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Mazur NI, Caballero MT, Nunes MC. Severe respiratory syncytial virus infection in children: burden, management, and emerging therapies. Lancet 2024:S0140-6736(24)01716-1. [PMID: 39265587 DOI: 10.1016/s0140-6736(24)01716-1] [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: 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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Kim G, Han S, Bae SP, Lee J, Heo NH, Lee D, Kim HJ. Lactate Levels as a Predictor of Emergency Department Revisits in Infants With Acute Bronchiolitis. Pediatr Emerg Care 2024; 40:660-664. [PMID: 38713833 DOI: 10.1097/pec.0000000000003220] [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: 05/09/2024]
Abstract
OBJECTIVE This study aimed to identify predictive biomarkers for unscheduled emergency department (ED) revisits within 24 hours of discharge in infants diagnosed with acute bronchiolitis (AB). METHODS A retrospective observational study was conducted on infants diagnosed with AB who visited 3 emergency medical centers between January 2020 and December 2022. The study excluded infants with comorbidities, congenital diseases, and prematurity and infants who revisited the ED after 24 hours of discharge. Demographic data, vital signs, and laboratory results were collected from the medical records. Univariable and multivariable logistic regression analyses were performed on factors with P of less than 0.1 in univariable analysis. Receiver operator curve analysis was used to assess the accuracy of lactate measurements in predicting ED revisits within 24 hours of discharge. RESULTS Out of 172 participants, 100 were in the revisit group and 72 in the discharge group. The revisit group was significantly younger and exhibited higher lactate levels, lower pH values, and higher pCO 2 levels compared to the discharge group. Univariable logistic regression identified several factors associated with revisits. Multivariable analysis found that only lactate was a variable correlated with predicting ED revisits (odds ratio, 18.020; 95% confidence interval [CI], 5.764-56.334). The receiver operator curve analysis showed an area under the curve of 0.856, with an optimal lactate cutoff value of 2.15. CONCLUSION Lactate value in infants diagnosed with AB were identified as a potential indicator of predicting unscheduled ED revisits within 24 hours of discharge. The predictive potential of lactate levels holds promise for enhancing prognosis prediction, reducing health care costs, and alleviating ED overcrowding. However, given the study's limitations, a more comprehensive prospective investigation is recommended to validate these findings.
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Affiliation(s)
- Gihyeon Kim
- From the Department of Emergency Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Sangsoo Han
- Department of Emergency Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Seong Phil Bae
- Department of Pediatrics, Soonchunhyang University Hospital, Seoul, Republic of Korea
| | - Jungwon Lee
- Department of Emergency Medicine, Soonchunhyang University Gumi Hospital, Gumi, Republic of Korea
| | - Nam Hun Heo
- Department of Biostatistics, Clinical Trial Center, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Dongwook Lee
- From the Department of Emergency Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Hyun Joon Kim
- From the Department of Emergency Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
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3
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Horvat CM, Suresh S, James N, Aneja RK, Au AK, Berry S, Blumer A, Bricker K, Clark RSB, Dolinich H, Hahner S, Jockel C, Kalivoda J, Loar I, Marasco D, Marcinick A, Marroquin O, O'brien J, Pelletier J, Ramgopal S, Venkataraman S, Angus DC, Butler G. A randomized, embedded, pragmatic, Bayesian clinical trial examining clinical decision support for high flow nasal cannula management in children with bronchiolitis: design and statistical analysis plan. Trials 2024; 25:484. [PMID: 39014495 PMCID: PMC11253479 DOI: 10.1186/s13063-024-08327-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: 03/22/2024] [Accepted: 07/08/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND High flow nasal cannula (HFNC) has been increasingly adopted in the past 2 decades as a mode of respiratory support for children hospitalized with bronchiolitis. The growing use of HFNC despite a paucity of high-quality data regarding the therapy's efficacy has led to concerns about overutilization. We developed an electronic health record (EHR) embedded, quality improvement (QI) oriented clinical trial to determine whether standardized management of HFNC weaning guided by clinical decision support (CDS) results in a reduction in the duration of HFNC compared to usual care for children with bronchiolitis. METHODS The design and summary of the statistical analysis plan for the REspiratory SupporT for Efficient and cost-Effective Care (REST EEC; "rest easy") trial are presented. The investigators hypothesize that CDS-coupled, standardized HFNC weaning will reduce the duration of HFNC, the trial's primary endpoint, for children with bronchiolitis compared to usual care. Data supporting trial design and eventual analyses are collected from the EHR and other real world data sources using existing informatics infrastructure and QI data sources. The trial workflow, including randomization and deployment of the intervention, is embedded within the EHR of a large children's hospital using existing vendor features. Trial simulations indicate that by assuming a true hazard ratio effect size of 1.27, equivalent to a 6-h reduction in the median duration of HFNC, and enrolling a maximum of 350 children, there will be a > 0.75 probability of declaring superiority (interim analysis posterior probability of intervention effect > 0.99 or final analysis posterior probability of intervention effect > 0.9) and a > 0.85 probability of declaring superiority or the CDS intervention showing promise (final analysis posterior probability of intervention effect > 0.8). Iterative plan-do-study-act cycles are used to monitor the trial and provide targeted education to the workforce. DISCUSSION Through incorporation of the trial into usual care workflows, relying on QI tools and resources to support trial conduct, and relying on Bayesian inference to determine whether the intervention is superior to usual care, REST EEC is a learning health system intervention that blends health system operations with active evidence generation to optimize the use of HFNC and associated patient outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT05909566. Registered on June 18, 2023.
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Affiliation(s)
- Christopher M Horvat
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
- Division of Health Informatics, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- UPMC, Pittsburgh, PA, USA.
| | - Srinivasan Suresh
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- Division of Health Informatics, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC, Pittsburgh, PA, USA
| | | | - Rajesh K Aneja
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC, Pittsburgh, PA, USA
| | - Alicia K Au
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC, Pittsburgh, PA, USA
| | - Scott Berry
- Berry Statistical Consultants, Austin, TX, USA
| | - Arthur Blumer
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- UPMC, Pittsburgh, PA, USA
| | - Kelly Bricker
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- UPMC, Pittsburgh, PA, USA
| | - Robert S B Clark
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC, Pittsburgh, PA, USA
| | - Heidilyn Dolinich
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- UPMC, Pittsburgh, PA, USA
| | - Sheila Hahner
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- UPMC, Pittsburgh, PA, USA
| | - Christina Jockel
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- UPMC, Pittsburgh, PA, USA
| | - Jordan Kalivoda
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- UPMC, Pittsburgh, PA, USA
| | - India Loar
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC, Pittsburgh, PA, USA
| | - Denee Marasco
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- UPMC, Pittsburgh, PA, USA
| | - Adrienne Marcinick
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- UPMC, Pittsburgh, PA, USA
| | | | | | - Jonathan Pelletier
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, OH, USA
| | - Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Shekhar Venkataraman
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC, Pittsburgh, PA, USA
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC, Pittsburgh, PA, USA
| | - Gabriella Butler
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- Division of Health Informatics, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC, Pittsburgh, PA, USA
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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.
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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.
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Byrd C, Noelck M, Kerns E, Bryan M, Hamline M, Garber M, Ostrow O, Riss V, Shadman K, Shein S, Willer R, Ralston S. Multicenter Quality Collaborative to Reduce Overuse of High-Flow Nasal Cannula in Bronchiolitis. Pediatrics 2024; 153:e2023063509. [PMID: 38682254 DOI: 10.1542/peds.2023-063509] [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] [Accepted: 01/03/2024] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND AND OBJECTIVES High-flow nasal cannula (HFNC) for bronchiolitis increased over the past decade without clear benefit. This quality improvement collaborative aimed to reduce HFNC initiation and treatment duration by 30% from baseline. METHODS Participating hospitals either reduced HFNC initiation (Pause) or treatment duration (Holiday) in patients aged <24 months admitted for bronchiolitis. Participants received either Pause or Holiday toolkits, including: intervention protocol, training/educational materials, electronic medical record queries for data acquisition, small-group coaching, webinars, and real-time access to run charts. Pause arm primary outcome was proportion of patients initiated on HFNC. Holiday arm primary outcome was geometric mean HFNC treatment duration. Length of stay (LOS) was balancing measure for both. Each arm served as contemporaneous controls for the other. Outcomes analyzed using interrupted time series (ITS) and linear mixed-effects regression. RESULTS Seventy-one hospitals participated, 30 in the Pause (5746 patients) and 41 in the Holiday (7903 patients). Pause arm unadjusted HFNC initiation decreased 32% without LOS change. ITS showed immediate 16% decrease in initiation (95% confidence interval [CI] -27% to -5%). Compared with contemporaneous controls, Pause hospitals reduced HFNC initiation by 23% (95% CI -35% to -10%). Holiday arm unadjusted HFNC duration decreased 28% without LOS change. ITS showed immediate 11.8 hour decrease in duration (95% CI -18.3 hours to -5.2 hours). Compared with contemporaneous controls, Holiday hospitals reduced duration by 11 hours (95% CI -20.7 hours to -1.3 hours). CONCLUSIONS This quality improvement collaborative reduced HFNC initiation and duration without LOS increase. Contemporaneous control analysis supports intervention effects rather than secular trends toward less use.
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Affiliation(s)
- Courtney Byrd
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Michelle Noelck
- Division of Hospital Medicine, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Ellen Kerns
- Department of Pediatrics, University of Nebraska College of Medicine, Omaha, Nebraska
| | - Mersine Bryan
- Division of Hospital Medicine and General Pediatrics, University of Washington College of Medicine, Seattle, Washington
| | - Michelle Hamline
- Division of Clinical Pediatrics, University of California, Davis, Davis, California
| | - Matthew Garber
- Division of Hospital Pediatrics, Department of Pediatrics, University of Florida College of Medicine, Jacksonville, Florida
| | - Olivia Ostrow
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Valerie Riss
- Department of Pediatrics, University of Vermont College of Medicine, Burlington, Vermont
| | - Kristin Shadman
- Division of Hospital Medicine and Complex Care, Department of Pediatrics, University of Wisconsin College of Medicine, Madison, Wisconsin
| | - Steven Shein
- Departments of Pediatrics and Pediatric Critical Care, University Hospitals, Rainbow Babies and Children's, Cleveland, Ohio
| | - Robert Willer
- Department of Pediatric Hospital Medicine, University of Utah College of Medicine, Salt Lake City, Utah
| | - Shawn Ralston
- Division of Hospital Medicine and General Pediatrics, University of Washington College of Medicine, Seattle, Washington
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Baloglu O, Flagg LK, Suleiman A, Gupta V, Fast JA, Wang L, Worley S, Agarwal HS. Association of Fluid Overload with Escalation of Respiratory Support and Endotracheal Intubation in Acute Bronchiolitis Patients. J Pediatr Intensive Care 2024; 13:7-17. [PMID: 38571992 PMCID: PMC10987226 DOI: 10.1055/s-0041-1735873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/05/2021] [Indexed: 10/20/2022] Open
Abstract
Fluid overload has been associated with increased oxygen requirement, prolonged duration of mechanical ventilation, and longer length of hospital stay in children hospitalized with pulmonary diseases. Critically ill infants with bronchiolitis admitted to the pediatric intensive care unit (PICU) also tend to develop fluid overload and there is limited information of its role on noninvasive respiratory support. Thus, our primary objective was to study the association of fluid overload in patients with bronchiolitis admitted to the PICU with respiratory support escalation (RSE) and need for endotracheal intubation (ETI). Infants ≤24 months of age with bronchiolitis and admitted to the PICU between 9/2009 and 6/2015 were retrospectively studied. Demographic variables, clinical characteristics including type of respiratory support and need for ETI were evaluated. Fluid overload as assessed by net fluid intake and output (net fluid balance), cumulative fluid balance (CFB) (mL/kg), and percentage fluid overload (FO%), was compared between patients requiring and not requiring RSE and among patients requiring ETI and not requiring ETI at 0 (PICU admission), 12, 24, 36, 48, 72, 96, and 120 hours. One-hundred sixty four of 283 patients with bronchiolitis admitted to the PICU qualified for our study. Thirty-four of 164 (21%) patients required escalation of respiratory support within 5 days of PICU admission and of these 34 patients, 11 patients required ETI. Univariate analysis by Kruskal-Wallis test of fluid overload as assessed by net fluid balance, CFB, and FO% between 34 patients requiring and 130 patients not requiring RSE and among 11 patients requiring ETI and 153 patients not requiring ETI, at 0, 12, 24, 36, 48, 72, 96 and 120 hours did not reveal any significant difference ( p >0.05) at any time interval. Multivariable logistic regression analysis revealed higher PRISM score (odds ratio [OR]: 4.95, 95% confidence interval [95% CI]: 1.79-13.66; p = 0.002), longer hours on high flow nasal cannula (OR: 4.86, 95% CI: 1.68-14.03; p = 0.003) and longer hours on noninvasive ventilation (OR: 11.16, 95% CI: 3.36-36.98; p < 0.001) were associated with RSE. Fluid overload as assessed by net fluid balance, CFB, and FO% was not associated with RSE or need for ETI in critically ill bronchiolitis patients admitted to the PICU. Further prospective studies involving larger number of patients with bronchiolitis are needed to corroborate our findings.
