First Episode Of Bronchiolitis Research Articles

Inter‐observer agreement between physicians, nurses, and respiratory therapists for respiratory clinical evaluation in bronchiolitis

Care providers for children with bronchiolitis use various tools to evaluate respiratory status. The use of a single tool by different types of care provider requires a high level of inter-observer agreement, an aspect rarely studied. This study, involving 82 physicians, nurses, and respiratory therapists aimed to evaluate inter-observer agreement for clinical evaluations in children hospitalized for a first episode of bronchiolitis. Respiratory evaluation included three frequently reported parameters of respiratory status: respiratory rate, retraction signs, and wheezing. The frequency of concordance for observers from the same and from different care provider groups was assessed using a weighted kappa statistic and considering all possible combinations of care providers. We also calculated inter-provider agreement as a function of patient age, regardless of care provider type. Overall inter-observer agreement for all provider pairs was 93.1%, with a weighted kappa statistic of 0.72 (95% CI, 0.66-0.78), indicating substantial agreement, with no difference as a function of pair composition. Inter-observer agreements for the various age groups ranged from 87% to 93%, with kappa scores ranging from 0.62 to 0.78. We conclude that a simple clinical evaluation for respiratory status assessment has a high level of inter-observer agreement within and between physicians, nurses and respiratory therapists. Thus, once the validity of this test has been confirmed in a large population sample, it should be possible to use this test to monitor children hospitalized with bronchiolitis and as an endpoint in clinical trials.

In Very Young Infants Severity of Acute Bronchiolitis Depends On Carried Viruses

BackgroundRT amplification reaction has revealed that various single viruses or viral co-infections caused acute bronchiolitis in infants, and RV appeared to have a growing involvement in early respiratory diseases. Because remaining controversial, the objective was to determine prospectively the respective role of RSV, RV, hMPV and co-infections on the severity of acute bronchiolitis in very young infants.Methods and Principal Findings209 infants (median age: 2.4 months) were enrolled in a prospective study of infants <1 year old, hospitalized for a first episode of bronchiolitis during the winter epidemic season and with no high risk for severe disease. The severity was assessed by recording SaO2% at admission, a daily clinical score (scale 0–18), the duration of oxygen supplementation and the length of hospitalization. Viruses were identified in 94.7% by RT amplification reaction: RSV only (45.8%), RV only (7.2%), hMPV only (3.8%), dual RSV/RV (14.3%), and other virus only (2%) or coinfections (9%). RV compared respectively with RSV and dual RSV/RV infection caused a significant less severe disease with a lower clinical score (5[3.2–6] vs. 6[4–8], p = 0.01 and 5.5[5–7], p = 0.04), a shorter time in oxygen supplementation (0[0–1] days vs. 2[0–3] days, p = 0.02 and 2[0–3] days, p = 0.03) and a shorter hospital stay (3[3–4.7] days vs.6 [5–8] days, p = 0.001 and 5[4–6] days, p = 0.04). Conversely, RSV infants had also longer duration of hospitalization in comparison with RSV/RV (p = 0.01) and hMPV (p = 0.04). The multivariate analyses showed that the type of virus carried was independently associated with the duration of hospitalization.ConclusionThis study underlined the role of RV in early respiratory diseases, as frequently carried by young infants with a first acute bronchiolitis. RSV caused the more severe disease and conversely RV the lesser severity. No additional effect of dual RSV/RV infection was observed on the severity.

A Multicenter, Randomized, Controlled Trial of Dexamethasone for Bronchiolitis

Corneli HM, Zorc JJ, Majahan P, et al. N Engl J Med. 2007;357(4):331–339 PURPOSE OF THE STUDY. To evaluate the efficacy of a single dose of oral dexamethasone (1 mg/kg) compared with placebo in the treatment of acute bronchiolitis. STUDY POPULATION. A total of 600 children (aged 2–12 months) with a first episode of wheezing diagnosed in the emergency department as moderate-to-severe bronchiolitis were included. METHODS. Patients were enrolled at 20 emergency departments during the months of November through April over a 3-year period. The primary outcome was respiratory assessment and score change during the first 4 hours. Later outcomes evaluated included length of hospital stay, medical visits, and adverse events. RESULTS. Baseline characteristics were similar for both groups. The admission rate was 39.7% for children assigned to dexamethasone compared with 41% for those assigned to placebo. Both groups had improvement during the observation period with similar mean changes in respiratory assessment score. For the patients admitted to the hospital, there was no difference in mean hospital stay (2.55 vs 2.27 days), subsequent hospital admissions, or adverse events. CONCLUSIONS. Single-dose dexamethasone did not prevent hospital admission for bronchiolitis. REVIEWER COMMENTS. This study finally allows for a definitive statement that no significant benefit can be seen with the use of corticosteroid for first episodes of wheezing. It should be noted that bronchodilator treatment was not regulated but seemed not to affect outcomes because treatment was equally distributed between the groups. This continues to strengthen the notion that supportive therapy with good hydration and preventing hypoxia are the most important interventions for a first episode of bronchiolitis.

