Bronchiolitis In Emergency Department Research Articles

Very high intensity of the bronchiolitis epidemic during the 2022-2023 season in France

Abstract Background During epidemic seasons, bronchiolitis affects young children with a large burden in emergency departments (EDs). Following the beginning of the COVID-19 pandemic and 2 perturbed seasons, the aim of this study was to assess the burden of bronchiolitis in EDs in terms of visits and post-discharge hospitalisations in 2022-23 compared with the pre-COVID seasons. Methods Santé publique France, collects ED data through OSCOUR® (95% of French ED visits). ED visits with a medical diagnosis of bronchiolitis (based on ICD-10 codes) in children under 2 years of age (yo) were included. The burden of the 2022-23 epidemic season (from 2022-W36 to 2023-W16) was compared with that of the pre-COVID seasons (2015-16 to 2019-20), by age group, in terms of visits and hospitalisations after discharge, in particular in intensive care units (ICUs) (annual data and means). Results In 2022-23, 99,864 ED visits for bronchiolitis and 31,505 post-discharge hospitalisations were registered for children under 2 yo (vs. respectively +49% and +44% compared to the pre-COVID seasons). It represented 15% of all ED visits and 33% of all hospitalisations after discharge of this age group (vs. 10% and 23% pre-COVID). Among children under 1 year, distribution of bronchiolitis ED visits by age group remained relatively stable in comparison with pre-COVID seasons. For children under 6 months, bronchiolitis accounted for 27% of all ED visits (19% pre-COVID), 45% of all hospitalisations (35% pre-COVID) and more than 70% of hospitalisations referred in ICU during 7 weeks (2 weeks pre-COVID). Conclusions The 2022-2023 bronchiolitis epidemic was of extreme intensity in France with a highest impact than for pre-covid seasons and leading to saturation of EDs. These findings were consistent with an increase in respiratory illness in children during the 2022-23 winter season, and raised questions about the impact of the COVID-19 pandemic on their epidemiology and a potential decrease of immunity. Key messages • Beside a very high intensity for the 2022-23 bronchiolitis epidemic, distribution of ED visits by age group remained relatively stable among children under 1 year. • In 2022-2023, among children under 6 months, during nearly two months (7 weeks), more than 70% of hospitalizations after discharged referred in ICU were due to bronchiolitis.

International Practice Patterns of Antibiotic Therapy and Laboratory Testing in Bronchiolitis.

International patterns of antibiotic use and laboratory testing in bronchiolitis in emergency departments are unknown. Our objective is to evaluate variation in the use of antibiotics and nonindicated tests in infants with bronchiolitis in 38 emergency departments in Pediatric Emergency Research Networks in Canada, the United States, Australia and New Zealand, the United Kingdom and Ireland, and Spain and Portugal. We hypothesized there would be significant variation, adjusted for patient characteristics. We analyzed a retrospective cohort study of previously healthy infants aged 2 to 12 months with bronchiolitis. Variables examined included network, poor feeding, dehydration, nasal flaring, chest retractions, apnea, saturation, respiratory rate, fever, and suspected bacterial infection. Outcomes included systemic antibiotic administration and urine, blood, or viral testing or chest radiography (CXR). In total, 180 of 2359 (7.6%) infants received antibiotics, ranging from 3.5% in the United Kingdom and Ireland to 11.1% in the United States. CXR (adjusted odds ratio [aOR] 2.3; 95% confidence interval 1.6-3.2), apnea (aOR 2.2; 1.1-3.5), and fever (aOR 2.4; 1.7-3.4) were associated with antibiotic use, which did not vary across networks (P = .15). In total, 768 of 2359 infants (32.6%) had ≥1 nonindicated test, ranging from 12.7% in the United Kingdom and Ireland to 50% in Spain and Portugal. Compared to the United Kingdom and Ireland, the aOR (confidence interval) results for testing were Canada 5.75 (2.24-14.76), United States 4.14 (1.70-10.10), Australia and New Zealand 2.25 (0.86-5.74), and Spain and Portugal 3.96 (0.96-16.36). Testing varied across networks (P < .0001) and was associated with suspected bacterial infections (aOR 2.12; 1.30-2.39) and most respiratory distress parameters. Viral testing (591 of 768 [77%]) and CXR (507 of 768 [66%]) were obtained most frequently. The rate of antibiotic use in bronchiolitis was low across networks and was associated with CXR, fever, and apnea. Nonindicated testing was common outside of the United Kingdom and Ireland and varied across networks irrespective of patient characteristics.

