Predicting Escalated Care in Infants With Bronchiolitis

Validity of Clinical Severity Scores for Respiratory Syncytial Virus: A Systematic Review

BACKGROUND

Respiratory syncytial virus (RSV) is a widespread respiratory pathogen, and RSV-related acute lower respiratory tract infections are the most common cause of respiratory hospitalization in children <2 years of age. Over the last 2 decades, a number of severity scores have been proposed to quantify disease severity for RSV in children, yet there remains no overall consensus on the most clinically useful score.

METHODS

We conducted a systematic review of English-language publications in peer-reviewed journals published since January 2000 assessing the validity of severity scores for children (≤24 months of age) with RSV and/or bronchiolitis, and identified the most promising scores. For included articles, (1) validity data were extracted, (2) quality of reporting was assessed using the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis checklist (TRIPOD), and (3) quality was assessed using the Prediction Model Risk Of Bias Assessment Tool (PROBAST). To guide the assessment of the validity data, standardized cutoffs were employed, and an explicit definition of what we required to determine a score was sufficiently validated.

RESULTS

Our searches identified 8541 results, of which 1779 were excluded as duplicates. After title and abstract screening, 6670 references were excluded. Following full-text screening and snowballing, 32 articles, including 31 scores, were included. The most frequently assessed scores were the modified Tal score and the Wang Bronchiolitis Severity Score; none of the scores were found to be sufficiently validated according to our definition. The reporting and/or design of all the included studies was poor. The best validated score was the Bronchiolitis Score of Sant Joan de Déu, and a number of other promising scores were identified.

CONCLUSIONS

No scores were found to be sufficiently validated. Further work is warranted to validate the existing scores, ideally in much larger datasets.

Understanding the use and outcomes of high-flow nasal cannula among infants admitted to Canadian hospitals with bronchiolitis (CanFLO): a protocol for a multicentre, retrospective cohort study

INTRODUCTION

Bronchiolitis is the most common viral lower respiratory tract infection in children under 2 years of age. Respiratory support with high-flow nasal cannula (HFNC) is increasingly used in this patient population with limited understanding of the patients most likely to benefit and considerable practice variability of use. This study aims to understand the factors associated with failure of HFNC support among patients with bronchiolitis and to describe the current practice variations of HFNC use in patients with bronchiolitis in Canadian hospitals including fluid management and parameters to initiate, escalate and discontinue HFNC support.

METHODS AND ANALYSIS

This is a multicentre retrospective cohort study including hospitalised patients aged 0-24 months with bronchiolitis requiring support with HFNC between January 2017 and December 2021. Clinical data will be collected from patient medical records from Canadian hospitals (n=12), including academic and community centres. HFNC failure will be defined as the need for escalation to non-invasive or invasive mechanical ventilation. Factors associated with HFNC failure will be analysed using logistic regression. Descriptive statistics will be used to describe practice variations of HFNC utilisation and management.

ETHICS AND DISSEMINATION

Approval from the Research Ethics Boards (REBs) has been obtained for each participating study site prior to onset of data collection including Clinical Trials Ontario for all Ontario hospital sites and REBs from British Columbia Children's Hospital, Stollery Children's Hospital, Montreal Children's Hospital and CHU Sainte-Justine. Study results will be disseminated through presentation at national/international conferences and publication in high-impact, peer-reviewed journals.

Respiratory Syncytial Virus Infection and Apnea Risk As Criteria for Hospitalization in Full Term Healthy Infants

Introduction Apnea is recognized as a serious and potentially life-threatening complication associated with Respiratory Syncope Virus (RSV). The literature reports a wide range of apnea rates for infants with comorbid factors. Prematurity and young chronological age have been historically associated with the risk of apnea in hospitalized infants. Few studies have specifically examined the risk of apnea in healthy infants presenting to the emergency department. Methods This is a retrospective review of infants diagnosed with RSV using a PCR assay. Patients were divided into "mild" and "severe" cohorts based on symptoms at presentation. This study occurred in the NYU Langone Long Island (NYULI) pediatric emergency department (ED), a midsize academic hospital in the Northeast United States. The study included infants <6 months of age, born full term without comorbid conditions such as chronic lung or cardiac conditions, seen in NYULI ED over three consecutive RSV seasons (2017-2020). The primary outcome was the risk of apneic events. Secondary outcomes included hospital admission, ICU admission, length of stay, and supplemental oxygen support. Results The risk of apnea was <2%, regardless of disease severity. There were no significant differences in demographics between mild and severe disease. Cohorts differed significantly in the number of hospitalizations (41 milds vs. 132 severe), ICU admissions (2 milds vs. 27 severe), need for oxygen support (17 milds vs. 92 severe), hospital readmissions (2 milds vs. 42 severe), and length of stay (2 days milds vs. 3 days severe). Conclusions Apnea does not pose a significant risk for healthy full-term infants with RSV disease of any severity. The decision to admit this population to the hospital should be based on clinical presentation and not solely on the perceived risk of apnea.

A Feeding Adequacy Scale for Children With Bronchiolitis: Prospective Multicenter Study

OBJECTIVES

To determine the measurement properties of the Feeding Adequacy Scale (FAS) in young children hospitalized with bronchiolitis.

METHODS

Multicenter cohort study of infants hospitalized with bronchiolitis at children's and community hospitals in Ontario, Canada. Caregivers and nurses completed the FAS, a 10-cm visual analog scale anchored by "not feeding at all" (score 0) and "feeding as when healthy" (score 10). The main outcome measures were feasibility, reliability, validity, and responsiveness of the FAS.

RESULTS

A total of 228 children were included with an average (SD) age of 6.3 (5.4) months. Completing the FAS was feasible for caregivers and nurses, with no floor or ceiling effects. Test-retest reliability was moderate for caregivers (intraclass correlation coefficient [ICC] 2,1 0.73; 95% confidence interval [CI] 0.63-0.80) and good for nurses (ICC 2,1 0.75; 95% CI 0.62-0.83). Interrater reliability between 1 caregiver and 1 nurse was moderate (ICC 1,1 0.55; 95% CI 0.45-0.64). For construct validity, the FAS was negatively associated with length of hospital stay and positively associated with both caregiver and nurse readiness for discharge scores (P values <.0001). The FAS demonstrated clinical improvement from the first FAS score at admission to the last FAS score at discharge, with significant differences between scores for both caregivers and nurses (P values for paired t test <.0001).

