen-Reid
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Catherine Pound
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Carolyn Beck
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jeremy Friedman
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Dana Arafeh
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ronik Kanani
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, North York General Hospital, Toronto, Ontario, Canada
| | - Patricia Parkin
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Sanjay Mahant
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
16
|
Szupieńko S, Buczek A, Szymański H. Nebulised 3% hypertonic saline versus 0.9% saline for treating patients hospitalised with acute bronchiolitis: protocol for a randomised, double-blind, multicentre trial. BMJ Open 2023; 13:e080182. [PMID: 38011984 PMCID: PMC10685959 DOI: 10.1136/bmjopen-2023-080182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/10/2023] [Indexed: 11/29/2023] Open
Abstract
INTRODUCTION Bronchiolitis is an acute viral infection of the lower respiratory tract. It is most commonly caused by respiratory syncytial virus. Being a common reason for hospitalisation, it affects 13-17% of all hospitalised children younger than 2 years. Only supportive therapy, including suctioning nasal secretions, water-electrolyte balance maintenance and oxygen supplementation when needed, is recommended. However, non-evidence-based diagnostic and therapeutic approaches, including the use of inhaled bronchodilators, nebulised epinephrine, and nebulised and systemic steroids, are common. The inhalation of 3% hypertonic saline is not recommended in bronchiolitis management. However, a recently published meta-analysis revealed that the inhalation of hypertonic saline can reduce the risk of hospitalisation for outpatients with bronchiolitis, while resulting in a shorter length of hospital stay and reduced severity of respiratory distress for inpatients, although the evidence is of low certainty. We aim to assess the efficacy of nebulised hypertonic saline for the treatment of children hospitalised with bronchiolitis. METHODS AND ANALYSIS This will be a randomised, double-blinded, parallel-group, controlled trial. Children younger than 2 years who are hospitalised due to bronchiolitis will be recruited from at least three paediatric departments in Poland. Bronchiolitis is defined as an apparent viral respiratory tract infection associated with airway obstruction that is manifested by at least one of following symptoms: tachypnoea, increased respiratory effort, crackles and/or wheezing. A total of 140 children will be randomised (1:1) to receive either hypertonic saline nebulisation (5 mL, three times a day) or normal saline at the same dose. The primary outcome measure will be the duration of hospitalisation. ETHICS AND DISSEMINATION The Bioethics Committee of the Lower Silesia Medical Chamber in Wroclaw approved the study protocol (4/PNDR/2023). Caregivers will receive oral and written information about the study and written informed consent will be obtained by the study physicians. The findings of the study will be submitted to a peer-reviewed journal, and abstracts will be submitted to relevant national and international conferences. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT06069336).
Collapse
Affiliation(s)
- Sara Szupieńko
- Department of Paediatrics, St Hedwig of Silesia Hospital, Trzebnica, Poland
| | - Aleksandra Buczek
- Department of Paediatrics, St Hedwig of Silesia Hospital, Trzebnica, Poland
| | - Henryk Szymański
- Department of Paediatrics, St Hedwig of Silesia Hospital, Trzebnica, Poland
| |
Collapse
|
17
|
Hernández-Villarroel AC, Ruiz-García A, Manzanaro C, Echevarría-Zubero R, Bote-Gascón P, Gonzalez-Bertolin I, Sainz T, Calvo C, Bueno-Campaña M. Lung Ultrasound: A Useful Prognostic Tool in the Management of Bronchiolitis in the Emergency Department. J Pers Med 2023; 13:1624. [PMID: 38138851 PMCID: PMC10745017 DOI: 10.3390/jpm13121624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 11/01/2023] [Accepted: 11/13/2023] [Indexed: 12/24/2023] Open
Abstract
Lung ultrasound, a non-invasive bedside technique for assessing paediatric patients with acute respiratory diseases, is becoming increasingly widespread. The aim of this prospective, observational cohort study was to evaluate the effectiveness of a clinical ultrasound score in assessing infants with acute bronchiolitis in the emergency department and its ability to accurately identify patients at a higher risk of clinical deterioration. Infants under 6 months of age with clinical symptoms compatible with acute bronchiolitis were enrolled and underwent clinical and lung ultrasound evaluations. The study included 50 patients, the median age of which was 2.2 months (IQR: 1-5), and the primary outcome was respiratory support. Infants requiring invasive or non-invasive ventilation showed higher scores (5 points [IQR: 3.5-5.5] vs. 2.5 [IQR: 1.5-4]). The outcome had an AUC of 0.85 (95%CI: 0.7-0.98), with a sensitivity of 87%, specificity of 64%, and negative predictive value of 96.4% for a score <3.5 points. Children who scored ≥3.5 points were more likely to require respiratory support within the next 24 h (estimated event-free survival of 82.9% compared to 100%, log-rank test p-value = 0.02). The results suggest that integrating lung ultrasound findings into clinical scores when evaluating infants with acute bronchiolitis could be a promising tool for improving prognosis.
Collapse
Affiliation(s)
- Aiza C. Hernández-Villarroel
- Department of Paediatrics and Neonatology, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain; (A.C.H.-V.); (A.R.-G.); (C.M.)
| | - Alicia Ruiz-García
- Department of Paediatrics and Neonatology, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain; (A.C.H.-V.); (A.R.-G.); (C.M.)
| | - Carlos Manzanaro
- Department of Paediatrics and Neonatology, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain; (A.C.H.-V.); (A.R.-G.); (C.M.)
| | - Regina Echevarría-Zubero
- Department of Paediatrics and Neonatology, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain; (A.C.H.-V.); (A.R.-G.); (C.M.)
| | - Patricia Bote-Gascón
- Paediatric Emergency Department, Hospital Universitario La Paz, 28046 Madrid, Spain; (P.B.-G.); (I.G.-B.)
| | - Isabel Gonzalez-Bertolin
- Paediatric Emergency Department, Hospital Universitario La Paz, 28046 Madrid, Spain; (P.B.-G.); (I.G.-B.)
| | - Talía Sainz
- Department of Paediatrics, Tropical and Infectious Diseases, Hospital Universitario La Paz, 28046 Madrid, Spain; (T.S.); (C.C.)
- IdiPAZ Research Institute, Translational Research Network for Paediatric Infectious Diseases (RITIP), 28029 Madrid, Spain
- Centre for Biomedical Research in Infectious Diseases (CIBERINFEC), 28029 Madrid, Spain
- Department of Paediatrics, Autonomous University of Madrid, 28029 Madrid, Spain
| | - Cristina Calvo
- Department of Paediatrics, Tropical and Infectious Diseases, Hospital Universitario La Paz, 28046 Madrid, Spain; (T.S.); (C.C.)
- IdiPAZ Research Institute, Translational Research Network for Paediatric Infectious Diseases (RITIP), 28029 Madrid, Spain
- Centre for Biomedical Research in Infectious Diseases (CIBERINFEC), 28029 Madrid, Spain
- Department of Paediatrics, Autonomous University of Madrid, 28029 Madrid, Spain
| | - Mercedes Bueno-Campaña
- Department of Paediatrics and Neonatology, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain; (A.C.H.-V.); (A.R.-G.); (C.M.)
- IdiPAZ Research Institute, Translational Research Network for Paediatric Infectious Diseases (RITIP), 28029 Madrid, Spain
- Centre for Biomedical Research in Infectious Diseases (CIBERINFEC), 28029 Madrid, Spain
| |
Collapse
|
18
|
Lawrence J, Hiscock H, South M. Bronchiolitis - The Simple Things in Life…. Hosp Pediatr 2023; 13:e314-e318. [PMID: 37706241 DOI: 10.1542/hpeds.2023-007237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Affiliation(s)
- Joanna Lawrence
- Electronic Medical Record Team, Royal Children's Hospital, Melbourne, Australia
- Health Services Research Unit, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- School of Population Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Harriet Hiscock
- Health Services Research Unit, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Mike South
- Electronic Medical Record Team, Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| |
Collapse
|
19
|
Porcaro F, Cutrera R, Vittucci AC, Villani A. Bronchiolitis guidelines: what about the Italian situation in a primary care setting? Ital J Pediatr 2023; 49:123. [PMID: 37726761 PMCID: PMC10510229 DOI: 10.1186/s13052-023-01527-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/08/2023] [Indexed: 09/21/2023] Open
Abstract
Acute viral bronchiolitis is the most common cause of hospitalization in children under 12 months of age. The variable clinical presentation and the potential for sudden deterioration of the clinical conditions require a close monitoring by healthcare professionals.In Italy, first access care for children is provided by primary care physicians (PCPs) who often must face to a heterogeneous disease presentation that, in some cases, make the management of patient with bronchiolitis challenging. Consequently, Italian studies report poor adherence to national and international guidelines processed to guide the clinicians in decision making in acute viral bronchiolitis.This paper aims to identify the potential factors contributing to the lack of adherence to the suggested guidelines derived by clear and evidence-based recommendations among primary care physicians operating in an outpatient setting, with a specific focus on the context of Italy. Particularly, we focus on the prescription of medications such as β2-agonists, systemic steroids, and antibiotics which are commonly prescribed by PCPs to address conditions that can mimic bronchiolitis.
Collapse
Affiliation(s)
- Federica Porcaro
- Pediatric Pulmonology and Cystic Fibrosis Unit, Bambino Gesù Children's Hospital, IRCCS, piazza di Sant'Onofrio 4, Rome, 00165, Italy.
| | - Renato Cutrera
- Pediatric Pulmonology and Cystic Fibrosis Unit, Bambino Gesù Children's Hospital, IRCCS, piazza di Sant'Onofrio 4, Rome, 00165, Italy
| | - Anna Chiara Vittucci
- Pediatric Unit, Pediatric Emergency Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alberto Villani
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| |
Collapse
|
20
|
Montejo M, Paniagua N, Pijoan JI, Saiz-Hernando C, Sanchez A, Rueda-Etxebarria M, Benito J. Factors associated with salbutamol overuse in bronchiolitis. Eur J Pediatr 2023; 182:4237-4245. [PMID: 37452844 DOI: 10.1007/s00431-023-05111-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/08/2023] [Accepted: 07/08/2023] [Indexed: 07/18/2023]
Abstract
Numerous studies have shown that quality improvement methods can reduce the use of medications in the management of bronchiolitis. Our objective is to identify factors related to the overuse of salbutamol in the treatment of bronchiolitis before and after an improvement initiative. Observational study of sociodemographic and clinical factors associated with the use of salbutamol in children diagnosed with bronchiolitis. This was a secondary analysis of a prospective cohort study conducted at 135 primary care (PC) centers and eight pediatric emergency departments (ED) in the Osakidetza/Basque Health Service (Spain) in two epidemic seasons between which a bronchiolitis integrated care pathway (BICP) had been implemented: pre-intervention season from October 2018 to March 2019 and post-intervention season from October 2019 to March 2020. Generalized linear mixed models were used to estimate association of studied variables on use of salbutamol over the two seasons. Four thousand one hundred thirty-four ED attendances and 8573 PC visits were included, of which 1936 (46.8%). And 4067 (47.4%) occurred in the post-intervention period respectively. Six independent risk factors were associated with overuse of salbutamol in both seasons: age ≥ 1 year, aOR 2.32 (2.01 to 2.68) in PC centers, and aOR 6.84 (4.98 to 9.39) in EDs; being seen in the last third of the bronchiolitis season, aOR 1.82 (1.51 to 2.18) in PC centers and aOR 1.78 (1.19 to 2.64) in EDs; making more than one visit to the PC center, aOR 4.18 (3.32 to 5.27) or the ED, aOR 2.06 (1.59 to 2.66); being seen by a general practitioner, aOR 1.97 (1.58 to 2.46) in PC centers; and having a more severe episode, aOR 3.01 (1.89 to 4.79) in EDs. Conclusion:There are factors associated with salbutamol overuse in children diagnosed with bronchiolitis in PC and emergency settings that persist after the deployment of quality improvement initiatives. What is Known: • Quality improvement initiatives have been shown to decrease the use of non-evidence-based treatments and testing in bronchiolitis. • The magnitude and pattern of change in the use of medications linked to the quality improvement initiatives are not uniform across the same health service. What is New: • Children diagnosed with bronchiolitis ≥ 1 year of age, seen in the last third of the bronchiolitis season, attending more than once, treated by a general practitioner, and/or with more severe episodes are more likely to be treated with salbutamol. • These factors may remain present despite the implementation of improvement initiatives focused on reducing the use of medications in the management of bronchiolitis.
Collapse
Affiliation(s)
- Marta Montejo
- Rontegi-Barakaldo Primary Care Center, Basque Health Service - Osakidetza, Barakaldo, Spain
- Biocruces Bizkaia Health Research Institute, Barakaldo, Biscay, Basque Country, Spain
| | - Natalia Paniagua
- Pediatric Emergency Department, Cruces University Hospital, Basque Health Service - Osakidetza, Plaza de Cruces S/N E-48903, Barakaldo, Spain
- Biocruces Bizkaia Health Research Institute, Barakaldo, Biscay, Basque Country, Spain
| | - Jose Ignacio Pijoan
- Clinical Epidemiology Unit, Cruces University Hospital, Basque Health Service - Osakidetza, Barakaldo, Spain
- CIBER of Epidemiology and Public Health (CIBERESP), Barakaldo, Spain
- Biocruces Bizkaia Health Research Institute, Barakaldo, Biscay, Basque Country, Spain
| | - Carlos Saiz-Hernando
- Department of Medical Documentation, Cruces University Hospital, Basque Health Service - Osakidetza, Barakaldo, Spain
- Biocruces Bizkaia Health Research Institute, Barakaldo, Biscay, Basque Country, Spain
| | - Alvaro Sanchez
- Primary Care Research Unit of Bizkaia, Basque Health Service - Osakidetza, Barakaldo, Spain
- Biocruces Bizkaia Health Research Institute, Barakaldo, Biscay, Basque Country, Spain
| | - Mikel Rueda-Etxebarria
- Primary Care Research Unit of Bizkaia, Basque Health Service - Osakidetza, Barakaldo, Spain
- Biocruces Bizkaia Health Research Institute, Barakaldo, Biscay, Basque Country, Spain
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital, Basque Health Service - Osakidetza, Plaza de Cruces S/N E-48903, Barakaldo, Spain.