Do Beta –2 Agonists Reduce Admission Rate in Children With Bronchiolitis?

Introduction: Bronchiolitis is a very common disease in children less than 2 years of age. RSV virus is the major cause of this illness and its admissions represent 18 % of all pediatric hospitalization in infant less than 1 year of age. Globally, RSV infections in children less than 5 years of age account for 3.4 million hospitalizations and the admission rate has relatively increased during the last 15 years, despite the routine use of Beta-2 agonists in children with bronchiolitis in emergency departments. Methods: The aim is to determine from the medical literature whether the use of Albuterol in children (less than 2 years of age) with bronchiolitis, reduce admission rate or not? PubMed, Scopus, web of science and OneFile gale were searched, 1591 articles identified. Randomized controlled trials that comparing Albuterol group recipients with placebo recipients in children (less than 2 years of age) were only included in this study. Results: 7 (RCT)s representing 670 patients with bronchiolitis published between 1990 to 2011, Risk of bias generally low and quality of evidence are high, (100%) of included studies have concluded that Beta-2 agonists did not reduce Admission rate in children with bronchiolitis (16.5% in Albuterol group vs 20% in placebo group [ odd ratio 0.74 , P = 0.20, confidence interval (CI) = (0.47 - 1.16) ]. Conclusion: Use of Beta-2 Agonists in children (less than 2 years of age) with bronchiolitis do not reduce the admission rate.

Practice Variations between Emergency Physicians and Pediatricians in Treating Acute Bronchiolitis in the Emergency Department: A Nationwide Study

BackgroundAlthough supportive care is the mainstay management for acute bronchiolitis, non–evidence-based diagnostic testing and medications remain common in emergency departments (EDs). ObjectiveOur aim was to compare emergency physicians (EPs) and pediatricians practice patterns in the management of acute bronchiolitis in the ED. MethodsA cross-sectional study was conducted by using registration and claims datasets from 2008 to 2011. Patients with acute bronchiolitis were divided into EP group and pediatrician group. ResultsA total of 2174 patients were enrolled. The diagnostic tests used, including chest x-ray (63.7% vs. 46%; adjusted odds ratio [OR] = 2.27; 95% CI 1.77–2.91), complete blood count (33.2% vs. 21.8%; adjusted OR = 1.74; 95% CI 1.33–2.26), C-reactive protein (35.1% vs. 22.6%; adjusted OR = 1.79; 95% CI 1.38–2.33), blood culture (23.9% vs. 14.3%; adjusted OR = 1.79; 95% CI 1.33–2.39), and arterial blood gas (3.7% vs. 1.8%, adjusted OR = 2.38; 95% CI 1.21–4.67), were higher in the EP group than in the pediatrician group. Intravenous fluid administration was also higher in the EP group (20.8% vs. 3.5%; adjusted OR = 7.49; 95% CI 5.12–10.8). In addition, EPs more frequently arranged for hospital admissions (36% vs. 19.5%; adjusted OR = 2.51; 95% CI 1.15–3.26). ConclusionsBoth EPs and pediatricians had high rates of ordering diagnostic testing for acute bronchiolitis patients in ED. Compared with pediatricians, EPs used more diagnostic tests for the patients with acute bronchiolitis in ED.

Bronchiolitis in ED: Nebulized Hypertonic Saline/Epinephrine?