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Affiliation(s)
- Orkun Baloglu
- Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
| | - Lauren K. Flagg
- Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
| | - Ahmad Suleiman
- Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
| | - Vedant Gupta
- Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
| | - Jamie A. Fast
- Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
| | - Lu Wang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, United States
| | - Sarah Worley
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, United States
| | - Hemant S. Agarwal
- Department of Pediatric Critical Care Medicine, Cleveland Clinic Childreǹs, Cleveland, Ohio, United States
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Akande M, Spencer SP, Moore-Clingenpeel M, Jamieson N, Karsies T. Impact of Respiratory Bacterial Codetection on Outcomes in Ventilated Infants With Bronchiolitis. Pediatr Infect Dis J 2024; 43:117-122. [PMID: 37922484 DOI: 10.1097/inf.0000000000004154] [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: 11/05/2023]
Abstract
BACKGROUND Viral bronchiolitis is a common cause of acute respiratory failure requiring intubation for infants. Bacterial respiratory tract infections can occur with bronchiolitis, although their prevalence and impact on outcomes are unclear, especially with increased use of noninvasive respiratory support. METHODS This was a single-center retrospective cohort study of children <2 years old requiring intubation in the emergency department for bronchiolitis from 2012 to 2017 who had viral testing plus a lower respiratory culture obtained. We evaluated the impact of bacterial codetection (positive respiratory culture plus moderate or many polymorphonuclear neutrophils on Gram stain) on mechanical ventilation (MV) duration and intensive care unit length of stay using multivariable gamma regression. RESULTS Of 149 patients enrolled, 52% had bacterial codetection. In adjusted analysis, patients with codetection had shorter MV duration [adjusted relative risk (aRR) 0.819, 95% confidence interval (CI): 0.69-0.98; marginal mean duration of 5.31 days (4.71-5.99) compared to 6.48 days (5.72-7.35) without codetection]. Patients with codetection had a shorter intensive care unit stay [aRR 0.806 (0.69-0.94); marginal mean length of stay 6.9 days (6.21-7.68) vs. 8.57 days (7.68-9.56) without codetection]. The association between codetection and duration of ventilation appears confined to those receiving earlier antibiotics (less than the median time) rather than later antibiotics [aRR 0.738 (0.56-0.95) for earlier vs. aRR 0.92 (0.70-1.18) for later]. CONCLUSIONS Respiratory bacterial codetection is common and associated with shorter MV duration in infants requiring early intubation for bronchiolitis. Early antibiotics may contribute to these outcomes, but further multicenter studies are needed to understand the role of codetection and antibiotics on bronchiolitis outcomes.
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Affiliation(s)
- Manzilat Akande
- From the Section of Critical Care, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Sandra P Spencer
- Department of Pediatrics, Section of Emergency Medicine, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Nathan Jamieson
- Department of Pediatrics, Section of Emergency Medicine, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Todd Karsies
- Division of Critical Care, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
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Demetriou EA, Boulton KA, Thapa R, Sun C, Gilroy J, Bowden MR, Guastella A. Burden of paediatric hospitalisations to the health care system, child and family: a systematic review of Australian studies (1990-2022). THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 40:100878. [PMID: 38116503 PMCID: PMC10730319 DOI: 10.1016/j.lanwpc.2023.100878] [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: 02/01/2023] [Revised: 07/15/2023] [Accepted: 08/03/2023] [Indexed: 12/21/2023]
Abstract
Background Paediatric hospitalisations represent a significant cost to the health system and cause significant burden to children and their families. Understanding trends in hospitalisation costs can assist with health planning and support strategies across stakeholders. The objective of this systematic review is to examine the trends in costs and burden of paediatric hospitalisations in Australia to help inform policy and promote the well-being of children and their families. Methods Electronic data sources (Embase, Medline, Web of Science, PSYCH-Info, CINAHL and Scopus) were searched from 1990 until December 2022. Any quantitative or qualitative studies conducted in Australian tertiary hospitals were included in the review. Eligible studies were those that included paediatric (<18 years) hospitalisations and reported on economic and/or non-economic costs for the child, family unit and/or health system. Study quality and risk of bias for each study were assessed with the Joanna Briggs Critical Appraisal Tools. We present a summary of the findings of the hospitalisation burden across major diagnostic admission categories and for the child and family unit. The systematic review was registered with Prospero (ID: CRD42021276202). Findings The review summarises a total of 88 studies published between 1990 and December 2022. Overall, the studies identified that paediatric hospitalisations incur significant financial costs, which have not shown significant reductions over time. In-patient direct hospital costs varied depending on the type of treatment and diagnostic condition. The costs per-case were found to range from just below AUD$2000 to AUD$20,000 or more. The financial burden on the family unit included loss of productivity, transport and travel costs. Some studies reported estimates of these costs upward of AUD$500 per day. Studies evaluating 'hospital in the home' options identified significant benefits in reducing hospitalisations and costs without compromising care. Interpretation Increasing focus on alternative models of care may help alleviate the significant costs associated with paediatric hospitalisation. Funding This research was supported by Hospitals United for Sick Kids (formerly Curing Homesickness).
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Affiliation(s)
- Eleni Andrea Demetriou
- Brain and Mind Centre, Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, 2050, Australia
| | - Kelsie Ann Boulton
- Brain and Mind Centre, Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, 2050, Australia
| | - Rinku Thapa
- Brain and Mind Centre, Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, 2050, Australia
| | - Carter Sun
- Brain and Mind Centre, Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, 2050, Australia
| | | | - Michael Russell Bowden
- Mental Health Branch, NSW Health, Sydney Children's Hospitals Network, Discipline of Psychiatry, Westmead Clinical School and The Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Australia
| | - Adam Guastella
- Brain and Mind Centre, Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, 2050, Australia
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9
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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.
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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
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10
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van Hasselt TJ, Webster K, Gale C, Draper ES, Seaton SE. Children born preterm admitted to paediatric intensive care for bronchiolitis: a systematic review and meta-analysis. BMC Pediatr 2023; 23:326. [PMID: 37386478 PMCID: PMC10308614 DOI: 10.1186/s12887-023-04150-7] [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: 02/07/2023] [Accepted: 06/23/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND To undertake a systematic review of studies describing the proportion of children admitted to a paediatric intensive care unit (PICU) for respiratory syncytial virus (RSV) and/or bronchiolitis who were born preterm, and compare their outcomes in PICU with children born at term. METHODS We searched Medline, Embase and Scopus. Citations and references of included articles were searched. We included studies published from the year 2000 onwards, from high-income countries, that examined children 0-18 years of age, admitted to PICU from the year 2000 onwards for RSV and/or bronchiolitis. The primary outcome was the percentage of PICU admissions born preterm, and secondary outcomes were observed relative risks of invasive mechanical ventilation and mortality within PICU. We used the Joanna Briggs Institute Checklist for Analytical Cross-Sectional Studies to assess risk of bias. RESULTS We included 31 studies, from 16 countries, including a total of 18,331 children. Following meta-analysis, the pooled estimate for percentage of PICU admissions for RSV/bronchiolitis who were born preterm was 31% (95% confidence interval: 27% to 35%). Children born preterm had a greater risk of requiring invasive ventilation compared to children born at term (relative risk 1.57, 95% confidence interval 1.25 to 1.97, I2 = 38%). However, we did not observe a significant increase in the relative risk for mortality within PICU for preterm-born children (relative risk 1.10, 95% confidence interval: 0.70 to 1.72, I2 = 0%), although the mortality rate was low across both groups. The majority of studies (n = 26, 84%) were at high risk of bias. CONCLUSIONS Among PICU admissions for bronchiolitis, preterm-born children are over-represented compared with the preterm birth rate (preterm birth rate 4.4% to 14.4% across countries included in review). Preterm-born children are at higher risk of mechanical ventilation compared to those born at term.
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Affiliation(s)
- Tim J van Hasselt
- Department of Population Health Sciences, University of Leicester, University Rd, Leicester, LE1 7RH, UK.
| | - Kirstin Webster
- Department of Population Health Sciences, University of Leicester, University Rd, Leicester, LE1 7RH, UK
| | - Chris Gale
- Neonatal Medicine, School of Public Health, Faculty of Medicine, Chelsea and Westminster Hospital Campus, Imperial College London, London, UK
| | - Elizabeth S Draper
- Department of Population Health Sciences, University of Leicester, University Rd, Leicester, LE1 7RH, UK
| | - Sarah E Seaton
- Department of Population Health Sciences, University of Leicester, University Rd, Leicester, LE1 7RH, UK
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11
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Yan J, Zhao L, Zhang T, Wei Y, Guo D, Guo W, Zheng J, Xu Y. Development and validation of a nomogram for predicting severe respiratory syncytial virus-associated bronchiolitis. BMC Infect Dis 2023; 23:249. [PMID: 37072700 PMCID: PMC10114343 DOI: 10.1186/s12879-023-08179-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: 10/28/2022] [Accepted: 03/17/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis and is related to the severity of the disease. This study aimed to develop and validate a nomogram for predicting severe bronchiolitis in infants and young children with RSV infection. METHODS A total of 325 children with RSV-associated bronchiolitis were enrolled, including 125 severe cases and 200 mild cases. A prediction model was built on 227 cases and validated on 98 cases, which were divided by random sampling in R software. Relevant clinical, laboratory and imaging data were collected. Multivariate logistic regression models were used to determine optimal predictors and to construct nomograms. The performance of the nomogram was evaluated by the area under the characteristic curve (AUC), calibration ability and decision curve analysis (DCA). RESULTS There were 137 (60.4%) mild and 90 (39.6%) severe RSV-associated bronchiolitis cases in the training group (n = 227) and 63 (64.3%) mild and 35 (35.7%) severe cases in the validation group (n = 98). Multivariate logistic regression analysis identified 5 variables as significant predictive factors to construct the nomogram for predicting severe RSV-associated bronchiolitis, including preterm birth (OR = 3.80; 95% CI, 1.39-10.39; P = 0.009), weight at admission (OR = 0.76; 95% CI, 0.63-0.91; P = 0.003), breathing rate (OR = 1.11; 95% CI, 1.05-1.18; P = 0.001), lymphocyte percentage (OR = 0.97; 95% CI, 0.95-0.99; P = 0.001) and outpatient use of glucocorticoids (OR = 2.27; 95% CI, 1.05-4.9; P = 0.038). The AUC value of the nomogram was 0.784 (95% CI, 0.722-0.846) in the training set and 0.832 (95% CI, 0.741-0.923) in the validation set, which showed a good fit. The calibration plot and Hosmer‒Lemeshow test indicated that the predicted probability had good consistency with the actual probability both in the training group (P = 0.817) and validation group (P = 0.290). The DCA curve shows that the nomogram has good clinical value. CONCLUSION A nomogram for predicting severe RSV-associated bronchiolitis in the early clinical stage was established and validated, which can help physicians identify severe RSV-associated bronchiolitis and then choose reasonable treatment.
