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Zhang L, Mendoza-Sassi RA, Wainwright CE, Aregbesola A, Klassen TP. Nebulised hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database Syst Rev 2023; 4:CD006458. [PMID: 37014057 PMCID: PMC10072872 DOI: 10.1002/14651858.cd006458.pub5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
BACKGROUND Airway oedema (swelling) and mucus plugging are the principal pathological features in infants with acute viral bronchiolitis. Nebulised hypertonic saline solution (≥ 3%) may reduce these pathological changes and decrease airway obstruction. This is an update of a review first published in 2008, and updated in 2010, 2013, and 2017. OBJECTIVES To assess the effects of nebulised hypertonic (≥ 3%) saline solution in infants with acute bronchiolitis. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily, Embase, CINAHL, LILACS, and Web of Science on 13 January 2022. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov on 13 January 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs using nebulised hypertonic saline alone or in conjunction with bronchodilators as an active intervention and nebulised 0.9% saline or standard treatment as a comparator in children under 24 months with acute bronchiolitis. The primary outcome for inpatient trials was length of hospital stay, and the primary outcome for outpatients or emergency department (ED) trials was rate of hospitalisation. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, data extraction, and assessment of risk of bias in included studies. We conducted random-effects model meta-analyses using Review Manager 5. We used mean difference (MD), risk ratio (RR), and their 95% confidence intervals (CI) as effect size metrics. MAIN RESULTS We included six new trials (N = 1010) in this update, bringing the total number of included trials to 34, involving 5205 infants with acute bronchiolitis, of whom 2727 infants received hypertonic saline. Eleven trials await classification due to insufficient data for eligibility assessment. All included trials were randomised, parallel-group, controlled trials, of which 30 were double-blinded. Twelve trials were conducted in Asia, five in North America, one in South America, seven in Europe, and nine in Mediterranean and Middle East regions. The concentration of hypertonic saline was defined as 3% in all but six trials, in which 5% to 7% saline was used. Nine trials had no funding, and five trials were funded by sources from government or academic agencies. The remaining 20 trials did not provide funding sources. Hospitalised infants treated with nebulised hypertonic saline may have a shorter mean length of hospital stay compared to those treated with nebulised normal (0.9%) saline or standard care (mean difference (MD) -0.40 days, 95% confidence interval (CI) -0.69 to -0.11; 21 trials, 2479 infants; low-certainty evidence). Infants who received hypertonic saline may also have lower postinhalation clinical scores than infants who received normal saline in the first three days of treatment (day 1: MD -0.64, 95% CI -1.08 to -0.21; 10 trials (1 outpatient, 1 ED, 8 inpatient trials), 893 infants; day 2: MD -1.07, 95% CI -1.60 to -0.53; 10 trials (1 outpatient, 1 ED, 8 inpatient trials), 907 infants; day 3: MD -0.89, 95% CI -1.44 to -0.34; 10 trials (1 outpatient, 9 inpatient trials), 785 infants; low-certainty evidence). Nebulised hypertonic saline may reduce the risk of hospitalisation by 13% compared with nebulised normal saline amongst infants who were outpatients and those treated in the ED (risk ratio (RR) 0.87, 95% CI 0.78 to 0.97; 8 trials, 1760 infants; low-certainty evidence). However, hypertonic saline may not reduce the risk of readmission to hospital up to 28 days after discharge (RR 0.83, 95% CI 0.55 to 1.25; 6 trials, 1084 infants; low-certainty evidence). We are uncertain whether infants who received hypertonic saline have a lower number of days to resolution of wheezing compared to those who received normal saline (MD -1.16 days, 95% CI -1.43 to -0.89; 2 trials, 205 infants; very low-certainty evidence), cough (MD -0.87 days, 95% CI -1.31 to -0.44; 3 trials, 363 infants; very low-certainty evidence), and pulmonary moist crackles (MD -1.30 days, 95% CI -2.28 to -0.32; 2 trials, 205 infants; very low-certainty evidence). Twenty-seven trials presented safety data: 14 trials (1624 infants; 767 treated with hypertonic saline, of which 735 (96%) co-administered with bronchodilators) did not report any adverse events, and 13 trials (2792 infants; 1479 treated with hypertonic saline, of which 416 (28%) co-administered with bronchodilators and 1063 (72%) hypertonic saline alone) reported at least one adverse event such as worsening cough, agitation, bronchospasm, bradycardia, desaturation, vomiting and diarrhoea, most of which were mild and resolved spontaneously (low-certainty evidence). AUTHORS' CONCLUSIONS Nebulised hypertonic saline may modestly reduce length of stay amongst infants hospitalised with acute bronchiolitis and may slightly improve clinical severity score. Treatment with nebulised hypertonic saline may also reduce the risk of hospitalisation amongst outpatients and ED patients. Nebulised hypertonic saline seems to be a safe treatment in infants with bronchiolitis with only minor and spontaneously resolved adverse events, especially when administered in conjunction with a bronchodilator. The certainty of the evidence was low to very low for all outcomes, mainly due to inconsistency and risk of bias.
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Affiliation(s)
- Linjie Zhang
- Faculty of Medicine, Federal University of Rio Grande, Rio Grande, Brazil
| | | | - Claire E Wainwright
- Department of Respiratory Medicine, Royal Children's Hospital, Brisbane, Australia
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Yu JF, Zhang Y, Liu ZB, Wang J, Bai LP. 3% nebulized hypertonic saline versus normal saline for infants with acute bronchiolitis: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2022; 101:e31270. [PMID: 36316926 PMCID: PMC10662888 DOI: 10.1097/md.0000000000031270] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/19/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND This study evaluated the efficacy and safety of 3% nebulized hypertonic saline (NHS) in infants with acute bronchiolitis (AB). METHODS We systematically searched the PUBMED, EMBASE, Cochrane Library, China National Knowledge Infrastructure Database, WANFANG, and VIP databases from inception to June 1, 2022. We included randomized controlled trials comparing NHS with 0.9% saline. Outcomes included the length of hospital stay (LOS), rate of hospitalization (ROH), clinical severity score (CSS), rate of readmission, respiratory distress assessment instrument, and adverse events. RevMan V5.4 software was used for statistical analysis. RESULTS A total of 27 trials involving 3495 infants were included in this study. Compared to normal saline, infants received 3% NHS showed better outcomes in LOS reduction (MD = -0.60, 95% CI [-1.04, -0.17], I2 = 92%, P = .007), ROH decrease (OR = 0.74, 95% CI [0.59, 0.91], I2 = 0%, P = .005), CSS improvement at day 1 (MD = -0.79, 95% CI [-1.23, -0.34], I2 = 74%, P < .001), day 2 (MD = -1.26, 95% CI [-2.02, -0.49], I2 = 91%, P = .001), and day 3 and over (MD = -1.27, 95% CI [-1.92, -0.61], I2 = 79%, P < .001), and respiratory distress assessment instrument enhancement (MD = -0.60, 95% CI [-0.95, -0.26], I2 = 0%, P < .001). No significant adverse events related to 3% NHS were observed. CONCLUSION This study showed that 3% NHS was better than 0.9% normal saline in reducing LOS, decreasing ROH, improving CSS, and in enhancing the severity of respiratory distress. Further studies are needed to validate these findings.
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Affiliation(s)
- Jin-Feng Yu
- Department of Pediatric Medicine, Hongqi Hospital Affiliated to Mudanjiang Medical University, Mudanjiang, China
| | - Yan Zhang
- Department of Hematology, Hongqi Hospital Affiliated to Mudanjiang Medical University, Mudanjiang, China
| | - Zhan-Bo Liu
- Department of Computer, Hongqi Hospital Affiliated to Mudanjiang Medical University, Mudanjiang, China
| | - Jing Wang
- Department of Pediatric Medicine, Hongqi Hospital Affiliated to Mudanjiang Medical University, Mudanjiang, China
| | - Li-Ping Bai
- Department of Pediatric Medicine, Hongqi Hospital Affiliated to Mudanjiang Medical University, Mudanjiang, China
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Buendía JA, Patiño DG. Budget Impact Analysis of Hypertonic Saline Inhalations for Infant Bronchiolitis: The Colombian National Health System Perspective. Value Health Reg Issues 2021; 28:14-18. [PMID: 34800827 DOI: 10.1016/j.vhri.2021.07.008] [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] [Received: 01/08/2021] [Revised: 07/02/2021] [Accepted: 07/10/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Nebulized 3% hypertonic solution (HS) is associated with lower total cost and higher quality-adjusted life-years. Nevertheless, the expected budget impact of this drug had not been explicitly estimated. The aim of this study was to evaluate the budget impact of 3% HS in the treatment of acute bronchiolitis in Colombia. METHODS A budget impact analysis was performed to evaluate the potential financial impact of the use of 3% HS. The analysis considered a 4-year time horizon and a Colombian national health system perspective. The incremental budget impact was calculated by subtracting the cost of the new treatment, in which 3 % HS (added to humidified oxygen) was reimbursed, from the cost of the conventional treatment without 3 % HS (only humidified oxygen or adrenaline nebulization). Univariate 1-way sensitivity analyses were performed. RESULTS In the base-case analysis, the 4-year costs associated with HS and non-3% HS were estimated to be $47 792 230 and $53 312 832, respectively, indicating savings for Colombian national health system equal to $5 520 602 if HS is adopted for the routine management of patients with acute bronchiolitis. This result was robust in univariate 1-way sensitivity analysis. CONCLUSION HS was cost saving in emergency settings for treating infants with acute bronchiolitis. This evidence can be used by decision makers in Colombia to improve clinical practice guidelines and should be replicated to validate their results in other middle-income countries.