Dexamethasone for Bronchiolitis—The Controversy Continues

Infectious Diseases| October 01 2007 Dexamethasone for Bronchiolitis—The Controversy Continues AAP Grand Rounds (2007) 18 (4): 38–39. https://doi.org/10.1542/gr.18-4-38 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Dexamethasone for Bronchiolitis—The Controversy Continues. AAP Grand Rounds October 2007; 18 (4): 38–39. https://doi.org/10.1542/gr.18-4-38 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search nav search search input Search input auto suggest search filter All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: bronchiolitis, dexamethasone Source: Corneli HM, Zorc JJ, Mahajan P, et al. A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med. 2007; 357:331–339; doi:10.1056NEJMoa071255 The bronchiolitis study group of the Pediatric Emergency Care Applied Research Network (PECARN) evaluated the effectiveness of a single oral dose of dexamethasone for bronchiolitis in a double-blinded, randomized, controlled trial. The study was conducted in 20 pediatric emergency departments during the months of November through April 2004 to 2006. Only previously healthy infants with a first episode of bronchiolitis that was assessed as moderate or severe based on a Respiratory Distress Assessment Instrument (RDAI) score of >6 (range 0 to 17) were eligible. A total of 600 infants two to 12 months old were enrolled in the study; 305 were randomized to the dexamethasone group (dose: 1 mg/kg, maximum 12 mg) and 295 to the placebo group. Study children received other treatments, such as inhaled bronchodilators, at the discretion of the examining physician. Eight infants were excluded from further analysis: two were admitted prior to receiving study medication, five received the wrong medication, and one received an insufficient dose of the medication. Respiratory Assessment Change Score (RACS), respiratory and heart rates, temperature, and oxygen saturation in room air were recorded one and four hours after drug administration and the decision to admit or discharge was made at the four-hour time point. Parents of study patients were contacted by telephone seven to ten days after the visit to determine if subsequent hospitalization, unscheduled medical visits, or adverse events had occurred. The primary outcome was whether the patient was discharged or hospitalized at the four-hour time point; RACS was a secondary outcome. Similar analyses comparing the efficacy of dexamethasone and placebo in the sub-group of children with a history of eczema or family history of asthma, were also conducted Baseline demographic and clinical characteristics were similar in the two groups. Among the 269 infants tested for respiratory syncytial virus (RSV), no difference in rate of hospitalization was found between those who were RSV-positive or -negative. There were no significant differences between infants in the dexamethasone or placebo group for mean RACS value and hospitalization rate (39.7% vs 41%, P=.74). Among those hospitalized the lengths of stay for infants in the two treatment groups were also not significantly different. Sub-group analyses had similar results. There were few adverse events, with no differences between the two groups. The authors conclude that one dose of oral dexamethasone failed to alter the respiratory status and subsequent outcome of infants with bronchiolitis. Drs. Rathore and Barton have disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. The use of corticosteroids in infants with bronchiolitis has been controversial, with several small studies providing contradictory results.1,2 A recent publication from one institution in Thailand, reviewed in these pages, found that a single dose of dexamethasone (0.6 mg/kg) administered to hospitalized... You do not currently have access to this content.

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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.

Is serum eosinophil cationic protein in bronchiolitis a predictor of asthma?

