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Peña-López Y, Sabater-Riera J, Raj P. Severe respiratory syncytial virus disease. JOURNAL OF INTENSIVE MEDICINE 2024; 4:405-416. [PMID: 39310066 PMCID: PMC11411437 DOI: 10.1016/j.jointm.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 03/05/2024] [Accepted: 03/05/2024] [Indexed: 09/25/2024]
Abstract
The burden of respiratory syncytial virus (RSV) disease is widely recognized. Main risk factors for severe disease, such as extreme ages, chronic cardiopulmonary conditions, and immunosuppression, typically coincide with poorer outcomes. While the majority of RSV hospitalizations involve healthy children, a higher proportion of hospitalized adults with underlying conditions need intensive care. Presently, treatment primarily consists of supportive measures. RSV-induced wheezing should be distinguished from respiratory tract thickening, without response to bronchodilators. Obstructive RSV disease frequently overlaps with viral pneumonia. Non-invasive mechanical ventilation and high-flow oxygen therapy represented significant advancements in the management of severe RSV disease in children and may also hold considerable importance in specific phenotypes of RSV disease in adults. Most severe infections manifest with refractory hypoxemia necessitating more advanced ventilatory support and/or extracorporeal membrane oxygenation therapy. Although bacterial co-infection rates are low, they have been associated with worse outcomes. Antibiotic prescription rates are high. Accurately diagnosing bacterial co-infections remains a challenge. Current evidence and antibiotic stewardship policies advise against indiscriminate antibiotic usage, even in severe cases. The role of currently developing antiviral therapies in severe RSV disease will be elucidated in the coming years, contingent upon the success of new vaccines and immune passive strategies involving nirsevimab.
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Affiliation(s)
- Yolanda Peña-López
- Microbiome Research Laboratory (MRL), Department of Immunology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Pediatric Critical Care Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
- Global Health eCore, Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Joan Sabater-Riera
- Intensive Care Department, Servei de Medicina Intensiva, IDIBELL-Hospital Universitari de Bellvitge, L´Hospitalet de Llobregat, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - Prithvi Raj
- Microbiome Research Laboratory (MRL), Department of Immunology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Mazur NI, Caballero MT, Nunes MC. Severe respiratory syncytial virus infection in children: burden, management, and emerging therapies. Lancet 2024; 404:1143-1156. [PMID: 39265587 DOI: 10.1016/s0140-6736(24)01716-1] [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] [Received: 05/16/2024] [Revised: 07/25/2024] [Accepted: 08/16/2024] [Indexed: 09/14/2024]
Abstract
The global burden of respiratory syncytial virus (RSV) lower respiratory tract infection (LRTI) in young children is high. The RSV prevention strategies approved in 2023 will be essential to lowering the global disease burden. In this Series paper, we describe clinical presentation, burden of disease, hospital management, emerging therapies, and targeted prevention focusing on developments and groundbreaking publications for RSV. We conducted a systematic search for literature published in the past 15 years and used a non-systematic approach to analyse the results, prioritising important papers and the most recent reviews per subtopic. Annually, 33 million episodes of RSV LRTI occur in children younger than 5 years, resulting in 3·6 million hospitalisations and 118 200 deaths. RSV LRTI is a clinical diagnosis but a clinical case definition and universal clinical tool to predict severe disease are non-existent. The advent of molecular point-of-care testing allows rapid and accurate confirmation of RSV infection and could reduce antibiotic use. There is no evidence-based treatment of RSV, only supportive care. Despite widespread use, evidence for high-flow nasal cannula (HFNC) therapy is insufficient and increased paediatric intensive care admissions and intubation indicate the need to remove HFNC therapy from standard care. RSV is now a vaccine-preventable disease in young children with a market-approved long-acting monoclonal antibody and a maternal vaccine targeting the RSV prefusion protein. To have a high impact on life-threatening RSV infection, infants at high risk, especially in low-income and middle-income countries, should be prioritised as an interim strategy towards universal immunisation. The implementation of RSV preventive strategies will clarify the full burden of RSV infection. Vaccine probe studies can address existing knowledge gaps including the effect of RSV prevention on transmission dynamics, antibiotic misuse, the respiratory microbiome composition, and long-term sequalae.