CONCLUSIONS

These results provide evidence of the feasibility, reliability, validity, and responsiveness of caregiver-completed and nurse-completed FAS as a measure of feeding adequacy in children hospitalized with bronchiolitis.

Point-of-care lung ultrasound score for predicting escalated care in children with respiratory distress

PURPOSE

Respiratory distress due to lower respiratory illnesses is a leading cause of death in children. Early recognition of high-risk populations is critical for the allocation of adequate resources. Our goal was to assess whether the lung ultrasound (US) score obtained at admission in children with respiratory distress predicts the need for escalated care.

METHODS

This prospective study included 0-18-year-old patients with respiratory distress admitted to three emergency departments in the state of Sao Paulo, Brazil, between July 2019 and September 2021. The enrolled patients underwent lung US performed by a pediatric emergency physician within two hours of arrival. Lung ultrasound scores ranging from 0 to 36 were computed. The primary outcome was the need for high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), or mechanical ventilation within 24 h.

RESULTS

A total of 103 patients were included. The diagnoses included wheezing (33%), bronchiolitis (27%), pneumonia (16%), asthma (9%), and miscellaneous (16%). Thirty-five patients (34%) required escalated care and had a higher lung ultrasound score: median 13 (0-34) vs 2 (0-21), p < 0.0001; area under the curve (AUC): 0.81 (95% confidence interval [CI]: 0.71-0.90). The best cut-off score derived from Youden's index was seven (sensitivity: 71.4%; specificity: 79.4%; odds ratio (OR): 9.6 [95% CI: 3.8-24.7]). A lung US score above 12 was highly specific and had a positive likelihood ratio of 8.74 (95% CI:3.21-23.86).

CONCLUSION

An elevated lung US score measured in the first assessment of children with any type of respiratory distress was predictive of severity as defined by the need for escalated care with HFNC, NIV, or mechanical ventilation.

Comparison of severity scales for acute bronchiolitis in real clinical practice

Several clinical scales have been developed to assess the severity of bronchiolitis as well as the probability of needing in-hospital care. A recent systematic review of 32 validated clinical scores for bronchiolitis concluded that 6 of them (Wood-Downes, M-WCAS, Respiratory Severity Score, Respiratory Clinical Score, Respiratory Score and Bronchiolitis risk of admission score) were the best ones regarding reliability, sensitivity, validity, and usability. However, to the best of our knowledge, no study has compared all of them in a clinical scenario. Also, after this review, three more scales were published: BROSJOD, Tal modified, and one score developed by PERN. Our main aim was to compare the ability of different clinical scales for bronchiolitis to predict any relevant outcome. A prospective observational study was conducted that included patients of up to 12 months old attended to, due to bronchiolitis, in the paediatric Emergency Department of a secondary university hospital from October 2019 to January 2022. For each patient, the attending clinician filled in a form with the items of the scales, decomposed, in order to prevent the clinician from knowing the score of each scale. Then, the patient was managed according to the protocol of our Emergency Department. A phone call was made to each patient in order to check whether the patient ended up being admitted in the next 48 h. In the case of those that were impossible to contact by phone, the clinical history was reviewed. For the purpose of the study, any of the following were considered to be a relevant outcome: admission to ward and need for supplementary oxygen, non-invasive ventilation (NIV) or intravenous fluids, and admission to the paediatric intensive care unit (PICU) within the next 48 h or death. For the aim of the study, the area under the curve (AUC) and the odds ratio (OR) for a relevant outcome were calculated in each scale. Also, the best cut-off point was estimated according to the Youden index, and its sensitivity (Sn) and specificity (Sp) for a relevant outcome were calculated. We included 265 patients (52.1% male) with a median age of 5.3 months (P₂₅-P₇₅ 2.6-7.4). Among them, 46 (17.4%) had some kind of relevant outcome. AUC for prediction of a relevant outcome ranged from 0.705 (Respiratory Score) to 0.786 (BRAS), although no scale performed significantly better than others. A score ≤ 2 in the PERN scale showed a sensitivity of 91.3% (CI95% 79.7-96.6) for a relevant outcome, with only 4 misdiagnosed patients (only 2 of them needed NIV).   Conclusions: There were no differences in the performance of the nine scales to predict relevant outcomes in patients with bronchiolitis. However, the PERN scale might be more useful to select patients at low risk of a severe outcome. What is Known: • Several clinical scales are used to assess the severity of bronchiolitis. Nevertheless, none of them seems to be better than others. What is New: • This is the first study comparing different bronchiolitis scales in a real clinical scenario. None of the nine scales compared performed better than the other. However, the PERN scale might be more useful to select patients at low risk of relevant outcomes.

Predictors of Intensive Care Admission in Hypoxemic Bronchiolitis Infants, Secondary Analysis of a Randomized Trial

OBJECTIVES

To evaluate in a preplanned secondary analysis of our parent randomized controlled trial predictors of intensive care unit (ICU) admission in infants with bronchiolitis and analyze if these predictors are equally robust for children receiving high-flow or standard-oxygen.

STUDY DESIGN

A secondary analysis of a multicenter, randomized trial of infants aged <12 months with bronchiolitis and an oxygen requirement was performed using admission and outcome data of all 1472 enrolled infants. The primary outcome was ICU admission. The predictors evaluated were baseline characteristics including physiological data and medical history.

RESULTS

Of the 1472 enrolled infants, 146 were admitted to intensive care. Multivariate predictors of ICU admission were age (weeks) (OR: 0.98 [95% CI: 0.96-0.99]), pre-enrolment heart rate >160/min (OR: 1.80 [95% CI: 1.23-2.63]), pre-enrolment SpO₂ (transcutaneous oxygen saturation) (%) (OR: 0.91 [95% CI: 0.86-0.95]), previous ICU admission (OR: 2.16 [95% CI: 1.07-4.40]), and time of onset of illness to hospital presentation (OR: 0.78 [95% CI: 0.65-0.94]). The predictors were equally robust for infants on high-flow nasal cannula therapy or standard-oxygen therapy.