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Affiliation(s)
- Jefferson Antonio Buendía
- Department of Pharmacology and Toxicology, School of Medicine, Research Group in Pharmacology and Toxicology (INFARTO), Universidad de Antioquia, Medellín, Colombia.
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Variability of Care of Infants With Severe Respiratory Syncytial Virus Bronchiolitis: A Multicenter Study. Pediatr Infect Dis J 2020; 39:808-813. [PMID: 32304465 DOI: 10.1097/inf.0000000000002707] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Viral bronchiolitis caused by respiratory syncytial virus (RSV) is a common childhood disease accounting for many hospitalizations worldwide. Some infants may clinically deteriorate, requiring admission to an intensive care unit. We aimed to describe diagnostic and therapeutic measures of bronchiolitis in Israeli pediatric intensive care units (PICUs) and evaluate intercenter variability of care. METHODS Medical records of all RSV-infected infants admitted to 5 Israeli PICUs over 4 RSV seasons were retrospectively reviewed. RESULTS Data on 276 infants with RSV-positive bronchiolitis, admitted to the participating PICUs were analyzed. Most of the infants were males with a mean admission age of 4.7 months. Approximately half of the infants had pre-existing conditions such as prematurity, cardiac disease or chronic lung disease. Respiratory distress was the most common symptom at presentation followed by hypoxemia and fever. There was significant variation in the methods used for RSV diagnosis, medical management and respiratory support of the infants. Furthermore, utilization of inhalational therapy and transfusion of blood products differed significantly between the centers. Although a bacterial pathogen was isolated in only 13.4% of the infants, 82.6% of the cohort was treated with antibiotics. CONCLUSIONS Significant variation was found between the different PICUs regarding RSV bronchiolitis diagnosis, medical management and respiratory support, which may not be accounted for by the differences in baseline and clinical characteristics of the infants. Some of these differences may be explained by uneven resource allocations. This diversity and the documented routine use of medications with weak evidence of efficacy calls for national guidelines for bronchiolitis management.
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Zając D, Russjan E, Kostrzon M, Kaczyńska K. Inhalations with Brine Solution from the 'Wieliczka' Salt Mine Diminish Airway Hyperreactivity and Inflammation in a Murine Model of Non-Atopic Asthma. Int J Mol Sci 2020; 21:E4798. [PMID: 32645931 PMCID: PMC7370210 DOI: 10.3390/ijms21134798] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 06/29/2020] [Accepted: 07/03/2020] [Indexed: 02/07/2023] Open
Abstract
Inhalations with brine solutions are old but underestimated add-ons to pharmacological treatments of inflammatory lung diseases. Although widely used, not all features underlying their action on the respiratory system have been explored. The aim of the present study was to elucidate the mechanism of the beneficial action of inhalations of brine solution from the 'Wieliczka' Salt Mine, a Polish health resort, in a murine model of non-atopic asthma. Asthma was induced in BALB/c mice by skin sensitization with dinitrofluorobenzene followed by an intratracheal challenge of cognate hapten. All animals underwent 12 inhalation sessions with brine solution, pure water or physiological saline. Control mice were not inhaled. We found that brine inhalations reduced, as compared to non-inhaled mice, the typical asthma-related symptoms, like airway hyperreactivity (AHR), the infiltration of pro-inflammatory cells into the bronchial tree, and the inflammation of the airways at the level of pro-inflammatory cytokines IL-1α, IL-1β and IL-6. The level of the anti-inflammatory IL-10 was elevated in brine-inhaled mice. Inhalations with pure water increased AHR, whereas saline had no influence, either on AHR or cytokine concentrations. These observations indicate that inhalations with a brine solution from the 'Wieliczka' Salt Mine diminish the asthma-related symptoms, mostly by reducing the inflammatory status and by decreasing AHR.
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Affiliation(s)
- Dominika Zając
- Department of Respiration Physiology, Mossakowski Medical Research Centre, Polish Academy of Sciences, 02-106 Warsaw, Poland
| | - Ewelina Russjan
- Department of Respiration Physiology, Mossakowski Medical Research Centre, Polish Academy of Sciences, 02-106 Warsaw, Poland
| | | | - Katarzyna Kaczyńska
- Department of Respiration Physiology, Mossakowski Medical Research Centre, Polish Academy of Sciences, 02-106 Warsaw, Poland
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Jaquet-Pilloud R, Verga ME, Russo M, Gehri M, Pauchard JY. Nebulised hypertonic saline in moderate-to-severe bronchiolitis: a randomised clinical trial. Arch Dis Child 2020; 105:236-240. [PMID: 31488402 DOI: 10.1136/archdischild-2019-317160] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 08/20/2019] [Accepted: 08/21/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate whether nebulised hypertonic saline (HS) treatment would decrease length of hospital stay (LOS) among infants with moderate-to severe-bronchiolitis compared with standard supportive care (SC). METHODS We conducted an open, multicentre, randomised clinical trial from 1 April 2013 to 31 March 2016, in Swiss children's hospitals. Patients aged 6 weeks to 24 months with a primary diagnosis of moderate or severe bronchiolitis were included. Children with previous episodes of wheezing, cardiac disease, chronic respiratory disease, immunodeficiency, prematurity (gestational age <34 weeks), corticotherapy in the preceding 2 weeks or inhaled bronchodilators within 24 hours before presentation were excluded. Patients were randomised to receive standard SC with nebulisation of 4 mL of 3% sodium chloride every 6 hours versus SSC. Main outcomes and measures were LOS duration of oxygen therapy, transfer to intensive care unit (ICU), readmission within 7 days following discharge and adverse events. RESULTS 121 children were randomised. No statistically significant differences were found between treatment groups at baseline (age, Wang Score, atopic history, smoking exposure). Children in the HS group had a non-significant difference in length of stay -2.8 hours (-10; 16) compared with the SC group. There were no differences in oxygen therapy duration, transfer to ICU, readmission rate or adverse events. The intervention was discontinued at the parents' request in 16% of the cases. CONCLUSION Our study does not support the use of HS nebulisation in children with moderate to severe bronchiolitis. TRIAL REGISTRATION NUMBER NCT01812525.
