How do we treat wheezing infants? Evidence or anecdote

European Respiratory Society statement on preschool wheezing disorders: updated definitions, knowledge gaps and proposed future research directions

Since the publication of the European Respiratory Society (ERS) task force reports on the management of preschool wheezing in 2008 and 2014, a large body of evidence has accumulated suggesting that the clinical phenotypes that were proposed (episodic (viral) wheezing and multiple-trigger wheezing) do not relate to underlying airway pathology and may not help determine response to treatment. Specifically, using clinical phenotypes alone may no longer be appropriate, and new approaches that can be used to inform clinical care are needed for future research. This ERS task force reviewed the literature published after 2008 related to preschool wheezing and has suggested that the criteria used to define wheezing disorders in preschool children should include age of diagnosis (0 to <6 years), confirmation of wheezing on at least one occasion, and more than one episode of wheezing ever. Furthermore, diagnosis and management may be improved by identifying treatable traits, including inflammatory biomarkers (blood eosinophils, aeroallergen sensitisation) associated with type-2 immunity and differential response to inhaled corticosteroids, lung function parameters and airway infection. However, more comprehensive use of biomarkers/treatable traits in predicting the response to treatment requires prospective validation. There is evidence that specific genetic traits may help guide management, but these must be adequately tested. In addition, the task force identified an absence of caregiver-reported outcomes, caregiver/self-management options and features that should prompt specialist referral for this age group. Priorities for future research include a focus on identifying 1) mechanisms driving preschool wheezing; 2) biomarkers of treatable traits and efficacy of interventions in those without allergic sensitisation/eosinophilia; 3) the need to include both objective outcomes and caregiver-reported outcomes in clinical trials; 4) the need for a suitable action plan for children with preschool wheezing; and 5) a definition of severe/difficult-to-treat preschool wheezing.

Using multifaceted education to improve management in acute viral bronchiolitis

OBJECTIVE

To establish current bronchiolitis management across hospitals in Wales, improve compliance with national guidelines and standardise evidence-based clinical practice.

DESIGN

A complete audit cycle with implementation of a multifaceted education bundle prior to the follow-up audit.

SETTING

Twelve acute paediatric departments between 1 November and 31 December in 2012 and 2013.

PATIENTS

All infants under 12 months with a clinical diagnosis of bronchiolitis.

INTERVENTIONS

The first audit assessed management of bronchiolitis with reference to both the Scottish Intercollegiate Guideline Network (SIGN) guidelines and local hospital guidelines. Following analysis and dissemination of these results, an education bundle was implemented nationwide, with completion of the audit cycle to assess change.

MAIN OUTCOME MEASURES

Compliance with SIGN recommendations for investigation, treatment and discharge. Compliance with the education bundle requirements also assessed in 2013.

RESULTS

Data were collected for 1599 infants. The education bundle was delivered in all hospitals. The level of severity, defined by oxygen saturations in air at presentation, length of stay and paediatric intensive care unit transfers, was equivalent for both years. Mean compliance percentage (95% CI) across Wales significantly improved between 2012 and 2013, with compliance with investigations increasing from 50% (46% to 53%) to 71% (68% to 74%), with management increasing from 65% (61% to 68%) to 74% (71% to 77%), and overall compliance improving from 38% (37% to 39%) to 59% (56% to 62%) in 2013.

CONCLUSIONS

This audit demonstrated a significant improvement in compliance following implementation of our educational bundle. This has enabled improvement in standardised and evidence-based patient care across Wales.

Impact of a bronchiolitis clinical care pathway on treatment and hospital stay

Bronchiolitis is a common lower respiratory tract infection of infancy where management has varied considerably in the past. The aim of the present study was to determine whether patient treatment and outcomes changed after introduction of a clinical care pathway. Infants aged up to 6 months admitted to hospital with bronchiolitis were identified as part of an annual audit of bronchiolitis management between winters 2003/2004 and 2009/2010. The primary outcome, duration of stay (DOS), was compared before and after the clinical pathway was introduced before the winter 2005/2006. There were 328 infants identified, mean age 75 days, respiratory syncitial virus was detected in 89%. After the clinical pathway was introduced, the proportion of infants prescribed salbutamol fell from 50% to 8% (p < 0.001) and ipratropium bromide from 38% to 0% (p < 0.001) but the proportion prescribed antibiotics was unchanged. The median DOS was 79 h prior to the clinical pathway and 66 h afterwards (p = 0.010) but there was no difference in days where supplemental oxygen or nasogastric feeding was required.

CONCLUSIONS

A clinical pathway for the management of acute bronchiolitis can be implemented in the hospital setting and the conservative approach, in particular not prescribing bronchodilators, is not associated with prolonged duration of stay.