CONCLUSION

Age <2 months, pre-enrolment heart rate >160/min, pre-enrolment SpO₂ of <87%, previous ICU admission and time of onset of ≤2 days to presentation are predictive of an ICU admission during the current hospital admission of infants with bronchiolitis independent of oxygenation method used.

TRIAL REGISTRATION

ACTRN12613000388718.

Routine laboratory test to assess the need of respiratory support in acute bronchiolitis

BACKGROUND AND OBJECTIVES

Accurate and readily available biomarkers to predict the clinical course of bronchiolitis would enable enhanced decision-making in this setting. We explored the relationship of several biochemical parameters available at the pediatric emergency care setting with the need of advanced respiratory support (ARS): continuous positive airway pressure (CPAP), biphasic positive airway pressure (BiPAP), or invasive mechanical ventilation (MV) in bronchiolitis.

METHODS

Single-center, prospective, observational, including infants aged less than 12 months diagnosed with acute bronchiolitis at the Pediatric Emergency Department. Determination of plasmatic values of several laboratory tests was performed at the time of hospital admission. Multivariate logistic analysis identified independent predictors for need of ARS.

RESULTS

From October 1, 2018 to May 1, 2020, we recruited 149 infants (58% males; median age of 1 [0.5-2.5] month). Thirty-seven (25%) cases required ARS. After adjusting by age, bacterial superinfection, and comorbidities in the multivariate analysis, only higher levels of glycemia (p = 0.001), C-reactive protein (CRP) (p = 0.028), CRP/albumin ratio (p = 0.032), and NT-proBNP (p = 0.001) remained independently associated with ARS. These biomarkers reached moderate prediction accuracy with area under the curve of receiver operator curve curves ranging from 0.701 to 0.830 (p = 0.001). All they presented relatively high specificity (0.75-0.84) and negative predictive values (0.77-0.89) with low sensitivity and positive predictive values. They also correlated significantly with length of stay hospitalization (p = 0.001).

CONCLUSION

Increased plasmatic levels of CRP, CRP/albumin ratio, glycemia, and NT-proBNP at hospital admission are associated with the need for ARS in infants with acute bronchiolitis.

Stakeholder Perspectives on Hospitalization Decisions and Shared Decision-Making in Bronchiolitis

OBJECTIVES

Our objective was to elicit clinicians' and parents' perspectives about decision-making related to hospitalization for children with bronchiolitis and the use of shared decision-making (SDM) to guide these decisions.

METHODS

We conducted individual, semistructured interviews with purposively sampled clinicians (pediatric emergency medicine physicians and nurses) at 2 children's hospitals and parents of children age <2 years with bronchiolitis evaluated in the emergency department at 1 hospital. Interviews elicited clinicians' and parents' perspectives on decision-making and SDM for bronchiolitis. We conducted an inductive analysis following the principles of grounded theory until data saturation was reached for both groups.

RESULTS

We interviewed 24 clinicians (17 physicians, 7 nurses) and 20 parents. Clinicians identified factors in 3 domains that contribute to hospitalization decision-making for children with bronchiolitis: demographics, clinical factors, and social-emotional factors. Although many clinicians supported using SDM for hospitalization decisions, most reported using a clinician-guided decision-making process in practice. Clinicians also identified several barriers to SDM, including the unpredictable course of bronchiolitis, perceptions of parents' preferences for engaging in SDM, and parents' emotions, health literacy, preferred language, and comfort with discharge. Parents wanted the opportunity to express their opinions during decision-making about hospitalization, although they often felt comfortable with the clinician's decision when adequately informed.

CONCLUSIONS

Although clinicians and parents of children with bronchiolitis are supportive of SDM, most hospitalization decision-making is clinician guided. Future investigation should evaluate how to address barriers and implement SDM in practice, including training clinicians in this SDM approach.

Factors associated with severe respiratory syncytial virus disease in hospitalised children: a retrospective analysis

BACKGROUND

Early recognition of children at risk of severe respiratory syncytial virus (RSV) lower respiratory tract infection is important as it informs management decisions. We aimed to evaluate factors associated with severe disease among young children hospitalised with RSV infection.

METHODS

We conducted a retrospective cohort study of all children <2 years of age hospitalised for RSV lower respiratory tract infection at a single tertiary paediatric hospital over three RSV seasons (January 2017-December 2019). We classified children as having 'moderate' or 'severe' disease based on the level of respiratory intervention and used univariable and multivariable regression models to determine factors associated with severe disease.

RESULTS

Of 970 hospitalised children, 386 (40%) were classified as having 'severe' and 584 (60%) as having 'moderate' RSV disease. On multivariable analyses, age <2 months (OR: 2.3, 95% CI 1.6 to 3.3, p<0.0001), prematurity (OR: 1.6, 95% CI 1.1 to 2.4, p=0.02) and RSV-parainfluenza virus type 3 (PIV3) codetection (OR: 2.6, 95% CI 1.05 to 6.5, p=0.04) were independently associated with severe disease.

CONCLUSION

Younger age, prematurity and PIV3 codetection were associated with severe RSV disease in children <2 years of age hospitalised with RSV infection. The association between PIV3 and severe RSV disease is a novel finding and warrants further investigation.

Association between respiratory rate oxygenation index and need for positive pressure ventilation in children on high flow nasal cannula for bronchiolitis

Our objective was to evaluate the association of respiratory rate oxygenation index (ROX) with the need for positive pressure ventilation in children < 2 years of age with bronchiolitis on high flow nasal cannula (HFNC) therapy. We performed a single-center prospective observational study of a convenience sample of children < 2 years of age with bronchiolitis who had HFNC initiated in the pediatric emergency department between November and March, 2018-2020. ROX was calculated as pulse oximetry/FiO₂/respiratory rate at HFNC initiation. Demographics, need for positive pressure ventilation (PPV), disposition, and hospital length of stay were collected. Logistic regression model was used to determine the odds ratio for PPV need relative to the highest ROX quartile. Of the 373 patients included, 49 (13.1%) required PPV. ROX was lower in patients who required PPV compared with those who did not (5.86 [4.71-7.42] vs. 6.74 [5.46-8.25]; p = 0.01). Logistic regression revealed that those patients whose ROX was in the lowest quartile (< 5.39) were three times more likely to require PPV compared to those in the highest quartile (> 8.21). These results held true after adjusting for confounders (odds ratio 3.1; 95% CI [1.3 to 7.5]; p = 0.02). The model's AUROC (0.701) indicated acceptable discrimination between cases and controls.