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Affiliation(s)
- Raphaelle Jaquet-Pilloud
- Department of Medical and Surgical Pediatrics, University Hospital of Lausanne, Lausanne, Switzerland
| | - Marie-Elise Verga
- Department of Medical and Surgical Pediatrics, University Hospital of Lausanne, Lausanne, Switzerland
| | - Michel Russo
- Pediatrics & Neonatal Medicine Department Hospital, Sion, Valais, Switzerland
| | - Mario Gehri
- Department of Medical and Surgical Pediatrics, University Hospital of Lausanne, Lausanne, Switzerland
| | - Jean-Yves Pauchard
- Department of Medical and Surgical Pediatrics, University Hospital of Lausanne, Lausanne, Switzerland
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House SA, Gadomski AM, Ralston SL. Evaluating the Placebo Status of Nebulized Normal Saline in Patients With Acute Viral Bronchiolitis: A Systematic Review and Meta-analysis. JAMA Pediatr 2020; 174:250-259. [PMID: 31905239 PMCID: PMC6990821 DOI: 10.1001/jamapediatrics.2019.5195] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE In therapeutic trials for acute viral bronchiolitis, consistent clinical improvement in groups that received nebulized normal saline (NS) as placebo raises the question of whether nebulized NS acts as a treatment rather than a placebo. OBJECTIVE To measure the short-term association of nebulized NS with physiologic measures of respiratory status in children with bronchiolitis by analyzing the changes in these measures between the use of nebulized NS and the use of other placebos and the changes before and after nebulized NS treatment. DATA SOURCES MEDLINE and Scopus were searched through March 2019, as were bibliographies of included studies and relevant systematic reviews, for randomized clinical trials evaluating nebulized therapies in bronchiolitis. STUDY SELECTION Randomized clinical trials comparing children 2 years or younger with bronchiolitis who were treated with nebulized NS were included. Studies enrolling a treatment group receiving an alternative placebo were included for comparison of NS with other placebos. DATA EXTRACTION AND SYNTHESIS Data abstraction was performed per PRISMA guidelines. Fixed- and random-effects, variance-weighted meta-analytic models were used. MAIN OUTCOMES AND MEASURES Pooled estimates of the association with respiratory scores, respiratory rates, and oxygen saturation within 60 minutes of treatment were generated for nebulized NS vs another placebo and for change before and after receiving nebulized NS. RESULTS A total of 29 studies including 1583 patients were included. Standardized mean differences in respiratory scores for nebulized NS vs other placebo (3 studies) favored nebulized NS by -0.9 points (95% CI, -1.2 to -0.6 points) at 60 minutes after treatment (P < .001). There were no differences in respiratory rate or oxygen saturation comparing nebulized NS with other placebo. The standardized mean difference in respiratory score (25 studies) after nebulized NS was -0.7 (95% CI, -0.7 to -0.6; I2 = 62%). The weighted mean difference in respiratory scores using a consistent scale (13 studies) after nebulized NS was -1.6 points (95% CI, -1.9 to -1.3 points; I2 = 72%). The weighted mean difference in respiratory rate (17 studies) after nebulized NS was -5.5 breaths per minute (95% CI, -6.3 to -4.6 breaths per minute; I2 = 24%). The weighted mean difference in oxygen saturation (23 studies) after nebulized NS was -0.4% (95% CI, -0.6% to -0.2%; I2 = 79%). CONCLUSIONS AND RELEVANCE Nebulized NS may be an active treatment for acute viral bronchiolitis. Further evaluation should occur to establish whether it is a true placebo.
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Affiliation(s)
- Samantha A. House
- Department of Pediatrics, Children’s Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire,Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Anne M. Gadomski
- Research Institute, Bassett Medical Center, Cooperstown, New York
| | - Shawn L. Ralston
- Department of Pediatrics, Johns Hopkins Medical School, Baltimore, Maryland
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Nebulized hypertonic saline 3% for 1 versus 3 days in hospitalized bronchiolitis: a blinded non-inferiority randomized controlled trial. BMC Pediatr 2019; 19:417. [PMID: 31699072 PMCID: PMC6839239 DOI: 10.1186/s12887-019-1804-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 10/24/2019] [Indexed: 11/16/2022] Open
Abstract
Background The use and optimal duration of treatment with nebulized hypertonic saline (HS) in infants hospitalized for acute bronchiolitis is unclear. The objective was to compare the efficacy of 1 versus 3 days of nebulized 3% HS at 72 h of treatment. We conducted a blinded non-inferiority randomized controlled trial including infants aged less than 12 months old, hospitalized for a moderate bronchiolitis. Methods Nebulisations of 3% HS for 1 day were followed by either the continuation of 3% HS (HS3d group) or switched to 0.9% normal isotonic saline (HS1d group) for 2 days Randomization was performed according to a predefined list with a 1:1 ratio, obtained with a random generator number with blocks.. Main outcome was mean Wang clinical severity score (CSS) after 72 h of treatment. Results One hundred sixteen infants (HS1d n = 59 and HS3d n = 57), were included over two epidemic seasons from 2014 to 2016, but recruitement did not reach the planned sample size. The difference for the Wang CSS score in the HS3d vs HS1d group was 0.71 [IC 90% 0.1; 1.3], above the precluded value of 0.4 set in the protocol defining the non-inferiority of shorter treatment duration. Clinical remission was more rapidly obtained in the HS3d than in HS1d (2.3 ± 1.6 vs 2.9 ± 1.4 days, p = 0.04), with a non-significant tendency for less need of nutritional support and supplemental oxygen in HS3d group. Clinical worsening and treatment intolerance were similar in the 2 groups. Conclusions Despite being underpowered, results seem not to be in favour of reducing the duration of nebulised HS treatment from 3 to 1 day in acute moderate bronchiolitis. Trial registration Clinical trials NCT 02538458, October 2014.
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O'Brien S, Borland ML, Cotterell E, Armstrong D, Babl F, Bauert P, Brabyn C, Garside L, Haskell L, Levitt D, McKay N, Neutze J, Schibler A, Sinn K, Spencer J, Stevens H, Thomas D, Zhang M, Oakley E, Dalziel SR. Australasian bronchiolitis guideline. J Paediatr Child Health 2019; 55:42-53. [PMID: 30009459 DOI: 10.1111/jpc.14104] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 06/01/2018] [Indexed: 11/29/2022]
Abstract
AIM Bronchiolitis is the most common lower respiratory tract disorder in infants aged less than 12 months, and research has demonstrated that there is substantial variation in practice patterns despite treatment being well defined. In order to align and improve the consistency of the management of bronchiolitis, an evidence-based guideline was developed for the Australasian population. METHODS The guideline development committee included representation from emergency and paediatric specialty medical and nursing personnel in addition to geographical representation across Australia and New Zealand - rural, remote and metropolitan. Formulation of the guideline included identification of population, intervention, comparator, outcomes and time questions and was associated with an extensive literature search from 2000 to 2015. Evidence was summarised and graded using the National Health and Medical Research Council and Grading of Recommendations Assessment, Development and Evaluation methodology, and consensus within the guideline group was sought using nominal group technique principles to formulate the clinical practice recommendations. The guideline was reviewed and endorsed by key paediatric health bodies. RESULTS The guideline consists of a usable clinical interface for bedside functionality supported by evidence summary and tables. The Grading of Recommendations Assessment, Development and Evaluation and National Health and Medical Research Council processes provided a systematic and transparent process to review and assess the literature, resulting in a guideline that is relevant to the management of bronchiolitis in the Australasian setting. CONCLUSION This is the first robust Australasian acute paediatric guideline and provides clear guidance for the management of the vast majority of patients seen in Australasian emergency departments and general paediatric wards with bronchiolitis.
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Affiliation(s)
- Sharon O'Brien
- Princess Margaret Hospital for Children, Perth, Western Australia, Australia.,School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Meredith L Borland
- Princess Margaret Hospital for Children, Perth, Western Australia, Australia.,Divisions of Paediatric and Emergency Medicine, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Elizabeth Cotterell
- Department of Paediatrics, School of Rural Medicine, University of New England, Armidale, New South Wales, Australia
| | - David Armstrong
- Department of Respiratory Medicine, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Franz Babl
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Paul Bauert
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Christine Brabyn
- Emergency Department, Waikato District Health Board, Hamilton, New Zealand
| | - Lydia Garside
- General Paediatrics, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Libby Haskell
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
| | - David Levitt
- University of Queensland, Brisbane, Queensland, Australia
| | - Nicola McKay
- Children's Healthcare Network Western Region, Sydney, New South Wales, Australia
| | | | - Andreas Schibler
- University of Queensland, Brisbane, Queensland, Australia.,Paediatric Intensive Care Unit, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia.,Paediatric Critical Care Research Group (PCCRG), Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
| | - Kam Sinn
- Emergency Department, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Janine Spencer
- Department of Paediatrics, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Helen Stevens
- Children's Healthcare Network, Sydney, New South Wales, Australia
| | - David Thomas
- General Paediatrics, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Michael Zhang
- Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Ed Oakley
- Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Paediatric Emergency Medicine Centre of Research Excellence, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Department of Surgery, University of Auckland, Auckland, New Zealand.,Department of Paediatrics: Youth and Child Health, University of Auckland, Auckland, New Zealand
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Chong SL, Lai OF, Castillo L, Yeo JG, Nadkarni N, Teoh OH, Lee JH. Nasal high-mobility group box 1 and caspase in bronchiolitis. Pediatr Pulmonol 2018; 53:1627-1632. [PMID: 30362259 DOI: 10.1002/ppul.24183] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 09/19/2018] [Accepted: 10/07/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Nasal biomarkers have potential to add objectivity to the clinical assessment of the child with bronchiolitis. We aim to study, if nasal caspase and high-mobility group box 1 protein (HMGB1) levels differ between patients who were hospitalized and those discharged from the emergency department (ED), among patients with bronchiolitis. METHODS Using an observational cross-sectional study design, we recruited patients younger than 24 months presenting to the ED from September 1, 2015 to May 31, 2017 with a diagnosis of acute bronchiolitis. We described the patients' clinical severity measured by the modified respiratory index score (RIS), and performed standardized collection and analysis of nasal caspase and HMGB1 levels. RESULTS Among 85 patients recruited, the median age was 5.0 months (interquartile range, IQR 3.3-7.2) and the median modified RIS score was 3 (IQR 2-4). Hospitalized patients had a 2.4-fold higher HMGB1 level than patients who were discharged from the ED (2.558 μg/mL [IQR 1.038-5.125] vs 1.056 μg/mL [IQR 0.409-2.395], P = 0.0013). There was no difference in median caspase level between hospitalized and discharged patients. The Area Under the Receiver Operating Characteristics curve predicting hospitalization was 0.7021 for HMGB1 compared to 0.5709 for RIS in this bronchiolitis cohort. CONCLUSIONS Our study findings show that nasal HMGB1 levels significantly differentiate between young children with bronchiolitis who were hospitalized compared to those fit for discharge. This exploratory study holds potential for future research on nasal HMGB1 for severity stratification in young children with acute bronchiolitis.