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Affiliation(s)
- Natalie I Mazur
- Department of Pediatrics, Wilhelmina Children's Hospital, Utrecht, Netherlands.
| | - Mauricio T Caballero
- Centro INFANT de Medicina Traslacional (CIMeT), Escuela de Bio y Nanotecnología, Universidad Nacional de San Martín (UNSAM), Buenos Aires, Argentina; Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
| | - Marta C Nunes
- Center of Excellence in Respiratory Pathogens, Hospices Civils de Lyon and Centre International de Recherche en Infectiologie, Équipe Santé Publique, Épidémiologie et Écologie Évolutive des Maladies Infectieuses, Inserm U1111, CNRS UMR5308, ENS de Lyon, Lyon, France; South African Medical Research Council, Vaccines & Infectious Diseases Analytics Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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3
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Nijman RG, Cadman E, Maconochie I. Emerging art of doing less. Arch Dis Child 2024; 109:775-776. [PMID: 38041657 DOI: 10.1136/archdischild-2023-326437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/16/2023] [Indexed: 12/03/2023]
Affiliation(s)
- Ruud Gerard Nijman
- Section of Paediatric Infectious Diseases, Imperial College London, London, UK
- Department of Paediatric Emergency Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Emily Cadman
- Department of Paediatric Emergency Medicine, Imperial College Healthcare NHS Trust, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Ian Maconochie
- Department of Paediatric Emergency Medicine, Imperial College Healthcare NHS Trust, London, UK
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Schmidt MN, Daugberg R, Nygaard U, Nielsen XC, Chawes B, Rytter MH, Schoos AMM. Normal saline for children with bronchiolitis: study protocol for a randomised controlled non-inferiority trial. BMJ Paediatr Open 2024; 8:e002273. [PMID: 38233083 PMCID: PMC10806597 DOI: 10.1136/bmjpo-2023-002273] [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: 09/15/2023] [Accepted: 12/14/2023] [Indexed: 01/19/2024] Open
Abstract
INTRODUCTION Bronchiolitis is one of the most common reasons for hospital admissions in early childhood. As supportive treatment, some treatment guidelines suggest using nasal irrigation with normal saline (NS) to facilitate clearance of mucus from the airways. In addition, most paediatric departments in Denmark use nebulised NS for the same purpose, which can mainly be administered as inpatient care. However, no studies have ever directly tested the effect of saline in children with bronchiolitis. METHODS AND ANALYSIS The study is an investigator-initiated, multicentre, open-label, randomised, controlled non-inferiority trial and will be performed at six paediatric departments in eastern Denmark. We plan to include 300 children aged 0-12 months admitted to hospital with bronchiolitis. Participating children are randomised 1:1:1 to nebulised NS, nasal irrigation with NS or no saline therapy. All other treatment will be given according to standard guidelines.The primary outcome is duration of hospitalisation, analysed according to intention-to-treat analysis using linear regression and Cox regression analysis. By including at least 249 children, we can prove non-inferiority with a limit of 12 hours admission, alpha 2.5% and a power of 80%. Secondary outcomes are need for respiratory support with nasal continuous positive airway pressure or high-flow oxygen therapy and requirement of fluid supplements (either by nasogastric tube or intravenous). ETHICS AND DISSEMINATION This study may inform current practice for supportive treatment of children with bronchiolitis. First, if NS is found to be helpful, it may be implemented into global guidelines. If no effect of NS is found, we can stop spending resources on an ineffective treatment. Second, if NS is effective, but nasal irrigation is non-inferior to nebulisation, it may reduce the workload of nurses, and possible duration of hospitalisation because the treatment can be delivered by the parents at home. TRIAL REGISTRATION NUMBER NCT05902702.