To examine their possible predictive value for the development of asthma, the serum concentration of eosinophil cationic protein (ECP) and the total eosinophil count were measured at admission in 25 children aged 1-17 months hospitalized for their first episode of bronchiolitis. After an average of three years the parents of 23 index patients answered a questionnaire to determine development of asthma. Eight children were defined as having asthma at follow-up based on at least three episodes of wheezing. The remaining 15 children had experienced only one or two episodes of wheezing, and all of these children had been wheeze free for the last year. The serum concentrations of ECP were similar in children who subsequently developed asthma (8.0 microg/l; 3.6 to 14.2 (median; quartiles)) and in those who did not (12 microg/l; 4.5 to 16.8). Moreover, the total eosinophil counts were similar in asthmatic (0.10 x 10(9)/l; 0.04 to 0.20) and non-asthmatic patients (0.09 x 10(9)/l; 0.02 to 0.13). In conclusion, our study suggest that neither the serum concentration of ECP nor the total eosinophil count can predict the development of asthma when measured in children admitted for their first episode of bronchiolitis, but larger studies need to be carried out to confirm these results.

Cellular immunity is activated and a TH-2 response is associated with early wheezing in infants after bronchiolitis

Objective: To determine whether abnormalities of cellular immunity are present and linked to early wheezing after bronchiolitis. Methods: We prospectively studied 26 infants hospitalized for a first episode of bronchiolitis and without any prior immune, cardiac, or respiratory disease. Blood was obtained at the time of enrollment and 5 months later for the assessment of the total cellular and differential counts, CD4 + (helper) and CD8 + (suppressor/cytotoxic) lymphocytes, and the activation markers CD23 (low-affinity immunoglobulin E receptor) and CD25 (interleukin-2 [IL-2] receptor). The cytokines interferon gamma (T-helper [TH] type-1 cytokine) and IL-4 (TH-2) were measured in plasma and in vitro after stimulation with IL-2 or with the house-dust mite (Dermatophagoides farinae) antigen. A daily log of episodes of wheezing was kept by parents after discharge. Results: We found an increase in blood eosinophils, an increased percentage of CD4 +, CD25 +, and CD23 + lymphocytes in subjects at 5 months compared with the time of bronchiolitis and with healthy subjects of the same age ( p <0.05). Plasma IL-4 levels, although not different from those of healthy subjects, also increased significantly. Peripheral blood lymphocytes from infants who wheezed produced more IL-4 in vitro, 5 months after bronchiolitis, in response to D. farinae antigen. In babies who wheezed, a positive correlation was found between the total number of days that wheezing occurred and the blood eosinophil count. Babies who wheezed more often (>20 days) had more peripheral blood basophils and eosinophils, and peripheral blood lymphocytes obtained from these subjects at the time of bronchiolitis produced less interferon gamma on stimulation with IL-2. Conclusions: Bronchiolitis is followed by activation of cellular immunity, and early wheezing in infants is associated with a TH-2 response. (J Pediatr 1997;130:584-93)

Effect of racemic epinephrine and salbutamol on clinical score and pulmonary mechanics in infants with bronchiolitis

To test the efficacy of a combined alpha- and beta-receptor agonist in acute bronchiolitis, we compared inhaled racemic epinephrine with salbutamol in a double-blind, crossover, randomized protocol. Twenty-four infants, 4.6 +/- 0.5 (mean +/- SEM) months of age, with their first episode of bronchiolitis were tested. After sedation with chloral hydrate, a clinical score and pulmonary mechanics measurements using simultaneous signals of airflow volume and transpulmonary pressure were recorded. After baseline measurements, infants received either nebulized salbutamol, 0.03 ml/kg, or racemic epinephrine, 0.1 ml/kg. Thirty minutes later, there was a significant decrease in clinical score after treatment with racemic epinephrine compared with the baseline score (p < 0.001); this difference was not present after salbutamol inhalation (p = 0.42). Only 13 patients had a decrease in clinical score after salbutamol therapy, in comparison with 20 infants treated with racemic epinephrine (p < 0.01). Both drug decreased respiratory rate, but the decrease was greater after the use of racemic epinephrine (p < 0.001). There was a significant decrease in inspiratory, expiratory, and total pulmonary resistance after treatment with racemic epinephrine compared with baseline values (p < 0.01) but no significant change after salbutamol inhalation. There was no significant correlation between the clinical score and pulmonary mechanics either at baseline or after drug treatment. We conclude that racemic epinephrine is superior to salbutamol in the treatment of infants with their first episode of acute bronchiolitis.