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Affiliation(s)
- Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Oi Fah Lai
- Department of Clinical Translational Research, Singapore General Hospital, Singapore
| | - Leodivica Castillo
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
| | - Joo Guan Yeo
- Duke-NUS Medical School, Singapore.,Division of Medicine, KK Women's and Children's Hospital, Singapore
| | - Nivedita Nadkarni
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Oon Hoe Teoh
- Duke-NUS Medical School, Singapore.,Respiratory Medicine Service, KK Women's and Children's Hospital, Singapore
| | - Jan Hau Lee
- Duke-NUS Medical School, Singapore.,Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
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11
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Palmu S, Mecklin M, Heikkilä P, Backman K, Peltola V, Renko M, Korppi M. National treatment guidelines decreased the use of racemic adrenaline for bronchiolitis in four Finnish university hospitals. Acta Paediatr 2018; 107:1966-1970. [PMID: 29752817 DOI: 10.1111/apa.14397] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/16/2018] [Accepted: 05/07/2018] [Indexed: 11/28/2022]
Abstract
AIM Inhaled racemic adrenaline was used for bronchiolitis in many hospitals in Finland prior to new national current care guidelines for bronchiolitis in 2014, which limited its recommendations to on-demand rescue therapy. We studied the drug's use before and after the new guidelines to gauge changes in prescribing habits. METHODS This 2012-2016 study analysed how many 0.5 mL doses of racemic adrenaline were used for children by emergency rooms, paediatric wards and paediatric intensive care units at four university hospitals and estimated drug and staff costs. RESULTS There were substantial differences in the yearly consumption of racemic adrenaline between the hospitals before and after the bronchiolitis guidelines were published, with reductions in drug costs and staff time. The overall use more than halved during the study period, particularly in two hospitals where baseline consumptions were highest, but not in a third where baseline consumption was already low. In the fourth, the baseline consumption was modest and there was a constant decrease during the study years. CONCLUSION The current care guidelines for bronchiolitis had some impact on clinical practice, as the overall use of racemic adrenaline more than halved, but considerable differences remained in the four study hospitals after their publication.
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Affiliation(s)
- Sauli Palmu
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Minna Mecklin
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Paula Heikkilä
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Katri Backman
- Department of Paediatrics; Kuopio University Hospital; University of Eastern Finland; Kuopio Finland
| | - Ville Peltola
- Department of Paediatrics and Adolescent Medicine; Turku University Hospital; University of Turku; Turku Finland
| | - Marjo Renko
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
- PEDEGO Research Unit; University of Oulu; Oulu University Hospital; Oulu Finland
| | - Matti Korppi
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
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12
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Harrison W, Angoulvant F, House S, Gajdos V, Ralston SL. Hypertonic Saline in Bronchiolitis and Type I Error: A Trial Sequential Analysis. Pediatrics 2018; 142:peds.2018-1144. [PMID: 30115731 DOI: 10.1542/peds.2018-1144] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2018] [Indexed: 11/24/2022] Open
Abstract
UNLABELLED : media-1vid110.1542/5799873875001PEDS-VA_2018-1144Video Abstract BACKGROUND AND OBJECTIVES: Meta-analyses of nebulized hypertonic saline (HS) for acute viral bronchiolitis have yielded disparate conclusions. Trial sequential analysis (TSA) is a novel method designed to account for potential sources of error in conventional meta-analysis. We sought to use TSA to determine if the existing literature base is sufficient to draw firm conclusions about the effectiveness of HS in bronchiolitis. METHODS We used the cohort of studies identified in previously published conventional meta-analyses. Included studies were those in which authors compared treatment with HS versus normal saline (or supportive care) in children with bronchiolitis to reduce hospital length of stay (LOS) or hospitalizations. TSA results are used to provide a required information size and monitoring boundaries for statistical significance. RESULTS For the LOS outcome, 17 studies including 1866 patients analyzed in which authors used conventional meta-analysis reveal a statistically significant benefit (mean difference = -0.41 days; 95% confidence interval = -0.07 to -0.75); however, TSA suggests that those conclusions are premature because of failure to reach the adequate information size of 2665 individuals. For the risk of hospitalization outcome, 8 studies including 1728 patients analyzed in which authors used conventional meta-analysis reveal a reduction in the relative risk of hospitalization (relative risk = 0.86; 95% confidence interval = 0.76 to 0.98); however, TSA suggests these conclusions are premature because of failure to reach the adequate information size of 4770. Both LOS and hospitalization results from conventional meta-analysis would be considered potentially false-positives by TSA. CONCLUSIONS TSA reveals that concluding benefit from HS for children with bronchiolitis potentially represents type I error.
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Affiliation(s)
- Wade Harrison
- Department of Pediatrics, Primary Children's Hospital and University of Utah, Salt Lake City, Utah
| | - Francois Angoulvant
- Service d'accueil des urgences pédiatriques, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Epidémiologie Clinique et Évaluation Économique Appliquées aux Populations Vulnérables, Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Samantha House
- Children's Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire.,Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Vincent Gajdos
- Service de Pédiatrie, Antoine Béclère University Hospital, Assistance Publique-Hôpitaux de Paris, Clamart, France; and.,Centre for Research in Epidemiology and Population Health, Villejuif, France
| | - Shawn L Ralston
- Children's Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire; .,Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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13
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Siu KK, Leung SY, Kong SY, Ng DKK. Management of Recurrent Preschool, Doctor-Diagnosed Wheeze. Indian J Pediatr 2018; 85:658-666. [PMID: 29308548 DOI: 10.1007/s12098-017-2537-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 10/18/2017] [Indexed: 01/26/2023]
Abstract
Preschool wheeze occurs in half of the children before they reach 6 y of age and recurrence is also common. Recurrent preschool wheeze is classified as either typical or atypical. For typical recurrent preschool wheeze, the diagnoses are either asthma or bronchiolitis/bronchitis. Responsiveness to a properly administered bronchodilator confirms asthma, atopic or otherwise. All atypical preschool wheeze should be referred to pediatric respirologist for assessment. Lung function test by impulse oscillometry (IOS) before and after bronchodilator is helpful to confirm airway hyperresponsiveness, an essential feature of asthma. Assessment of atopy is important by either skin prick test or serum IgE level. Treatment of acute wheeze includes standard supportive care, bronchodilator for those diagnosed with asthma and hypertonic saline for those diagnosed as having acute bronchiolitis. Other treatments included nebulized adrenaline for acute bronchiolitis and systemic steroids for asthma. For those with significant respiratory distress, continuous positive airway pressure (CPAP) or heated humidified high flow should be considered. Daily or intermittent inhaled corticosteroid or intermittent montelukast would reduce asthma exacerbation rate. A significant proportion of preschool wheeze persists till school age. An early diagnosis of asthma would be important to allow early optimal management.
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Affiliation(s)
- Ka-Ka Siu
- Department of Pediatrics, Kwong Wah Hospital, 25 Waterloo Road, Hong Kong, SAR, China
| | - Shuk-Yu Leung
- Department of Pediatrics, Kwong Wah Hospital, 25 Waterloo Road, Hong Kong, SAR, China
| | - Sum-Yi Kong
- Department of Pediatrics, Kwong Wah Hospital, 25 Waterloo Road, Hong Kong, SAR, China
| | - Daniel Kwok-Keung Ng
- Department of Pediatrics, Kwong Wah Hospital, 25 Waterloo Road, Hong Kong, SAR, China.