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Affiliation(s)
- Marika Nathalie Schmidt
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Kobenhavn, Denmark
- Department of Pediatrics, Slagelse Hospital, Slagelse, Denmark
| | - Rie Daugberg
- Department of Pediatrics, Slagelse Hospital, Slagelse, Denmark
| | - Ulrikka Nygaard
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Kobenhavn, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Kobenhavn, Denmark
| | - Xiaohui Chen Nielsen
- Department of Clinical Microbiology, Zealand University Hospital Koge, Koge, Denmark
| | - Bo Chawes
- Faculty of Health and Medical Sciences, University of Copenhagen, Kobenhavn, Denmark
- Department of Pediatrics, Herlev Hospital, Herlev, Denmark
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Maren Heilskov Rytter
- Department of Pediatrics, Slagelse Hospital, Slagelse, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Kobenhavn, Denmark
| | - Ann-Marie Malby Schoos
- Department of Pediatrics, Slagelse Hospital, Slagelse, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Kobenhavn, Denmark
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
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Ren Y, Qin S, Liu X, Feng B, Liu J, Zhang J, Yuan P, Yu K, Mei H, Chen M. Hyperoxia can Induce Lung Injury by Upregulating AECII Autophagy and Apoptosis Via the mTOR Pathway. Mol Biotechnol 2023:10.1007/s12033-023-00945-2. [PMID: 37938537 DOI: 10.1007/s12033-023-00945-2] [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: 06/27/2023] [Accepted: 10/11/2023] [Indexed: 11/09/2023]
Abstract
Oxygen therapy is a crucial medical intervention, but it is undeniable that it can lead to lung damage. The mTOR pathway plays a pivotal role in governing cell survival, including autophagy and apoptosis, two phenomena deeply entwined with the evolution of diseases. However, it is unclarified whether the mTOR pathway is involved in hyperoxic acute lung injury (HALI). The current study aims to clarify the molecular mechanism underlying the pathogenesis of HALI by constructing in vitro and in vivo models using H2O2 and hyperoxia exposure, respectively. To investigate the role of mTOR, the experiment was divided into five groups, including normal group, injury group, mTOR inhibitor group, mTOR activator group, and DMSO control group. Western blotting, Autophagy double labeling, TUNEL staining, and HE staining were applied to evaluate protein expression, autophagy activity, cell apoptosis, and pathological changes in lung tissues. Our data revealed that hyperoxia can induce autophagy and apoptosis in Type II alveolar epithelial cell (AECII) isolated from the treated rats, as well as injuries in the rat lung tissues; also, H2O2 stimulation increased autophagy and apoptosis in MLE-12 cells. Noticeably, the experiments performed in both in vitro and in vivo models proved that the mTOR inhibitor Rapamycin (Rapa) functioned synergistically with hyperoxia or H2O2 to promote AECII autophagy, which led to increased apoptosis and exacerbated lung injury. On the contrary, activation of mTOR with MHY1485 suppressed autophagy activity, consequently resulting in reduced apoptosis and lung injury in H2O2-challenged MLE-12 cells and hyperoxia-exposed rats. In conclusion, hyperoxia caused lung injury via mTOR-mediated AECII autophagy.
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Affiliation(s)
- Yingcong Ren
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, Guizhou, China
| | - Song Qin
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, Guizhou, China
| | - Xinxin Liu
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, Guizhou, China
| | - Banghai Feng
- Department of Critical Care Medicine, Zunyi Hospital of Traditional Chinese Medicine, Zunyi, 563000, Guizhou, China
| | - Junya Liu
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, Guizhou, China
| | - Jing Zhang
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, Guizhou, China
| | - Ping Yuan
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, Guizhou, China
| | - Kun Yu
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, Guizhou, China
| | - Hong Mei
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, Guizhou, China
| | - Miao Chen
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi, 563000, Guizhou, China.
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Winer JC, Richardson T, Berg KJ, Berry J, Chang PW, Etinger V, Hall M, Kim G, Meneses Paz JC, Treasure JD, Aronson PL. Effect Modifiers of the Association of High-Flow Nasal Cannula and Bronchiolitis Length of Stay. Hosp Pediatr 2023; 13:1018-1027. [PMID: 37795554 PMCID: PMC10593863 DOI: 10.1542/hpeds.2023-007295] [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: 10/06/2023]
Abstract
BACKGROUND AND OBJECTIVES High-flow nasal cannula (HFNC) therapy for hospitalized children with bronchiolitis is associated with a longer length of stay (LOS) when used outside of the ICU. We sought to explore the association between HFNC and LOS to identify if demographic and clinical factors may modify the effect of HFNC usage on LOS. METHODS In this multicenter retrospective cohort study, we used a combination of hospital records and the Pediatric Health Information System. We included encounters from September 1, 2018 to March 31, 2020 for patients <2 years old diagnosed with bronchiolitis. Multivariable Poisson regression was performed for the association of LOS with measured covariates, including fixed main effects and interaction terms between HFNC and other factors. RESULTS Of 8060 included patients, 2179 (27.0%) received HFNC during admission. Age group, weight, complex chronic condition, initial tachypnea, initial desaturation, and ICU services were significantly associated with LOS. The effect of HFNC on LOS differed among hospitals (P < .001), with the estimated increase in LOS ranging from 32% to 139%. The effect of HFNC on LOS was modified by age group, initial desaturation, and ICU services, with 1- to 6-month-old infants, patients without initial desaturation, and patients without ICU services having the highest association between HFNC and LOS, respectively. CONCLUSIONS We identified multiple potential effect modifiers for the relationship between HFNC and LOS. The authors of future prospective studies should investigate the effect of HFNC usage on LOS in non-ICU patients without documented desaturation.