- Biocruces Bizkaia Health Research Institute, Barakaldo, Biscay, Basque Country, Spain.
| |
Collapse
|
21
|
Sarkis R, Liu W, DeTallo C, Baloglu O, Latifi SQ, Agarwal HS. Association of enteral feeds in critically ill bronchiolitis patients supported by high-flow nasal cannula with adverse events and outcomes. Eur J Pediatr 2023; 182:4015-4025. [PMID: 37389681 DOI: 10.1007/s00431-023-05085-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/13/2023] [Accepted: 06/24/2023] [Indexed: 07/01/2023]
Abstract
To study association of enteral feeds in bronchiolitis patients supported by different levels of high flow nasal cannula (HFNC) with adverse events, nutritional goals, and clinical outcomes. Bronchiolitis patients ≤ 24 months of age treated with < 1 L/kg/min, 1-2 L/kg/min and > 2 L/kg/min of HFNC between January 2014 and December 2021 were studied retrospectively at a tertiary care children's hospital. Adverse events (aspiration pneumonia, emesis, and respiratory support escalation), nutritional goals (initiation of enteral feeds, achievement of nutritional goal volume and goal calories, percentage weight change during hospital stay) and clinical outcomes (HFNC duration, oxygen supplementation duration after HFNC, length of hospital stay following HFNC support, total length of hospital stay and follow-up for 1 month after hospital discharge) were compared between fed and non-fed patients on HFNC. Six hundred thirty-six (489 fed and 147 not-fed) bronchiolitis patients on HFNC studied. 260 patients, 317 patients and 59 patients were supported by < 1 L/kg/min, 1-2 L/kg/min and > 2 L/kg/min of HFNC, respectively. Enterally fed patients had significantly less adverse events (OR = 0.14, 95% CI 0.083 - 0.23, p < 0.001), significantly better nutritional goals: earlier initiation of enteral feeds by 65% in time (mean ratio = 0.35, 95% CI 0.28 - 0.43, p < 0.001), earlier achievement of goal volume and goal calorie needs by 14% in time (mean ratio = 0.86, 95% CI 0.78 to 0.96, p = 0.005) and significantly better clinical outcomes: shorter HFNC duration by 29.75 h (95% CI 20.19 -39.31, p < 0.001), shorter oxygen supplementation duration after HFNC by 12.14 h (95% CI 6.70 -17.59, p < 0.001), shorter length of hospital stay after HFNC support by 21.35 h (95% CI 14.71-27.98, p < 0.001) and shorter total length of hospital stay by 51.10 h (95% CI 38.65 -63.55, p < 0.001), as compared to non-fed patients, after adjusting for age, weight, prematurity, comorbidities, admission time, admission bronchiolitis score, admission respiratory rate, and HFNC levels. The number of revisits and readmissions at 7 and 30 days after hospital discharge were not significantly different (p > 0.05) between the fed and non-fed groups. Conclusion: Enteral feeding of bronchiolitis patients supported by different levels of HFNC is associated with less adverse events and better nutrition goals and clinical outcomes. What is Known: •There is general apprehension to feed critically ill bronchiolitis patients supported by high flow nasal cannula. What is New: •Our study reveals that enteral feeding of critically ill bronchiolitis patients supported by different levels of high flow nasal cannula is associated with minimal adverse events, better nutritional goals and improved clinical outcomes as compared to non-fed patients.
Collapse
Affiliation(s)
- Reem Sarkis
- Department of Pediatric Emergency Medicine, Akron Children's Hospital, Akron, OH, USA
| | - Wei Liu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Christina DeTallo
- Department of Pediatric Gastroenterology, Cleveland Clinic Children's, Cleveland, OH, USA
| | - Orkun Baloglu
- Department of Pediatric Critical Care Medicine, Cleveland Clinic Children's, Cleveland, OH, USA
| | - Samir Q Latifi
- Department of Pediatric Critical Care Medicine, Cleveland Clinic Children's, Cleveland, OH, USA
| | - Hemant S Agarwal
- Department of Pediatric Critical Care Medicine, Cardinal Glennon Children's Hospital, Division of Pediatric Critical Care, 1465 South Grand Boulevard, Suite 2601 F, Saint Louis, MO, 63104, USA.
| |
Collapse
|
22
|
Zurca AD, González-Dambrauskas S, Colleti J, Vasquez-Hoyos P, Prata-Barbosa A, Boothe D, Combs BE, Lee JH, Franklin D, Pon S, Karsies T, Shein SL. Intensivists' Reported Management of Critical Bronchiolitis: More Data and New Guidelines Needed. Hosp Pediatr 2023; 13:660-670. [PMID: 37424406 PMCID: PMC10375032 DOI: 10.1542/hpeds.2023-007120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
OBJECTIVES Existing bronchiolitis guidelines do not reflect the needs of infants admitted to the PICU. This study aimed to identify PICU providers' reported practice variations and explore the need for critical bronchiolitis clinical guidelines. METHODS Cross-sectional electronic survey available in English, Spanish, and Portuguese between November 2020 and March 2021, distributed via research networks from North and Latin America, Asia, and Australia/New Zealand. RESULTS A total of 657 PICU providers responded, including 344 English, 204 Spanish, and 109 Portuguese. PICU providers indicated frequently using (≥25% of time) diagnostic modalities for nonintubated and intubated patients on PICU admission (complete blood count [75%-97%], basic metabolic panel [64%-92%], respiratory viral panel [90%-95%], chest x-ray [83%-98%]). Respondents also reported regularly (≥25% of time) prescribing β-2 agonists (43%-50%), systemic corticosteroids (23%-33%), antibiotics (24%-41%), and diuretics (13%-41%). Although work of breathing was the most common variable affecting providers' decision to initiate enteral feeds for nonintubated infants, hemodynamic status was the most common variable for intubated infants (82% of providers). Most respondents agreed it would be beneficial to have specific guidelines for infants with critical bronchiolitis who are requiring both noninvasive (91% agreement) and invasive (89% agreement) respiratory support. CONCLUSIONS PICU providers report performing diagnostic and therapeutic interventions for infants with bronchiolitis more frequently than recommended by current clinical guidelines, with interventions occurring more frequently for infants requiring invasive support. More clinical research is needed to inform the creation of evidence-based guidelines specifically for infants with critical bronchiolitis.
Collapse
Affiliation(s)
| | - Sebastián González-Dambrauskas
- Departamento de Pediatría y Unidad de Cuidados Intensivos de Niñosdel Centro Hospitalario Pereira Rossell, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
| | - Jose Colleti
- Department of Pediatrics, Hospital Israelita Albert Einstein and Hospital Assunção Rede D’Or, São Paulo, Brazil
| | - Pablo Vasquez-Hoyos
- Universidad Nacional de Colombia and Fundación Universitaria de Ciencias de la Salud, Bogota, Colombia
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
| | - Arnaldo Prata-Barbosa
- Department of Pediatrics, Instituto D’Or de Pesquisa e Ensino, Rio de Janeiro, Brazil
| | - David Boothe
- Penn State College of Medicine, Hershey, Pennsylvania
| | - Bryan E. Combs
- Division of Pediatric Critical Care, Rainbow Babies and Children’s Hospital, Cleveland, Ohio
| | - Jan Hau Lee
- Department of Pediatric Subspecialties, KK Women’s and Children’s Hospital and Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore
| | - Donna Franklin
- Children’s Critical Care Research Group, Gold Coast University Hospital and Menzies Health Institute, Griffith University, Brisbane, Queensland, Australia
| | - Steven Pon
- Department of Pediatrics, Weill Cornell Medical College, New York, New York
| | - Todd Karsies
- Division of Pediatric Critical Care, Nationwide Children’s Hospital, Columbus, Ohio
| | - Steven L. Shein
- Division of Pediatric Critical Care, Rainbow Babies and Children’s Hospital, Cleveland, Ohio
| |
Collapse
|
23
|
Abbate F, Depietri G, Tinelli C, Massimetti G, Picariello S, Peroni D, Di Cicco M. Impact of the publication of the Italian guidelines for bronchiolitis on the management of hospitalized children in Pisa, Italy. Pediatr Pulmonol 2023. [PMID: 37154513 DOI: 10.1002/ppul.26460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 04/19/2023] [Accepted: 04/27/2023] [Indexed: 05/10/2023]
Abstract
Bronchiolitis represents one of the major causes of hospitalization and mortality in children younger than 1 year, but its management continues to be heterogenous both in those who are hospitalized and in those who are not. To assess the impact of the publication of the Italian guidelines on bronchiolitis in October 2014, we analyzed data from children aged ≤12 months admitted for bronchiolitis at the University Hospital of Pisa from January 2010 to December 2019, dividing them into two groups based on whether admission was either preceding (Group 1) or following (Group 2) the publication of the guidelines. 346 patients (mean age 4.1 ± 2.8 months, 55% males) were admitted in the study period; 43.3%, 49.4%, and 7.3% of patients had mild, moderate or severe bronchiolitis, respectively. The mean length of hospital stay was 6.7 ± 2.9 days; 90.5% of the patients underwent nasal swab and 200 patients tested positive for RSV (in mono or coinfection with other viruses). We found no difference in RSV prevalence and severity distribution between the two groups, while we observed a significant reduction in the use of both chest X-rays (66.9% vs. 34.8%, p < 0.001), blood testing (93.4% vs. 58.2%, p < 0.001) and inhaled or systemic corticosteroids (93.1% vs. 47.8%, p < 0.001) in Group 2. No significant reduction in the use of antibiotics and of inhaled β2 agonists was found. Our data suggest that the publication of the Italian guidelines for bronchiolitis has contributed to improving the management of patients admitted for bronchiolitis in our Unit.
Collapse
Affiliation(s)
- Federica Abbate
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Pediatrics Unit, Pisa University Hospital, Pisa, Italy
| | - Greta Depietri
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Pediatrics Unit, Pisa University Hospital, Pisa, Italy
| | - Camilla Tinelli
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Gabriele Massimetti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Sara Picariello
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Pediatrics Unit, Pisa University Hospital, Pisa, Italy
| | - Diego Peroni
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Pediatrics Unit, Pisa University Hospital, Pisa, Italy
| | - Maria Di Cicco
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Pediatrics Unit, Pisa University Hospital, Pisa, Italy
| |
Collapse
|
24
|
Roqué-Figuls M, Giné-Garriga M, Granados Rugeles C, Perrotta C, Vilaró J. Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. Cochrane Database Syst Rev 2023; 4:CD004873. [PMID: 37010196 PMCID: PMC10070603 DOI: 10.1002/14651858.cd004873.pub6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
BACKGROUND Acute bronchiolitis is the leading cause of medical emergencies during winter months in infants younger than 24 months old. Chest physiotherapy is sometimes used to assist infants in the clearance of secretions in order to decrease ventilatory effort. This is an update of a Cochrane Review first published in 2005 and updated in 2006, 2012, and 2016. OBJECTIVES To determine the efficacy of chest physiotherapy in infants younger than 24 months old with acute bronchiolitis. A secondary objective was to determine the efficacy of different techniques of chest physiotherapy (vibration and percussion, passive exhalation, or instrumental). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, Web of Science, PEDro (October 2011 to 20 April 2022), and two trials registers (5 April 2022). SELECTION CRITERIA Randomised controlled trials (RCTs) in which chest physiotherapy was compared to control (conventional medical care with no physiotherapy intervention) or other respiratory physiotherapy techniques in infants younger than 24 months old with bronchiolitis. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS Our update of the searches dated 20 April 2022 identified five new RCTs with 430 participants. We included a total of 17 RCTs (1679 participants) comparing chest physiotherapy with no intervention or comparing different types of physiotherapy. Five trials (246 participants) assessed percussion and vibration techniques plus postural drainage (conventional chest physiotherapy), and 12 trials (1433 participants) assessed different passive flow-oriented expiratory techniques, of which three trials (628 participants) assessed forced expiratory techniques, and nine trials (805 participants) assessed slow expiratory techniques. In the slow expiratory subgroup, two trials (78 participants) compared the technique with instrumental physiotherapy techniques, and two recent trials (116 participants) combined slow expiratory techniques with rhinopharyngeal retrograde technique (RRT). One trial used RRT alone as the main component of the physiotherapy intervention. Clinical severity was mild in one trial, severe in four trials, moderate in six trials, and mild to moderate in five trials. One study did not report clinical severity. Two trials were performed on non-hospitalised participants. Overall risk of bias was high in six trials, unclear in five, and low in six trials. The analyses showed no effects of conventional techniques on change in bronchiolitis severity status, respiratory parameters, hours with oxygen supplementation, or length of hospital stay (5 trials, 246 participants). Regarding instrumental techniques (2 trials, 80 participants), one trial observed similar results in bronchiolitis severity status when comparing slow expiration to instrumental techniques (mean difference 0.10, 95% confidence interval (C) -0.17 to 0.37). Forced passive expiratory techniques failed to show an effect on bronchiolitis severity in time to recovery (2 trials, 509 participants; high-certainty evidence) and time to clinical stability (1 trial, 99 participants; high-certainty evidence) in infants with severe bronchiolitis. Important adverse effects were reported with the use of forced expiratory techniques. Regarding slow expiratory techniques, a mild to moderate improvement was observed in bronchiolitis severity score (standardised mean difference -0.43, 95% CI -0.73 to -0.13; I2 = 55%; 7 trials, 434 participants; low-certainty evidence). Also, in one trial an improvement in time to recovery was observed with the use of slow expiratory techniques. No benefit was observed in length of hospital stay, except for one trial which showed a one-day reduction. No effects were shown or reported for other clinical outcomes such as duration on oxygen supplementation, use of bronchodilators, or parents' impression of physiotherapy benefit. AUTHORS' CONCLUSIONS We found low-certainty evidence that passive slow expiratory technique may result in a mild to moderate improvement in bronchiolitis severity when compared to control. This evidence comes mostly from infants with moderately acute bronchiolitis treated in hospital. The evidence was limited with regard to infants with severe bronchiolitis and those with moderately severe bronchiolitis treated in ambulatory settings. We found high-certainty evidence that conventional techniques and forced expiratory techniques result in no difference in bronchiolitis severity or any other outcome. We found high-certainty evidence that forced expiratory techniques in infants with severe bronchiolitis do not improve their health status and can lead to severe adverse effects. Currently, the evidence regarding new physiotherapy techniques such as RRT or instrumental physiotherapy is scarce, and further trials are needed to determine their effects and potential for use in infants with moderate bronchiolitis, as well as the potential additional effect of RRT when combined with slow passive expiratory techniques. Finally, the effectiveness of combining chest physiotherapy with hypertonic saline should also be investigated.