CONCLUSION

Low ROX index was associated with the need for PPV in children with bronchiolitis on HFNC. The risk stratification provided and ROX threshold for risk stratification require confirmation in other populations with a larger sample size.

WHAT IS KNOWN

• Demographic and clinical factors associated with high flow nasal cannula (HFNC) therapy in children with bronchiolitis has been studied.

WHAT IS NEW

• This is the first study to  report the utility of association of Respiratory Rate Oxygenation (ROX) index for need for positive pressure ventilation (PPV) in children  < 2 years of age with bronchiolitis on HFNC therapy. • ROX was lower in children who required PPV and children whose ROX was in the lowest quartile (< 5.39) were three times more likely to require PPV compared to those in the highest quartile (> 8.21).

Risk Factors Associated with Mechanical Ventilation in Critical Bronchiolitis

The American Academy of Pediatrics (AAP) recommends supportive care for the management of bronchiolitis. However, patients admitted to the intensive care unit with severe (critical) bronchiolitis define a unique group with varying needs for both non-invasive and invasive respiratory support. Currently, no guidance exists to help clinicians discern who will progress to invasive mechanical support. Here, we sought to identify key clinical features that distinguish pediatric patients with critical bronchiolitis requiring invasive mechanical ventilation from those that did not. We conducted a retrospective cohort study at a tertiary pediatric medical center. Children ≤2 years old admitted to the pediatric intensive care unit (PICU) from January 2015 to December 2019 with acute bronchiolitis were studied. Patients were divided into non-invasive respiratory support (NRS) and invasive mechanical ventilation (IMV) groups; the IMV group was further subdivided depending on timing of intubation relative to PICU admission. Of the 573 qualifying patients, 133 (23%) required invasive mechanical ventilation. Median age and weight were lower in the IMV group, while incidence of prematurity and pre-existing neurologic or genetic conditions were higher compared to the NRS group. Multi-microbial pneumonias were diagnosed more commonly in the IMV group, in turn associated with higher severity of illness scores, longer PICU lengths of stay, and more antibiotic usage. Within the IMV group, those intubated earlier had a shorter duration of mechanical ventilation and PICU length of stay, associated with lower pathogen load and, in turn, shorter antibiotic duration. Taken together, our data reveal that critically ill patients with bronchiolitis who require mechanical ventilation possess high risk features, including younger age, history of prematurity, neurologic or genetic co-morbidities, and a propensity for multi-microbial infections.

Creating a Pediatric Prehospital Destination Decision Tool Using a Modified Delphi Method

Decisions for patient transport by emergency medical services (EMS) are individualized; while established guidelines help direct adult patients to specialty hospitals, no such pediatric equivalents are in wide use. When children are transported to a hospital that cannot provide definitive care, care is delayed and may cause adverse events. Therefore, we created a novel evidence-based decision tool to support EMS destination choice. A multidisciplinary expert panel (EP) of stakeholders reviewed published literature. Four facility capability levels for pediatric care were defined. Using a modified Delphi method, the EP matched specific conditions to a facility pediatric-capability level in a draft tool. The literature review and EP recommendations identified seventeen pediatric medical conditions at risk for secondary transport. In the first voting round, two were rejected, nine met consensus for a specific facility capability level, and six did not reach consensus on the destination facility level. A second round reached consensus on a facility level for the six conditions as well as revision of one previously rejected condition. In the third round, the panel selected a visual display format. Finally, the panel unanimously approved the PDTree. Using a modified Delphi technique, we developed the PDTree EMS destination decision tool by incorporating existing evidence and the expertise of a multidisciplinary panel.

The Pediatric Emergency Research Network (PERN): A decade of global research cooperation in paediatric emergency care

OBJECTIVES

The Pediatric Emergency Research Network (PERN) was launched in 2009 with the intent for existing national and regional research networks in paediatric emergency care to organise globally for the conduct of collaborative research across networks.

METHODS

PERN has grown from five to eight member networks over the past decade. With an executive committee comprising representatives from all member networks, PERN plays a supportive and collaborative rather than governing role. The full impact of PERN's facilitation of international collaborative research, although somewhat difficult to quantify empirically, can be measured indirectly by the observed growth of the field, the nature of the increasingly challenging research questions now being addressed and the collective capacity to generate and implement new knowledge in treating acutely ill and injured children.

RESULTS

Beginning as a pandemic response studying H1N1 influenza risk factors in children, PERN research has progressed to multiple observational studies and ongoing global randomised controlled trials (RCTs). As a recent example, PERN has developed sufficient network infrastructure to enable the rapid initiation of a prospective observational study in response to the current COVID-19 pandemic.

CONCLUSIONS

Following its success with developing global research, the PERN goal now is to promote the implementation of scientific advances into everyday clinical practice by: (i) expanding the capacity for global RCTs; (ii) deepening the focus on implementation science; (iii) increasing attention to healthcare disparities; and (iv) expanding PERN's reach into resource-restricted regions. Through these actions, PERN aims to meet the needs of acutely ill and injured children throughout the world.

The Pediatric Emergency Research Network: A Decade of Global Research Cooperation in Pediatric Emergency Care

OBJECTIVES

The Pediatric Emergency Research Network (PERN) was launched in 2009 with the intent for existing national and regional research networks in pediatric emergency care to organize globally for the conduct of collaborative research across networks.