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14
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Mecklin M, Heikkilä P, Korppi M. The change in management of bronchiolitis in the intensive care unit between 2000 and 2015. Eur J Pediatr 2018; 177:1131-1137. [PMID: 29766326 DOI: 10.1007/s00431-018-3156-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 03/19/2018] [Accepted: 04/16/2018] [Indexed: 11/29/2022]
Abstract
This case-control study evaluated interventions for bronchiolitis in relation to time in the pediatric intensive care unit (PICU) during a 16-year surveillance period. Together, 105 infants aged < 12 months were treated for bronchiolitis in the PICU, and for them, we selected 210 controls admitted for bronchiolitis closest to cases. We collected data on treatments in the PICU, at the ward and in the emergency department for three periods: years 2000-2005, 2006-2010, and 2011-2015. Median hospital length of stay for PICU patients were 7 days (interquartile range 5-12), 5 days (4-8) and 8 days (4-12.5, p = 0.127), respectively. By time, the use of inhaled beta-agonist (68 vs. 44 vs. 38%, p = 0.019) and systemic corticosteroids (29 vs. 15 vs. 5%, p = 0.019) decreased, but that of racemic adrenaline (59 vs. 78 vs. 84%, p = 0.035) and hypertonic saline (0 vs. 0 vs. 54%, p < 0.001) inhalations increased in the PICU. Similar changes were seen at the ward. In the PICU, non-invasive ventilation therapies increased significantly, but intubation rates did not decline.Conclusion: Beta-agonists and systemic corticosteroids were used less by time in intensive care for infant bronchiolitis, but the use of hypertonic saline and racemic adrenaline increased, though their effectiveness has been questioned. What is Known: • Until now, studies have shown which treatments do not work in bronchiolitis, and so, there is no consensus how infants with bronchiolitis should be treated. In particular, there is no consensus on different interventions in intensive care for bronchiolitis. What is New: • During 2000-2015, treatments with inhaled beta-agonists and systemic corticosteroids decreased but treatments with racemic adrenaline and hypertonic saline inhalations increased in intensive care for bronchiolitis. Similar changes were seen at the ward. Though non-invasive ventilation therapies increased, the intubation rate did not decline.
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Affiliation(s)
- Minna Mecklin
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Arvo Building, FI-33014, Tampere, Finland.
| | - Paula Heikkilä
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Arvo Building, FI-33014, Tampere, Finland
| | - Matti Korppi
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Arvo Building, FI-33014, Tampere, Finland
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15
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Oakley E, Brys T, Borland M, Neutze J, Phillips N, Krieser D, Dalziel SR, Davidson A, Donath S, Jachno K, South M, Williams A, Babl FE. Medication use in infants admitted with bronchiolitis. Emerg Med Australas 2018; 30:389-397. [PMID: 29573212 DOI: 10.1111/1742-6723.12968] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 02/14/2018] [Accepted: 02/18/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are no medications known that improve the outcome of infants with bronchiolitis. Studies have shown the management of bronchiolitis to be varied. OBJECTIVES To describe medication use at the seven study hospitals from a recent multi-centre randomised controlled trial on hydration in bronchiolitis (comparative rehydration in bronchiolitis [CRIB]). METHODS A retrospective analysis of extant data of infants between 2 months (corrected for prematurity) and 12 months of age admitted with bronchiolitis identified through the CRIB trial. CRIB study records, medical records, pathology and radiology databases were used to collect data using a standardised form and entered in a single site database. Medications investigated included salbutamol, adrenaline, steroids, ipratropium bromide, normal saline, hypertonic saline, steroids and antibiotics. RESULTS There were 3456 infants available for analysis, of which 42.0% received at least one medication during hospitalisation. Medication use varied by site between 27.0 and 48.7%. The most frequently used medication was salbutamol (25.5%). Medication use in general, and salbutamol use in particular, increased by 8.2 and 9.3%, respectively, per month after 4 months of age; from 22.9 and 3.6% at 4 months to 81.4 and 68.8% at 11 months. In infants admitted to the intensive care unit (ICU) compared with those not admitted to ICU 81.6 and 39.5%, respectively, received medication at one point during the hospital stay. CONCLUSIONS Medication was used for infants with bronchiolitis frequently and variably in Australia and New Zealand. Medication use increased with age. Better strategies for translating evidence into practice are needed.
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Affiliation(s)
- Ed Oakley
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Trusha Brys
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Meredith Borland
- Department of Emergency Medicine, Princess Margaret Hospital, Perth, Western Australia, Australia.,School of Paediatrics and Child Health and School of Primary, Rural and Aboriginal Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Jocelyn Neutze
- Department of Emergency Medicine, Kidz First Hospital Middlemore, Auckland, New Zealand
| | - Natalie Phillips
- Emergency Department, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia.,Children's Health Research Centre, The University of Queensland, Medical Research Institute, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - David Krieser
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Emergency Medicine, Sunshine Hospital, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Andrew Davidson
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Anaesthesia, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Susan Donath
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kim Jachno
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Mike South
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Amanda Williams
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Franz E Babl
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
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16
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Morikawa Y, Miura M, Furuhata MY, Morino S, Omori T, Otsuka M, Chiga M, Obonai T, Hataya H, Kaneko T, Ishikura K, Honda M, Hasegawa Y. Nebulized hypertonic saline in infants hospitalized with moderately severe bronchiolitis due to RSV infection: A multicenter randomized controlled trial. Pediatr Pulmonol 2018; 53:358-365. [PMID: 29327810 DOI: 10.1002/ppul.23945] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 12/13/2017] [Indexed: 11/09/2022]
Abstract
INTRODUCTION The efficacy of nebulized hypertonic saline (HS) therapy for shortening hospital length of stay (LOS) or improving bronchiolitic symptoms remains controversial. Most studies enrolled small numbers of subjects and did not consider the role of respiratory syncytial virus (RSV), the most common cause of acute bronchiolitis. Our aim was to evaluate the efficacy and safety of nebulized HS therapy for acute bronchiolitis due to RSV in moderately ill hospitalized infants. MATERIALS AND METHODS This was an open-label, multicenter, randomized controlled trial comparing a nebulized HS treatment group with a normal saline (NS) group. The subjects, 128 infants with bronchiolitis due to RSV, were admitted to five hospitals in Tokyo, Japan. Three-percent HS or NS was administered via bronchodilator four times daily post-admission. The primary outcome was LOS, defined as the time until the patients fulfilled the discharge criteria, namely, absence of fever, no need for supplemental oxygen, and adequate feeding. Survival analysis was conducted in accordance with the intention-to-treat principle. RESULTS The baseline characteristics were similar between the two groups. There was no significant overall difference in LOS between the groups (4.81 ± 2.14 days in HS vs 4.61 ± 2.18 days in NS; P = 0.60). Survival analysis by log-rank test also showed no significance (P = 0.62). Multivariate adjustment did not significantly alter the results. The treatment was well-tolerated, with no adverse effects attributable to the use of HS. CONCLUSIONS Nebulized HS therapy did not significantly reduce LOS among infants with bronchiolitis due to RSV.
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Affiliation(s)
- Yoshihiko Morikawa
- Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Masaru Miura
- Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Department of Pediatric Cardiology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | | | - Saeko Morino
- Department of Infectious Diseases, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Tae Omori
- Department of Pediatrics, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Masahiro Otsuka
- Department of Pediatrics, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Michiko Chiga
- Department of Pediatrics, Tokyo Metropolitan Ohtsuka Hospital, Tokyo, Japan
| | - Toshimasa Obonai
- Department of Pediatrics, Tokyo Metropolitan Health and Medical Treatment Corporation, Tama-Hokubu Medical Center, Tokyo, Japan
| | - Hiroshi Hataya
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Tetsuji Kaneko
- Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Kenji Ishikura
- Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Masataka Honda
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yukihiro Hasegawa
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Department of Endocrinology and Metabolism, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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17
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Heikkilä P, Renko M, Korppi M. Hypertonic saline inhalations in bronchiolitis-A cumulative meta-analysis. Pediatr Pulmonol 2018; 53:233-242. [PMID: 29266869 DOI: 10.1002/ppul.23928] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 11/26/2017] [Indexed: 11/08/2022]
Abstract
We undertook a cumulative meta-analysis for the efficacy of hypertonic saline (HS) compared to normal saline (NS) inhalations or no inhalations as controls in bronchiolitis. We performed literature searches from PubMed, Scopus, and by hand search until 20 June 2017. We accepted published randomized controlled trials of HS inhalations in children with bronchiolitis aged <24 months. We evaluated the differences between treatment group with HS and control group without HS inhalations for the length-of-stay in hospital (LOS) by cumulative mean difference (MD) and in hospitalization rate by cumulative risk ratio (RR). We identified 18 studies including 2102 children treated in hospital, and the cumulative MD in LOS was -0.471 days (95% confidence interval [CI] -0.765 to -0.177, Higgins heterogeneity test [I2 ] 72.9%). The cumulative MD reduced in more recently published papers. In studies with the upper age limit of 12 months, the cumulative MD was -0.408 days (95%CI -0.733 to -0.083) without any important heterogeneity (I2 = 0%). If only studies with a very low risk of bias were included, the cumulative MD was 0.034 (95%CI -0.361 to 0.293) without any important heterogeneity (I2 = 0%). We identified eight studies including 1834 children in the outpatient setting, and the cumulative risk ratio for hospitalization was 0.771 (95%CI 0.619-0.959, I2 55.8%). In conclusion, HS inhalations offered only limited clinical benefits, though the differences between HS and control groups were statistically significant. The heterogeneity between the studies was substantial. Further studies are warranted with consistent definitions of bronchiolitis and comparable research frames.
