Risk Factors Associated with Mechanical Ventilation in Critical Bronchiolitis.

Rachel K. Marlow,Nichole Nemec,Melissa L. Cullimore,Sydney Brouillette,Cheng Zheng,Sidharth Mahapatra,Ariann Lenihan,Joseph D. Lukowski,Vannessa Williams

doi:10.3390/children8111035

Abstract

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

Highlights

Despite the wide spectrum of etiologic causes, respiratory syncytial virus (RSV), which accounts for up to 80% of cases, has been linked with more severe disease compared to non-RSV bronchiolitis, especially in the premature population [1,3,6,7,8]
No guidelines exist for the management of critical bronchiolitis requiring admission to the pediatric intensive care unit (PICU), which represents 15–22% of admitted bronchiolitis patients [5,9,10]
We examined patients with acute respiratory failure in the setting of critical bronchiolitis managed on Non-invasive respiratory support (NRS) to identify clinical and demographic features that differentiated the NRS group from the invasive mechanical ventilation (IMV) group

Summary

Introduction

Distinguishing factors predictive of higher illness severity include demographic features (low birth weight [11], prematurity [2,7], young age [2,5,7,12]), clinical features at admission (tachypnea [11], retractions [5,12], or desaturation at admission [5]), and comorbidities (chronic lung disease, congenital heart disease, Trisomy 21, or neuromuscular disorders [2,3,7]) None of these studies identified risk factors associated with higher likelihood of invasive mechanical ventilation

Results

Discussion

Conclusion