METHODS

The Pediatric Emergency Research Network has grown from 5- to 8-member networks over the past decade. With an executive committee comprising representatives from all member networks, PERN plays a supportive and collaborative rather than governing role. The full impact of PERN's facilitation of international collaborative research, although somewhat difficult to quantify empirically, can be measured indirectly by the observed growth of the field, the nature of the increasingly challenging research questions now being addressed, and the collective capacity to generate and implement new knowledge in treating acutely ill and injured children.

RESULTS

Beginning as a pandemic response with a high-quality retrospective case-controlled study of H1N1 influenza risk factors, PERN research has progressed to multiple observational studies and ongoing global randomized controlled trials. As a recent example, PERN has developed sufficient network infrastructure to enable the rapid initiation of a prospective observational study in response to the current coronavirus disease 2019 pandemic. In light of the ongoing need for translation of research knowledge into equitable clinical practice and to promote health equity, PERN is committed to a coordinated international effort to increase the uptake of evidence-based management of common and treatable acute conditions in all emergency department settings.

CONCLUSIONS

The Pediatric Emergency Research Network's successes with global research, measured by prospective observational and interventional studies, mean that the network can now move to improve its ability to promote the implementation of scientific advances into everyday clinical practice. Achieving this goal will involve focus in 4 areas: (1) expanding the capacity for global randomized controlled trials; (2) deepening the focus on implementation science; (3) increasing attention to healthcare disparities and their origins, with growing momentum toward equity; and (4) expanding PERN's global reach through addition of sites and networks from resource-restricted regions. Through these actions, PERN will be able to build on successes to face the challenges ahead and meet the needs of acutely ill and injured children throughout the world.

[Predictors of hospitalization plus airway support among infants with recurrent wheezing in the emergency department]

OBJECTIVE

Most patients with recurrent wheezing are infants under 2 years of age. Clinical prediction models of the risk of receiving airway support during the hospital stay in this population have been poorly studied in tropical countries. This study aimed to evaluate the clinical predictors of hospitalization plus airway support among infants with recurrent wheezing evaluated in the emergency department in Colombia.

METHODS

A retrospective cohort study was performed. This study included all infants with two or more wheezing episodes who were younger than two years old in two tertiary centers in Rionegro, Colombia, between January 2019 and December 2019. The primary outcome measure was hospitalization plus any airway support. A multivariable logistic regression model was used to identify factors independently associated with hospitalization plus any airway support.

RESULTS

A total of 85 infants were hospitalized plus any airway support, of whom 34(40%) were treated with high flow nasal canula, 2(2%) received non-invasive ventilation, 6(7%) were mechanically ventilated, and 43 (51%) received conventional oxygen therapy. The multivariable logistic regression model showed that predictors of hospitalization plus airway support included prematurity (OR=1.79, 95%CI: 1.04-3.10), poor feeding (OR=2.22, 95%CI: 1.25-3.94), nasal flaring and/or grunting (OR=4.27, 95%CI: 2.41-7.56), and previous wheezing episodes requiring hospitalization (OR=3.36, 95%CI: 1.86-7.08). The model has a high specificity (99.6%) with acceptable discrimination and an area under the curve of 0.70(95%CI: 0.60-0.74).

CONCLUSIONS

The present study shows that prematurity, poor feeding, nasal flaring and/or grunting, and more than one previous episode of wheezing requiring hospitalization are independent predictors of hospitalization plus airway support in a population of infants with recurrent wheezing in the emergency department. More evidence must be collected to examine the results in other tropical countries.

Capillary blood gas in infants with bronchiolitis: Can end-tidal capnography replace it?

OBJECTIVES

To explore the predictive ability of capillary blood gas (CBG) pCO₂ for respiratory decompensation in infants aged ≤6 months with bronchiolitis admitted from the emergency department; to determine whether end-tidal CO₂ (etCO₂) capnography can serve as a less invasive substitute for CBG pCO₂.

STUDY DESIGN

This was a prospective cohort study of previously healthy infants aged ≤6 months admitted for bronchiolitis from the emergency department (ED). Initial CBG pCO₂ and etCO₂ capnography were obtained in the ED prior to inpatient admission. Simple logistic regression modeling was used to examine the associations of CBG pCO₂ and etCO₂ capnography with respiratory decompensation. Pearson's correlation measured the relationship between CBG pCO₂ and etCO₂ capnography.

RESULTS

Of 134 patients, 61 had respiratory decompensation. There was a significant association between CBG pCO₂ and respiratory decompensation (OR = 1.07, p = 0.003), even after outlying values were excluded (OR = 1.06, p = 0.005). End tidal CO₂ capnography was not significantly associated with decompensation (OR = 1.02, p = 0.17), even after outlying values were excluded (OR = 1.02, p = 0.24). There was a moderate correlation between etCO₂ capnography and CBG pCO₂ (r = 0.39, p < 0.001).

CONCLUSION

In infants with bronchiolitis, CBG pCO₂ provides an objective measure for predicting respiratory decompensation, and a single etCO₂ measurement should not replace its use.

Viral lower respiratory tract infections-strict admission guidelines for young children can safely reduce admissions

Viral lower respiratory tract infection (VLRTI) is the most common cause of hospital admission among small children in high-income countries. Guidelines to identify children in need of admission are lacking in the literature. In December 2012, our hospital introduced strict guidelines for admission. This study aims to retrospectively evaluate the safety and efficacy of the guidelines. We performed a single-center retrospective administrative database search and medical record review. ICD-10 codes identified children < 24 months assessed at the emergency department for VLRTI for a 10-year period. To identify adverse events related to admission guidelines implementation, we reviewed patient records for all those discharged on primary contact followed by readmission within 14 days. During the study period, 3227 children younger than 24 months old were assessed in the ED for VLRTI. The proportion of severe adverse events among children who were discharged on their initial emergency department contact was low both before (0.3%) and after the intervention (0.5%) (p=1.0). Admission rates before vs. after the intervention were for previously healthy children > 90 days 65.3% vs. 53.3% (p<0.001); for healthy children ≤ 90 days 85% vs. 68% (p<0.001); and for high-risk comorbidities 74% vs. 71% (p=0.5).Conclusion: After implementation of admission guidelines for VLRTI, there were few adverse events and a significant reduction in admissions to the hospital from the emergency department. Our admission guidelines may be a safe and helpful tool in the assessment of children with VLRTI. What is Known: • Viral lower respiratory tract infection, including bronchiolitis, is the most common cause of hospitalization for young children in the developed world. Treatment is mainly supportive, and hospitalization should be limited to the cases in need of therapeutic intervention. • Many countries have guidelines for the management of the disease, but the decision on whom to admit for inpatient treatment is often subjective and may vary even between physicians in the same hospital. What is New: • Implementation of admission criteria for viral lower respiratory tract infection may reduce the rate of hospital admissions without increasing adverse events.