A bronchiolitis integrated care pathway for children

There is currently no standard in the UK for the management and prevention of bronchiolitis, leading to widespread variation in the management of infants. The authors feel that existing guidelines are not followed as a result of a lack of understanding and motivation to ensure that the necessary services and funding are available to manage patients according to recommendations. This pathway was developed to facilitate the implementation of standardized care for infants with or at risk for bronchiolitis. The integrated care pathway (ICP) for bronchiolitis was developed by a multidisciplinary steering group over the course of four facilitated workshops. During these workshops the steering group defined the ideal patient journey and then detailed each of the steps in the pathway with the information that should be assessed and collected to optimally manage patients. The results of the pathway development process and the ICP itself are the process map, ICP forms and the evidence review including commissioning outcomes. This ICP for bronchiolitis is based on expert consensus, multistakeholder input and a critique of published evidence. The steering group urges health professionals to work together across networks to improve the care for children both at risk for and with bronchiolitis.

Regular vs prn nebulized treatment in wheeze preschool children

BACKGROUND

International guidelines recommend regular treatment with inhaled glucocorticoids for children with frequent wheezing; however, prn inhaled bronchodilator alone or in combination with glucocorticoid is also often used in practice. We aimed to evaluate whether regular nebulized glucocorticoid plus a prn bronchodilator or a prn nebulized bronchodilator/glucocorticoid combination is more effective than prn bronchodilator alone in preschool children with frequent wheeze.

METHODS

Double-blind, double-dummy, randomized, parallel-group trial. After a 2-week run-in period, 276 symptomatic children with frequent wheeze, aged 1-4 years, were randomly assigned to three groups for a 3-month nebulized treatment: (1) 400 microg beclomethasone bid plus 2500 microg salbutamol prn; (2) placebo bid plus 800 microg beclomethasone/1600 microg salbutamol combination prn; (3) placebo bid plus 2500 microg salbutamol prn. The percentage of symptom-free days was the primary outcome measure. Secondary outcomes included symptom scores, use of relief medication and exacerbation frequency.

RESULTS

As compared with prn salbutamol (61.0 +/- 24.83 [SD]), the percentage of symptom-free days was higher with regular beclomethasone (69.6%, SD 20.89; P = 0.034) but not with prn combination (64.9%, SD 24.74). Results were no different in children with or without risk factors for developing persistent asthma. The effect of prn combination was no different from that of regular beclomethasone on the primary and on several important secondary outcomes.

CONCLUSIONS

Regular inhaled glucocorticoid is the most effective treatment for frequent wheezing in preschool children. However, prn bronchodilator/glucocorticoid combination might be an alternative option, but it requires further study.

Persistent cough and failure to thrive: a presentation of foreign body aspiration in a child with asthma

Severe failure to thrive (FTT) in a child with asthma and a persistent cough should not be explained solely by asthma and warrants a thorough and prompt evaluation. The finding of a foreign body in our case was surprising, because it does not usually present as or lead to FTT. Good clinical judgment and habits could prevent the course of events that we described in this case. Following are the key lessons to be learned from this presentation: (1) maintain a high index of suspicion for foreign body aspiration, even in toddlers with asthma, (2) pay special attention to a child with FTT, (3) be aware of localizing findings on physical examination and chest radiographs, and (4) perform a chest radiograph no later than after 1 month of chronic cough.

Virus-induced airway dysfunction: pathogenesis and biomechanisms

BACKGROUND

Viral respiratory tract infections cause significant morbidity and mortality. Respiratory viruses are suspected to play a role in the inception of asthma early in life. Respiratory syncytial virus (RSV) is the most common cause of infant bronchiolitis, which is associated with the development of childhood wheezing and asthma. However, it is not clear whether this association is "causal" or "circumstantial."

METHODS

Animal models have been pivotal in studying the pathophysiology of viral respiratory infections. Various approaches to assessing airway inflammation and function have been used to define the mechanisms of virus-induced airway dysfunction and to address clinically relevant questions regarding the role of RSV in wheezing and asthma after bronchiolitis.

RESULTS

Viral lower respiratory tract infections alter airway function in humans and animals. The extent and duration of the alterations may depend on the virus itself, host factors and environmental factors. Animal studies demonstrated that viral infection induces airway hyperresponsiveness and enhances this alteration in the allergen-sensitized and exposed host. This altered airway function is mediated by immune and neurogenic inflammatory mechanisms. Recent studies in mice show that neonatal RSV infection sensitizes the newborn to develop an asthma-like phenotype on reinfection, providing further opportunities to investigate the role of RSV in postbronchiolitis wheezing and asthma in this animal model.

CONCLUSIONS

Further studies are needed to fully establish the mechanisms underlying the pathophysiology of viral respiratory tract infections and to clarify their role in the inception and/or progression of chronic airway diseases such as asthma. The results of ongoing therapeutic studies promise to minimize the impact of such viral infections.