Collapse
Affiliation(s)
- Marta Roqué-Figuls
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Maria Giné-Garriga
- Department of Physical Activity and Sport Sciences, Faculty of Psychology, Education and Sport Sciences (FPCEE) Blanquerna, Universitat Ramon Llull, Barcelona, Spain
| | - Claudia Granados Rugeles
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Carla Perrotta
- School of Public Health, University College Dublin, Dublin, Ireland
| | - Jordi Vilaró
- Blanquerna Faculty of Health Sciences. GRoW, Global Research on Wellbeing, Ramon Llull University, Barcelona, Spain
| |
Collapse
|
25
|
Selin S, Mecklin M, Korppi M, Heikkilä P. Twenty-one-year follow-up revealed guideline-concordant and non-concordant trends in intensive care of bronchiolitis. Eur J Pediatr 2023:10.1007/s00431-023-04940-2. [PMID: 36988679 PMCID: PMC10257585 DOI: 10.1007/s00431-023-04940-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023]
Abstract
To evaluate the management of bronchiolitis in the paediatric intensive care unit (PICU) before and after publication of the national bronchiolitis guidelines in June 2015. All infants treated between 2016-2020 for bronchiolitis in the PICU of Tampere University Hospital at < 12 months of age were included. The data were retrospectively collected from electronic patient records. The current results reflecting the post-guideline era were compared with previously published results for the pre-guideline 2000-2015 period. These two studies used identical protocols. Forty-six infants treated in the PICU were included. During the post-guideline era, inhaled adrenaline was given to 26 (57%), salbutamol to 7 (15%), and hypertonic saline inhalations to 35 (75%) patients. Forty-three patients (94%) received high-flow oxygen therapy (HFOT). Seventeen patients (37%) were treated with nasal continuous positive airway pressure (CPAP) and 4 (9%) with mechanical ventilation. CONCLUSION When post-guideline years were compared with pre-guideline years, the use of bronchodilators decreased in agreement, but the use of inhaled saline increased in disagreement with the guidelines. The use of respiratory support increased, evidently because of an introduction of the non-invasive HFOT treatment modality. WHAT IS KNOWN • Oxygen supplementation and respiratory support, when needed, are the cornerstones of bronchiolitis treatment. • Medicines are frequently given to infants with bronchiolitis, especially if intensive care is needed, although evidence of their effectiveness is lacking. WHAT IS NEW • Nearly all (94%) infants who needed intensive care were treated with HFOT and 37% with nasal CPAP, and finally, only 9% were intubated, which reflects the effectiveness of non-invasive techniques. • When pre- and post-guideline eras were compared, use of racemic adrenaline decreased from 84 to 57%, but use of hypertonic saline increased up to 75%, which disagrees with the current guidelines.
Collapse
Affiliation(s)
- Sofia Selin
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Minna Mecklin
- Tampere Centre for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Matti Korppi
- Tampere Centre for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Paula Heikkilä
- Tampere Centre for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland.
| |
Collapse
|
26
|
Manti S, Staiano A, Orfeo L, Midulla F, Marseglia GL, Ghizzi C, Zampogna S, Carnielli VP, Favilli S, Ruggieri M, Perri D, Di Mauro G, Gattinara GC, D’Avino A, Becherucci P, Prete A, Zampino G, Lanari M, Biban P, Manzoni P, Esposito S, Corsello G, Baraldi E. UPDATE - 2022 Italian guidelines on the management of bronchiolitis in infants. Ital J Pediatr 2023; 49:19. [PMID: 36765418 PMCID: PMC9912214 DOI: 10.1186/s13052-022-01392-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 11/29/2022] [Indexed: 02/12/2023] Open
Abstract
Bronchiolitis is an acute respiratory illness that is the leading cause of hospitalization in young children. This document aims to update the consensus document published in 2014 to provide guidance on the current best practices for managing bronchiolitis in infants. The document addresses care in both hospitals and primary care. The diagnosis of bronchiolitis is based on the clinical history and physical examination. The mainstays of management are largely supportive, consisting of fluid management and respiratory support. Evidence suggests no benefit with the use of salbutamol, glucocorticosteroids and antibiotics with potential risk of harm. Because of the lack of effective treatment, the reduction of morbidity must rely on preventive measures. De-implementation of non-evidence-based interventions is a major goal, and educational interventions for clinicians should be carried out to promote high-value care of infants with bronchiolitis. Well-prepared implementation strategies to standardize care and improve the quality of care are needed to promote adherence to guidelines and discourage non-evidence-based attitudes. In parallel, parents' education will help reduce patient pressure and contribute to inappropriate prescriptions. Infants with pre-existing risk factors (i.e., prematurity, bronchopulmonary dysplasia, congenital heart diseases, immunodeficiency, neuromuscular diseases, cystic fibrosis, Down syndrome) present a significant risk of severe bronchiolitis and should be carefully assessed. This revised document, based on international and national scientific evidence, reinforces the current recommendations and integrates the recent advances for optimal care and prevention of acute bronchiolitis.
Collapse
Affiliation(s)
- Sara Manti
- grid.10438.3e0000 0001 2178 8421University of Messina, Messina, Italy
| | - Annamaria Staiano
- grid.4691.a0000 0001 0790 385XSIP “Società Italiana di Pediatria”, University “Federico II”, Naples, Italy
| | - Luigi Orfeo
- grid.476687.c0000 0001 0944 2874SIN “Società Italiana di Neonatologia”, Hospital San Giovanni Calibita Fatebenefratelli, Rome, Italy
| | - Fabio Midulla
- grid.7841.aSIMRI ”Società Italiana per le Malattie Respiratorie Infantili”, University of Rome “La Sapienza”, Rome, Italy
| | - Gian Luigi Marseglia
- grid.419425.f0000 0004 1760 3027SIAIP “Società Italiana di Allergologia e Immunologia Pediatrica”, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chiara Ghizzi
- AMIETIP ”Accademia Medica Infermieristica di Emergenza e Terapia Intensiva Pediatrica”, Major Hospital Polyclinic: Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Bologna, Italy
| | - Stefania Zampogna
- SIMEUP “Società Italiana di Medicina di Emergenza ed Urgenza Pediatrica”, Pugliese Ciaccio Hospital, Catanzaro, Italy
| | - Virgilio Paolo Carnielli
- SIMP “Società Italiana di Medicina Perinatale”, University Hospital of Ancona Umberto I G M Lancisi G Salesi, Ancona, Italy
| | - Silvia Favilli
- SICP “Società Italiana di Cardiologia Pediatrica”, University Hospital Meyer, Firenze, Italy
| | - Martino Ruggieri
- grid.8158.40000 0004 1757 1969SINP “Società Italiana di Neurologia Pediatrica”, University of Catania, Catania, Italy
| | - Domenico Perri
- grid.415069.f0000 0004 1808 170XSIPO “Società Italiana Pediatria Ospedaliera”, San Giuseppe Moscati Hospital, Aversa, Italy
| | - Giuseppe Di Mauro
- SIPPS “Società Italiana di Pediatria Preventiva e Sociale”, Local Health Authority Caserta, Caserta, Italy
| | - Guido Castelli Gattinara
- grid.414125.70000 0001 0727 6809SITIP “Società Italiana di Infettivologia Pediatrica”, Bambino Gesu Pediatric Hospital, Rome, Italy
| | - Antonio D’Avino
- FIMP “Federazione Italiana Medici Pediatri”, Local Health Authority Naples 1 Centre, Naples, Italy
| | - Paolo Becherucci
- SICuPP “Società Italiana delle Cure Primarie Pediatriche”, Florence City Council, Florence, Italy
| | - Arcangelo Prete
- grid.412311.4AIEOP “Società Italiana di Ematologia e Oncologia Pediatrica”, IRCCS University Hospital of Bologna, Bologna, Italy
| | - Giuseppe Zampino
- grid.411075.60000 0004 1760 4193SIMGePeD “Società Italiana Malattie Genetiche Pediatriche e Disabilità Congenite”, University Hospital Agostino Gemelli, Rome, Italy
| | - Marcello Lanari
- grid.6292.f0000 0004 1757 1758Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Paolo Biban
- grid.411475.20000 0004 1756 948XUniversity Hospital of Verona, Verona, Italy
| | - Paolo Manzoni
- grid.417165.00000 0004 1759 6939Ospedale Degli Infermi, Biella, Italy ,grid.7605.40000 0001 2336 6580University of Turin, Turin, Italy
| | - Susanna Esposito
- grid.10383.390000 0004 1758 0937University of Parma, Parma, Italy
| | - Giovanni Corsello
- grid.10776.370000 0004 1762 5517University of Palermo, Palermo, Italy
| | - Eugenio Baraldi
- Department of Women's and Children's Health, Neonatal Intensive Care Unit, University Hospital of Padova, Padova, Italy.
| |
Collapse
|
27
|
Granda E, Urbano M, Andrés P, Corchete M, Cano A, Velasco R. Comparison of severity scales for acute bronchiolitis in real clinical practice. Eur J Pediatr 2023; 182:1619-1626. [PMID: 36702906 DOI: 10.1007/s00431-023-04840-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 01/09/2023] [Accepted: 01/21/2023] [Indexed: 01/28/2023]
Abstract
Several clinical scales have been developed to assess the severity of bronchiolitis as well as the probability of needing in-hospital care. A recent systematic review of 32 validated clinical scores for bronchiolitis concluded that 6 of them (Wood-Downes, M-WCAS, Respiratory Severity Score, Respiratory Clinical Score, Respiratory Score and Bronchiolitis risk of admission score) were the best ones regarding reliability, sensitivity, validity, and usability. However, to the best of our knowledge, no study has compared all of them in a clinical scenario. Also, after this review, three more scales were published: BROSJOD, Tal modified, and one score developed by PERN. Our main aim was to compare the ability of different clinical scales for bronchiolitis to predict any relevant outcome. A prospective observational study was conducted that included patients of up to 12 months old attended to, due to bronchiolitis, in the paediatric Emergency Department of a secondary university hospital from October 2019 to January 2022. For each patient, the attending clinician filled in a form with the items of the scales, decomposed, in order to prevent the clinician from knowing the score of each scale. Then, the patient was managed according to the protocol of our Emergency Department. A phone call was made to each patient in order to check whether the patient ended up being admitted in the next 48 h. In the case of those that were impossible to contact by phone, the clinical history was reviewed. For the purpose of the study, any of the following were considered to be a relevant outcome: admission to ward and need for supplementary oxygen, non-invasive ventilation (NIV) or intravenous fluids, and admission to the paediatric intensive care unit (PICU) within the next 48 h or death. For the aim of the study, the area under the curve (AUC) and the odds ratio (OR) for a relevant outcome were calculated in each scale. Also, the best cut-off point was estimated according to the Youden index, and its sensitivity (Sn) and specificity (Sp) for a relevant outcome were calculated. We included 265 patients (52.1% male) with a median age of 5.3 months (P25-P75 2.6-7.4). Among them, 46 (17.4%) had some kind of relevant outcome. AUC for prediction of a relevant outcome ranged from 0.705 (Respiratory Score) to 0.786 (BRAS), although no scale performed significantly better than others. A score ≤ 2 in the PERN scale showed a sensitivity of 91.3% (CI95% 79.7-96.6) for a relevant outcome, with only 4 misdiagnosed patients (only 2 of them needed NIV). Conclusions: There were no differences in the performance of the nine scales to predict relevant outcomes in patients with bronchiolitis. However, the PERN scale might be more useful to select patients at low risk of a severe outcome. What is Known: • Several clinical scales are used to assess the severity of bronchiolitis. Nevertheless, none of them seems to be better than others. What is New: • This is the first study comparing different bronchiolitis scales in a real clinical scenario. None of the nine scales compared performed better than the other. However, the PERN scale might be more useful to select patients at low risk of relevant outcomes.