Physiometric Response to High-Flow Nasal Cannula Support in Acute Bronchiolitis

OBJECTIVES

To describe the rate of high-flow nasal cannula (HFNC) nonresponse and paired physiometric responses (changes [∆] in heart rate [HR] and respiratory rate [RR]) before and after HFNC initiation in hospitalized children with bronchiolitis.

METHODS

We performed a single-center, prospective descriptive study in a PICU within a quaternary referral center, assessing children aged ≤2 years admitted for bronchiolitis on HFNC from November 2017 to March 2020. We excluded for cystic fibrosis, airway anomalies, pulmonary hypertension, tracheostomy, neuromuscular disease, congenital heart disease, or preadmission intubation. Primary outcomes were paired ∆ and %∆ in HR and RR before and after HFNC initiation. Secondary outcomes were HFNC nonresponse rate (ie, intubation or transition to noninvasive positive pressure ventilation). Analyses included χ², Student's t, Wilcoxon rank, and paired testing.

RESULTS

Of the 172 children studied, 56 (32.6%) experienced HFNC nonresponse at a median of 14.4 (interquartile range: 4.8-36) hours and 11 (6.4%) were intubated. Nonresponders had a greater frequency of bacterial pneumonia, but otherwise no major differences in demographics, comorbidities, or viral pathogens were noted. Responders experienced reductions in both %ΔRR (-17.1% ± 15.8% vs +5.3% ± 22.3%) and %ΔHR (-6.5% ± 10.5% vs 0% ± 10.9%) compared with nonresponders.

CONCLUSIONS

In this prospective, observational cohort study, we provide baseline data describing expected physiologic changes after initiation of HFNC for children admitted to the PICU for bronchiolitis. In our descriptive analysis, patients with comorbid bacterial pneumonia appear to be at additional risk for subsequent HFNC nonresponse.

Challenges in the prevention or treatment of RSV with emerging new agents in children from low- and middle-income countries

INTRODUCTION

Respiratory syncytial virus (RSV) causes approximately 120,000 deaths annually in children <5 years, with 99% of fatalities occurring in low- and middle-income countries (LMICs).

AREAS COVERED

There are numerous RSV interventions in development, including long-acting monoclonal antibodies, vaccines (maternal and child) and treatments which are expected to become available soon. We reviewed the key challenges and issues that need to be addressed to maximize the impact of these interventions in LMICs. The epidemiology of RSV in LMICs was reviewed (PubMed search to 30 June 2020 inclusive) and the need for more and better-quality data, encompassing hospital admissions, community contacts, and longer-term respiratory morbidity, emphasized. The requirement for an agreed clinical definition of RSV lower respiratory tract infection was proposed. The pros and cons of the new RSV interventions are reviewed from the perspective of LMICs.

EXPERT OPINION

We believe that a vaccine (or combination of vaccines, if practicable) is the only viable solution to the burden of RSV in LMICs. A coordinated program, analogous to that with polio, involving governments, non-governmental organizations, the World Health Organization, the manufacturers and the healthcare community is required to realize the full potential of vaccine(s) and end the devastation of RSV in LMICs.

Day of Illness and Outcomes in Bronchiolitis Hospitalizations

BACKGROUND

Bronchiolitis is often described to follow an expected clinical trajectory, with a peak in severity between days 3 and 5. This predicted trajectory may influence anticipatory guidance and clinical decision-making. We aimed to determine the association between day of illness at admission and outcomes, including hospital length of stay, receipt of positive-pressure ventilation, and total cough duration.

METHODS

We compiled data from 2 multicenter prospective studies involving bronchiolitis hospitalizations in patients <2 years. Patients were excluded for complex conditions. We assessed total cough duration via weekly postdischarge phone calls. We used mixed-effects multivariable regression models to test associations between day of illness and outcomes, with adjustment for age, sex, insurance (government versus nongovernment), race, and ethnicity.

RESULTS

The median (interquartile range) day of illness at admission for 746 patients was 4 (2-5) days. Day of illness at admission was not associated with length of stay (coefficient 0.01 days, 95% confidence interval [CI]: -0.05 to 0.08 days), positive-pressure ventilation (adjusted odds ratio: 1.0, 95% CI: 0.9 to 1.1), or total cough duration (coefficient 0.33 days, 95% CI: -0.01 to 0.67 days). Additionally, there was no significant difference in day of illness at discharge in readmitted versus nonreadmitted patients (5.9 vs 6.4 days, P = .54). The median cough duration postdischarge was 6 days, with 65 (14.3%) patients experiencing cough for 14+ days.

CONCLUSIONS

We found no associations between day of illness at admission and outcomes in bronchiolitis hospitalizations. Practitioners should exercise caution when making clinical decisions or providing anticipatory guidance based on symptom duration.

National survey of feasibility of NIV trials for management of children with bronchiolitis

BACKGROUND

Bronchiolitis is a major cause of admission to hospital in children. Non-invasive ventilation (NIV) support with continuous positive airway pressure (CPAP) or high-flow nasal cannula (HFNC) oxygen is routinely used for infants in the UK with bronchiolitis.

OBJECTIVE

To establish UK paediatric practice regarding management of bronchiolitis, and to explore issues pertinent to the design of a potential future randomised controlled trial of NIV.

DESIGN

Screening logs were completed in hospitals in England capturing information on paediatric bronchiolitis admissions. An online national survey of clinical practice was disseminated to healthcare professionals (HCPs) across the UK to ascertain current management strategies.