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Affiliation(s)
- Jisi Yan
- Department of Respiratory Medicine, Tianjin University Children's Hospital (Tianjin Children's Hospital), 238 Longyan Road, Beichen District, Tianjin, 300000, China
- Clinical School of Pediatrics, Tianjin Medical University, Tianjin, China
- Department of Neonatology, Tianjin Central Hospital of Gynecology Obstetrics, 156 Nankai SAN Lu, Nankai District, Tianjin, 300100, China
| | - LiHua Zhao
- Department of Respiratory Medicine, Tianjin University Children's Hospital (Tianjin Children's Hospital), 238 Longyan Road, Beichen District, Tianjin, 300000, China
| | - Tongqiang Zhang
- Department of Respiratory Medicine, Tianjin University Children's Hospital (Tianjin Children's Hospital), 238 Longyan Road, Beichen District, Tianjin, 300000, China
- Clinical School of Pediatrics, Tianjin Medical University, Tianjin, China
| | - Yupeng Wei
- Department of Respiratory Medicine, Tianjin University Children's Hospital (Tianjin Children's Hospital), 238 Longyan Road, Beichen District, Tianjin, 300000, China
- Clinical School of Pediatrics, Tianjin Medical University, Tianjin, China
- Department of Neonatology, Tianjin Central Hospital of Gynecology Obstetrics, 156 Nankai SAN Lu, Nankai District, Tianjin, 300100, China
| | - Detong Guo
- Department of Respiratory Medicine, Tianjin University Children's Hospital (Tianjin Children's Hospital), 238 Longyan Road, Beichen District, Tianjin, 300000, China
- Clinical School of Pediatrics, Tianjin Medical University, Tianjin, China
| | - Wei Guo
- Department of Respiratory Medicine, Tianjin University Children's Hospital (Tianjin Children's Hospital), 238 Longyan Road, Beichen District, Tianjin, 300000, China.
| | - Jun Zheng
- Department of Neonatology, Tianjin Central Hospital of Gynecology Obstetrics, 156 Nankai SAN Lu, Nankai District, Tianjin, 300100, China.
| | - Yongsheng Xu
- Department of Respiratory Medicine, Tianjin University Children's Hospital (Tianjin Children's Hospital), 238 Longyan Road, Beichen District, Tianjin, 300000, China.
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12
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13
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Pedersen ESL, Kuehni CE. Preventing bronchiolitis among infants with non-pharmaceutical interventions outside pandemics: is it realistic? Eur Respir J 2023; 61:61/2/2202214. [PMID: 36796850 DOI: 10.1183/13993003.02214-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 11/28/2022] [Indexed: 02/18/2023]
Affiliation(s)
- Eva S L Pedersen
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Claudia E Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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14
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Andersson Marforio S, Hansen C, Ekvall Hansson E, Lundkvist Josenby A. Frequent body position changes and physical activity as effective as standard care for infants hospitalised with acute respiratory infections - a randomised controlled trial. Multidiscip Respir Med 2023; 18:885. [PMID: 36743946 PMCID: PMC9892929 DOI: 10.4081/mrm.2023.885] [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: 10/03/2022] [Accepted: 12/12/2022] [Indexed: 01/27/2023] Open
Abstract
Background No definite consensus has been reached yet on the best treatment strategy for the large group of infants hospitalised with bronchiolitis or pneumonia. Minimal handling is often recommended, although not evaluated scientifically. There is a need to evaluate the management, as the infants often are critically affected, and the costs for society are high. The aim of this RCT was to evaluate the most common physiotherapy intervention in Sweden for this patient group, including frequent changes in body position and stimulation of physical activity, compared to standard care. Methods Infants 0-24 months old, without previous cardiac or respiratory diagnoses and born in gestational week 35+, were recruited in two Swedish hospitals. The participants (n=109) were randomised to either interventions in addition to standard care (intervention group) or to standard care alone (control group). The primary outcome measure was time to improvement. The secondary outcomes were immediate changes in oxygen saturation, heart rate and respiratory rate, time to improved general condition (parents' assessment), and lung complications. Results The median time to improvement was 6 hours in both groups (p=0.54). The result was similar when we adjusted for age in months, sex, tobacco smoke exposure, heredity for asthma/atopic disease, and early stage of the infection (for those with RSV), p=0.69. Analyses of the immediate changes showed no significant differences either (p=0.49-0.89). Time to improved general condition was median 3 hours in the intervention group and 6 hours in the control group, p=0.76. No lung complications occurred. Conclusions No statistically significant differences in outcomes were detected between the intervention group and the control group. Both strategies were found to be equally effective and safe, indicating that the current recommendation of minimal handling for these infants should be reconsidered. Furthermore, the findings suggest that this treatment can be safely continued.
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Affiliation(s)
- Sonja Andersson Marforio
- Department of Health Sciences, Lund University, Lund,Skåne University Hospital, Lund, Sweden,Department of Health Sciences, Lund University, Margaretavägen 1B, Lund, S-22240, Sweden.
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15
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Buendía JA, Feliciano-Alfonso JE, Laverde MF. Systematic review and meta-analysis of efficacy and safety of continuous positive airways pressure versus high flow oxygen cannula in acute bronchiolitis. BMC Pediatr 2022; 22:696. [PMID: 36463122 PMCID: PMC9719123 DOI: 10.1186/s12887-022-03754-9] [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: 07/22/2022] [Accepted: 11/15/2022] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION There are a trend towards increasing use of High-Flow Nasal Cannula (HFNC), outside of paediatric intensive care unit. Give this trend is necessary to update the actual evidence and to assess available published literature to determinate the efficacy of HFNC over Continuous Positive Air Pressure (CPAP) as treatment for children with severe bronchiolitis. METHODS We searched MEDLINE, EMBASE, LILACS, and COCHRANE Central, and gray literature in clinical trials databases ( www. CLINICALTRIALS gov ), from inception to June 2022. The inclusion criteria for the literature were randomized clinical trials (RCTs) that included children < 2 years old, with acute moderate or severe bronchiolitis. All study selection and data extractions are performed independently by two reviewers. RESULTS The initial searches including 106 records. Only five randomized controlled trial that met the inclusion criteria were included in meta-analysis. The risk of invasive mechanical ventilation was not significantly different in CPAP group and HFNC group [OR: 1.18, 95% CI (0.74, 1.89), I² = 0%] (very low quality). The risk of treatment failure was less significantly in CPAP group than HFNC group [OR: 0.51, 95% CI (0.36, 0.75), I² = 0%] (very low quality). CONCLUSION In conclusion, there was no significant difference between HFNC and CPAP in terms of risk of invasive mechanical ventilation. CPAP reduces de risk of therapeutic failure with a highest risk of non severe adverse events. More trials are needed to confirm theses results.
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Affiliation(s)
- Jefferson Antonio Buendía
- grid.412881.60000 0000 8882 5269Research group in Pharmacology and Toxicology ”INFARTO”, Department of Pharmacology and Toxicology, University of Antioquia, Medellín, Colombia ,grid.412881.60000 0000 8882 5269Facultad de Medicina, Universidad de Antioquia, Carrera 51D, Medellín, Colombia
| | - John Edwin Feliciano-Alfonso
- grid.412881.60000 0000 8882 5269Research group in Pharmacology and Toxicology ”INFARTO”, Department of Pharmacology and Toxicology, University of Antioquia, Medellín, Colombia ,grid.10689.360000 0001 0286 3748Departamento de Medicina Interna, Universidad Nacional de Colombia, Bogota, Colombia
| | - Mauricio Fernandez Laverde
- grid.411140.10000 0001 0812 5789Unidad de Cuidado Intensivo Pediatrico. Hospital Pablo Tobon Uribe. Medellin. Facultad de Medicina, Universidad CES, Carrera 51D, Medellín, Colombia
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16
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Bronchiolitis therapies and misadventures. Paediatr Respir Rev 2022:S1526-0542(22)00066-5. [PMID: 36280580 DOI: 10.1016/j.prrv.2022.09.003] [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: 09/21/2022] [Accepted: 09/26/2022] [Indexed: 11/21/2022]
Abstract
Viral bronchiolitis, which is most commonly caused by an infection with the respiratory syncytial virus (RSV), can lead to respiratory difficulties in young children which may require hospitalization. Despite years of research and medical trials, the mainstay of bronchiolitis treatment remains supportive only. This review provides an overview of the history of different treatments for bronchiolitis, including those that failed, as well as new therapies that are under study. Future studies for the treatment of bronchiolitis should consider different age-groups, important subgroups (i.e., those with a prior history of wheezing, those with a family history of asthma and those with non-RSV viral etiologies) whose response to treatment may differ from that of the composite group.
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17
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Eşki A, Öztürk GK, Turan C, Özgül S, Gülen F, Demir E. High-flow nasal cannula oxygen in children with bronchiolitis: A randomized controlled trial. Pediatr Pulmonol 2022; 57:1527-1534. [PMID: 35293153 DOI: 10.1002/ppul.25893] [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: 06/26/2021] [Revised: 01/22/2022] [Accepted: 03/14/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To determine whether high-flow nasal cannula oxygen (HFNCO) provided enhanced respiratory support in bronchiolitis than low-flow oxygen (LFO). METHODS We conducted a prospective, randomized controlled trial in children between 1 and 24 months diagnosed with moderate-to-severe bronchiolitis requiring oxygen therapy. Participants received LFO via face mask (6-10 L/min) or HFNCO (2 L/kg/min). Primary outcomes were the time that heart rate (HR) and respiratory rate (RR) return to their normal range for age and the time that baseline clinical respiratory score (CRS) regress to a lower severity score. Secondary outcomes were changes in HR, RR, and CRS over time, length of stay (LOS), duration of oxygen requirement, treatment failure, and adverse event (AE). RESULTS Eighty-seven children were enrolled (48 in LFO; 39 in HFNCO). The time that HR and RR baseline values reached their normal range for age was shorter in HFNCO therapy (2.0 h [1.0-4.0] vs. 12.0 h [2.0-24.0], and 4.0 h [2.0-12.0] vs. 24.0 h [4.0-48.0], respectively; p < 0.001); additionally, the improvement in CRS emerged more quickly in children treated with HFNCO (2.0 h [1.0-4.0] vs. 4.0 h [2.0-24.0]; p = 0.003). While the duration of oxygen requirement (19.0 h [4.0-30.0] vs. 29.5 h [14.0-45.7]; p = 0.009) and treatment failure (3% vs. 21%) was statistically lower in children who received HFNCO, there were no differences in LOS and AE between groups. CONCLUSION HFNCO may provide enhanced respiratory support with a notable improvement in HR, RR, and CRS than LFO. Comprehensive studies are needed to assess the clinical efficacy of HFNCO therapy.
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Affiliation(s)
- Aykut Eşki
- Division of Pediatric Pulmonology, Department of Pediatrics, Gazi Yaşargil Gynecology, Child Health, and Diseases Training and Research Hospital, University of Health Sciences, Diyarbakır, Turkey
| | - Gökçen Kartal Öztürk
- Division of Pediatric Pulmonology, Department of Pediatrics, Ege University Medical Faculty, Ege University Children Hospital, Izmir, Turkey
| | - Caner Turan
- Division of Emergency Medicine, Department of Pediatrics, Ege University Medical Faculty, Ege University Children Hospital, Izmir, Turkey
| | - Semiha Özgül
- Department of Medical Informatics, School of Medicine, Ege University, Izmir, Turkey
| | - Figen Gülen
- Division of Pediatric Pulmonology, Department of Pediatrics, Ege University Medical Faculty, Ege University Children Hospital, Izmir, Turkey
| | - Esen Demir
- Division of Pediatric Pulmonology, Department of Pediatrics, Ege University Medical Faculty, Ege University Children Hospital, Izmir, Turkey
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18
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Gelbart B, McSharry B, Delzoppo C, Erickson S, Lee K, Butt W, Rea M, Wang X, Beca J, Kazemi A, Shann F. Pragmatic Randomized Trial of Corticosteroids and Inhaled Epinephrine for Bronchiolitis in Children in Intensive Care. J Pediatr 2022; 244:17-23.e1. [PMID: 35093318 DOI: 10.1016/j.jpeds.2022.01.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/22/2021] [Accepted: 01/18/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine whether the combination of systemic corticosteroids and nebulized epinephrine, compared with standard care, reduces the duration of positive pressure support in children with bronchiolitis admitted to intensive care. STUDY DESIGN We performed a pragmatic, multicenter, open-label, randomized trial between July 2013 and November 2019 in children younger than 18 months old with a clinical diagnosis of bronchiolitis. The intervention group received the equivalent of 13 mg/kg prednisolone over 3 days, then 1 mg/kg daily for 3 days, plus 0.05 mL/kg of nebulized 1% epinephrine made up to 6 ml with 0.9% saline via jet nebulizer and mask using oxygen at 12 l/min every 30 minutes for 5 doses, then 1-4 hourly for 3 days, then as required for 3 days. The primary outcome was clinician-managed duration of positive pressure support in intensive care defined as high-flow nasal-prong oxygen, nasopharyngeal continuous positive airway pressure, or mechanical ventilation. RESULTS In total, 210 children received positive pressure support. In the corticosteroid-epinephrine group, 107 children received positive pressure support for a geometric mean of 26 (95% CI, 22-32) hours compared with 40 (95% CI 34-47) hours in 103 controls, adjusted ratio 0.66 (95% CI 0.51-0.84), P = .001. In the intervention group, 41 (38%) children experienced at least 1 adverse event, compared with 39 (38%) in the control group. CONCLUSIONS In children with severe bronchiolitis, the duration of clinician-managed pressure support was reduced by regular treatment with systemic corticosteroids and inhaled epinephrine compared with standard care. CLINICAL TRIAL REGISTRATION Australian Clinical Trials Research Network: ACTRN12613000316707.