Collapse
Affiliation(s)
- Elena Granda
- Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain.
| | - Mario Urbano
- Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Pilar Andrés
- Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Marina Corchete
- Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Alfredo Cano
- Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Roberto Velasco
- Pediatric Emergency Department, Hospital Universitario Río Hortega, Valladolid, Spain
| |
Collapse
|
28
|
O’Brien SL, Haskell L, Tavender EJ, Wilson S, Borland ML, Oakley E, Dalziel SR, Gill FJ. Factors influencing health professionals' use of high-flow nasal cannula therapy for infants with bronchiolitis - A qualitative study. Front Pediatr 2023; 11:1098577. [PMID: 37009298 PMCID: PMC10060553 DOI: 10.3389/fped.2023.1098577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 02/06/2023] [Indexed: 04/04/2023] Open
Abstract
Aim To explore the factors influencing the use of high-flow nasal cannula (HFNC) therapy for infants with bronchiolitis. Design Qualitative approach using semi-structured interviews. Methods The semi-structured interviews (face-to-face or virtual) were conducted between September 2020 and February 2021. Deductive content analysis was used to map key influencing factors for use of HFNC therapy to the Theoretical Domains Framework (TDF). Results Nineteen interviews were undertaken before reaching thematic saturation (7 nurses, 12 doctors) in emergency departments and paediatric wards from four purposively selected hospitals in Australia and New Zealand. Influencing factors were mapped to eight domains in the TDF with 21 themes identified. Main findings included: (1) Health professionals' expectations of HFNC therapy on patient deterioration, work of breathing and oxygenation; (2) Staff emotions relating to concern and anxiety about deterioration and "need to do something"; (3) Social influences from other health professionals and parents and (4) Environmental factors relating to logistics of care and patient transfer considerations. These factors, combined with the ready availability of HFNC equipment and health professionals having the required skills to administer the therapy, contributed to its initiation. Conclusion Individual/personal and contextual/environmental factors contribute to the use of HFNC therapy for infants with bronchiolitis. It is evident these influences contribute substantially to increased use, despite evidence-based guidelines recommending a more nuanced approach to this therapy. These findings will inform a targeted implementation intervention to promote evidence-based use of HFNC therapy in infants with bronchiolitis.
Collapse
Affiliation(s)
- Sharon L. O’Brien
- Emergency Department, Perth Children's Hospital, Nedlands, WA, Australia
- School of Nursing, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
- Correspondence: Sharon L. O’Brien sharon.o’
| | - Libby Haskell
- Children’s Emergency Department, Starship Children’s Hospital, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Emma J. Tavender
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Parkville, VIC, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Parkville, VIC, Australia
| | - Sally Wilson
- School of Nursing, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
| | - Meredith L. Borland
- Emergency Department, Perth Children's Hospital, Nedlands, WA, Australia
- Divisions of Emergency Medicine and Paediatrics, School of Medicine, University of Western Australia, Crawley, WA, Australia
| | - Ed Oakley
- Clinical Sciences Theme, Murdoch Children’s Research Institute, Parkville, VIC, Australia
- Emergency Department, Royal Children’s Hospital, Parkville, VIC, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Parkville, VIC, Australia
| | - Stuart R. Dalziel
- Children’s Emergency Department, Starship Children’s Hospital, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Fenella J. Gill
- School of Nursing, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
- enAble Institute, Curtin University, Bentley, WA, Australia
- Nursing Research, Perth Children’s Hospital, Child & Adolescent Health Service, Nedlands, WA, Australia
| |
Collapse
|
29
|
Milési C, Baudin F, Durand P, Emeriaud G, Essouri S, Pouyau R, Baleine J, Beldjilali S, Bordessoule A, Breinig S, Demaret P, Desprez P, Gaillard-Leroux B, Guichoux J, Guilbert AS, Guillot C, Jean S, Levy M, Noizet-Yverneau O, Rambaud J, Recher M, Reynaud S, Valla F, Radoui K, Faure MA, Ferraro G, Mortamet G. Clinical practice guidelines: management of severe bronchiolitis in infants under 12 months old admitted to a pediatric critical care unit. Intensive Care Med 2023; 49:5-25. [PMID: 36592200 DOI: 10.1007/s00134-022-06918-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/13/2022] [Indexed: 01/03/2023]
Abstract
PURPOSE We present guidelines for the management of infants under 12 months of age with severe bronchiolitis with the aim of creating a series of pragmatic recommendations for a patient subgroup that is poorly individualized in national and international guidelines. METHODS Twenty-five French-speaking experts, all members of the Groupe Francophone de Réanimation et Urgence Pédiatriques (French-speaking group of paediatric intensive and emergency care; GFRUP) (Algeria, Belgium, Canada, France, Switzerland), collaborated from 2021 to 2022 through teleconferences and face-to-face meetings. The guidelines cover five areas: (1) criteria for admission to a pediatric critical care unit, (2) environment and monitoring, (3) feeding and hydration, (4) ventilatory support and (5) adjuvant therapies. The questions were written in the Patient-Intervention-Comparison-Outcome (PICO) format. An extensive Anglophone and Francophone literature search indexed in the MEDLINE database via PubMed, Web of Science, Cochrane and Embase was performed using pre-established keywords. The texts were analyzed and classified according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. When this method did not apply, an expert opinion was given. Each of these recommendations was voted on by all the experts according to the Delphi methodology. RESULTS This group proposes 40 recommendations. The GRADE methodology could be applied for 17 of them (3 strong, 14 conditional) and an expert opinion was given for the remaining 23. All received strong approval during the first round of voting. CONCLUSION These guidelines cover the different aspects in the management of severe bronchiolitis in infants admitted to pediatric critical care units. Compared to the different ways to manage patients with severe bronchiolitis described in the literature, our original work proposes an overall less invasive approach in terms of monitoring and treatment.
Collapse
Affiliation(s)
- Christophe Milési
- Pediatric Intensive Care Unit, Montpellier University Hospital, Montpellier, France.
| | - Florent Baudin
- Pediatric Intensive Care Unit, Lyon Hospital Femme-Mère-Enfants, Bron, France
| | - Philippe Durand
- Pediatric Intensive Care Unit, Bicêtre Hospital, Assistance Publique des Hôpitaux de Paris, Kremlin-Bicêtre, France
| | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, Sainte-Justine University Hospital, Montreal, Canada
| | - Sandrine Essouri
- Pediatric Department, Sainte-Justine University Hospital, Montreal, Canada
| | - Robin Pouyau
- Pediatric Intensive Care Unit, Lyon Hospital Femme-Mère-Enfants, Bron, France
| | - Julien Baleine
- Pediatric Intensive Care Unit, Montpellier University Hospital, Montpellier, France
| | - Sophie Beldjilali
- Pediatric Intensive Care Unit, La Timone University Hospital, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Alice Bordessoule
- Pediatric Intensive Care Unit, Geneva University Hospital, Geneva, Switzerland
| | - Sophie Breinig
- Pediatric Intensive Care Unit, Toulouse University Hospital, Toulouse, France
| | - Pierre Demaret
- Intensive Care Unit, Liège University Hospital, Liège, Belgium
| | - Philippe Desprez
- Pediatric Intensive Care Unit, Point-à-Pitre University Hospital, Point-à-Pitre, France
| | | | - Julie Guichoux
- Pediatric Intensive Care Unit, Bordeaux University Hospital, Bordeaux, France
| | - Anne-Sophie Guilbert
- Pediatric Intensive Care Unit, Strasbourg University Hospital, Strasbourg, France
| | - Camille Guillot
- Pediatric Intensive Care Unit, Lille University Hospital, Lille, France
| | - Sandrine Jean
- Pediatric Intensive Care Unit, Trousseau Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Michael Levy
- Pediatric Intensive Care Unit, Robert Debré Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | | | - Jérôme Rambaud
- Pediatric Intensive Care Unit, Trousseau Hospital, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Morgan Recher
- Pediatric Intensive Care Unit, Lille University Hospital, Lille, France
| | - Stéphanie Reynaud
- Pediatric Intensive Care Unit, Lyon Hospital Femme-Mère-Enfants, Bron, France
| | - Fréderic Valla
- Pediatric Intensive Care Unit, Lyon Hospital Femme-Mère-Enfants, Bron, France
| | - Karim Radoui
- Pneumology EHS Pediatric Department, Faculté de Médecine d'Oran, Canastel, Oran, Algeria
| | | | - Guillaume Ferraro
- Pediatric Emergency Department, Nice University Hospital, Nice, France
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble-Alpes University Hospital, Grenoble, France
| |
Collapse
|
30
|
Lirette MP, Kuppermann N, Finkelstein Y, Zemek R, Plint AC, Florin TA, Babl FE, Dalziel S, Freedman S, Roland D, Lyttle MD, Schnadower D, Steele D, Fernandes RM, Stephens D, Kharbanda A, Johnson DW, Macias C, Benito J, Schuh S. International variation in evidence-based emergency department management of bronchiolitis: a retrospective cohort study. BMJ Open 2022; 12:e059784. [PMID: 36600373 PMCID: PMC9730363 DOI: 10.1136/bmjopen-2021-059784] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES We aimed to evaluate the international variation in the use of evidence-based management (EBM) in bronchiolitis. We hypothesised that management consistent with full-EBM practices is associated with the research network of care, adjusted for patient-level characteristics. Secondary objectives were to determine the association between full-EBM and (1) hospitalisation and (2) emergency department (ED) revisits resulting in hospitalisation within 21 days. DESIGN A secondary analysis of a retrospective cohort study. SETTING 38 paediatric EDs belonging to the Paediatric Emergency Research Network in Canada, USA, Australia/New Zealand UK/Ireland and Spain/Portugal. PATIENTS Otherwise healthy infants 2-11 months old diagnosed with bronchiolitis between 1 January 2013 and 31 December, 2013. OUTCOME MEASURES Primary outcome was management consistent with full-EBM, that is, no bronchodilators/corticosteroids/antibiotics, no chest radiography or laboratory testing. Secondary outcomes included hospitalisations during the index and subsequent ED visits. RESULTS 1137/2356 (48.3%) infants received full-EBM (ranging from 13.2% in Spain/Portugal to 72.3% in UK/Ireland). Compared with the UK/Ireland, the adjusted ORs (aOR) of full-EBM receipt were lower in Spain/Portugal (aOR 0.08, 95% CI 0.02 to 0.29), Canada (aOR 0.13 (95% CI 0.06 to 0.31) and USA (aOR 0.16 (95% CI 0.07 to 0.35). EBM was less likely in infants with dehydration (aOR 0.49 (95% CI 0.33 to 0.71)), chest retractions (aOR 0.69 (95% CI 0.52 to 0.91)) and nasal flaring (aOR 0.69 (95% CI 0.52 to 0.92)). EBM was associated with reduced odds of hospitalisation at the index visit (aOR 0.77 (95% CI 0.60 to 0.98)) but not at revisits (aOR 1.17 (95% CI 0.74 to 1.85)). CONCLUSIONS Infants with bronchiolitis frequently do not receive full-EBM ED management, particularly those outside of the UK/Ireland. Furthermore, there is marked variation in full-EBM between paediatric emergency networks, and full-EBM delivery is associated with lower likelihood of hospitalisation. Given the global bronchiolitis burden, international ED-focused deimplementation of non-indicated interventions to enhance EBM is needed.
Collapse
Affiliation(s)
- Marie-Pier Lirette
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Nathan Kuppermann
- The Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento, California, USA
- University of California Davis Health System, Sacramento, California, USA
| | - Yaron Finkelstein
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Hospital for Sick Children Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Roger Zemek
- Division of Pediatric Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Division of Pediatric Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Amy C Plint
- Division of Pediatric Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Division of Pediatric Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Todd Adam Florin
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Franz E Babl
- Emergency Department, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
- The University of Melbourne/The Royal Children's Hospital CICH, Parkville, Victoria, Australia
| | - Stuart Dalziel
- Emergency Department, Starship Children's Health, Auckland, Auckland, New Zealand
- Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Stephen Freedman
- Department of Pediatrics, Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
- University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester Royal Infirmary, Leicester, UK
- SAPPHIRE Group, Health Sciences, University of Leicester, Leicester, Leicestershire, UK
| | - Mark David Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
- Faculty of Health and Applied Life Sciences, University of the West of England, Bristol, UK
| | - David Schnadower
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Dale Steele
- Pediatric Emergency Medicine, Hasbro Children's Hospital, Providence, Rhode Island, USA
- Departments of Emergency Medicine, Pediatrics and Health Services, Policy & Practice, Brown University, Providence, Rhode Island, USA
| | - Ricardo M Fernandes
- Department of Pediatrics, Hospital de Santa Maria, Lisboa, Portugal
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Universidade de Lisboa Instituto de Medicina Molecular, Lisboa, Portugal
| | - Derek Stephens
- Hospital for Sick Children Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Anupam Kharbanda
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota, USA
| | - David W Johnson
- University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Departments of Pediatrics, Emergency Medicine, and Physiology and Pharmacology, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | - Charles Macias
- Division of Pediatric Emergency Medicine, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Spain
| | - Suzanne Schuh
- Hospital for Sick Children Research Institute, University of Toronto, Toronto, Ontario, Canada
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
31
|
Rodriguez-Martinez CE, Sossa-Briceño MP, Antonio Buendia J. Comparison of two oxygen saturation targets to decide on hospital discharge of infants with viral bronchiolitis living at high altitudes: a cost-effectiveness analysis. Curr Med Res Opin 2022; 38:2047-2053. [PMID: 35993483 DOI: 10.1080/03007995.2022.2115774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES The objective of the current study was to evaluate the cost-effectiveness of two pulse oximetry (SpO2) thresholds to decide on hospital discharge when all other discharge criteria are met, in infants with viral bronchiolitis living at high altitudes. METHODS A decision analysis model was developed to estimate the cost-effectiveness of the use of an SpO2 threshold of 90% versus one of 85% for deciding whether infants hospitalized for viral bronchiolitis can be safely discharged to home, from a third-party payer's perspective. The main outcome was discharge to home at day 4 of the initial hospitalization. The time horizon was 28 days after discharge from hospital. We performed deterministic sensitivity analyses and probabilistic sensitivity analyses. RESULTS Compared to the use of an SpO2 threshold of 90%, treating infants with viral bronchiolitis with the use of an SpO2 threshold of 85% resulted in lower total costs (US$119.39 vs. US$188.357 mean cost per patient) and a greater probability of discharge to home at day 4 of the initial hospitalization (0.8400 vs. 0.7600), therefore being a dominant strategy. Sensitivity analyses were in line with base case results. CONCLUSIONS In Bogota, a high-altitude city, in infants admitted for viral bronchiolitis, the use of an SpO2 threshold of 85% to decide on hospital discharge when all other discharge criteria are met is dominant because it entails a greater probability of discharge to home at day 4 of the initial hospitalization and generates fewer costs than the use of an SpO2 threshold of 90%.