RESULTS

Screening logs captured data on 393 infants from 8 hospitals. Reasons for admission were most commonly respiratory distress and/or poor fluid intake. Oxygen was administered for 54% of admissions. Respiratory (CPAP and HFNC) and non-respiratory support administered varied considerably. The national survey was completed by 111 HCPs from 76 hospitals. Data were obtained on criteria used to commence and wean NIV, responsibilities for altering NIV settings, minimum training requirements for staff managing a child on NIV, and numbers of trained staff. Most centres were interested in and capable of running a trial of NIV, even out of normal office hours.

CONCLUSIONS

Respiratory and non-respiratory management of bronchiolitis in UK centres varies widely. A trial of HFNC oxygen therapy in this group of patients is feasible and HCPs would be willing to randomise patients into such a trial. Future work should focus on defining trial eligibility criteria.

How to use N-terminal pro-brain natriuretic peptide (NT-proBNP) in assessing disease severity in bronchiolitis

Bronchiolitis is a common viral illness which can lead to severe respiratory compromise and can coexist with or mask cardiac failure. Brain natriuretic peptide (BNP) and the inactive portion of its pro-hormone: N-terminal pro-BNP (NT-proBNP) are excreted in response to cardiomyocyte stretching and are established biomarkers in cardiac failure. Here, we discuss the technicalities of NT-proBNP testing and review available evidence regarding NT-proBNP testing in bronchiolitis. We identified and appraised seven studies assessing the role of BNP or NT-proBNP as biomarkers of bronchiolitis severity, in children with and without underlying congenital cardiac disease. One study of 76 children with dyspnoea showed that the median NT-proBNP level in children with cardiac failure was 7321 pg/mL vs 241 pg/mL in children with a respiratory cause of dyspnoea vs 87.21 pg/mL in healthy controls (p<0.05). A cut-off of 726 pg/mL could aid differentiation between cardiac and respiratory causes of respiratory distress. Other evidence showed a positive correlation between BNP levels and bronchiolitis severity, and that raised BNP can predict acute heart failure in children with congenital cardiac disease presenting with bronchiolitis. However, most studies consisted of small cohorts with conflicting evidence between them. Furthermore, several studies assessed BNP rather than NT-proBNP directly. BNP has a shorter half-life, which may affect analysis. In conclusion, NT-proBNP is a rapid and inexpensive test with the potential to be a useful biomarker in severe bronchiolitis and cases complicated by acute cardiac failure. However, studies with larger cohorts are required to better establish this role.

A randomised trial of high-flow nasal cannula in infants with moderate bronchiolitis

BACKGROUND

The objective was to determine whether high-flow nasal cannula (HFNC), a promising respiratory support in infant bronchiolitis, could reduce the proportion of treatment failure requiring escalation of care.

METHODS

In this randomised controlled trial, we assigned infants aged <6 months who had moderate bronchiolitis to receive either HFNC at 3 L·kg^-1·min^-1 or standard oxygen therapy. Crossover was not allowed. The primary outcome was the proportion of patients in treatment failure requiring escalation of care (mostly noninvasive ventilation) within 7 days following randomisation. Secondary outcomes included rates of transfer to the paediatric intensive care unit (PICU), oxygen, number of artificial nutritional support-free days and adverse events.

RESULTS

The analyses included 268 patients among the 2621 infants assessed for inclusion during two consecutive seasons in 17 French paediatric emergency departments. The percentage of infants in treatment failure was 14% (19 out of 133) in the study group, compared to 20% (27 out of 135) in the control group (OR 0.66, 95% CI 0.35-1.26; p=0.21). HFNC did not reduce the risk of admission to PICU (21 (15%) out of 133 in the study group versus 26 (19%) out of 135 in the control group) (OR 0.78, 95% CI 0.41-1.41; p=0.45). The main reason for treatment failure was the worsening of modified Wood clinical asthma score (m-WCAS). Short-term assessment of respiratory status showed a significant difference for m-WCAS and respiratory rate in favour of HFNC. Three pneumothoraces were reported in the study group.

CONCLUSIONS

In patients with moderate bronchiolitis, there was no evidence of lower rate of escalating respiratory support among those receiving HFNC therapy.

Machine learning-based prediction of acute severity in infants hospitalized for bronchiolitis: a multicenter prospective study

We aimed to develop machine learning models to accurately predict bronchiolitis severity, and to compare their predictive performance with a conventional scoring (reference) model. In a 17-center prospective study of infants (aged < 1 year) hospitalized for bronchiolitis, by using routinely-available pre-hospitalization data as predictors, we developed four machine learning models: Lasso regression, elastic net regression, random forest, and gradient boosted decision tree. We compared their predictive performance-e.g., area-under-the-curve (AUC), sensitivity, specificity, and net benefit (decision curves)-using a cross-validation method, with that of the reference model. The outcomes were positive pressure ventilation use and intensive treatment (admission to intensive care unit and/or positive pressure ventilation use). Of 1,016 infants, 5.4% underwent positive pressure ventilation and 16.0% had intensive treatment. For the positive pressure ventilation outcome, machine learning models outperformed reference model (e.g., AUC 0.88 [95% CI 0.84-0.93] in gradient boosted decision tree vs 0.62 [95% CI 0.53-0.70] in reference model), with higher sensitivity (0.89 [95% CI 0.80-0.96] vs. 0.62 [95% CI 0.49-0.75]) and specificity (0.77 [95% CI 0.75-0.80] vs. 0.57 [95% CI 0.54-0.60]). The machine learning models also achieved a greater net benefit over ranges of clinical thresholds. Machine learning models consistently demonstrated a superior ability to predict acute severity and achieved greater net benefit.

Characterizing Avoidable Transfer Admissions in Infants Hospitalized for Bronchiolitis

OBJECTIVES

The appropriateness of interfacility transfer admissions for bronchiolitis to pediatric centers is uncertain. We characterized avoidable transfer admissions for bronchiolitis. We hypothesized that a higher proportion of hospitalized infants transferred from a community emergency department (ED) or hospital (transfer admission) would be discharged within 48 hours with little or no intervention, compared with direct admissions from an enrolling ED (nontransfer admission).