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Affiliation(s)
- Ben Gelbart
- Royal Children's Hospital Paediatric Intensive Care Unit, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia.
| | - Brent McSharry
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, Australia
| | - Carmel Delzoppo
- Royal Children's Hospital Paediatric Intensive Care Unit, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Simon Erickson
- Paediatric Critical Care Unit, Perth Children's Hospital, Perth, Australia
| | - Katherine Lee
- Department of Paediatrics, University of Melbourne, Melbourne, Australia; Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Australia
| | - Warwick Butt
- Royal Children's Hospital Paediatric Intensive Care Unit, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Miriam Rea
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, Australia
| | - Xiaofang Wang
- Department of Paediatrics, University of Melbourne, Melbourne, Australia; Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Australia
| | - John Beca
- Paediatric Intensive Care Unit, Starship Children's Hospital, Auckland, Australia
| | - Alex Kazemi
- Intensive Care Unit, Middlemore Hospital, Auckland, Australia
| | - Frank Shann
- Royal Children's Hospital Paediatric Intensive Care Unit, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia
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Shein SL, Yehya N. Trials and Tribulations in Bronchiolitis. J Pediatr 2022; 244:8-10. [PMID: 35240136 DOI: 10.1016/j.jpeds.2022.02.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 02/24/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Steven L Shein
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - Nadir Yehya
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania.
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20
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Krawiec C, Williams D, Walter V, Thomas NJ. Evaluation of reported medical services provided to pediatric viral bronchiolitis diagnoses during the COVID-19 pandemic. Respir Med Res 2022; 81:100909. [PMID: 35436722 PMCID: PMC8993416 DOI: 10.1016/j.resmer.2022.100909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 02/22/2022] [Accepted: 03/29/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Mitigation strategies were implemented during the coronavirus disease 2019 (COVID-19) pandemic that slowed the spread of this virus and other respiratory viruses. The objective of this study is to assess the impact of COVID-19 mitigation strategies on the medical services that children less than 1 year of age with acute bronchiolitis required (emergency department services, hospitalization, critical care services, and mechanical ventilation). METHODS This was a retrospective observational cohort study utilizing TriNetX ® electronic health record (EHR) data. We included subjects less than 1 year of age with a diagnosis of acute bronchiolitis. After the query, the study population was divided into two groups [pre-COVID-19 (March 1st, 2019 until February 29th, 2020) and COVID-19 (March 1st, 2020 until February 1th, 2021)]. We analyzed the following data: age, sex, race, diagnostic codes, common terminology procedures (CPT), and antimicrobials administered. RESULTS A total of 5063 subjects (n,%) were included [4378 (86.5%) pre-COVID-19 and 685 (13.5%) during the COVID-19 pandemic]. More subjects were diagnosed with acute bronchiolitis in the pre-COVID time frame (4378, 1.8% of all hospitalizations) when compared to the COVID-19 pandemic time frame (685, 0.5%). When diagnosed with acute bronchiolitis, the frequency of emergency department services, critical care services, hospitalization, and mechanical ventilationwere similar between the two cohorts. CONCLUSIONS During the COVID-19 pandemic, less infants were diagnosed with acute bronchiolitis but the frequency of emergency department services, hospitalization, and mechanical ventilation, reportedly required was similar. Longer-term studies are needed to evaluate the benefits of COVID-19 mitigation strategies on common viruses that require critical care.
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Affiliation(s)
- Conrad Krawiec
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, 500 University Drive, P.O. Box 850, Hershey, PA 17033-0850, USA.
| | - Duane Williams
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, 500 University Drive, P.O. Box 850, Hershey, PA 17033-0850, USA
| | - Vonn Walter
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, 500 University Drive, Hershey, PA 17033-0850, USA
| | - Neal J Thomas
- Department of Pediatrics, Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, 500 University Drive, P.O. Box 850, Hershey, PA 17033-0850, USA; Department of Public Health Sciences, Pennsylvania State University College of Medicine, 500 University Drive, Hershey, PA 17033-0850, USA
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Bond DM, Ampt A, Festa M, Teo A, Nassar N, Schell D. Factors associated with admission of children to an intensive care unit and readmission to hospital within 28 days of discharge: A population-based study. J Paediatr Child Health 2022; 58:579-587. [PMID: 34704639 DOI: 10.1111/jpc.15766] [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: 12/27/2020] [Revised: 09/12/2021] [Accepted: 09/20/2021] [Indexed: 11/28/2022]
Abstract
AIM Hospital readmissions within 28 days are an important performance measurement of quality and safety of health care. The aims of this study were to examine the rates, trends and characteristics of paediatric intensive care unit admissions, and factors associated with readmissions to hospital within 28 days of discharge. METHODS This retrospective, population-based record linkage study included all children ≥28 days and <16 years old admitted to an intensive care unit (ICU) in a New South Wales (NSW) public hospital from 2004 to 2013. Data were sourced from the NSW Admitted Patients Data Collection and the NSW Registry of Births, Deaths and Marriages, Death Registration. RESULTS We identified 21 200 ICU admissions involving 17 130 children. Admissions increased by 24% over the study period with the greatest increase attributed to respiratory and musculoskeletal conditions. A higher proportion of children were <5 years, male, lived in major cities, were publicly insured and had chronic conditions. The median length of ICU stay was 42 h and overall hospital stay was 7 days. There were 905 deaths, two-thirds during the index admission with the leading causes being injuries, cancer and infections. Twenty-three per cent of ICU admissions were readmitted to hospital within 28 days of discharge. Associated independent factors were younger age, longer index hospital stay and emergency index admission. Children with chronic conditions of cancer and genitourinary disorders were more likely to be readmitted. CONCLUSIONS Identification of complex chronic conditions, consideration of long-term health planning and interventions intended to reduce readmission is warranted in order to reduce the burden to families and the health-care system.
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Affiliation(s)
- Diana M Bond
- Child Population Health Research, Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Amanda Ampt
- Child Population Health Research, Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Marino Festa
- Kids Critical Care Research, Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Arthur Teo
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Natasha Nassar
- Child Population Health Research, Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - David Schell
- Kids Critical Care Research, Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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22
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Andersson-Marforio S, Lundkvist Josenby A, Hansen C, Ekvall Hansson E. Physiotherapy interventions encouraging frequent changes of the body position and physical activity for infants hospitalised with bronchiolitis: an internal feasibility study of a randomised control trial. Pilot Feasibility Stud 2022; 8:76. [PMID: 35351205 PMCID: PMC8966163 DOI: 10.1186/s40814-022-01030-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 03/09/2022] [Indexed: 11/20/2022] Open
Abstract
Background The effect of a treatment that includes frequent changes of the body position for infants with bronchiolitis has not been evaluated, although it is often used in Swedish hospitals. Because of this, a randomised control trial (RCT) has begun with the aim to evaluate this treatment, comparing the effect of an individualised physiotherapy intervention, a non-individualised intervention, and standard care in a control group. The objective of this internal pilot study was to address uncertainties concerning the ongoing RCT and to determine whether the trial is feasible or not, possibly with adjustments to the protocol. Methods Descriptive analyses of the recruitment, retention, data supply for the primary end point, and the usability of the primary outcome measure in the full RCT were performed. A safety analysis was conducted by an independent analysis group. Results Ninety-one infants were included, 33 (36.3%), 28 (30.8%), and 30 (33.0%) in the respective allocation groups. Fifty-nine (64.8%) were boys. The median age was 2.5 (min–max 0.2–23.7) months. They remained in the study for a median of 46 hours (min–max 2–159). The recruitment rate was 19%. The data supply for the primary end point and for the primary outcome measure was lower than anticipated in the original sample size calculation. Difficulties concerning utilising the primary outcome measure were identified. The safety analysis detected no risks of harm related to participation in the study. Conclusions It is feasible to continue the RCT with modifications of the analysis plan. Participation in the study was not associated with any safety risks. Trial registration
ClinicalTrials.gov NCT03575091. Registered 2 July 2018. Retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s40814-022-01030-2.
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Affiliation(s)
| | - Annika Lundkvist Josenby
- Department of Health Sciences, Lund University, Margaretavägen 1B, S-22240, Lund, Sweden.,Children's Hospital, Skåne University Hospital, S-22185, Lund, Sweden
| | - Christine Hansen
- Children's Hospital, Skåne University Hospital, S-22185, Lund, Sweden
| | - Eva Ekvall Hansson
- Department of Health Sciences, Lund University, Margaretavägen 1B, S-22240, Lund, Sweden
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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.
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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
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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
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25
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Coon ER, Hester G, Ralston SL. Why Are So Many Children With Bronchiolitis Going to the Intensive Care Unit? JAMA Pediatr 2022; 176:231-233. [PMID: 34928316 DOI: 10.1001/jamapediatrics.2021.5186] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Eric R Coon
- Department of Pediatrics, Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City
| | - Gabrielle Hester
- Department of Value and Clinical Excellence, Children's Minnesota, Minneapolis
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26
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Rodriguez-Gonzalez M, Rodriguez-Campoy P, Estalella-Mendoza A, Castellano-Martinez A, Flores-Gonzalez JC. Characterization of Cardiopulmonary Interactions and Exploring Their Prognostic Value in Acute Bronchiolitis: A Prospective Cardiopulmonary Ultrasound Study. Tomography 2022; 8:142-157. [PMID: 35076624 PMCID: PMC8788562 DOI: 10.3390/tomography8010012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/26/2021] [Accepted: 12/31/2021] [Indexed: 12/14/2022] Open
Abstract
We aimed to delineate cardiopulmonary interactions in acute bronchiolitis and to evaluate the capacity of a combined cardiopulmonary ultrasonography to predict the need for respiratory support. This was a prospective observational single-center study that includes infants <12 month of age admitted to a hospital due to acute bronchiolitis. All the included patients underwent clinical, laboratory and cardiopulmonary ultrasonographic evaluation at the same time point within 24 h of hospital admission. The existence of significant correlation between cardiac and respiratory parameters was the primary outcome. The association of different cardiopulmonary variables with the need of respiratory support higher than O2, the length of stay hospitalization, the PICU stay and the duration of respiratory support were a secondary outcome. We enrolled 112 infants (median age 1 (0.5–3) months; 62% males) hospitalized with acute bronchiolitis. Increased values of the pulmonary variables (BROSJOD score, pCO2 and LUS) showed moderate correlations with NT-proBNP and all echocardiographic parameters indicative of pulmonary hypertension and myocardial dysfunction (Tei index). Up to 36 (32%) infants required respiratory support during the hospitalization. This group presented with higher lung ultrasound score (p < 0.001) and increased values of NT-proBNP (p < 0.001), the Tei index (p < 0.001) and pulmonary artery pressures (p < 0.001). All the analyzed respiratory and cardiac variables showed moderate-to-strong correlations with the LOS of hospitalization and the time of respiratory support. Lung ultrasound and echocardiography showed a moderate-to-strong predictive accuracy for the need of respiratory support in the ROC analysis, with the AUC varying from 0.74 to 0.87. Those cases of bronchiolitis with a worse pulmonary status presented with a more impaired cardiac status. Cardiopulmonary ultrasonography could be a useful tool to easily identify high-risk populations for complicated acute bronchiolitis hospitalization.
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Affiliation(s)
| | - Patricia Rodriguez-Campoy
- Pediatric Intensive Care Unit, Puerta del Mar University Hospital, 11010 Cadiz, Spain; (P.R.-C.); (A.E.-M.); (J.C.F.-G.)
| | - Ana Estalella-Mendoza
- Pediatric Intensive Care Unit, Puerta del Mar University Hospital, 11010 Cadiz, Spain; (P.R.-C.); (A.E.-M.); (J.C.F.-G.)
| | - Ana Castellano-Martinez
- Pediatric Nephrology Division, Puerta del Mar University Hospital, 11010 Cadiz, Spain
- Correspondence:
| | - Jose Carlos Flores-Gonzalez
- Pediatric Intensive Care Unit, Puerta del Mar University Hospital, 11010 Cadiz, Spain; (P.R.-C.); (A.E.-M.); (J.C.F.-G.)