Collapse
Affiliation(s)
- Carlos E Rodriguez-Martinez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia
- Department of Pediatric Pulmonology, School of Medicine, Universidad El Bosque, Bogota, Colombia
| | - Monica P Sossa-Briceño
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia
| | - Jefferson Antonio Buendia
- Department of Pharmacology and Toxicology, School of Medicine, Research Group in Pharmacology and Toxicology (INFARTO), Universidad de Antioquia, Medellín, Colombia
| |
Collapse
|
32
|
O'Brien S, Haskell L, Schembri R, Gill FJ, Wilson S, Borland ML, Oakley E, Dalziel SR. Prevalence of high flow nasal cannula therapy use for management of infants with bronchiolitis in Australia and New Zealand. J Paediatr Child Health 2022; 58:2230-2235. [PMID: 36066264 PMCID: PMC10947204 DOI: 10.1111/jpc.16199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 08/09/2022] [Accepted: 08/21/2022] [Indexed: 11/27/2022]
Abstract
AIM To determine the prevalence of high flow nasal cannula (HFNC) therapy in infants presenting to hospital in Australia and New Zealand with bronchiolitis over four bronchiolitis seasons. Secondary aims were to determine temporal trends in HFNC use, and associations between HFNC, hospital length of stay (LOS) and intensive care unit (ICU) admission. METHODS A planned sub-study of a multi-centre international cluster randomised controlled trial investigating knowledge translation strategies for a bi-national bronchiolitis guideline. Demographics, management and outcomes data were collected retrospectively for infants presenting with bronchiolitis to 26 hospitals between 1 May 2014 and 30 November 2017. Prevalence data are presented as absolute frequencies (95% confidence interval (CI)) with differences between groups for continuous and categorical variables analysed using linear and logistic regression, respectively. RESULTS 11 715 infants were included with 3392 (29.0%, 95% CI (28.1-29.8%)) receiving oxygen therapy; of whom 1817 (53.6%, 95% CI (51.9-55.3%)) received HFNC. Use of oxygen therapy did not change over the four bronchiolitis seasons (P = 0.12), while the proportion receiving HFNC increased (2014, 336/2587 (43.2%); 2017, 609/3720 (57.8%); P ≤ 0.001). Infants who received HFNC therapy were not substantially different to infants who received oxygen therapy without HFNC. HFNC use was associated with increases in both hospital LOS (P < 0.001) and ICU admissions (P < 0.001). CONCLUSION Use of HFNC therapy for infants with bronchiolitis increased over 4 years. Of those who received oxygen therapy, the majority received HFNC therapy without improvement in hospital LOS or ICU admissions. Strategies to guide appropriate HFNC use in infants with bronchiolitis are required.
Collapse
Affiliation(s)
- Sharon O'Brien
- Emergency DepartmentPerth Children's HospitalPerthWestern AustraliaAustralia
- School of Nursing, Faculty of Health SciencesCurtin UniversityPerthWestern AustraliaAustralia
| | - Libby Haskell
- Children's Emergency DepartmentStarship Children's HospitalAucklandNew Zealand
- Department of Paediatrics: Child and Youth HealthUniversity of AucklandAucklandNew Zealand
| | - Rachel Schembri
- Clinical Epidemiology and BiostatisticsMelbourne Children's Trials Centre, Murdoch Children's Research InstituteMelbourneVictoriaAustralia
| | - Fenella J Gill
- School of Nursing, Faculty of Health SciencesCurtin UniversityPerthWestern AustraliaAustralia
- Child & Adolescent Health ServicePerth Children's HospitalPerthWestern AustraliaAustralia
| | - Sally Wilson
- School of Nursing, Faculty of Health SciencesCurtin UniversityPerthWestern AustraliaAustralia
| | - Meredith L Borland
- Emergency DepartmentPerth Children's HospitalPerthWestern AustraliaAustralia
- Divisions of Emergency Medicine and Paediatrics, School of MedicineUniversity of Western AustraliaPerthWestern AustraliaAustralia
| | - Ed Oakley
- Emergency DepartmentRoyal Children's HospitalParkvilleVictoriaAustralia
- Emergency ResearchMurdoch Children's Research InstituteMelbourneVictoriaAustralia
- Departments of Paediatrics and Critical CareUniversity of MelbourneMelbourneVictoriaAustralia
| | - Stuart R Dalziel
- Children's Emergency DepartmentStarship Children's HospitalAucklandNew Zealand
- Departments of Surgery and Paediatrics: Child and Youth HealthUniversity of AucklandAucklandNew Zealand
| | | |
Collapse
|
33
|
OVERCHUK A, TOKARCHUK N, STARYNETS L. Analysis of the allergic inflammation markers of bronchiolitis in infants. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2022. [DOI: 10.23736/s0393-3660.21.04700-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
34
|
Ambrożej D, Makrinioti H, Whitehouse A, Papadopoulos N, Ruszczyński M, Adamiec A, Castro-Rodriguez JA, Alansari K, Jartti T, Feleszko W. Respiratory virus type to guide predictive enrichment approaches in the management of the first episode of bronchiolitis: A systematic review. Front Immunol 2022; 13:1017325. [PMID: 36389820 PMCID: PMC9647543 DOI: 10.3389/fimmu.2022.1017325] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/17/2022] [Indexed: 11/23/2022] Open
Abstract
It has become clear that severe bronchiolitis is a heterogeneous disease; even so, current bronchiolitis management guidelines rely on the one-size-fits-all approach regarding achieving both short-term and chronic outcomes. It has been speculated that the use of molecular markers could guide more effective pharmacological management and achieve the prevention of chronic respiratory sequelae. Existing data suggest that asthma-like treatment (systemic corticosteroids and beta2-agonists) in infants with rhinovirus-induced bronchiolitis is associated with improved short-term and chronic outcomes, but robust data is still lacking. We performed a systematic search of PubMed, Embase, Web of Science, and the Cochrane’s Library to identify eligible randomized controlled trials to determine the efficacy of a personalized, virus-dependent application of systemic corticosteroids in children with severe bronchiolitis. Twelve studies with heterogeneous methodology were included. The analysis of the available results comparing the respiratory syncytial virus (RSV)-positive and RSV-negative children did not reveal significant differences in the associatons between systemic corticosteroid use in acute episode and duration of hospitalization (short-term outcome). However, this systematic review identified a trend of the positive association between the use of systematic corticosteroids and duration of hospitalization in RSV-negative infants hospitalized with the first episode of bronchiolitis (two studies). This evidence is not conclusive. Taken together, we suggest the design for future studies to assess the respiratory virus type in guiding predictive enrichment approaches in infants presenting with the first episode of bronchiolitis.
Collapse
Affiliation(s)
- Dominika Ambrożej
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Warsaw, Poland
- Doctoral School, Medical University of Warsaw, Warsaw, Poland
| | - Heidi Makrinioti
- Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Abigail Whitehouse
- Centre for Genomics and Child Health, Queen Mary University of London, London, United Kingdom
| | - Nikolas Papadopoulos
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, United Kingdom
- Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens, Greece
| | - Marek Ruszczyński
- Department of Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Aleksander Adamiec
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Warsaw, Poland
- Doctoral School, Medical University of Warsaw, Warsaw, Poland
| | - Jose A. Castro-Rodriguez
- Department of Pediatric Pulmonology and Cardiology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Khalid Alansari
- Department of Pediatric Emergency Medicine, Sidra Medicine, Doha, Qatar
- Clinical Pediatrics, Qatar University College of Medicine, Doha, Qatar
- Clinical Pediatrics, Weill Cornell Medical College- Qatar, Doha, Qatar
| | - Tuomas Jartti
- Department of Pediatrics, Turku University Hospital and University of Turku, Turku, Finland
- PEDEGO Research Unit, Medical Research Center, University of Oulu, Oulu, Finland
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland
| | - Wojciech Feleszko
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Warsaw, Poland
- *Correspondence: Wojciech Feleszko,
| |
Collapse
|
35
|
Lawrence J, Walpola R, Boyce SL, Bryant PA, Sharma A, Hiscock H. Home Care for Bronchiolitis: A Systematic Review. Pediatrics 2022; 150:189386. [PMID: 36065737 DOI: 10.1542/peds.2022-056603] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2022] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Bronchiolitis is the leading cause of pediatric hospital admissions. Hospital-at-Home (HAH) delivers hospital-level care at home, relieving pressure on the hospital system. OBJECTIVES We aimed to review the feasibility, acceptability, and safety of HAH for bronchiolitis, and assess the cost-impact to hospitals and society. DATA SOURCES Ovid Medline, Embase, Pubmed, Cochrane Library, CINAHL, and Web of Science. STUDY SELECTION Studies (randomized control trials, retrospective audits, prospective observational trials) of infants with bronchiolitis receiving HAH (oxygen, nasogastric feeding, remote monitoring). Studies were limited to English language since 2000. DATA EXTRACTION We reviewed all studies in duplicate for inclusion, data extraction, and risk of bias. RESULTS Ten studies met inclusion criteria, all for home oxygen therapy (HOT). One abstract on nasogastric feeding did not meet full inclusion criteria. No studies on remote monitoring were found. HOT appears feasible in terms of uptake (70%-82%) and successful completion, both at altitude and sea-level. Caregiver acceptability was reported in 2 qualitative studies. There were 7 reported adverse events (0.6%) with 0 mortality in 1257 patients. Cost studies showed evidence of savings, although included costs to hospitals only. LIMITATIONS Small number of studies with heterogenous study design and quality. No adequately powered randomized control studies. CONCLUSIONS Evidence exists to support HOT as feasible, acceptable, and safe. Evidence of cost-effectiveness remains limited. Further research is needed to understand the relevant impact of HAH versus alternative interventions to reduce oxygen prescribing. Other models of care looking at nasogastric feeding support and remote monitoring should be explored.
Collapse
Affiliation(s)
- Joanna Lawrence
- Hospital in the Home.,Health Services Research Unit.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,School of Population Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Ramesh Walpola
- School of Population Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Suzanne L Boyce
- Hospital in the Home.,Department of General Paediatrics.,Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Australia
| | - Penelope A Bryant
- Hospital in the Home.,Infectious Disease Unit, Royal Children's Hospital, Melbourne, Australia.,Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Anurag Sharma
- School of Population Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Harriet Hiscock
- Health Services Research Unit.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| |
Collapse
|
36
|
Freire GC, Diong C, Gandhi S, Saunders N, Neuman MI, Freedman SB, Friedman JN, Cohen E. Variation in low-value radiograph use for children in the emergency department: a cross-sectional study of administrative databases. CMAJ Open 2022; 10:E889-E899. [PMID: 36220182 PMCID: PMC9578750 DOI: 10.9778/cmajo.20210140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Radiograph use contributes to low-value care for children in emergency departments (EDs), but little is known about systemic factors associated with their use. This study compares low-value radiograph use across ED settings by hospital type, pediatric volumes and physician specialty. METHODS This is a cross-sectional study of routinely collected administrative data. We included children (age 0-18 yr) discharged from EDs in Ontario, Canada, between 2010 and 2019 with diagnoses of bronchiolitis, asthma, abdominal pain and constipation. Multiple clinical practice guidelines recommend against routine radiograph use in these conditions. Logistic regression evaluated odds of low-value radiograph by ED setting (pediatric academic [referent], adult academic, community with or without pediatric consultation services), pediatric volume and physician specialty (pediatric emergency medicine [PEM, referent], emergency medicine [EM], family medicine with EM training, pediatrics, family medicine), adjusting for demographic, clinical and provider characteristics. We used generalized estimating equations to account for clustering by ED. RESULTS Of the total 9 862 787 eligible pediatric ED discharges in Ontario, 60 914 children had bronchiolitis, 141 921 asthma, 333 332 abdominal pain and 110 514 constipation; 26.0% received low-value radiographs. Compared with pediatric EDs and PEM physicians (referents), patients with bronchiolitis were most likely to have a chest radiograph in adult academic EDs (adjusted odds ratio [OR] 5.1 [95% confidence interval (CI) 4.6-5.6]) and by family physicians with EM training (adjusted OR 4.8 [95% CI 4.5-5.1]). Patients with asthma were more likely to have a chest radiograph in adult academic EDs (adjusted OR 3.0 [95% CI 2.8-3.2]) and by EM physicians (adjusted OR 2.8 [95% CI 2.6-3.0]). Patients with abdominal pain and constipation were more likely to have abdominal radiographs in community hospitals with pediatric consultation (adjusted OR 1.6 [95% CI 1.6-1.7] and 2.3 [95% CI 2.3-2.4], respectively) and by family physicians with EM training (adjusted OR 1.6 [95% CI 1.6-1.7] and 2.1 [95% CI 2.0-2.2], respectively). INTERPRETATION Over the decade-long study period, low-value radiograph use was frequent for children with 4 common conditions seen in Ontario EDs. Quality improvement initiatives aimed at reducing unnecessary radiographs in children should focus on EM physicians practising in EDs that primarily treat adult patients.