METHODS

We analyzed a 17-center, prospective infant cohort (age <1 year) hospitalized for bronchiolitis (2011-2014). An avoidable transfer admission (primary outcome) was hospitalization for <48 hours without an intervention for severe illness in which a pediatric specialist could be beneficial (oxygen, advanced airway management, life support). Parenteral fluids and routine medications were excluded. We compared admissions by patient, ED, inpatient, and transferring hospital characteristics to identify factors associated with avoidable transfer admissions. Multivariable logistic regression was used to identify predictors of avoidable transfer admission.

RESULTS

Among 1007 infants, 558 (55%) were nontransfer admissions, 164 (16%) were transfer admissions, and 204 (20%) were referrals from clinics; 81 (8%) were missing referral type. Significantly fewer transferred infants were hospitalized for <48 hours with little or no intervention (40 of 164; 24% [95% confidence interval 18%-32%]) than nontransferred infants (199 of 558; 36% [95% confidence interval 32%-40%]; P = .007). Avoidable transfer admissions were more likely to be children of color, have nonprivate insurance, receive fewer ED interventions, and originate from small EDs. A multivariable model revealed that minority race and/or ethnicity, normal oxygenation, and small ED transfers increased odds of avoidable transfer admission.

CONCLUSIONS

Although most transferred infants hospitalized for bronchiolitis required interventions for severe illness, 1 in 4 admissions were potentially avoidable.

Prevalence of Continuous Pulse Oximetry Monitoring in Hospitalized Children With Bronchiolitis Not Requiring Supplemental Oxygen

IMPORTANCE

US national guidelines discourage the use of continuous pulse oximetry monitoring in hospitalized children with bronchiolitis who do not require supplemental oxygen.

OBJECTIVE

Measure continuous pulse oximetry use in children with bronchiolitis.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter cross-sectional study was performed in pediatric wards in 56 US and Canadian hospitals in the Pediatric Research in Inpatient Settings Network from December 1, 2018, through March 31, 2019. Participants included a convenience sample of patients aged 8 weeks through 23 months with bronchiolitis who were not receiving active supplemental oxygen administration. Patients with extreme prematurity, cyanotic congenital heart disease, pulmonary hypertension, home respiratory support, neuromuscular disease, immunodeficiency, or cancer were excluded.

EXPOSURES

Hospitalization with bronchiolitis without active supplemental oxygen administration.

MAIN OUTCOMES AND MEASURES

The primary outcome, receipt of continuous pulse oximetry, was measured using direct observation. Continuous pulse oximetry use percentages were risk standardized using the following variables: nighttime (11 pm to 7 am), age combined with preterm birth, time after weaning from supplemental oxygen or flow, apnea or cyanosis during the present illness, neurologic impairment, and presence of an enteral feeding tube.

RESULTS

The sample included 3612 patient observations in 33 freestanding children's hospitals, 14 children's hospitals within hospitals, and 9 community hospitals. In the sample, 59% were male, 56% were white, and 15% were black; 48% were aged 8 weeks through 5 months, 28% were aged 6 through 11 months, 16% were aged 12 through 17 months, and 9% were aged 18 through 23 months. The overall continuous pulse oximetry monitoring use percentage in these patients, none of whom were receiving any supplemental oxygen or nasal cannula flow, was 46% (95% CI, 40%-53%). Hospital-level unadjusted continuous pulse oximetry use ranged from 2% to 92%. After risk standardization, use ranged from 6% to 82%. Intraclass correlation coefficient suggested that 27% (95% CI, 19%-36%) of observed variation was attributable to unmeasured hospital-level factors.

CONCLUSIONS AND RELEVANCE

In a convenience sample of children hospitalized with bronchiolitis who were not receiving active supplemental oxygen administration, monitoring with continuous pulse oximetry was frequent and varied widely among hospitals. Because of the apparent absence of a guideline- or evidence-based indication for continuous monitoring in this population, this practice may represent overuse.

Acute severe paediatric asthma: study protocol for the development of a core outcome set, a Pediatric Emergency Reserarch Networks (PERN) study

BACKGROUND

Acute severe childhood asthma is an infrequent, but potentially life-threatening emergency condition. There is a wide range of different approaches to this condition, with very little supporting evidence, leading to significant variation in practice. To improve knowledge in this area, there must first be consensus on how to conduct clinical trials, so that valid comparisons can be made between future studies. We have formed an international working group comprising paediatricians and emergency physicians from North America, Europe, Asia, the Middle East, Africa, South America, Central America, Australasia and the United Kingdom.

METHODS/DESIGN

A 5-stage approach will be used: (1) a comprehensive list of outcomes relevant to stakeholders will be compiled through systematic reviews and qualitative interviews with patients, families, and clinicians; (2) Delphi methodology will be applied to reduce the comprehensive list to a core outcome set; (3) we will review current clinical practice guidelines, existing clinical trials, and literature on bedside assessment of asthma severity. We will then identify practice differences in tne clinical assessment of asthma severity, and determine whether further prospective work is needed to achieve agreement on inclusion criteria for clinical trials in acute paediatric asthma in the emergency department (ED) setting; (4) a retrospective chart review in Australia and New Zealand will identify the incidence of serious clinical complications such as intubation, ICU admission, and death in children hospitalized with acute severe asthma. Understanding the incidence of such outcomes will allow us to understand how common (and therefore how feasible) particular outcomes are in asthma in the ED setting; and finally (5) a meeting of the Pediatric Emergency Research Networks (PERN) asthma working group will be held, with invitation of other clinicians interested in acute asthma research, and patients/families. The group will be asked to achieve consensus on a core set of outcomes and to make recommendations for the conduct of clinical trials in acute severe asthma. If this is not possible, the group will agree on a series of prioritized steps to achieve this aim.

DISCUSSION

The development of an international consensus on core outcomes is an important first step towards the development of consensus guidelines and standardised protocols for randomized controlled trials (RCTs) in this population. This will enable us to better interpret and compare future studies, reduce risks of study heterogeneity and outcome reporting bias, and improve the evidence base for the management of this important condition.