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Reducing PICU-to-Floor Time-to-Transfer Decision in Critically Ill Bronchiolitis Patients using Quality Improvement Methodology. Pediatr Qual Saf 2022; 7:e506. [PMID: 35071949 PMCID: PMC8782107 DOI: 10.1097/pq9.0000000000000506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 08/10/2021] [Indexed: 11/29/2022] Open
Abstract
Supplemental Digital Content is available in the text. Introduction: Specific criteria for de-escalation from the PICU are often not included in viral bronchiolitis institutional pathways. Variability of transfer preferences can prolong PICU length of stay. We aimed to decrease the time from reaching floor-appropriate heated high flow nasal cannula (HHF) settings to the transfer decision by 20% through standardizing PICU-to-floor transfer assessment in a PICU bronchiolitis cohort. Methods: We included PICU bronchiolitis admissions from October 2019 to April 2020, who were 6-months to 2-years-old with no comorbidities nor intubation during their encounter. Our intervention bundle included introduction of transfer criteria and standardization of transfer-readiness assessment. The primary outcome was time from reaching floor-appropriate HHF settings [8 L per minutes (Lpm)] to placement of the transfer order (“time-to-transfer decision”). The secondary outcome was PICU length of stay. The main process measure was the proportion of patients transferred on ≥6 Lpm HHF. Balancing measures included Rapid Response Team activation and unplanned PICU readmission. We assessed admissions meeting inclusion criteria from December, 2018-March, 2019 for the preintervention baseline. Results: Special cause variation indicated improvement in our primary outcome and process measures. Comparison of baseline to postintervention revealed a reduction in median time-to-transfer decision (14.4–7.8 hours; P < 0.001) and increase in children transferred on ≥6 Lpm (51%–72%; P < 0.001). We observed no change in PICU length of stay or balancing measures. Conclusion: Standardizing de-escalation criteria and transfer-readiness assessment reduced the time-to-transfer decision out of the PICU and increased the proportion transferred on ≥6 Lpm HHF for children with viral bronchiolitis without increasing PICU readmissions.
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Sagar H, Dhal S. Managing bronchiolitis in pediatric patients: Current evidence. INDIAN JOURNAL OF RESPIRATORY CARE 2022. [DOI: 10.4103/ijrc.ijrc_153_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
OBJECTIVES To derive and internally validate a bronchiolitis-specific illness severity score (the Critical Bronchiolitis Score) that out-performs mortality-based illness severity scores (e.g., Pediatric Risk of Mortality) in measuring expected duration of respiratory support and PICU length of stay for critically ill children with bronchiolitis. DESIGN Retrospective database study using the Virtual Pediatric Systems (VPS, LLC; Los Angeles, CA) database. SETTING One-hundred twenty-eight North-American PICUs. PATIENTS Fourteen-thousand four-hundred seven children less than 2 years old admitted to a contributing PICU with primary diagnosis of bronchiolitis and use of ICU-level respiratory support (defined as high-flow nasal cannula, noninvasive ventilation, invasive mechanical ventilation, or negative pressure ventilation) at 12 hours after PICU admission. INTERVENTIONS Patient-level variables available at 12 hours from PICU admission, duration of ICU-level respiratory support, and PICU length of stay data were extracted for analysis. After randomly dividing the cohort into derivation and validation groups, patient-level variables that were significantly associated with the study outcomes were selected in a stepwise backward fashion for inclusion in the final score. Score performance in the validation cohort was assessed using root mean squared error and mean absolute error, and performance was compared with that of existing PICU illness severity scores. MEASUREMENTS AND MAIN RESULTS Twelve commonly available patient-level variables were included in the Critical Bronchiolitis Score. Outcomes calculated with the score were similar to actual outcomes in the validation cohort. The Critical Bronchiolitis Score demonstrated a statistically significantly stronger association with duration of ICU-level respiratory support and PICU length of stay than mortality-based scores as measured by root mean squared error and mean absolute error. CONCLUSIONS The Critical Bronchiolitis Score performed better than PICU mortality-based scores in measuring expected duration of ICU-level respiratory support and ICU length of stay. This score may have utility to enrich interventional trials and adjust for illness severity in observational studies in this very common PICU condition.
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30
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Change in Pediatric Health Care Spending and Drug Utilization during the COVID-19 Pandemic. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8121183. [PMID: 34943379 PMCID: PMC8699860 DOI: 10.3390/children8121183] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 11/26/2021] [Accepted: 12/09/2021] [Indexed: 12/23/2022]
Abstract
Objective: To evaluate how the restrictive measures implemented during the SARS-CoV-2 pandemic have influenced the incidence of the most common children’s diseases and the consumption of medications in 2020 compared to 2019. Methods: We involved all family pediatricians of the local health authority of Latina, from which we requested data of monthly visits in 2019 and 2020 for six common diseases disseminated through droplets and contact, and the territorial and integrative pharmaceutical unit of the area, from which we requested data of the net expenditure regarding the most commonly used drugs at pediatric age. Results: There was significant reduction in the incidence of the evaluated diseases and in the consumption of investigated drugs between 2019 and 2020 in the months when the restrictive measures were in place, with an attenuation of this effect during the months of the gradual loosening of those measures. Conclusion: Nonpharmaceutical intervention measures have caused changes in the diffusion of common pediatric diseases. We believe that the implementation of a reasonable containment strategy, even outside of the pandemic, could positively influence the epidemiology of infectious and allergic diseases in children, and healthcare system spending.
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31
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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.
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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
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Risk Factors Associated with Mechanical Ventilation in Critical Bronchiolitis. CHILDREN 2021; 8:children8111035. [PMID: 34828749 PMCID: PMC8618830 DOI: 10.3390/children8111035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/06/2021] [Accepted: 11/09/2021] [Indexed: 11/17/2022]
Abstract
The American Academy of Pediatrics (AAP) recommends supportive care for the management of bronchiolitis. However, patients admitted to the intensive care unit with severe (critical) bronchiolitis define a unique group with varying needs for both non-invasive and invasive respiratory support. Currently, no guidance exists to help clinicians discern who will progress to invasive mechanical support. Here, we sought to identify key clinical features that distinguish pediatric patients with critical bronchiolitis requiring invasive mechanical ventilation from those that did not. We conducted a retrospective cohort study at a tertiary pediatric medical center. Children ≤2 years old admitted to the pediatric intensive care unit (PICU) from January 2015 to December 2019 with acute bronchiolitis were studied. Patients were divided into non-invasive respiratory support (NRS) and invasive mechanical ventilation (IMV) groups; the IMV group was further subdivided depending on timing of intubation relative to PICU admission. Of the 573 qualifying patients, 133 (23%) required invasive mechanical ventilation. Median age and weight were lower in the IMV group, while incidence of prematurity and pre-existing neurologic or genetic conditions were higher compared to the NRS group. Multi-microbial pneumonias were diagnosed more commonly in the IMV group, in turn associated with higher severity of illness scores, longer PICU lengths of stay, and more antibiotic usage. Within the IMV group, those intubated earlier had a shorter duration of mechanical ventilation and PICU length of stay, associated with lower pathogen load and, in turn, shorter antibiotic duration. Taken together, our data reveal that critically ill patients with bronchiolitis who require mechanical ventilation possess high risk features, including younger age, history of prematurity, neurologic or genetic co-morbidities, and a propensity for multi-microbial infections.
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33
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Clinical utility of the pediatric respiratory rate-oxygenation index. Eur J Pediatr 2021; 180:3419-3420. [PMID: 34027623 DOI: 10.1007/s00431-021-04126-8] [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: 04/18/2021] [Revised: 04/18/2021] [Accepted: 05/16/2021] [Indexed: 10/21/2022]
Abstract
A recently published study evaluated the pediatric respiratory rate-oxygenation index to predict high-flow nasal cannula therapy failure in children. This commentary outlines limitations to the clinical applicability of the study results and suggestions for future research.
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34
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Haskell L, Oakley E, Dalziel SR. A Trial of Albuterol Should Still be Considered for Children with Severe Bronchiolitis-Reply. JAMA Pediatr 2021; 175:1183-1184. [PMID: 34369986 DOI: 10.1001/jamapediatrics.2021.2603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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
| | - Ed Oakley
- The Royal Children's Hospital 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.,Department of Surgery , The University of Auckland, Auckland, New Zealand
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Vásquez-Hoyos P, Pardo-Carrero R, Jaramillo-Bustamante J, González-Dambrauskas S, Carvajal C, Diaz F, Fernández A, Jabornisky R, Muzzio S, Cidral E, Mansur A, Céspedes Lesczinsky M, Velasco Z, Grigolli Cesar R, Cruces P, Cordova T, Aranguiz Quintanilla D, Sepúlveda J, Padilla I, Donoso A, Núñez Sánchez MJ, Donoso A, Wegner A, Asistencial C, del Río S, Pietroboni Fuster P, Rosales Fernández J, Sanabria S, Ferre A, España M, Iroa A, Navatta R, Benech E, Carro M, Fernández A, Monteverde N, Carbonell M, Alonso B, Serra A, Fátima Varela L, Cristina Courtie L, Martínez J, Cantirán K, Matrai L, Mislej C, Castro L, Menta S, Talasimov C, María José Caggiano L, Pedrozo L, Franco A, Martínez Arroyo L, Dubra S, Inverso A, Mouta N, Parada M, Karina Etulain L. Ingreso en cuidados intensivos debido a bronquiolitis grave en Colombia: ¿dónde nos encontramos en relación con el resto de Latinoamérica? Med Intensiva 2021. [DOI: 10.1016/j.medin.2019.12.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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36
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Linssen RS, van Woensel JBM, Bont L, Recher M, Campbell H, Ralston SL, Bem RA. Are changes in practice a cause of the rising burden of bronchiolitis for paediatric intensive care units? THE LANCET RESPIRATORY MEDICINE 2021; 9:1094-1096. [DOI: 10.1016/s2213-2600(21)00367-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 08/03/2021] [Indexed: 10/20/2022]
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Lin J, Zhang Y, Song A, Ying L, Dai J. Exploring the appropriate dose of nebulized hypertonic saline for bronchiolitis: a dose-response meta-analysis. J Investig Med 2021; 70:46-54. [PMID: 34518319 DOI: 10.1136/jim-2021-001947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 02/05/2023]
Abstract
Nebulized hypertonic saline (HS) has gathered increasing attention in bronchiolitis. This study aims to evaluate the relationship between the dose of nebulized HS and the effects on bronchiolitis. Five electronic databases-PubMed, EMBASE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and ISRCTN-were searched until May 2021. Randomized controlled trials (RCTs) that investigated the effect of HS on bronchiolitis were included. A total of 35 RCTs met the eligibility criteria. HS nebulization may shorten the length of stay (LOS) in hospital (mean difference -0.47, 95% CI -0.71 to -0.23) and improve the 24-hour, 48-hour, and 72-hour Clinical Severe Score (CSS) in children with bronchiolitis. The results showed that there was no significant difference between 3% HS and the higher doses (>3%) of HS in LOS and 24-hour CSS. Although the dose-response meta-analysis found that there may be a linear relationship between different doses and effects, the slope of the linear model changed with different included studies. Besides, HS nebulization could reduce the rate of hospitalization of children with bronchiolitis (risk ratio 0.88, 95% CI 0.78 to 0.98), while the trial sequential analysis indicated the evidence may be insufficient and potentially false positive. This study showed that nebulized HS is an effective and safe therapy for bronchiolitis. More studies are necessary to be conducted to evaluate the effects of different doses of HS on bronchiolitis.