Collapse
Affiliation(s)
- Gabrielle C Freire
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Christina Diong
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Sima Gandhi
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Natasha Saunders
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Mark I Neuman
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Stephen B Freedman
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Jeremy N Friedman
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta
| | - Eyal Cohen
- Division of Emergency Medicine (Freire), Division of Pediatric Medicine (Saunders, Friedman, Cohen), Department of Pediatrics (Freire, Saunders, Friedman, Cohen), The Hospital for Sick Children, University of Toronto; Child Health Evaluative Sciences (Saunders, Cohen), Hospital for Sick Children Research Institute; ICES (Diong, Gandhi, Saunders, Cohen); Institute of Health Policy, Management, and Evaluation (Saunders, Cohen), University of Toronto; Edwin S.H. Leong Centre for Healthy Children (Cohen), University of Toronto, Toronto, Ont.; Division of Emergency Medicine (Neuman), Boston Children's Hospital, Department of Pediatrics (Neuman), Harvard Medical School, Boston, Mass.; Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine (Freedman), Cumming School of Medicine, University of Calgary, Calgary, Alta.
| |
Collapse
|
37
|
Ramsden V, Babl FE, Dalziel SR, Middleton S, Oakley E, Haskell L, Lithgow A, Orsini F, Schembri R, Wallace A, Wilson CL, McInnes E, Wilson PH, Tavender E. Sustainability of evidence-based practices in the management of infants with bronchiolitis in hospital settings - a PREDICT study protocol. BMC Health Serv Res 2022; 22:1099. [PMID: 36038929 PMCID: PMC9423692 DOI: 10.1186/s12913-022-08450-z] [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: 06/16/2022] [Accepted: 08/12/2022] [Indexed: 11/10/2022] Open
Abstract
Background Understanding how and why de-implementation of low-value practices is sustained remains unclear. The Paediatric Research in Emergency Departments International CollaboraTive (PREDICT) Bronchiolitis Knowledge Translation (KT) Study was a cluster randomised controlled trial conducted in 26 Australian and New Zealand hospitals (May-November 2017). Results showed targeted, theory-informed interventions (clinical leads, stakeholder meetings, train-the-trainer workshop, targeted educational package, audit/feedback) were effective at reducing use of five low-value practices for bronchiolitis (salbutamol, glucocorticoids, antibiotics, adrenaline and chest x-ray) by 14.1% in acute care settings. The primary aim of this study is to determine the sustainability (continued receipt of benefits) of these outcomes at intervention hospitals two-years after the removal of study supports. Secondary aims are to determine sustainability at one-year after removal of study support at intervention hospitals; improvements one-and-two years at control hospitals; and explore factors that influence sustainability at intervention hospitals and contribute to improvements at control hospitals. Methods A mixed-methods study design. The quantitative component is a retrospective medical record audit of bronchiolitis management within 24 hours of emergency department (ED) presentations at 26 Australian (n = 20) and New Zealand (n = 6) hospitals, which participated in the PREDICT Bronchiolitis KT Study. Data for a total of 1800 infants from intervention and control sites (up to 150 per site) will be collected to determine if improvements (i.e., no use of all five low-value practices) were sustained two- years (2019) post-trial (primary outcome; composite score); and a further 1800 infants from intervention and control sites will be collected to determine sustained improvements one- year (2018) post-trial (secondary outcome). An a priori definition of sustainability will be used. The qualitative component will consist of semi-structured interviews with three to five key emergency department and paediatric inpatient medical and nursing staff per site (total n = 78-130). Factors that may have contributed to sustaining outcomes and/or interventions will be explored and mapped to an established sustainability framework. Discussion This study will improve our understanding of the sustainability of evidence-based bronchiolitis management in infants. Results will also advance implementation science research by informing future de-implementation strategies to reduce low-value practices and sustain practice change in paediatric acute care. Trial registration Australian and New Zealand Clinical Trials Registry No: ACTRN12621001287820.
Collapse
Affiliation(s)
- Victoria Ramsden
- Australian Catholic University, 40 Edward Street, North Sydney, NSW, 2060, Australia.,Emergency Research, Murdoch Children's Research Institute, The Royal Children's Hospital, Level 4 West, 50 Flemington Road, Parkville, VIC, 3052, Australia.,University of Notre Dame, 160 Oxford Street, Darlinghurst, NSW, 2010, Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, The Royal Children's Hospital, Level 4 West, 50 Flemington Road, Parkville, VIC, 3052, Australia.,Emergency Department, The Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia.,Departments of Paediatrics and Critical Care, The University of Melbourne, Grattan Street, Parkville, VIC, 3010, Australia
| | - Stuart R Dalziel
- Departments of Surgery and Paediatrics, Child and Youth Health, University of Auckland, 28 Park Road, Grafton, Auckland, 1023, New Zealand.,Children's Emergency Department, Starship Children's Hospital, 2 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, and Australian Catholic University, Sydney, Australia.,St Vincent's Hospital, Level 5 DeLacy Building, Victoria Road, Darlinghurst, NSW, 2010, Australia
| | - Ed Oakley
- Emergency Research, Murdoch Children's Research Institute, The Royal Children's Hospital, Level 4 West, 50 Flemington Road, Parkville, VIC, 3052, Australia.,Emergency Department, The Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia.,Departments of Paediatrics and Critical Care, The University of Melbourne, Grattan Street, Parkville, VIC, 3010, Australia
| | - Libby Haskell
- Departments of Surgery and Paediatrics, Child and Youth Health, University of Auckland, 28 Park Road, Grafton, Auckland, 1023, New Zealand.,Children's Emergency Department, Starship Children's Hospital, 2 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Anna Lithgow
- Royal Darwin Hospital, 105 Rocklands Dr, Tiwi, Northern Territory, 0810, Australia
| | - Francesca Orsini
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials Centre, Murdoch Children's Research Institute, The Royal Children's Hospital, 50 Flemington Road, VIC, 3052, Parkville, Australia
| | - Rachel Schembri
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials Centre, Murdoch Children's Research Institute, The Royal Children's Hospital, 50 Flemington Road, VIC, 3052, Parkville, Australia
| | - Alexandra Wallace
- Departments of Surgery and Paediatrics, Child and Youth Health, University of Auckland, 28 Park Road, Grafton, Auckland, 1023, New Zealand.,Department of Paediatrics, Waikato Hospital, Selwyn St, Hamilton Central, Hamilton, 3204, New Zealand
| | - Catherine L Wilson
- Emergency Research, Murdoch Children's Research Institute, The Royal Children's Hospital, Level 4 West, 50 Flemington Road, Parkville, VIC, 3052, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne, and Australian Catholic University, Sydney, Australia
| | - Peter H Wilson
- Australian Catholic University, Building 460, Level 8, 250 Victoria Parade, East Melbourne, Victoria, 3002, Australia
| | - Emma Tavender
- Emergency Research, Murdoch Children's Research Institute, The Royal Children's Hospital, Level 4 West, 50 Flemington Road, Parkville, VIC, 3052, Australia. .,Departments of Paediatrics and Critical Care, The University of Melbourne, Grattan Street, Parkville, VIC, 3010, Australia.
| |
Collapse
|
38
|
Dalziel SR, Haskell L, O'Brien S, Borland ML, Plint AC, Babl FE, Oakley E. Bronchiolitis. Lancet 2022; 400:392-406. [PMID: 35785792 DOI: 10.1016/s0140-6736(22)01016-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 03/27/2022] [Accepted: 05/26/2022] [Indexed: 02/06/2023]
Abstract
Viral bronchiolitis is the most common cause of admission to hospital for infants in high-income countries. Respiratory syncytial virus accounts for 60-80% of bronchiolitis presentations. Bronchiolitis is diagnosed clinically without the need for viral testing. Management recommendations, based predominantly on high-quality evidence, advise clinicians to support hydration and oxygenation only. Evidence suggests no benefit with use of glucocorticoids or bronchodilators, with further evidence required to support use of hypertonic saline in bronchiolitis. Evidence is scarce in the intensive care unit. Evidence suggests use of high-flow therapy in bronchiolitis is limited to rescue therapy after failure of standard subnasal oxygen only in infants who are hypoxic and does not decrease rates of intensive care unit admission or intubation. Despite systematic reviews and international clinical practice guidelines promoting supportive rather than interventional therapy, universal de-implementation of interventional care in bronchiolitis has not occurred and remains a major challenge.
Collapse
Affiliation(s)
- Stuart R Dalziel
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand; Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.
| | - Libby Haskell
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand; Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
| | - Sharon O'Brien
- Emergency Department, Perth Children's Hospital, Perth, WA, Australia; School of Nursing, Curtin University, Perth, WA, Australia
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, WA, Australia; Division of Paediatrics, School of Medicine, University of Western Australia, Perth, WA, Australia; Division of Emergency Medicine, School of Medicine, University of Western Australia, Perth, WA, Australia
| | - Amy C Plint
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada; Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Emergency Department, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Franz E Babl
- Department of Emergency Medicine, Royal Children's Hospital, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Ed Oakley
- Department of Emergency Medicine, Royal Children's Hospital, Melbourne, VIC, Australia; Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia
| |
Collapse
|
39
|
Korppi M. Local healthcare professionals need to work together to implement bronchiolitis guidelines that stop unnecessary tests and treatments. Acta Paediatr 2022; 111:1319-1323. [PMID: 35263462 DOI: 10.1111/apa.16322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 11/27/2022]
Abstract
AIM This mini review summarised studies published over a 10-year period on the impact of guidelines for diagnosing and managing bronchiolitis in children, with a special focus on interventions that enhanced adherence during implementation. METHODS PubMed was searched from 1 December 2011 to 31 November 2021 for papers published in English that used the terms bronchiolitis, child or infant, guidelines and either implementation or impact. After the exclusion criteria had been applied, 27 articles were reviewed in more detail. Eight described protocols without any comparisons and were excluded. Ten of the 19 remaining studies evaluated the impact of bronchiolitis guidelines, and 9 examined the effects of interventions linked to their publication. RESULTS Just releasing evidence-based guidelines had a poor impact, but this improved when local tailored current care, clinical practice or best-practice guidelines were issued. Even better results were achieved when all the staff treating bronchiolitis patients participated in the preparation and implementation of local guidelines. Adherence to the guidelines was as high as 85% when multidisciplinary, and multifaceted interventions were used to complement the publication of guidelines. CONCLUSION Healthcare professionals need to work together to avoid children receiving bronchiolitis management that is unnecessary and not based on evidence.
Collapse
Affiliation(s)
- Matti Korppi
- Centre for Child Health Research Faculty of Medicine and Life Sciences University of Tampere and University Hospital Tampere Finland
| |
Collapse
|
40
|
Andina Martínez D, Escalada Pellitero S, Viaño Nogueira P, Alonso Cadenas JA, Martín Díaz MJ, de la Torre-Espi M, Jiménez García R. Decrease in the use of bronchodilators in the management of bronchiolitis after applying improvement initiatives. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2022; 96:476-484. [DOI: 10.1016/j.anpede.2021.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 05/05/2021] [Indexed: 11/29/2022] Open
|
41
|
Abstract
OBJECTIVES To evaluate the contribution of PICU care to increasing hospital charges for patients with bronchiolitis over a 10-year study period. DESIGN In this retrospective multicenter study, changes in annual hospital charges (adjusted for inflation) were analyzed using linear regression for subjects admitted to the PICU with invasive mechanical ventilation (PICU + IMV) and without IMV (PICU - IMV), and for children not requiring PICU care. SETTING Free-standing children's hospitals contributing to the Pediatric Health Information System (PHIS) database. SUBJECTS Children less than 2 years with bronchiolitis discharged from a PHIS hospital between July 2009 and June 2019. Subjects were categorized as high risk if they were born prematurely or had a chronic complex condition. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS PICU patients were 26.5% of the 283,006 included subjects but accrued 66% of the total $14.83 billion in charges. Annual charges increased from $1.01 billion in 2009-2010 to $2.07 billion in 2018-2019, and PICU patients accounted for 83% of this increase. PICU + IMV patients were 22% of all PICU patients and accrued 64% of all PICU charges, but PICU - IMV patients without a high-risk condition had the highest relative increase in annual charges, increasing from $76.7 million in 2009-2010 to $377.9 million in 2018-2019 (374% increase, ptrend < 0.001). CONCLUSIONS In a multicenter cohort study of children hospitalized with bronchiolitis, PICU patients, especially low-risk children without the need for IMV, were the highest driver of increased hospital charges over a 10-year study period.