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Affiliation(s)
- Jeffrey C Winer
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Kathleen J Berg
- Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
- University of Kansas School of Medicine, Kansas City, Kansas
| | - Jay Berry
- Complex Care, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Pearl W Chang
- Seattle Children's Hospital, University of Washington, Seattle, Washington
| | | | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Grace Kim
- Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | - Jennifer D Treasure
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati Ohio
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Aricò MO, Wrona D, Lavezzo G, Valletta E. Nasal CPAP in the Pediatric Ward to Reduce PICU Admissions for Severe Bronchiolitis? Pediatr Rep 2023; 15:599-607. [PMID: 37873801 PMCID: PMC10594455 DOI: 10.3390/pediatric15040055] [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: 08/30/2023] [Revised: 09/30/2023] [Accepted: 10/07/2023] [Indexed: 10/25/2023] Open
Abstract
In treating acute bronchiolitis in infants, the decision to use continuous positive airway pressure (CPAP) often involves infant referral from the pediatric ward to the pediatric intensive care unit (PICU). We present our experience of CPAP use in a general pediatric ward, aiming to reduce the pressure on the PICU in recent outbreaks of bronchiolitis. Clinical data of patients less than 12 months of age and admitted for bronchiolitis from 1 October 2021 to 31 March 2023 were retrospectively collected. Of 82 infants admitted for bronchiolitis, 16 (19%) were treated with nasal CPAP (nCPAP group); of the remaining 66, 21 (26%) were treated with a low-flow nasal cannula (LFNC) only, 1 (1%) was also treated a with high-flow nasal cannula (HFNC), 12 (15%) were treated with an HFNC only, and 41 (50%) were treated without oxygen support (no-nCPAP group). Overall, coinfection with RSV and SARS-CoV-2 was observed in three patients and SARS-CoV-2 infection was observed in two patients. None of them required any type of oxygen support. Only 3/16 (19%) infants in the nCPAP group were referred to the PICU due to worsening clinical conditions despite nCPAP support. In our experience of treating epidemic bronchiolitis, nCPAP can be safely managed in a general pediatric ward, thus reducing the burden of admissions to the PICU. Training and regular updating of the pediatric staff, careful monitoring of the patient, and close cooperation with the PICU were instrumental for our team.
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Affiliation(s)
- Melodie O. Aricò
- Department of Pediatrics, G.B. Morgagni—L. Pierantoni Hospital, AUSL Romagna, 48018 Forli, Italy;
| | - Diana Wrona
- School of Specialization in Pediatrics, University of Bologna, 40138 Bologna, Italy; (D.W.); (G.L.)
| | - Giovanni Lavezzo
- School of Specialization in Pediatrics, University of Bologna, 40138 Bologna, Italy; (D.W.); (G.L.)
| | - Enrico Valletta
- Department of Pediatrics, G.B. Morgagni—L. Pierantoni Hospital, AUSL Romagna, 48018 Forli, Italy;
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Akrama O, Armstrong L, Desai MK, Horner Le Riche A, Keating L, Knowles C, Perera Y, Porter T, Hirst R. Journal update monthly top five. Emerg Med J 2023; 40:678-679. [PMID: 37611954 DOI: 10.1136/emermed-2023-213505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 08/25/2023]
Affiliation(s)
- Osama Akrama
- Emergency Department, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Luke Armstrong
- Emergency Department, Royal Berkshire NHS Foundation Trust, Reading, UK
| | | | | | - Liza Keating
- Emergency Department, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Charlotte Knowles
- Emergency Department, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Yanithra Perera
- Emergency Department, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Thomas Porter
- Emergency Department, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Robert Hirst
- Emergency Department, North Bristol NHS Trust, Bristol, UK
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