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Affiliation(s)
- Jilei Lin
- Department of Respiratory Medicine, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yin Zhang
- Department of Respiratory and Critical Care Medicine, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Anchao Song
- School of Public Health and Management, Chongqing Medical University, Chongqing, China
| | - Linyan Ying
- Department of Respiratory Disease, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Jihong Dai
- Department of Respiratory Disease, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
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Fahey KP, Gelbart B, Oberender F, Thompson J, Rozen T, James C, McLaren C, Sniderman J, Uahwatanasakul W. Interhospital transport of children with bronchiolitis by a statewide emergency transport service. CRIT CARE RESUSC 2021; 23:292-299. [PMID: 38046083 PMCID: PMC10692503 DOI: 10.51893/2021.3.oa6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To investigate the rate of interhospital emergency transport for bronchiolitis and intensive care admission following the introduction of high flow nasal cannula and standardised paediatric observation and response charts. Design: Retrospective cohort study. Setting: A statewide paediatric intensive care transport service and its two referral paediatric intensive care units (PICUs) in Victoria, Australia. Participants: Children less than 2 years old emergently transported with bronchiolitis during two time periods: 2008-2012 and 2015-2019. Main outcome measures: Incidence rates of bronchiolitis transport episodes, PICU admissions and respiratory support. Results: 802 children with bronchiolitis were transported during the study period, 233 in the first period (2008-2012) and 569 in the second period (2015-2019). The rate of interhospital transport for bronchiolitis increased from 32.9 to 71.8 per 100 000 children aged 0-2 years. The population-adjusted rate of PICU admission increased from 16.2 to 36.6 per 100 000 children aged 0-2 years. Metropolitan hospitals were the predominant referral source and this increased from 60.1% of transports to 78.6% (P < 0.001). In children admitted to a PICU, the administration of high flow nasal cannula during transport increased significantly from 1.7% to 75.9% (P < 0.001) and a concomitant reduction in continuous positive airway pressure and mechanical ventilation occurred (40-12.4% and 27-6.9% respectively; P < 0.001). The proportion of mechanical ventilation as well as PICU and hospital length of stay decreased over time. Conclusions: The population-adjusted rate of interhospital transport and admission to the PICU for bronchiolitis increased over time. This occurred despite a lower rate of non-invasive and invasive mechanical ventilation during transport and in the PICU.
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Affiliation(s)
- Kieren P. Fahey
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, VIC, Australia
- Department of Paediatrics, Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Melbourne, VIC, Australia
| | - Felix Oberender
- Paediatric Intensive Care Unit, Monash Children’s Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Jenny Thompson
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, VIC, Australia
| | - Tom Rozen
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Melbourne, VIC, Australia
| | - Christopher James
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, VIC, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Murdoch Children’s Research Institute, Melbourne, VIC, Australia
| | - Catriona McLaren
- Paediatric Intensive Care Unit, Monash Children’s Hospital, Melbourne, VIC, Australia
| | - Jonathan Sniderman
- Department of Critical Care, Paediatrics, Schulich School of Medicine and Dentistry, London, On, Canada
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Linssen RS, Teirlinck AC, van Boven M, Biarent D, Stona L, Amigoni A, Comoretto RI, Leteurtre S, Bruandet A, Bentsen GK, Drage IM, Wang X, Campbell H, van Woensel JBM, Bont L, Bem RA. Increasing burden of viral bronchiolitis in the pediatric intensive care unit; an observational study. J Crit Care 2021; 68:165-168. [PMID: 34304966 DOI: 10.1016/j.jcrc.2021.07.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/05/2021] [Accepted: 07/12/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Viral bronchiolitis is a major cause of pediatric intensive care unit (PICU) admission. Insight in the trends of bronchiolitis-associated PICU admissions is limited, but imperative for future PICU resource and capacity planning. MATERIALS AND METHODS We retrospectively studied trends in PICU admissions for bronchiolitis in six European sites, including three full national registries, between 2000 and 2019 and calculated population-based estimates per 100,000 children where appropriate. Information concerning risk factors for severe disease and use of invasive mechanical ventilation was also collected when available. RESULTS In total, there were 15,606 PICU admissions for bronchiolitis. We observed an increase in the annual number, rate and estimates per 100,000 children of PICU admissions for bronchiolitis at all sites over the last two decades, while the proportion of patients at high risk for severe disease remained relatively stable. CONCLUSIONS The international increased burden of bronchiolitis for the PICU is concerning, and warrants further international attention and investigation.
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Affiliation(s)
- Rosalie S Linssen
- Pediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands.
| | - Anne C Teirlinck
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Michiel van Boven
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Dominique Biarent
- Pediatric Intensive Care and Emergency Department, Hospital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Belgium
| | - Luca Stona
- Fondazione Penta Child Health Research ONLUS, Padova, Italy
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Department of Woman's and Child's, Health, University Hospital of Padova, Padova, Italy
| | - Rosanna I Comoretto
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Stephane Leteurtre
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France; Groupe Francophone de Réanimation et d'Urgences pédiatriques - GFRUP-, Paris, France
| | - Amélie Bruandet
- Medical Information Department, Lille University Hospital, Lille, France
| | - Gunnar K Bentsen
- Division of Emergencies and Critical Care, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Inger Marie Drage
- Division of Emergencies and Critical Care, Oslo University Hospital - Ullevaal, Oslo, Norway
| | - Xin Wang
- Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Harry Campbell
- Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Job B M van Woensel
- Pediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Louis Bont
- UMCU Laboratory of Translational Immunology, Wilhelmina Children's Hospital, University Medical Center of Utrecht, Utrecht, the Netherlands; Respiratory Syncytial Virus Network (ReSViNET) Foundation, Zeist, the Netherlands
| | - Reinout A Bem
- Pediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
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Dafydd C, Saunders BJ, Kotecha SJ, Edwards MO. Efficacy and safety of high flow nasal oxygen for children with bronchiolitis: systematic review and meta-analysis. BMJ Open Respir Res 2021; 8:e000844. [PMID: 34326153 PMCID: PMC8323377 DOI: 10.1136/bmjresp-2020-000844] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 07/11/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND To assess the published evidence to establish the efficacy and safety of high flow oxygen cannula (HFNC) as respiratory support for children up to 24 months of age with bronchiolitis within acute hospital settings. METHODS We searched eight databases up to March 2021. Studies including children up to 24 months of age with a diagnosis of bronchiolitis recruited to an randomised controlled trial were considered in the full meta-analysis. At least one arm of the study must include HFNC as respiratory support and report at least one of the outcomes of interest. Studies were identified and extracted by two reviewers. Data were analysed using Review Manager V.5.4. RESULTS From 2943 article titles, 308 full articles were screened for inclusion. 23 studies met the inclusion criteria, 15 were included in the metanalyses. Four studies reported on treatment failure rates when comparing HFNC to standard oxygen therapy (SOT). Data suggests HFNC is superior to SOT (OR 0.45, 95% CI 0.36 to 0.57). Four studies reported on treatment failure rates when comparing HFNC to continuous positive airways pressure (CPAP). No significant difference was found between CPAP and HFNC (OR 1.64, 95% CI 0.96 to 2.79; p=0.07). Four studies report on adverse outcomes when comparing HFNC to SOT. No significant difference was found between HFNC & SOT (OR 1.47, 95% CI 0.54 to 3.99). CONCLUSION HFNC is superior to SOT in terms of treatment failure and there is no significant difference between HFNC and CPAP in terms of treatment failure. The results suggest HFNC is safe to use in acute hospital settings.
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Affiliation(s)
- Carwyn Dafydd
- Children's Hospital for Wales, University of Wales Hospital, Cardiff, Cardiff, UK
| | - Benjamin J Saunders
- Children's Hospital for Wales, University of Wales Hospital, Cardiff, Cardiff, UK
| | - Sarah J Kotecha
- Department of Child Health, Cardiff University, Cardiff, South Glamorgan, UK
| | - Martin O Edwards
- Children's Hospital for Wales, University of Wales Hospital, Cardiff, Cardiff, UK
- Department of Child Health, Cardiff University, Cardiff, South Glamorgan, UK
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Vásquez-Hoyos P, Pardo-Carrero R, Jaramillo-Bustamante JC, González-Dambrauskas S, Carvajal C, Diaz F. Admission to intensive care due to severe bronchiolitis in Colombia: How are we with respect to the rest of Latin America? Med Intensiva 2021; 45:e18-e21. [PMID: 34217640 DOI: 10.1016/j.medine.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/21/2019] [Indexed: 11/27/2022]
Affiliation(s)
- P Vásquez-Hoyos
- Hospital de San José, FUCS, Universidad Nacional de Colombia, Bogotá, Colombia.
| | | | | | - S González-Dambrauskas
- Unidad de Cuidados Intensivos Pediátricos Especializados (CIPe), Casa de Galicia, Montevideo, Uruguay
| | - C Carvajal
- Universidad de Los Andes, Región Metropolitana, Chile
| | - F Diaz
- Hospital El Carmen de Maipú, Santiago, Chile; Instituto de Ciencias Biomédicas, Universidad del Desarrollo, Santiago, Chile
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Miura S, Yamaoka K, Miyata S, Butt W, Smith S. Clinical impact of implementing humidified high-flow nasal cannula on interhospital transport among children admitted to a PICU with respiratory distress: a cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:194. [PMID: 34090490 PMCID: PMC8180008 DOI: 10.1186/s13054-021-03620-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/27/2021] [Indexed: 11/17/2022]
Abstract
Background There is a limited evidence for humidified high-flow nasal cannula (HHFNC) use on inter-hospital transport. Despite this, its use during transport is increasing in children with respiratory distress worldwide. In 2015 HHFNC was implemented on a specialized pediatric retrieval team serving for Victoria. The aim of this study is to investigate the effect of the HHFNC implementation on the retrieval team on the paediatric intensive care unit (PICU) length of stay and respiratory support use. Methods We performed a cohort study using a comparative interrupted time-series approach controlling for patient and temporal covariates, and population-adjusted analysis. We studied 3022 children admitted to a PICU in Victoria with respiratory distress January 2010–December 2019. Patients were divided in pre-intervention era (2010–2014) and post-intervention era (2015–2019). Results 1006 children following interhospital transport and 2016 non-transport children were included. Median (IQR) age was 1.4 (0.7–4.5) years. Pneumonia (39.1%) and bronchiolitis (34.3%) were common. On retrieval, HHFNC was used in 5.0% (21/420) and 45.9% (269/586) in pre- and post-intervention era. In an unadjusted model, median (IQR) PICU length of stay was 2.2 (1.1–4.2) and 1.7 (0.9–3.2) days in the pre- and post-intervention era in transported children while the figures were 2.4 (1.3–4.9) and 2.1 (1.2–4.5) days in non-transport children. In the multivariable regression model, the intervention was associated with the reduced PICU length of stay (ratio 0.64, 95% confidential interval 0.49–0.83, p = 0.001) with the predicted reduction of PICU length of stay being − 10.6 h (95% confidential interval − 16.9 to − 4.3 h), and decreased respiratory support use (− 25.1 h, 95% confidential interval − 47.9 to − 2.3 h, p = 0.03). Sensitivity analyses including a model excluding less severe children showed similar results. In population-adjusted analyses, respiratory support use decreased from 4837 to 3477 person-hour per year in transported children over the study era, while the reduction was 594 (from 9553 to 8959) person-hour per year in non-transport children. With regard to the safety, there were no escalations of respiratory support mode during interhospital transport. Conclusions The implementation of HHFNC on interhospital transport was associated with the reduced PICU length of stay and respiratory support use among PICU admissions with respiratory distress. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03620-7.