Collapse
Affiliation(s)
- Katherine N Slain
- Department of Pediatrics, Division of Pediatric Critical Care, Rainbow Babies & Children's Hospital, Cleveland, OH
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Sindhoosha Malay
- Department of Pediatrics, Division of Pediatric Critical Care, Rainbow Babies & Children's Hospital, Cleveland, OH
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Steven L Shein
- Department of Pediatrics, Division of Pediatric Critical Care, Rainbow Babies & Children's Hospital, Cleveland, OH
- Case Western Reserve University School of Medicine, Cleveland, OH
| |
Collapse
|
42
|
Franklin D, Schibler A. Rising Intensive Care Costs in Bronchiolitis Infants-Is Nasal High Flow the Culprit? Pediatr Crit Care Med 2022; 23:218-222. [PMID: 35238842 DOI: 10.1097/pcc.0000000000002900] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Donna Franklin
- Gold Coast University Hospital, Children's Emergency and Critical Care Research, Southport, QLD, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
- The University of Queensland, Faculty of Medicine, Brisbane, QLD, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, VIC, Australia
- Wesley Medical Research, St Andrew's War Memorial Hospital, Brisbane, QLD, Australia
| | - Andreas Schibler
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, VIC, Australia
- Wesley Medical Research, St Andrew's War Memorial Hospital, Brisbane, QLD, Australia
| |
Collapse
|
43
|
Haskell L, Tavender EJ, O'Brien S, Wilson CL, Borland ML, Cotterell E, Babl FE, Zannino D, Sheridan N, Oakley E, Dalziel SR. Can targeted interventions change the factors influencing variation in management of infants with bronchiolitis? A survey of Australian and New Zealand clinicians: A paediatric research in emergency departments international collaborative (PREDICT) study. J Paediatr Child Health 2022; 58:302-311. [PMID: 34498782 DOI: 10.1111/jpc.15710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 08/17/2021] [Indexed: 11/29/2022]
Abstract
AIM This study aimed to determine whether targeted interventions, proven to be effective at improving evidence-based bronchiolitis management, changed factors previously found to influence variation in bronchiolitis management. METHODS This survey assessed change in factors influencing clinicians' (nurses and doctors) bronchiolitis management at baseline and post-intervention in a cluster randomised controlled trial of targeted, theory-informed interventions aiming to de-implement non-evidence-based bronchiolitis management (no use of chest X-ray, salbutamol, antibiotics, glucocorticoids and adrenaline). Survey questions addressed previously identified factors influencing bronchiolitis management from six Theoretical Domains Framework domains (knowledge; skills; beliefs about consequences; social/professional role and identity; environmental context and resources; social influences). Data analysis was descriptive. RESULTS A total of 1958 surveys (baseline = 996; post-intervention = 962) were completed by clinicians from the emergency department and paediatric inpatient units from 26 hospitals (intervention = 13; control = 13). Targeted bronchiolitis interventions significantly increased knowledge of the Australasian Bronchiolitis Guideline (intervention clinicians = 74%, control = 39%, difference = 34.7%, 95% confidence interval (CI) = 25.6-43.8%), improved skills in diagnosing (intervention doctors = 89%, control = 76%, difference = 12.6%, 95% CI = 6.2-19%) and managing bronchiolitis (intervention doctors = 87%, control = 76%, difference = 9.9%, 95% CI = 3.7-16.1%), positively influenced both beliefs about consequences regarding salbutamol use (intervention clinicians = 49%, control = 29%, difference = 20.3%, 95% CI = 13.2-27.4%) and nurses questioning non-evidence-based bronchiolitis management (chest X-ray: intervention = 71%, control = 51%, difference = 20.8%, 95% CI = 11.4-30.2%; glucocorticoids: intervention = 64%, control = 40%, difference = 21.9%, 95% CI = 10.4-33.5%) (social/professional role and identity). A 14% improvement in evidence-based bronchiolitis management favouring intervention hospitals was demonstrated in the cluster randomised controlled trial. CONCLUSION Targeted interventions positively changed factors influencing bronchiolitis management resulting in improved evidence-based bronchiolitis care. This study has important implications for improving bronchiolitis management and future development of interventions to de-implement low-value care.
Collapse
Affiliation(s)
- Libby Haskell
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Emma J Tavender
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Sharon O'Brien
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,School of Nursing, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Catherine L Wilson
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,Division of Emergency Medicine, School of Medicine, University of Western Australia, Perth, Western Australia, Australia.,Division of Paediatrics, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Elizabeth Cotterell
- Armidale Rural Referral Hospital, Armidale, New South Wales, Australia.,School of Rural Medicine, University of New England, Armidale, New South Wales, Australia
| | - Franz E Babl
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Diana Zannino
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials Centre, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | | | - Ed Oakley
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Critical Care, University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Paediatric Research in Emergency Departments International Collaborative (PREDICT), Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| |
Collapse
|
44
|
Ball M, Hilditch C, Hargreaves GA, Baulderstone D. Impact of initial flow rate of high-flow nasal cannula on clinical outcomes in infants with bronchiolitis. J Paediatr Child Health 2022; 58:141-145. [PMID: 34342375 DOI: 10.1111/jpc.15679] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 07/23/2021] [Indexed: 11/29/2022]
Abstract
AIM Bronchiolitis is a common condition in the paediatric population. Severe cases often receive respiratory support with high-flow nasal cannula (HFNC). Significant variation in the application of HFNC exists throughout Australia and internationally. This study aimed to determine if the flow rate used initially and when ceasing HFNC at the end of the illness alters clinical outcomes. METHODS A retrospective analysis was conducted of 251 children less than 12 months of age when admitted to the Women's and Children's Hospital Adelaide with bronchiolitis requiring HFNC therapy between the period of April 2016 to April 2019. The primary outcome was to determine if commencing HFNC therapy at different rates (1 L/kg/min, 1.5 L/kg/min and 2 L/kg/min) affected length of stay or treatment failure (escalation in physiological parameters or respiratory support). RESULTS Treatment failure occurred in 33%, 13% and 26% of those starting at 1 L/kg/min, 1.5 L/kg/min and 2 L/kg/min, respectively. Commencing HFNC therapy at 1 L/kg/min increased length of stay by an average of 30 h (P < 0.001) and the likelihood of treatment failure (P < 0.002) compared with starting at 1.5 L/kg/min. There was no statistical difference in outcomes between starting at 1.5 L/kg/min and 2 L/kg/min. There was no significant difference in the length of stay from the starting of weaning HFNC to time of discharge. CONCLUSIONS The commencing flow rates of initial HFNC therapy impact individual patient's outcomes, including length of stay and rates of treatment failure. Clinicians should consider commencing HFNC at 1.5 L/kg/min or 2 L/kg/min in infants that have failed low-flow oxygen therapy.
Collapse
Affiliation(s)
- Megan Ball
- Department of General Medicine, Women's and Children's Health Network, Adelaide, South Australia, Australia
| | - Cathie Hilditch
- Department of General Medicine, Women's and Children's Health Network, Adelaide, South Australia, Australia
| | - Garth A Hargreaves
- Department of General Medicine, Women's and Children's Health Network, Adelaide, South Australia, Australia
| | - David Baulderstone
- Department of General Medicine, Women's and Children's Health Network, Adelaide, South Australia, Australia
| |
Collapse
|
45
|
Andina‐Martinez D, Alonso‐Cadenas JA, Cobos‐Carrascosa E, Bodegas I, Oltra‐Benavent M, Plazaola A, Epalza C, Jimenez‐García R, Moraleda C, Tagarro A. SARS-CoV-2 acute bronchiolitis in hospitalized children: Neither frequent nor more severe. Pediatr Pulmonol 2022; 57:57-65. [PMID: 34664782 PMCID: PMC8661835 DOI: 10.1002/ppul.25731] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/03/2021] [Accepted: 10/14/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Endemic coronaviruses have been found in acute bronchiolitis, mainly as a coinfecting virus. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been responsible for respiratory illness in hospitalized children. The characteristics of patients with bronchiolitis have not been extensively described. METHODS Cross-sectional study of patients with bronchiolitis and SARS-CoV-2 infection enrolled in a prospective multicenter cohort of children hospitalized with COVID-19 in Spain from March 1, 2020 to February 28, 2021. RESULTS Twelve of 666 children infected with SARS-CoV-2 who required hospital admission met the diagnostic criteria for bronchiolitis (1.8%). Median age was 1.9 months (range: 0.4-10.1). Six cases had household contact with a confirmed or probable COVID-19 case. Main complaints were cough (11 patients), rhinorrhea (10), difficulty breathing (8), and fever (8). Eleven cases were classified as mild or moderate and one as severe. Laboratory tests performed in seven patients did not evidence anemia, lymphopenia, or high C-reactive protein levels. Chest X-rays were performed in six children, and one case showed remarkable findings. Coinfection with metapneumovirus was detected in the patient with the most severe course; Bordetella pertussis was detected in another patient. Seven patients required oxygen therapy. Albuterol was administered in four patients. One patient was admitted to the pediatric intensive care unit. Median length of admission was 4 days (range: 3-14). No patient died or showed any sequelae at discharge. Two patients developed recurrent bronchospasms. CONCLUSION SARS-CoV-2 infection does not seem to be a main trigger of severe bronchiolitis, and children with this condition should be managed according to clinical practice guidelines.
Collapse
Affiliation(s)
| | | | - Elena Cobos‐Carrascosa
- Research Institute Hospital 12 de Octubre in Madrid (i+12)Foundation for Biomedical Research of the 12 de Octubre HospitalMadridSpain
| | - Inmaculada Bodegas
- Department of PediatricsQuiron Salud Madrid University HospitalMadridSpain
| | | | - Ane Plazaola
- Paediatric DepartmentHospital Infanta SofíaMadridSpain
| | - Cristina Epalza
- Research Institute Hospital 12 de Octubre in Madrid (i+12)Foundation for Biomedical Research of the 12 de Octubre HospitalMadridSpain
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Universitario 12 de Octubre, Universidad ComplutensePediatric Research and Clinical Trials Unit (UPIC)MadridSpain
| | | | - Cinta Moraleda
- Research Institute Hospital 12 de Octubre in Madrid (i+12)Foundation for Biomedical Research of the 12 de Octubre HospitalMadridSpain
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Universitario 12 de Octubre, Universidad ComplutensePediatric Research and Clinical Trials Unit (UPIC)MadridSpain
| | - Alfredo Tagarro
- Research Institute Hospital 12 de Octubre in Madrid (i+12)Foundation for Biomedical Research of the 12 de Octubre HospitalMadridSpain
- Hospital Universitario Infanta SofíaUniversidad Europea de MadridMadridSpain
| | | |
Collapse
|
46
|
Courtney A, Bernard A, Burgess S, Davies K, Foster K, Kapoor V, Levitt D, Sly PD. Bolus Versus Continuous Nasogastric Feeds for Infants With Bronchiolitis: A Randomized Trial. Hosp Pediatr 2022; 12:1-10. [PMID: 34927683 DOI: 10.1542/hpeds.2020-005702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Infants hospitalized with bronchiolitis are commenced on nasogastric feeding to maintain hydration. Feeding strategies vary according to physician or institution preference. The current study hypothesized that continuous nasogastric feeding would prolong length of stay (LOS) when compared to bolus feeding. METHODS A randomized, parallel-group, superiority clinical trial was performed within an Australian children's hospital throughout 2 bronchiolitis seasons from May 2018 to October 2019. Infants <12 months hospitalized with bronchiolitis and requiring supplemental nasogastric feeding were randomly assigned to continuous or bolus nasogastric regimens. LOS was the primary outcome. Secondary outcome measures included pulmonary aspirations and admissions to intensive care. RESULTS The intention-to-treat analysis included 189 patients: 98 in the bolus nasogastric feeding group and 91 in the continuous group. There was no significant difference in LOS (median LOS of the bolus group was 54.25 hours [interquartile range 40.25-82] and 56 hours [interquartile range 38-78.75] in the continuous group). A higher proportion of admissions to intensive care was detected in the continuous group (28.57% [26 of 91] of the continuous group vs 11.22% [11 of 98] of the bolus group [P value 0.004]). There were no clinically significant pulmonary aspirations or statistically significant differences in vital signs between the groups within 6 hours of feed initiation. CONCLUSIONS No significant difference in LOS was found between bolus and continuous nasogastric feeding strategies for infants hospitalized with bronchiolitis. The continuous feeding group had a higher proportion of intensive care admissions, and there were no aspiration events.
Collapse
Affiliation(s)
- Alyssa Courtney
- Queensland Children's Hospital, South Brisbane, Queensland, Australia.,The University of Queensland, Queensland, Australia
| | - Anne Bernard
- The University of Queensland, Queensland, Australia.,Queensland Cyber Infrastructure Foundation (QCIF) Facility for Advanced Bioinformatics, Institute for Molecular Bioscience, The University of Queensland, Queensland, Australia
| | - Scott Burgess
- Queensland Children's Hospital, South Brisbane, Queensland, Australia.,The University of Queensland, Queensland, Australia.,Queensland Children's Lung and Sleep Specialists, Queensland, Australia
| | - Katie Davies
- Queensland Children's Hospital, South Brisbane, Queensland, Australia.,The University of Queensland, Queensland, Australia
| | - Kelly Foster
- Queensland Children's Hospital, South Brisbane, Queensland, Australia.,University of Southern Queensland, Ipswich, Queensland, Australia
| | - Vishal Kapoor
- Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - David Levitt
- Queensland Children's Hospital, South Brisbane, Queensland, Australia.,The University of Queensland, Queensland, Australia
| | - Peter D Sly
- Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Children's Health and Environment Program, Child Health Research Centre University of Queensland, Queensland, Australia
| |
Collapse
|
47
|
Bottau P, Liotti L, Laderchi E, Palpacelli A, Calamelli E, Colombo C, Serra L, Cazzato S. Something Is Changing in Viral Infant Bronchiolitis Approach. Front Pediatr 2022; 10:865977. [PMID: 35498813 PMCID: PMC9047867 DOI: 10.3389/fped.2022.865977] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/23/2022] [Indexed: 11/13/2022] Open
Abstract
Acute Viral Bronchiolitis is one of the leading causes of hospitalization in the first 12-24 months of life. International guidelines on the management of bronchiolitis broadly agree in recommending a minimal therapeutic approach, not recommending the use of bronchodilators. Guidelines, generally, consider bronchiolitis as a "unique disease" and this runs the risk of not administering therapy in some patients who could benefit from the use of bronchodilators, for instance, in those who will develop asthma later in their life and face first episode in the age of bronchiolitis. Today, there is growing evidence that bronchiolitis is not a single illness but can have different "endotypes" and "phenotypes," based on age, personal or family history of atopy, etiology, and pathophysiological mechanism. There is evidence that some phenotypes of bronchiolitis are more strongly associated with asthma features and are linked to higher risk for asthma development. In these populations, possible use of bronchodilators might have a better impact. Age seems to be the main feature to suggest a good response to a bronchodilator-trial, because, among children > 6 months old with bronchiolitis, the presence of a subset of patients with virus-induced wheezing or the first episode of asthma is more likely. While waiting for new research to define the relationship between therapeutic options and different phenotypes, a bronchodilator-trial (using short-acting β2 agonists with metered-dose inhalers and valved holding chambers) seems appropriate in every child with bronchiolitis and age > 6 months.