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Affiliation(s)
- Paula Heikkilä
- Tampere Centre for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Marjo Renko
- Tampere Centre for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland.,PEDEGO Research Unit, University of Oulu, Oulu, Finland
| | - Matti Korppi
- Tampere Centre for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
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18
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Zhang L, Mendoza‐Sassi RA, Wainwright C, Klassen TP. Nebulised hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database Syst Rev 2017; 12:CD006458. [PMID: 29265171 PMCID: PMC6485976 DOI: 10.1002/14651858.cd006458.pub4] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Airway oedema (swelling) and mucus plugging are the principal pathological features in infants with acute viral bronchiolitis. Nebulised hypertonic saline solution (≥ 3%) may reduce these pathological changes and decrease airway obstruction. This is an update of a review first published in 2008, and previously updated in 2010 and 2013. OBJECTIVES To assess the effects of nebulised hypertonic (≥ 3%) saline solution in infants with acute bronchiolitis. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily, Embase, CINAHL, LILACS, and Web of Science on 11 August 2017. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov on 8 April 2017. SELECTION CRITERIA We included randomised controlled trials and quasi-randomised controlled trials using nebulised hypertonic saline alone or in conjunction with bronchodilators as an active intervention and nebulised 0.9% saline, or standard treatment as a comparator in children under 24 months with acute bronchiolitis. The primary outcome for inpatient trials was length of hospital stay, and the primary outcome for outpatients or emergency department trials was rate of hospitalisation. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, data extraction, and assessment of risk of bias in included studies. We conducted random-effects model meta-analyses using Review Manager 5. We used mean difference (MD), risk ratio (RR), and their 95% confidence intervals (CI) as effect size metrics. MAIN RESULTS We identified 26 new trials in this update, of which 9 await classification due to insufficient data for eligibility assessment, and 17 trials (N = 3105) met the inclusion criteria. We included a total of 28 trials involving 4195 infants with acute bronchiolitis, of whom 2222 infants received hypertonic saline.Hospitalised infants treated with nebulised hypertonic saline had a statistically significant shorter mean length of hospital stay compared to those treated with nebulised 0.9% saline (MD -0.41 days, 95% CI -0.75 to -0.07; P = 0.02, I² = 79%; 17 trials; 1867 infants) (GRADE quality of evidence: low). Infants who received hypertonic saline also had statistically significant lower post-inhalation clinical scores than infants who received 0.9% saline in the first three days of treatment (day 1: MD -0.77, 95% CI -1.18 to -0.36, P < 0.001; day 2: MD -1.28, 95% CI -1.91 to -0.65, P < 0.001; day 3: MD -1.43, 95% CI -1.82 to -1.04, P < 0.001) (GRADE quality of evidence: low).Nebulised hypertonic saline reduced the risk of hospitalisation by 14% compared with nebulised 0.9% saline among infants who were outpatients and those treated in the emergency department (RR 0.86, 95% CI 0.76 to 0.98; P = 0.02, I² = 7%; 8 trials; 1723 infants) (GRADE quality of evidence: moderate).Twenty-four trials presented safety data: 13 trials (1363 infants, 703 treated with hypertonic saline) did not report any adverse events, and 11 trials (2360 infants, 1265 treated with hypertonic saline) reported at least one adverse event, most of which were mild and resolved spontaneously. AUTHORS' CONCLUSIONS Nebulised hypertonic saline may modestly reduce length of stay among infants hospitalised with acute bronchiolitis and improve clinical severity score. Treatment with nebulised hypertonic saline may also reduce the risk of hospitalisation among outpatients and emergency department patients. However, we assessed the quality of the evidence as low to moderate.
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Affiliation(s)
- Linjie Zhang
- Federal University of Rio GrandeFaculty of MedicineRua Visconde Paranaguá 102CentroRio GrandeRSBrazil96201‐900
| | - Raúl A Mendoza‐Sassi
- Federal University of Rio GrandeFaculty of MedicineRua Visconde Paranaguá 102CentroRio GrandeRSBrazil96201‐900
| | - Claire Wainwright
- Royal Children's HospitalDepartment of Respiratory MedicineHerston RoadHerstonBrisbaneQueenslandAustralia4029
| | - Terry P Klassen
- Manitoba Institute of Child Health513‐715 McDermot AvenueWinnipegMBCanadaR3E 3P4
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19
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Petrarca L, Jacinto T, Nenna R. The treatment of acute bronchiolitis: past, present and future. Breathe (Sheff) 2017; 13:e24-e26. [PMID: 29158779 PMCID: PMC5685214 DOI: 10.1183/20734735.000717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Lower respiratory tract infections are a common cause of hospitalisation in infants. It is estimated that infants younger than 12 months with bronchiolitis account for 18% of all paediatric admission [1], representing a great burden to industrialised healthcare systems each winter. Acute bronchiolitis treatment: little has changed from late 19th century to nowadays, promising strategies incominghttp://ow.ly/BmH230aWoXr
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Affiliation(s)
- Laura Petrarca
- Dept of Paediatrics and Infantile Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
| | - Tiago Jacinto
- Dept of Allergy, Instituto and Hospital CUF, Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal.,Dept of Cardiovascular and Respiratory Sciences, Porto Health School, Porto, Portugal
| | - Raffaella Nenna
- Dept of Paediatrics and Infantile Neuropsychiatry, "Sapienza" University of Rome, Rome, Italy
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Guo C, Sun X, Wang X, Guo Q, Chen D. Network Meta-Analysis Comparing the Efficacy of Therapeutic Treatments for Bronchiolitis in Children. JPEN. JOURNAL OF PARENTERAL AND ENTERAL NUTRITION 2017; 42:186-195. [PMID: 29388676 PMCID: PMC7166391 DOI: 10.1002/jpen.1030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 06/30/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND This study aims to compare placebo (PBO) and 7 therapeutic regimens-namely, bronchodilator agents (BAs), hypertonic saline (HS), BA ± HS, corticosteroids (CS), epinephrine (EP), EP ± CS, and EP ± HS-to determine the optimal bronchiolitis treatment. METHODS We plotted networks using the curative outcome of several studies and specified the relations among the experiments by using mean difference, standardized mean difference, and corresponding 95% credible interval. The surface under the cumulative ranking curve (SUCRA) was used to separately rank each therapy on clinical severity score (CSS) and length of hospital stay (LHS). RESULTS This network meta-analysis included 40 articles from 1995 to 2016 concerning the treatment of bronchiolitis in children. All 7 therapeutic regimens displayed no significant difference to PBO with regard to CSS in our study. Among the 7 therapies, BA performed better than CS. As for LHS, EP and EP ± HS had an advantage over PBO. Moreover, EP and EP ± HS were also more efficient than BA. The SUCRA results showed that EP ± CS is most effective, and EP ± HS is second most effective with regard to CSS. With regard to LHS, EP ± HS ranked first, EP ± CS ranked second, and EP ranked third. CONCLUSIONS We recommend EP ± CS and EP ± HS as the first choice for bronchiolitis treatment in children because of their outstanding performance with regard to CSS and LHS.