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Affiliation(s)
- Shinya Miura
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne, 50 Flemington Road, Parkville, VIC, 3052, Australia. .,Teikyo University Graduate School of Public Health, Tokyo, Japan.
| | - Kazue Yamaoka
- Teikyo University Graduate School of Public Health, Tokyo, Japan
| | - Satoshi Miyata
- Teikyo University Graduate School of Public Health, Tokyo, Japan
| | - Warwick Butt
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne, 50 Flemington Road, Parkville, VIC, 3052, Australia.,Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - Sile Smith
- Paediatric Intensive Care Unit, The Royal Children's Hospital Melbourne, 50 Flemington Road, Parkville, VIC, 3052, Australia.,Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Australia
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Pelletier JH, Au AK, Fuhrman D, Clark RSB, Horvat C. Trends in Bronchiolitis ICU Admissions and Ventilation Practices: 2010-2019. Pediatrics 2021; 147:e2020039115. [PMID: 33972381 PMCID: PMC8785748 DOI: 10.1542/peds.2020-039115] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To determine the changes in ICU admissions, ventilatory support, length of stay, and cost for patients with bronchiolitis in the United States. METHODS Retrospective cross-sectional study of the Pediatric Health Information Systems database. All patients age <2 years admitted with bronchiolitis and discharged between January 1, 2010 and December 31, 2019, were included. Outcomes included proportions of annual ICU admissions, invasive mechanical ventilation (IMV), noninvasive ventilation (NIV), and cost. RESULTS Of 203 859 admissions for bronchiolitis, 39 442 (19.3%) were admitted to an ICU, 6751 (3.3%) received IMV, and 9983 (4.9%) received NIV. ICU admissions for bronchiolitis doubled from 11.7% in 2010 to 24.5% in 2019 (P < .001 for trend), whereas ICU admissions for all children in Pediatric Health Information Systems <2 years of age increased from 16.0% to 21.1% during the same period (P < .001 for trend). Use of NIV increased sevenfold from 1.2% in 2010 to 9.5% in 2019 (P < .001 for trend). Use of IMV did not significantly change (3.3% in 2010 to 2.8% in 2019, P = .414 for trend). In mixed-effects multivariable logistic regression, discharge year was a significant predictor of NIV (odds ratio: 1.24; 95% confidence interval [CI]: 1.23-1.24) and ICU admission (odds ratio: 1.09; 95% CI: 1.09-1.09) but not IMV (odds ratio: 1.00; 95% CI: 1.00-1.00). CONCLUSIONS The proportions of children with bronchiolitis admitted to an ICU and receiving NIV have substantially increased, whereas the proportion receiving IMV is unchanged over the past decade. Further study is needed to better understand the factors underlying these temporal patterns.
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Affiliation(s)
- Jonathan H Pelletier
- Division of Pediatric Critical Care Medicine, Department Critical Care Medicine, and
| | - Alicia K Au
- Division of Pediatric Critical Care Medicine, Department Critical Care Medicine, and
| | - Dana Fuhrman
- Division of Pediatric Critical Care Medicine, Department Critical Care Medicine, and
| | - Robert S B Clark
- Division of Pediatric Critical Care Medicine, Department Critical Care Medicine, and
| | - Christopher Horvat
- Division of Pediatric Critical Care Medicine, Department Critical Care Medicine, and
- Division of Health Informatics, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Raman S, Brown G, Long D, Gelbart B, Delzoppo C, Millar J, Erickson S, Festa M, Schlapbach LJ. Priorities for paediatric critical care research: a modified Delphi study by the Australian and New Zealand Intensive Care Society Paediatric Study Group. CRIT CARE RESUSC 2021; 23:194-201. [PMID: 38045513 PMCID: PMC10692499 DOI: 10.51893/2021.2.oa6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Most interventions in paediatric critical care lack high grade evidence. We aimed to identify the key research priorities and key clinical outcome measures pertinent to research in paediatric intensive care patients. Design: Modified three-stage Delphi study combining staged online surveys, followed by a face-to-face discussion and final voting. Setting: Paediatric intensive care units in Australia and New Zealand. Participants: Medical and nursing staff working in intensive care. Main outcome measurements: Self-reported priorities for research. Results: 193 respondents provided a total of 267 research questions and 234 outcomes. In Stage 3, the top 56 research questions and 50 outcomes were discussed face to face, which allowed the identification of the top 20 research questions with the Hanlon prioritisation score and the top 20 outcomes. Topics centred on the use of intravenous fluids (restrictive v liberal fluids, use of fluid resuscitation bolus, early inotrope use, type of intravenous fluid, and assessment of fluid responsiveness), and patient- and family-centred outcomes (health-related quality of life, liberation) emerged as priorities. While mortality, length of stay, and organ support/organ dysfunction were considered important and the most feasible outcomes, long term quality of life and neurodevelopmental measures were rated highly in terms of their importance. Conclusions: Using a modified Delphi method, this study provides guidance towards prioritisation of research topics in paediatric critical care in Australia and New Zealand, and identifies study outcomes of key relevance to clinicians and experts in the field.
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Affiliation(s)
- Sainath Raman
- Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland, Children’s, Hospital, Brisbane, QLD, Australia
| | - Georgia Brown
- University of Melbourne, Melbourne, VIC, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
| | - Debbie Long
- Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland, Children’s, Hospital, Brisbane, QLD, Australia
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Ben Gelbart
- University of Melbourne, Melbourne, VIC, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
| | - Carmel Delzoppo
- University of Melbourne, Melbourne, VIC, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
| | - Johnny Millar
- University of Melbourne, Melbourne, VIC, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
| | - Simon Erickson
- Paediatric Intensive Care Unit, Perth Children’s Hospital, Perth, WA, Australia
| | - Marino Festa
- Paediatric Intensive Care Unit, Children’s Hospital Westmead, Sydney, NSW, Australia
- Kids Critical Care Research Group, Kids Research, Sydney Children’s Hospitals Network, Sydney, NSW, Australia
| | - Luregn J. Schlapbach
- Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland, Children’s, Hospital, Brisbane, QLD, Australia
- Pediatric and Neonatal Intensive Care Unit, University Children’s Hospital Zurich, and Children’s Research Center, University of Zurich, Zurich, Switzerland
| | - for the Australian and New Zealand Intensive Care Society Paediatric Study Group (ANZICS PSG)
- Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland, Children’s, Hospital, Brisbane, QLD, Australia
- University of Melbourne, Melbourne, VIC, Australia
- Paediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, VIC, Australia
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Perth Children’s Hospital, Perth, WA, Australia
- Paediatric Intensive Care Unit, Children’s Hospital Westmead, Sydney, NSW, Australia
- Kids Critical Care Research Group, Kids Research, Sydney Children’s Hospitals Network, Sydney, NSW, Australia
- Pediatric and Neonatal Intensive Care Unit, University Children’s Hospital Zurich, and Children’s Research Center, University of Zurich, Zurich, Switzerland
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Impact of Failure of Noninvasive Ventilation on the Safety of Pediatric Tracheal Intubation. Crit Care Med 2021; 48:1503-1512. [PMID: 32701551 DOI: 10.1097/ccm.0000000000004500] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Noninvasive ventilation is widely used to avoid tracheal intubation in critically ill children. The objective of this study was to assess whether noninvasive ventilation failure was associated with severe tracheal intubation-associated events and severe oxygen desaturation during tracheal intubation. DESIGN Prospective multicenter cohort study of consecutive intubated patients using the National Emergency Airway Registry for Children registry. SETTING Thirteen PICUs (in 12 institutions) in the United States and Canada. PATIENTS All patients undergoing tracheal intubation in participating sites were included. Noninvasive ventilation failure group included children with any use of high-flow nasal cannula, continuous positive airway pressure, or bilevel noninvasive ventilation in the 6 hours prior to tracheal intubation. Primary tracheal intubation group included children without exposure to noninvasive ventilation within 6 hours before tracheal intubation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Severe tracheal intubation-associated events (cardiac arrest, esophageal intubation with delayed recognition, emesis with aspiration, hypotension requiring intervention, laryngospasm, pneumothorax, pneumomediastinum) and severe oxygen desaturation (< 70%) were recorded prospectively. The study included 956 tracheal intubation encounters; 424 tracheal intubations (44%) occurred after noninvasive ventilation failure, with a median of 13 hours (interquartile range, 4-38 hr) of noninvasive ventilation. Noninvasive ventilation failure group included more infants (47% vs 33%; p < 0.001) and patients with a respiratory diagnosis (56% vs 30%; p < 0.001). Noninvasive ventilation failure was not associated with severe tracheal intubation-associated events (5% vs 5% without noninvasive ventilation; p = 0.96) but was associated with severe desaturation (15% vs 9% without noninvasive ventilation; p = 0.005). After controlling for baseline differences, noninvasive ventilation failure was not independently associated with severe tracheal intubation-associated events (p = 0.35) or severe desaturation (p = 0.08). In the noninvasive ventilation failure group, higher FIO2 before tracheal intubation (≥ 70%) was associated with severe tracheal intubation-associated events. CONCLUSIONS Critically ill children are frequently exposed to noninvasive ventilation before intubation. Noninvasive ventilation failure was not independently associated with severe tracheal intubation-associated events or severe oxygen desaturation compared to primary tracheal intubation.
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Linssen RS, den Hollander B, Bont L, van Woensel JBM, Bem RA. The Association between Weather Conditions and Admissions to the Paediatric Intensive Care Unit for Respiratory Syncytial Virus Bronchiolitis. Pathogens 2021; 10:pathogens10050567. [PMID: 34067031 PMCID: PMC8150834 DOI: 10.3390/pathogens10050567] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 04/21/2021] [Accepted: 05/05/2021] [Indexed: 12/01/2022] Open
Abstract
Respiratory syncytial virus (RSV) bronchiolitis is a leading cause of global child morbidity and mortality. Every year, seasonal RSV outbreaks put high pressure on paediatric intensive care units (PICUs) worldwide, including in the Netherlands, and this burden appears to be increasing. Weather conditions have a strong influence on RSV activity, and climate change has been proposed as a potential important determinant of future RSV-related health care utilisation. In this national study spanning a total of 13 years with 2161 PICU admissions for RSV bronchiolitis, we aimed (1) to identify meteorological variables that were associated with the number of PICU admissions for RSV bronchiolitis in the Netherlands and (2) to determine if longitudinal changes in these variables occurred over time as a possible explanation for the observed increase in PICU burden. Poisson regression modelling was used to identify weather variables (aggregated in months and weeks) that predicted PICU admissions, and linear regression analysis was used to assess changes in the weather over time. Maximum temperature and global radiation best predicted PICU admissions, with global radiation showing the most stable strength of effect in both month and week data. However, we did not observe a significant change in these weather variables over the 13-year time period. Based on our study, we could not identify changing weather conditions as a potential contributing factor to the increased RSV-related PICU burden in the Netherlands.
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Affiliation(s)
- Rosalie S. Linssen
- Paediatric Intensive Care Unit, Emma Children’s Hospital, Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands; (B.d.H.); (J.B.M.v.W.); (R.A.B.)
- Amsterdam Reproduction & Development (AR&D) and the Amsterdam Infection & Immunity (AR&I) Research Institutes Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands
- Correspondence: ; Tel.: +31-20-56-62453-E
| | - Bibiche den Hollander
- Paediatric Intensive Care Unit, Emma Children’s Hospital, Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands; (B.d.H.); (J.B.M.v.W.); (R.A.B.)
| | - Louis Bont
- UMCU Laboratory of Translational Immunology, University Medical Center Utrecht, Wilhelmina Children’s Hospital, 3584 EA Utrecht, The Netherlands;
- Respiratory Syncytial Virus Network (ReSViNET) Foundation, 3703 CD Zeist, The Netherlands
| | - Job B. M. van Woensel
- Paediatric Intensive Care Unit, Emma Children’s Hospital, Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands; (B.d.H.); (J.B.M.v.W.); (R.A.B.)
| | - Reinout A. Bem
- Paediatric Intensive Care Unit, Emma Children’s Hospital, Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands; (B.d.H.); (J.B.M.v.W.); (R.A.B.)
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47
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Elliott SA, Gaudet LA, Fernandes RM, Vandermeer B, Freedman SB, Johnson DW, Plint AC, Klassen TP, Allain D, Hartling L. Comparative Efficacy of Bronchiolitis Interventions in Acute Care: A Network Meta-analysis. Pediatrics 2021; 147:peds.2020-040816. [PMID: 33893229 DOI: 10.1542/peds.2020-040816] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/06/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Uncertainty exists as to which treatments are most effective for bronchiolitis, with considerable practice variation within and across health care sites. OBJECTIVE A network meta-analysis to compare the effectiveness of common treatments for bronchiolitis in children aged ≤2 years. DATA SOURCES Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform were searched from inception to September 1, 2019. STUDY SELECTION A total 150 randomized controlled trials comparing a placebo or active comparator with any bronchodilator, glucocorticoid steroid, hypertonic saline solution, antibiotic, helium-oxygen therapy, or high-flow oxygen therapy were included. DATA EXTRACTION Data were extracted by 1 reviewer and independently verified. Primary outcomes were admission rate on day 1 and by day 7 and hospital length of stay. Strength of evidence was assessed by using Confidence in Network Meta-Analysis . RESULTS Nebulized epinephrine (odds ratio: 0.64, 95% confidence interval [CI]: 0.44 to 0.93, low confidence) and nebulized hypertonic saline plus salbutamol (odds ratio: 0.44, 95% CI: 0.23 to 0.84, low confidence) reduced the admission rate on day 1. No treatment significantly reduced the admission rate on day 7. Nebulized hypertonic saline (mean difference: -0.64 days, 95% CI: -1.01 to -0.26, low confidence) and nebulized hypertonic saline plus epinephrine (mean difference: -0.91 days, 95% CI: -1.14 to -0.40, low confidence) reduced hospital length of stay. LIMITATIONS Because we did not report adverse events in this analysis, we cannot make inferences about the safety of these treatments. CONCLUSIONS Although hypertonic saline alone, or combined with epinephrine, may reduce an infant's stay in the hospital, poor strength of evidence necessitates additional rigorous trials.