Collapse
Affiliation(s)
- Paolo Bottau
- Pediatric and Neonatology Unit, Imola Hospital, Imola, Italy
| | - Lucia Liotti
- Pediatric Unit, Department of Mother and Child Health, Salesi Children's Hospital, Ancona, Italy
| | - Eleonora Laderchi
- Postgraduate School of Pediatrics, University of Bologna, Bologna, Italy
| | - Alessandra Palpacelli
- Pediatric Unit, Department of Mother and Child Health, Salesi Children's Hospital, Ancona, Italy
| | | | - Carlotta Colombo
- Postgraduate School of Pediatrics, University of Bologna, Bologna, Italy
| | - Laura Serra
- Pediatric and Neonatology Unit, Imola Hospital, Imola, Italy
| | - Salvatore Cazzato
- Pediatric Unit, Department of Mother and Child Health, Salesi Children's Hospital, Ancona, Italy
| |
Collapse
|
48
|
Sander B, Finkelstein Y, Lu H, Nagamuthu C, Graves E, Ramsay LC, Kwong JC, Schuh S. Healthcare cost attributable to bronchiolitis: A population-based cohort study. PLoS One 2021; 16:e0260809. [PMID: 34855892 PMCID: PMC8639079 DOI: 10.1371/journal.pone.0260809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 11/17/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To determine 1-year attributable healthcare costs of bronchiolitis. METHODS Using a population-based matched cohort and incidence-based cost analysis approach, we identified infants <12 months old diagnosed in an emergency department (ED) or hospitalized with bronchiolitis between April 1, 2003 and March 31, 2014. We propensity-score matched infants with and without bronchiolitis on sex, age, income quintile, rurality, co-morbidities, gestational weeks, small-for-gestational-age status and pre-index healthcare cost deciles. We calculated mean attributable 1-year costs using a generalized estimating equation model and stratified costs by age, sex, income quintile, rurality, co-morbidities and prematurity. RESULTS We identified 58,375 infants with bronchiolitis (mean age 154±95 days, 61.3% males, 4.2% with comorbidities). Total 1-year mean bronchiolitis-attributable costs were $4,313 per patient (95%CI: $4,148-4,477), with $2,847 (95%CI: $2,712-2,982) spent on hospitalizations, $610 (95%CI: $594-627) on physician services, $562 (95%CI: $556-567)] on ED visits, $259 (95%CI: $222-297) on other healthcare costs and $35 ($27-42) on drugs. Attributable bronchiolitis costs were $2,765 (95%CI: $2735-2,794) vs $111 (95%CI: $102-121) in the initial 10 days post index date, $4,695 (95%CI: $4,589-4,800) vs $910 (95%CI: $847-973) in the initial 180 days and $1,158 (95%CI: $1,104-1213) vs $639 (95%CI: $599-679) during days 181-360. Mean 1-year bronchiolitis costs were higher in infants <3 months old [$5,536 (95%CI: $5,216-5,856)], those with co-morbidities [$17,530 (95%CI: $14,683-20,377)] and with low birthweight [$5,509 (95%CI: $4,927-6,091)]. CONCLUSIONS Compared to no bronchiolitis, bronchiolitis incurs five-time and two-time higher healthcare costs within the initial and subsequent six-months, respectively. Most expenses occur in the initial 10 days and relate to hospitalization.
Collapse
Affiliation(s)
- Beate Sander
- University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
- * E-mail:
| | - Yaron Finkelstein
- University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Research Institute, Division of Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Hong Lu
- ICES, Toronto, Ontario, Canada
| | | | | | - Lauren C. Ramsay
- University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey C. Kwong
- University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
| | - Suzanne Schuh
- University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
- Research Institute, Division of Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| |
Collapse
|
49
|
Gill PJ, Anwar MR, Kornelsen E, Parkin P, Mahood Q, Mahant S. Parenteral versus enteral fluid therapy for children hospitalised with bronchiolitis. Cochrane Database Syst Rev 2021; 12:CD013552. [PMID: 34852398 PMCID: PMC8635777 DOI: 10.1002/14651858.cd013552.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The main focus of treatment for children hospitalised with bronchiolitis is supportive, including oxygen supplementation, respiratory support, and fluid therapy. Up to half of infants hospitalised with bronchiolitis require non-oral fluid therapy due to dehydration or concerns related to the safety of oral feeding. The two main modalities used for non-oral fluid therapy are parenteral (intravenous (IV)) and enteral tube (nasogastric (NG) or orogastric (OG)). However, it is not known which mode is optimal in young children. OBJECTIVES To systematically review randomised clinical trials (RCTs) of the effectiveness and safety of parenteral and enteral tube fluid therapy for children under two years of age hospitalised with bronchiolitis. SEARCH METHODS We conducted a search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, Web of Science, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 8 March 2021. We handsearched conference proceedings, conducted forward and backward searching of citation lists of relevant articles, and contacted experts. SELECTION CRITERIA We included RCTs and quasi-RCTs of children aged up to two years admitted to hospital with a clinical diagnosis of bronchiolitis who required fluid therapy. The trials compared enteral tube fluid therapy with parenteral fluid therapy. The primary outcome was difference in length of hospital stay in hours after each non-oral fluid therapy modality. As actual time of discharge can be impacted by various factors, we also assessed theoretical length of stay (i.e. time when a patient is safe for discharge). We assessed several secondary outcomes. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS: The searches yielded 615 unique records, of which four articles underwent full-text screening. We included two trials (810 children). Oakley 2013 was an open, non-blinded RCT of infants aged two to 12 months admitted to hospitals in Australia and New Zealand with a clinical diagnosis of bronchiolitis during three bronchiolitis seasons. The trial enrolled 759 children, of which 381 were randomised to NG tube therapy and 378 to IV therapy. Risk of bias was low in most domains. Kugelman 2013 was an open, non-blinded RCT that enrolled infants aged less than six months with a clinical diagnosis of "moderate bronchiolitis" at a single hospital in Israel. The study enrolled 51 infants, of which 31 were assigned to NG or OG tube therapy and 20 to IV therapy. Risk of bias was unclear in most domains. The application of enteral tube fluid therapy compared to IV fluid therapy probably makes little to no difference for actual length of hospital stay (mean difference (MD) 6.8 hours, 95% confidence interval (CI) -4.7 to 18.4 hours; 2 studies, 810 children, moderate certainty evidence). There was also little to no difference for theoretical length of stay (MD 4.4 hours, 95% CI -3.6 to 12.4 hours; 2 studies, 810 children, moderate certainty evidence). For the secondary outcomes, enteral tube fluid therapy probably makes little to no difference for time to resume full oral feeding compared to IV fluid therapy (MD 2.8 hours, 95% CI -3.6 to 9.2 hours; 2 studies, 810 children, moderate certainty evidence). The use of enteral tube for fluid therapy probably results in a large increase in the success of insertion of fluid modality at first attempt (risk ratio (RR) 1.52, 95% CI 1.36 to 1.69; 1 study, 617 children, moderate certainty evidence), and probably largely reduces the chances of change in fluid therapy modality (RR 0.52, 95% CI 0.38 to 0.71; 1 study, 759 children, moderate certainty evidence) compared to IV fluid. Oakley 2013 reported 47 local complication events after discharge in the IV fluid group compared to 30 events in the NG tube group. They also evaluated parental satisfaction, which was high with both modalities. Enteral tube fluid therapy makes little to no difference to the duration of oxygen supplementation (MD 2.2 hours, 95% CI -5.0 to 9.5 hours; 2 studies, 810 children, moderate certainty evidence). Compared with the IV fluid therapy group, there was a 17% relative reduction in the number of intensive care unit admissions (RR 0.83, 95% CI 0.47 to 1.46; 1 study, 759 children, moderate certainty evidence) and a 19% relative reduction in number of readmissions to hospital (RR 0.81, 95% CI 0.33 to 2.04; 1 study, 678 children, moderate certainty evidence) in the enteral tube fluid therapy group. Adverse events were uncommon in both trials, with likely little to no differences between groups. AUTHORS' CONCLUSIONS Based on two RCTs, enteral tube feeding likely results in little to no difference in length of hospital stay compared with the IV fluid group. However, enteral tube fluid therapy likely results in a large increase in the success of insertion of fluid modality at first attempt, and a large reduction in change in modality of fluid therapy. It also probably reduces local complications compared to the IV fluid group. Despite bronchiolitis being one of the most prevalent childhood conditions, we identified only two studies with under 1000 participants in total, which highlights the need for multicentre trials. Future studies should explore type of fluid administered, parent-reported outcomes and preferences, and the role of shared decision-making.
Collapse
Affiliation(s)
- Peter J Gill
- Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Mohammed Rashidul Anwar
- Child Health Evaluation Sciences, The Hospital for Sick Children (SickKids), Toronto, Canada
| | | | - Patricia Parkin
- Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Quenby Mahood
- The Hospital for Sick Children (SickKids), Toronto, Canada
| | - Sanjay Mahant
- Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| |
Collapse
|
50
|
Haskell L, Tavender EJ, O'Brien S, Wilson CL, Babl FE, Borland ML, Schembri R, Orsini F, Cotterell E, Sheridan N, Oakley E, Dalziel SR. Process evaluation of a cluster randomised controlled trial to improve bronchiolitis management - a PREDICT mixed-methods study. BMC Health Serv Res 2021; 21:1282. [PMID: 34844605 PMCID: PMC8628472 DOI: 10.1186/s12913-021-07279-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bronchiolitis is the most common reason for hospitalisation in infants. All international bronchiolitis guidelines recommend supportive care, yet considerable variation in practice continues with infants receiving non-evidence based therapies. We developed six targeted, theory-informed interventions; clinical leads, stakeholder meeting, train-the-trainer, education delivery, other educational materials, and audit and feedback. A cluster randomised controlled trial (cRCT) found the interventions to be effective in reducing use of five non-evidence based therapies in infants with bronchiolitis. This process evaluation paper aims to determine whether the interventions were implemented as planned (fidelity), explore end-users' perceptions of the interventions and evaluate cRCT outcome data with intervention fidelity data. METHODS A pre-specified mixed-methods process evaluation was conducted alongside the cRCT, guided by frameworks for process evaluation of cRCTs and complex interventions. Quantitative data on the fidelity, dose and reach of interventions were collected from the 13 intervention hospitals during the study and analysed using descriptive statistics. Qualitative data identifying perception and acceptability of interventions were collected from 42 intervention hospital clinical leads on study completion and analysed using thematic analysis. RESULTS The cRCT found targeted, theory-informed interventions improved bronchiolitis management by 14.1%. The process evaluation data found variability in how the intervention was delivered at the cluster and individual level. Total fidelity scores ranged from 55 to 98% across intervention hospitals (mean = 78%; SD = 13%). Fidelity scores were highest for use of clinical leads (mean = 98%; SD = 7%), and lowest for use of other educational materials (mean = 65%; SD = 19%) and audit and feedback (mean = 65%; SD = 20%). Clinical leads reflected positively about the interventions, with time constraints being the greatest barrier to their use. CONCLUSION Our targeted, theory-informed interventions were delivered with moderate fidelity, and were well received by clinical leads. Despite clinical leads experiencing challenges of time constraints, the level of fidelity had a positive effect on successfully de-implementing non-evidence-based care in infants with bronchiolitis. These findings will inform widespread rollout of our bronchiolitis interventions, and guide future practice change in acute care settings. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry: ACTRN12616001567415 .
Collapse
Affiliation(s)
- Libby Haskell
- Children's Emergency Department, Starship Children's Hospital, Private Bag, Auckland, 92019, New Zealand.,Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Emma J Tavender
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Melbourne, VIC, Australia.,Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia
| | - Sharon O'Brien
- Emergency Department, Perth Children's Hospital, Perth, WA, Australia.,Curtin University, Perth, WA, Australia
| | - Catherine L Wilson
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Franz E Babl
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Melbourne, VIC, Australia.,Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia.,Emergency Department, The Royal Children's Hospital, Melbourne, Australia
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, WA, Australia.,Divisions of Emergency Medicine and Paediatrics, School of Medicine, University of Western Australia, Perth, WA, Australia
| | - Rachel Schembri
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials, Centre, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Francesca Orsini
- Clinical Epidemiology and Biostatistics, Melbourne Children's Trials, Centre, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Elizabeth Cotterell
- Armidale Rural Referral Hospital, Armidale, NSW, Australia.,School of Rural Medicine, University of New England, Armidale, NSW, Australia
| | | | - Ed Oakley
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Melbourne, VIC, Australia.,Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia.,Emergency Department, The Royal Children's Hospital, Melbourne, Australia
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Private Bag, Auckland, 92019, New Zealand. .,Departments of Surgery and Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.
| | | |
Collapse
|