Source: Grewal S, Ali S, McConnell DW, et al. A randomized trial of nebulized 3% hypertonic saline with epinephrine in the treatment of acute bronchiolitis in the emergency department. Arch Pediatr Adolesc Med. 2009; 163:(11) 1007– 1012; doi: 10.1001/archpediatrics.2009.196To determine whether nebulized 3% hypertonic saline has a clinical benefit in infants with bronchiolitis, a randomized, double-blind, controlled trial was performed in the emergency department (ED) on 46 infants with mild to moderate bronchiolitis. All patients were selected from the pediatric ED at Stollery Children’s Hospital in Edmonton, Alberta, Canada. Infants aged 6 weeks to 12 months seen with a first episode of wheezing, clinical symptoms of a viral respiratory infection, an initial oxygen saturation of 85%–96%, and an initial Respiratory Distress Assessment Instrument (RDAI) score of 4 or higher were included in the study. The RDAI score ranges from 0 to 17 and is calculated based on wheezing type and location and retraction severity and location. Exclusion criteria included pre-existing cardiac or pulmonary disease, previous diagnosis of asthma by a physician, any use of bronchodilators prior to the current illness, language barrier, and no telephone access for follow-up.The selected infants were randomly assigned to receive either hypertonic saline containing 2.5 mL of 3% saline with 0.5 mL of 2.25% racemic epinephrine, or the same volume of normal saline (0.9% saline) with 2.25% racemic epinephrine. All were administered via a nebulizer driven by a 6 L/min flow of oxygen. A repeat dose could be given at the discretion of the ED physician. Measurements of oxygen saturation, respiratory rate, heart rate, and RDAI score were made immediately prior to administration of the aerosol, and at 30, 60, 90, and 120 minutes after administration. One patient in each group withdrew or was dropped. Baseline characteristics of the two groups were similar with regard to age, gender, family history of asthma, smoke exposure, respiratory syncytial virus positivity (82.6% and 81.8%, respectively, for the hypertonic saline and normal saline groups), and baseline respiratory rate.A discretionary second dose was administered in 56% (13/23) of the hypertonic saline group and 48% (11/23) of the normal saline (control) group. No differences between the two groups in respiratory distress, oxygen saturation, or returns to the ED (3/23 vs 4/23) were apparent. Additionally, while a difference with regard to hospital admission was noted between the hypertonic saline group (8/23) and the normal saline group (13/23), this difference did not reach statistical significance.The authors conclude that 3% hypertonic saline did not demonstrate the effectiveness in this ED setting that had been demonstrated in inpatient studies.While this study was unable to identify a significant benefit from one or two doses of 3% hypertonic saline during a two-hour period, the results differ from those of an ambulatory study of infants with bronchiolitis seen at the Pediatric and Adolescent Ambulatory Community Clinic of General Health Services of Petach-Tikva, Israel,1 which found a significant decrease in symptoms during the first two days from three-times-daily use, a result similar to that seen in three inpatient studies included in a Cochrane review.2 While there was no decrease in the rate of hospitalization in that study, it was low (6%–9%) in both groups. The current study found fewer hospitalizations in the 3% hypertonic saline group. While the differences in hospitalization were not statistically significant, the possibility of a type 2 error (accepting the absence of a population difference based on a relatively small sample) must be considered.The data available from the various studies now support routine use of 3% hypertonic saline with either epinephrine or a β2 agonist such as albuterol in hospitalized patients with the expectation of more rapid clinical improvement and a one-day decrease in hospital stay. Use in the ED is not yet routinely justified, but a larger study powered to examine further the potential for decreasing hospitalizations would be needed. For infants not requiring hospitalization, more rapid improvement in symptoms from hypertonic saline must be weighed against the expense and inconvenience of three-times-daily use of an aerosol for a self-limited problem with a low likelihood of requiring repeat emergent care or hospitalization. Although not yet studied, it would be of interest to see if there is any benefit to using hypertonic saline in more severe bronchiolitis patients at risk for or requiring assisted ventilation.

High volume normal saline alone is as effective as nebulized salbutamol‐normal saline, epinephrine‐normal saline, and 3% saline in mild bronchiolitis

The objective of this study was to investigate the effectivenesses of nebulized salbutamol, epinephrin, 3% saline, and normal saline (0.9% NaCl) in the treatment of mildly affected infants with acute bronchiolitis. We enrolled 186 children (mean age 9.5 +/- 5.3 months, range 1.5-24 months, 65.1% male) with a first episode of wheezing diagnosed as mild bronchiolitis in emergency department. Patients were randomized in a double-blind fashion to receive 4 ml dose either of 1.5 mg epinephrine plus normal saline (group 1; n = 38) or 1.5 mg epinephrine plus 3% saline (group 2; n = 39) or 2.5 mg salbutamol plus normal saline (group 3; n = 36) or 2.5 mg salbutamol plus 3% saline (group 4; n = 36) or normal saline alone (group 5; n = 37) at 0 and 30 min. Thus, all treatment modalities included high amount of NaCl (72-240 mg). Clinical score, oxygen saturation and heart rate were assessed at 0, 30, 60, and 120 min. After discharge, patients were reassessed by telephone contact at 48 hr and 6 months. The baseline characteristics were similar in all groups (P > 0.05). The outcome of patients at 120 min was found significantly better than the baseline values (P < 0.05). There were no significant differences between the outcome variables of the groups (P > 0.05). No adverse effects attributable to nebulized therapy were seen. In conclusion, all treatment modalities used in this study, including a total of 8 ml normal saline inhalation at 30-min interval showed clinically significant and swift improvement in mildly affected ambulatory infants with acute bronchiolitis.