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Affiliation(s)
- Caili Guo
- Department of Respiratory, Children's Hospital of Zhengzhou City, Zhengzhou, Henan, China
| | - Xiaomin Sun
- Department of Respiratory, Children's Hospital of Zhengzhou City, Zhengzhou, Henan, China
| | - Xiaowen Wang
- Department of Respiratory, Children's Hospital of Zhengzhou City, Zhengzhou, Henan, China
| | - Qing Guo
- Department of Respiratory, Children's Hospital of Zhengzhou City, Zhengzhou, Henan, China
| | - Dan Chen
- Department of Respiratory, Children's Hospital of Zhengzhou City, Zhengzhou, Henan, China
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Shmueli E, Berger T, Herman YA, Chodick G, Rom E, Bilavsky E, Ashkenazi-Hoffnung L, Ashkenazi S, Amir J, Prais D. Real-life comparison of three general paediatric wards showed similar outcomes for children with bronchiolitis despite different treatment regimens. Acta Paediatr 2017; 106:1507-1511. [PMID: 28510350 DOI: 10.1111/apa.13921] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 04/21/2017] [Accepted: 05/12/2017] [Indexed: 11/30/2022]
Abstract
AIM This study evaluated the effectiveness of three different treatments for bronchiolitis in a tertiary paediatric facility. METHODS Patients with bronchiolitis who were younger than two years of age and were randomly allocated to three general wards at Schneider Children's Medical Center, Israel, after admission were included. Different treatment protocols in the wards were retrospectively compared. RESULTS The study comprised 286 children. The clinical and laboratory parameters on admission were similar between the wards. In Ward C where nebulised hypertonic saline was infrequently administered (6.7%), the mean number of days with oxygen saturation under 92% and the meanlength of hospital stay (1.8 and 3.8 days) were significantly lower than Ward A (2.8 and 5.3 days) and Ward B, (2.9 and 4.7 days) where nebulised hypertonic saline was given more frequently (38.7%-74.7%). Multivariate analysis indicated that low saturation on admission, leukocytosis and use of nebulised hypertonic saline or adrenalin were independent predictors of a longer period of desaturation and hospital stay. CONCLUSION Different treatment protocols for bronchiolitis were used in three paediatric wards in this real-life study. No treatment regimen proved superior. Inhalations of hypertonic saline or adrenaline were associated with a longer hospital stay.
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Affiliation(s)
- Einat Shmueli
- Department of Pediatrics C; Schneider Children's Medical Center of Israel; Petach Tikva Israel
| | - Tal Berger
- Department of Pediatrics B; Schneider Children's Medical Center of Israel; Petach Tikva Israel
| | - Yonatan A. Herman
- Department of Pediatrics A; Schneider Children's Medical Center of Israel; Petach Tikva Israel
| | - Gabriel Chodick
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Eran Rom
- Department of Pediatrics C; Schneider Children's Medical Center of Israel; Petach Tikva Israel
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Efraim Bilavsky
- Department of Pediatrics C; Schneider Children's Medical Center of Israel; Petach Tikva Israel
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Liat Ashkenazi-Hoffnung
- Department of Pediatrics C; Schneider Children's Medical Center of Israel; Petach Tikva Israel
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Shai Ashkenazi
- Department of Pediatrics A; Schneider Children's Medical Center of Israel; Petach Tikva Israel
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Jacob Amir
- Department of Pediatrics C; Schneider Children's Medical Center of Israel; Petach Tikva Israel
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Dario Prais
- Department of Pediatrics C; Schneider Children's Medical Center of Israel; Petach Tikva Israel
- Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv Israel
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Chong SL, Teoh OH, Nadkarni N, Yeo JG, Lwin Z, Ong YKG, Lee JH. The modified respiratory index score (RIS) guides resource allocation in acute bronchiolitis. Pediatr Pulmonol 2017; 52:954-961. [PMID: 28114728 DOI: 10.1002/ppul.23663] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 11/14/2016] [Accepted: 12/15/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVE Bronchiolitis is a common disease in early childhood with increasing healthcare utilization. We aim to study how well a simple and improved respiratory score (the modified Respiratory Index Score [RIS]) would perform when predicting for a warranted admission. METHODS This is an observational prospective study, from June 2015 to December 2015 in a paediatric emergency department (ED) of a large tertiary hospital in Singapore. We included children aged less than 2 years old, presenting with typical symptoms and signs of bronchiolitis but excluded children with four or more previous wheezes, a gestation of <35 weeks, and known cardiopulmonary disease. We also performed a sensitivity analysis for children presenting with their first wheeze. We defined a warranted admission as a composite of: The need for airway intervention, intravenous hydration, and a hospital stay of 2 days or more. RESULTS Among 1,818 patients, the median age was 10.8 months (IQR 7.2-15.9). The median modified RIS score was 4.0 (IQR 3.0-5.0). A total of 19 (1.0%) children required respiratory support, 101 (5.6%) received intravenous hydration, and 571 (31.4%) required a hospital stay of 2 days or more. After adjusting for age and duration of illness, a modified RIS score of >4 predicted significantly for a warranted admission (adjusted Odds Ratio: 3.28, 95% confidence interval: 2.62-4.12). The association remained significant among children presenting with their first wheeze. CONCLUSIONS This simple respiratory tool predicts for the need for respiratory support, intravenous hydration, and a significant hospital stay of 2 days or more. Pediatr Pulmonol. 2017; 52:954-961. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Oon Hoe Teoh
- Department of Paediatrics, Respiratory Medicine Service, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Nivedita Nadkarni
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Joo Guan Yeo
- Division of Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Zaw Lwin
- Department of Emergency Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Yong-Kwang Gene Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
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Bar-Yoseph R, Kugelman N, Livnat G, Gur M, Hakim F, Nir V, Bentur L. Halotherapy as asthma treatment in children: A randomized, controlled, prospective pilot study. Pediatr Pulmonol 2017; 52:580-587. [PMID: 27723955 DOI: 10.1002/ppul.23621] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 09/12/2016] [Accepted: 09/27/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND OBJECTIVES Asthma is a chronic inflammatory disorder requiring intermittent or continuous anti-inflammatory therapy. Patients often turn to alternative treatments as complements or replacements to conventional treatments. We aimed to evaluate the effect of salt room chambers (halotherapy) on bronchial hyper-responsiveness (BHR), fractional exhaled nitric oxide (FeNO), and quality of life in children with asthma. PATIENTS AND METHODS Children aged 5-13 years with a clinical diagnosis of mild asthma not receiving anti-inflammatory therapy. Patients were randomized in this double-blind, controlled study to salt room with halogenerator (treatment group), or without halogenerator (control group). We evaluated the effect of salt room therapy on BHR, FeNO, spirometry, and pediatric asthma quality of life questionnaire (PAQLQ). The treatment period lasted 7 weeks, 14 sessions. RESULTS Twenty-nine patients were randomized to the salt room with halogenerator (treatment group), and 26 patients to the salt room without salt halogenerator (control group). A statistically significant improvement in BHR was demonstrated in the treatment group, which remained unchanged in the control group. There was no improvement in spirometry or FeNO levels following treatment. The treatment group showed a statistical improvement in most parameters of quality of life questionnaires. CONCLUSIONS Our pilot study suggests that salt room with halogenerator, may have some beneficial effects in mild asthmatic children. Randomized and larger controlled trials with long-term follow-up are necessary. Pediatr Pulmonol. 2017;52:580-587. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ronen Bar-Yoseph
- Pediatric Pulmonology Institute, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Nir Kugelman
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Galit Livnat
- Pediatric Pulmonology Institute, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Michal Gur
- Pediatric Pulmonology Institute, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Fahed Hakim
- Pediatric Pulmonology Institute, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Vered Nir
- Pediatric Pulmonology Institute, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Lea Bentur
- Pediatric Pulmonology Institute, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Prospective Multicentre Study on the Epidemiology and Current Therapeutic Management of Severe Bronchiolitis in Spain. BIOMED RESEARCH INTERNATIONAL 2017; 2017:2565397. [PMID: 28421191 PMCID: PMC5380832 DOI: 10.1155/2017/2565397] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 02/14/2017] [Accepted: 02/27/2017] [Indexed: 12/04/2022]
Abstract
Objective. To determine the epidemiology and therapeutic management of patients with severe acute bronchiolitis (AB) admitted to paediatric intensive care units (PICUs) in Spain. Design. Descriptive, prospective, multicentre study. Setting. Sixteen Spanish PICUs. Patients. Patients with severe AB who required admission to any of the participating PICUs over 1 year. Interventions. Both epidemiological variables and medical treatment received were recorded. Results. A total of 262 patients were recruited; 143 were male (54.6%), with median age of 1 month (0–23). Median stay in the PICU was 7 days (1–46). Sixty patients (23%) received no nebuliser treatment, while the rest received a combination of inhalation therapies. One-quarter of patients (24.8%) received corticosteroids and 56.5% antibiotic therapy. High-flow oxygen therapy was used in 14.3% and noninvasive ventilation (NIV) was used in 75.6%. Endotracheal intubation was required in 24.4% of patients. Younger age, antibiotic therapy, and invasive mechanical ventilation (IMV) were risk factors that significantly increased the stay in the PICU. Conclusions. Spanish PICUs continue to routinely use nebulised bronchodilator treatment and corticosteroid therapy. Despite NIV being widely used in this condition, intubation was required in one-quarter of cases. Younger age, antibiotic therapy, and IMV were associated with a longer stay in the PICU.