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Affiliation(s)
- Sarah Alexandra Elliott
- Alberta Research Centre for Health Evidence and.,Cochrane Child Health, Department of Pediatrics, Faculty of Medicine and Dentistry, Edmonton Clinic Health Academy, University of Alberta Edmonton, Canada
| | | | - Ricardo M Fernandes
- Cochrane Child Health, Department of Pediatrics, Faculty of Medicine and Dentistry, Edmonton Clinic Health Academy, University of Alberta Edmonton, Canada.,Clinical Pharmacology and Therapeutics Laboratory, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, Lisboa, Portugal.,Department of Pediatrics, Hospital de Santa Maria, Avenida Professor Egas Moniz, Lisboa, Portugal
| | - Ben Vandermeer
- Cochrane Child Health, Department of Pediatrics, Faculty of Medicine and Dentistry, Edmonton Clinic Health Academy, University of Alberta Edmonton, Canada
| | - Stephen B Freedman
- Departments of Pediatrics, Emergency Medicine, and Physiology and Pharmacology, Cumming School of Medicine, Alberta Children's Hospital Research Institute, University of Calgary and Alberta Children's Hospital Foundation, Calgary, Canada
| | - David W Johnson
- Departments of Pediatrics, Emergency Medicine, and Physiology and Pharmacology, Cumming School of Medicine, Alberta Children's Hospital Research Institute, University of Calgary and Alberta Children's Hospital Foundation, Calgary, Canada
| | - Amy C Plint
- Division of Emergency Medicine, Department of Pediatrics, Faculty of Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Terry P Klassen
- Children's Hospital Research Institute of Manitoba and Department of Pediatrics and Child Health, Max Rudy School of Medicine, University of Manitoba, Winnipeg, Canada; and
| | - Dominic Allain
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta and Stollery Children's Hospital, Edmonton, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence and .,Cochrane Child Health, Department of Pediatrics, Faculty of Medicine and Dentistry, Edmonton Clinic Health Academy, University of Alberta Edmonton, Canada
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Clerico A, Aimo A, Cantinotti M. Cardiac biomarkers for outcome prediction in infant bronchiolitis: Too soon to discard troponin? Clin Chim Acta 2021; 518:170-172. [PMID: 33839092 DOI: 10.1016/j.cca.2021.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 04/06/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Acute bronchiolitis, usually caused by the respiratory syncytial virus, is the most common cause of severe respiratory distress in infants. The clinical relevance of cardiac biomarkers for diagnosis and prognosis of bronchiolitis in infants is still controversial. AIM This Editorial discuss the results of a recent on the clinical relevance of cardiac specific biomarkers, NT-proBNP and cardiac troponin I (cTnI) in 40 infants with bronchiolitis, 37% requiring admission in the ICU. RESULTS NT-proBNP levels were significantly associated with prolonged hospitalization and duration of oxygen therapy, while cTnI levels, measured with high-sensitivity (hs) methods, did not. Furthermore NT-proBNP was significantly correlated with left and right ventricular functional echocardiographic parameters, while hs-cTnI was not associated with any echocardiographic parameter. DISCUSSION Recent results confirm that NT-proBNP assay has a crucial role in the diagnosis, prognosis and follow-up of patients with cardiac disease not only in adult, but even in pediatric age). On the other hand, the clinical usefulness of assay of hs-cTnI and hs-cTnT in pediatric cardiology, at present time, may be greatly limited by the lack of reliable reference intervals. CONCLUSIONS Further well-designed multi-center studies are needed to more accurately evaluate the clinical relevance of cardio-specific biomarkers, and in particular of hs-cTnI and hs-cTnT assay, on prognosis of infants with bronchiolitis.
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Affiliation(s)
- Aldo Clerico
- Fondazione CNR-Regione Toscana G. Monasterio and Scuola Superiore Sant'Anna, Pisa, Italy.
| | - Alberto Aimo
- Fondazione CNR-Regione Toscana G. Monasterio and Scuola Superiore Sant'Anna, Pisa, Italy
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Rodríguez-González M, Estepa-Pedregosa L, Estalella-Mendoza A, Castellano-Martínez A, Rodríguez-Campoy P, Carlos Flores-González J. Early elevated NT-proBNP but not troponin I is associated with severe bronchiolitis in infants. Clin Chim Acta 2021; 518:173-179. [PMID: 33831420 DOI: 10.1016/j.cca.2021.03.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 03/27/2021] [Accepted: 03/28/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND We aimed to explore and to compare the association between the NT-proBNP and high-sensitivity troponin I (hs-cTnI) at early stages of acute bronchiolitis with echocardiographic alterations, clinical severity and outcomes. METHODS A single centre, prospective observational study including previously healthy infants aged 1-12 months with bronchiolitis admitted to a tertiary hospital from April 2019 to March 2020. All patients underwent clinical, laboratory and echocardiographic evaluation at the same time point within 12 h of hospital admission. NT-proBNP > 1121 pg/ml and hs-cTnI > 26 ng/L were considered elevated. The primary outcome measure was the association of raised cardiac biomarkers with the need for PICU admission. RESULTS We enrolled 40 infants with median levels of NT-proBNP of 1176 (520-3030) pg/ml and hs-cTnI of 11.5 (5-21) ng/L at the time of hospital admission. Raised levels of NT-proBNP and hs-cTnI in 50% and 20% of cases, respectively. Of them, 15 (37%) required PICU admission during the hospitalization. Increased NT-proBNP was associated with PICU admission (adjusted OR 9.5 (CI95% 1.4-64); p = 0.020), prolonged hospitalization (β = 2.7; p = 0.012) and duration of oxygen administration (β = 2.7; p = 0.004) in the multivariate analysis. There were no differences in hs-cTnI levels regarding PICU admission (p = 0.866). Increased hs-cTnI levels were only associated with oxygen administration duration (Spearman rho = 0.38; p = 0.017), but this association disappeared in the multivariate analysis. Only NT-proBNP was associated with echocardiographic parameters of myocardial dysfunction (p < 0.001), and pulmonary hypertension (p < 0.001) CONCLUSION: Early elevated NT-proBNP but not hs-cTnI could be used as a biomarker for myocardial strain and disease severity in bronchiolitis.
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Affiliation(s)
- Moisés Rodríguez-González
- Pediatric Cardiology Unit, Puerta del Mar University Hospital, Cádiz, Spain; Biomedical Research and Innovation Institute of Cádiz (INiBICA) Research Unit, Puerta del Mar University Hospital University of Cádiz, Spain
| | - Lorena Estepa-Pedregosa
- Pediatric Intensive Care Unit, Puerta del Mar University Hospital, Cádiz, Spain; Biomedical Research and Innovation Institute of Cádiz (INiBICA) Research Unit, Puerta del Mar University Hospital University of Cádiz, Spain
| | - Ana Estalella-Mendoza
- Pediatric Intensive Care Unit, Puerta del Mar University Hospital, Cádiz, Spain; Biomedical Research and Innovation Institute of Cádiz (INiBICA) Research Unit, Puerta del Mar University Hospital University of Cádiz, Spain
| | - Ana Castellano-Martínez
- Pediatric Nephrology Division, Puerta del Mar University Hospital, Cádiz, Spain; Biomedical Research and Innovation Institute of Cádiz (INiBICA) Research Unit, Puerta del Mar University Hospital University of Cádiz, Spain.
| | - Patricia Rodríguez-Campoy
- Pediatric Intensive Care Unit, Puerta del Mar University Hospital, Cádiz, Spain; Biomedical Research and Innovation Institute of Cádiz (INiBICA) Research Unit, Puerta del Mar University Hospital University of Cádiz, Spain
| | - Jose Carlos Flores-González
- Pediatric Intensive Care Unit, Puerta del Mar University Hospital, Cádiz, Spain; Biomedical Research and Innovation Institute of Cádiz (INiBICA) Research Unit, Puerta del Mar University Hospital University of Cádiz, Spain
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50
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Martinez-Garcia A, Naranjo-Saucedo AB, Rivas JA, Romero Tabares A, Marín Cassinello A, Andrés-Martín A, Sánchez Laguna FJ, Villegas R, Pérez León FDP, Moreno Conde J, Parra Calderón CL. A Clinical Decision Support System (KNOWBED) to Integrate Scientific Knowledge at the Bedside: Development and Evaluation Study. JMIR Med Inform 2021; 9:e13182. [PMID: 33709932 PMCID: PMC7991993 DOI: 10.2196/13182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 12/18/2020] [Accepted: 01/23/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The evidence-based medicine (EBM) paradigm requires the development of health care professionals' skills in the efficient search of evidence in the literature, and in the application of formal rules to evaluate this evidence. Incorporating this methodology into the decision-making routine of clinical practice will improve the patients' health care, increase patient safety, and optimize resources use. OBJECTIVE The aim of this study is to develop and evaluate a new tool (KNOWBED system) as a clinical decision support system to support scientific knowledge, enabling health care professionals to quickly carry out decision-making processes based on EBM during their routine clinical practice. METHODS Two components integrate the KNOWBED system: a web-based knowledge station and a mobile app. A use case (bronchiolitis pathology) was selected to validate the KNOWBED system in the context of the Paediatrics Unit of the Virgen Macarena University Hospital (Seville, Spain). The validation was covered in a 3-month pilot using 2 indicators: usability and efficacy. RESULTS The KNOWBED system has been designed, developed, and validated to support clinical decision making in mobility based on standards that have been incorporated into the routine clinical practice of health care professionals. Using this tool, health care professionals can consult existing scientific knowledge at the bedside, and access recommendations of clinical protocols established based on EBM. During the pilot project, 15 health care professionals participated and accessed the system for a total of 59 times. CONCLUSIONS The KNOWBED system is a useful and innovative tool for health care professionals. The usability surveys filled in by the system users highlight that it is easy to access the knowledge base. This paper also sets out some improvements to be made in the future.
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Affiliation(s)
- Alicia Martinez-Garcia
- Group of Research and Innovation in Biomedical Informatics, Biomedical Engineering and Health Economy, Institute of Biomedicine of Seville, IBiS / Virgen del Rocío University Hospital / CSIC / University of Seville, Seville, Spain
| | - Ana Belén Naranjo-Saucedo
- Group of Research and Innovation in Biomedical Informatics, Biomedical Engineering and Health Economy, Institute of Biomedicine of Seville, IBiS / Virgen del Rocío University Hospital / CSIC / University of Seville, Seville, Spain
| | - Jose Antonio Rivas
- Group of Research and Innovation in Biomedical Informatics, Biomedical Engineering and Health Economy, Institute of Biomedicine of Seville, IBiS / Virgen del Rocío University Hospital / CSIC / University of Seville, Seville, Spain
| | - Antonio Romero Tabares
- Publications Department, Andalusian Institute of Emergencies and Public Safety, Seville, Spain
| | | | | | | | - Roman Villegas
- Group of Research and Innovation in Biomedical Informatics, Biomedical Engineering and Health Economy, Institute of Biomedicine of Seville, IBiS / Virgen del Rocío University Hospital / CSIC / University of Seville, Seville, Spain
| | - Francisco De Paula Pérez León
- Group of Research and Innovation in Biomedical Informatics, Biomedical Engineering and Health Economy, Institute of Biomedicine of Seville, IBiS / Virgen del Rocío University Hospital / CSIC / University of Seville, Seville, Spain
| | - Jesús Moreno Conde
- Group of Research and Innovation in Biomedical Informatics, Biomedical Engineering and Health Economy, Institute of Biomedicine of Seville, IBiS / Virgen del Rocío University Hospital / CSIC / University of Seville, Seville, Spain
| | - Carlos Luis Parra Calderón
- Group of Research and Innovation in Biomedical Informatics, Biomedical Engineering and Health Economy, Institute of Biomedicine of Seville, IBiS / Virgen del Rocío University Hospital / CSIC / University of Seville, Seville, Spain.,Department of Innovation Technology, Virgen del Rocío University Hospital, Seville, Spain
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