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Carr SB, Main E. Acute bronchiolitis-Should we be doing more? Pediatr Pulmonol 2017; 52:279-280. [PMID: 28221735 DOI: 10.1002/ppul.23642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 10/22/2016] [Accepted: 11/03/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Siobhan B Carr
- Department of Paediatric Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London
| | - Eleanor Main
- Physiotherapy Department in Respiratory, Critical Care and Anaesthesia, UCL Great Ormond Street Institute of Child Health, London
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Abstract
Viral bronchiolitis is a common clinical syndrome affecting infants and young children. Concern about its associated morbidity and cost has led to a large body of research that has been summarised in systematic reviews and integrated into clinical practice guidelines in several countries. The evidence and guideline recommendations consistently support a clinical diagnosis with the limited role for diagnostic testing for children presenting with the typical clinical syndrome of viral upper respiratory infection progressing to the lower respiratory tract. Management is largely supportive, focusing on maintaining oxygenation and hydration of the patient. Evidence suggests no benefit from bronchodilator or corticosteroid use in infants with a first episode of bronchiolitis. Evidence for other treatments such as hypertonic saline is evolving but not clearly defined yet. For infants with severe disease, the insufficient available data suggest a role for high-flow nasal cannula and continuous positive airway pressure use in a monitored setting to prevent respiratory failure.
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Affiliation(s)
- Todd A Florin
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Amy C Plint
- Division of Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada; Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Joseph J Zorc
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Clinical Examination Does Not Predict Response to Albuterol in Ventilated Infants With Bronchiolitis. Pediatr Crit Care Med 2017; 18:e18-e23. [PMID: 27811530 DOI: 10.1097/pcc.0000000000000999] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Bronchiolitis is a common respiratory infection in infants that is sometimes treated with albuterol. Response to albuterol is determined by clinical assessment, but this subjective determination is potentially unreliable. In this study, we compared providers' clinical assessment of response to albuterol with the measurement of response by pulmonary mechanics in intubated, sedated, and ventilated infants. DESIGN Before and 20 minutes following racemic albuterol therapy, a nurse, respiratory therapist, and physician performed simultaneous examinations and assessed response to albuterol in a population of intubated infants with bronchiolitis. Measurements of ventilator-derived pulmonary mechanics were obtained at these same times. SETTING This study was conducted in a PICU of a children's hospital. PATIENTS Seventy-five paired clinical assessments were made in 25 infants who were intubated and mechanically ventilated for severe bronchiolitis. INTERVENTIONS Pulmonary function measurements and clinical assessments before and after administration of albuterol. MEASUREMENTS AND MAIN RESULTS Response to albuterol was defined using a threshold of improvement in respiratory system resistance from baseline. Nine children (36%) had greater than 20% change and were deemed responders. Providers' discrimination of response was poor. The positive predictive values of nurses, respiratory therapists, and physicians were 38%, 25%, and 25%, respectively, and the negative predictive values were 67%, 54%, and 59%, respectively. Overall accuracy was 44% for nurses, 40% for respiratory therapists, and 48% for physicians. When comparing separate assessments of wheezing, aeration, and expiratory time, there was poor agreement between groups of providers in all variables (κ < 0.4 for each). CONCLUSIONS A provider's clinical assessment was not a reliable method for determining response to albuterol in children with bronchiolitis. Without assessment of pulmonary mechanics, caution should be used in classifying children with bronchiolitis as responders to albuterol.
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Affiliation(s)
- Linjie Zhang
- Federal University of Rio Grande Rio Grande, Brazil
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Anthracopoulos MB. Nebulised hypertonic saline for acute bronchiolitis or 'there and back again' to use Tolkien's subtitle for The Hobbit. Acta Paediatr 2016; 105:1006-8. [PMID: 27514006 DOI: 10.1111/apa.13509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Michael B Anthracopoulos
- Respiratory Unit, Department of Paediatrics, University Hospital of Patras, School of Medicine of the University of Patras, Rion-Patras, Greece. ,
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30
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Is it urgent to update the Spanish clinical practice guidelines for acute bronchiolitis management? An Pediatr (Barc) 2016. [DOI: 10.1016/j.anpede.2016.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Martínez-Blanco B, Martinón-Torres F. ¿Es urgente actualizar las guías de práctica clínica españolas para el tratamiento de la bronquiolitis aguda? An Pediatr (Barc) 2016; 85:106-108. [DOI: 10.1016/j.anpedi.2016.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 01/14/2016] [Accepted: 01/15/2016] [Indexed: 10/22/2022] Open
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Auten R, Schwarze J, Ren C, Davis S, Noah TL. Pediatric Pulmonology year in review 2015: Part 1. Pediatr Pulmonol 2016; 51:733-9. [PMID: 27124279 DOI: 10.1002/ppul.23423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 03/03/2016] [Accepted: 03/12/2016] [Indexed: 02/04/2023]
Abstract
Our journal covers a broad range of research and scholarly topics related to children's respiratory disorders. For updated perspectives on the rapidly expanding knowledge in our field, we will summarize the past year's publications in our major topic areas, as well as selected publications in these areas from the core clinical journal literature outside our own pages. The current review covers articles on neonatal lung disease, pulmonary physiology, and respiratory infection. Pediatr Pulmonol. 2016;51:733-739. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
| | - Jurgen Schwarze
- Department of Child Life and Health, The University of Edinburgh, Edinburgh, United Kingdom
| | - Clement Ren
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Stephanie Davis
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Terry L Noah
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Overmann KM, Florin TA. Nebulised hypertonic saline may be less effective than previously reported in reducing hospital length of stay and admission rate in acute bronchiolitis. ACTA ACUST UNITED AC 2016; 21:143. [DOI: 10.1136/ebmed-2016-110452] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Paul SP, Rogers EK, Bhatt JM. NICE guidelines on bronchiolitis: a robust appraisal of current evidence. Br J Hosp Med (Lond) 2016; 77:212-5. [DOI: 10.12968/hmed.2016.77.4.212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Siba P Paul
- Consultant Paediatrician in the Department of Paediatrics, Torbay Hospital, Torquay TQ2 7AA
| | | | - Jayesh M Bhatt
- Consultant Respiratory Paediatrician in the Department of Respiratory Paediatrics, Nottingham Children's Hospital, Nottingham
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35
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Actualités en médecine d’urgence. ANNALES FRANCAISES DE MEDECINE D URGENCE 2016. [DOI: 10.1007/s13341-016-0636-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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36
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Midulla F, Lombardi E, Pijnenburg M, Balfour-Lynn IM, Grigg J, Bohlin K, Rusconi F, Pohunek P, Eber E. Paediatrics: messages from Munich. ERJ Open Res 2015; 1:00016-2015. [PMID: 27730136 PMCID: PMC5005136 DOI: 10.1183/23120541.00016-2015] [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: 04/19/2015] [Accepted: 04/24/2015] [Indexed: 11/05/2022] Open
Abstract
The aim of this article is to describe paediatric highlights from the 2014 European Respiratory Society (ERS) International Congress in Munich, Germany. Abstracts from the seven groups of the ERS Paediatric Assembly (Respiratory Physiology and Sleep, Asthma and Allergy, Cystic Fibrosis, Respiratory Infection and Immunology, Neonatology and Paediatric Intensive Care, Respiratory Epidemiology, and Bronchology) are presented in the context of the current literature.
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Affiliation(s)
- Fabio Midulla
- Dept of Paediatrics, Sapienza University of Rome, Rome, Italy
| | - Enrico Lombardi
- Dept of Paediatrics, Anna Meyer Children's University Hospital, Florence, Italy
| | - Marielle Pijnenburg
- Dept of Paediatrics, Erasmus MC – Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ian M. Balfour-Lynn
- Dept of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
| | | | - Kajsa Bohlin
- Dept of Neonatology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Franca Rusconi
- Unit of Epidemiology, Anna Meyer Children's University Hospital, Florence, Italy
| | - Petr Pohunek
- Dept of Paediatrics, 2nd Faculty of Medicine and University Hospital Motol, Charles University, Prague, Czech Republic
| | - Ernst Eber
- Respiratory and Allergic Disease Division, Dept of Paediatrics, Medical University of Graz, Graz, Austria
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