Management Of Acute Bronchiolitis Research Articles

Acute Bronchiolitis: The Less, the Better?

Acute bronchiolitis is a viral infection of the lower respiratory tract affecting infants aged under 12 months, variably presenting with respiratory distress, diffuse crackles and inflammatory wheezing. The main causative agent is Respiratory Syncytial Virus (RSV). The diagnosis is clinical and treatment mainly supportive. Despite the availability of more than 30 international guidelines, consistent management recommendations are lacking and considerable variability in patients' care persists among different providers. To review and describe current knowledge about epidemiology, physiopathology, clinic, diagnosis and management of acute bronchiolitis, with particular emphasis on updated evidence and future perspectives in terms of treatment and prevention. We searched Cochrane for systematic reviews and PubMed for scientific articles published in the last 10 years, using a combination of the following search terms: "bronchiolitis", "respiratory syncytial virus", "epidemiology", "risk factors", "severity", "diagnosis", "clinic", "diagnostic imaging", "management", "asthma", "wheezing", "bronchodilator", "steroids", "hypertonic saline", "oxygen", "blood gas analysis", "HHHFNC", "rehydration", "enteral feeding", "parenteral hydration", "prevention", "vaccine" and "COVID-19 or SARS-CoV2". We accordingly performed a deep and extensive selection of the most updated and considerable literature on the matter, summarizing the most significant evidence concerning all aspects of acute bronchiolitis (epidemiology, clinic, diagnosis, management and prevention). Furthermore, we examined references and available guidelines from UK, USA, Canada, Italy and Spain. Results are extensively discussed below. Although acute bronchiolitis has been a widely known disease for decades, its therapeutic approach remained unchanged and essentially limited to respiratory and metabolic support. Despite the abundance of studies, there is no significant evidence concerning therapeutic alternatives (e.g. steroids, inhaled hypertonic solution), which are therefore not recommended. According to most recent data, "acute bronchiolitis" definition encompasses a plethora of different clinical entities related to each subject's genetic and immune predisposition. Therefore, future research should focus on the precise characterization of such subcategories in order to individualize therapeutic management and ensure the most appropriate evidence-based care.

Comparing Treatment with Nebulized 3% Hypertonic Saline Versus Nebulized 0.9% Saline In Patients With Acute Bronchiolitis: A Double-Blind Randomized Controlled Trial

Objective: To establish the therapeutic role of nebulized hypertonic saline solution in the management of acute bronchiolitis in terms of primary and secondary outcomes. Methods: This randomized control trial was conducted in the Pediatric department of Holy Family Hospital, Rawalpindi for 8 months from September 2021 to April 2022 after ethical approval. A total of 65 cases of acute bronchiolitis were enrolled who were divided into two groups. The intervention group was nebulized with 3 ml of 3% hypertonic saline 6 hourly while the control group was nebulized with 0.9% saline 6 hourly during hospital stay in addition to the standard treatment. Children in both groups were monitored in terms of clinical severity score, feeding, hydration status, length of hospital stay, duration of oxygen supplementation, development of any adverse effect, and outcome (length of hospital stay and clinical severity score) was observed. Data was collected on a predesigned proforma, and SPSS version 21 was used to analyze the data. Results: Two groups were comparable for age, gender, and baseline characteristics including clinical severity score. Length of hospital stay was significantly less in the hypertonic saline group 75.53 ±43 .87 versus 45.92 ± 12.19 (p-value 0.000). Similarly, in patients requiring oxygen, treatment with hypertonic saline significantly reduced the duration of nebulization, 27.21 ±26.20 versus 10.67± 7.91 (p-value 0.03). However clinical severity score between the two groups was not different, 5.42 ± 2.88 in the saline group and 4.50 ± 2.88 p value 0.921. Conclusion: Nebulization with hypertonic saline reduces oxygen requirement and benefits in reducing the length of hospital stay. Keywords: Bronchiolitis, Hypertonic saline (HS), Normal saline (NS)

Management of Acute Bronchiolitis in Spoke Hospitals in Northern Italy: Analysis and Outcome.

Bronchiolitis is an acute viral infection of the lower respiratory tract that affects infants and young children. Respiratory syncytial virus (RSV) is the most common causative agent; however, other viruses can be involved in this disease. We retrospectively reviewed the clinical features of infants aged less than 12 months hospitalized for acute bronchiolitis in our Pediatric Units of Chivasso, Cirié, and Ivrea in Piedmont, Northern Italy, over two consecutive bronchiolitis seasons (September 2021-March 2022 and September 2022-March 2023). Patient-, disease-, and treatment-related variables were analyzed. The probability of therapeutic success (discharge home) was 96% for all patients (93% for RSV vs. 98% for non-RSV patients, p > 0.05). Among 192 patients, 42 infants (22%) underwent high-flow oxygen support (HFNC), and only 8 (4%) needed to be transferred to our hub referral hospital. Factors associated with hub hospital transfer were the age under 1 month and the failure of HFNC. The wide and increasing use of HFNC in pediatric inpatients improved the management of bronchiolitis in Spoke hospitals, reducing transfer to a hub hospital provided with Intensive Care Units.

Design and reliability study of a parental knowledge, attitude, and practice questionnaire on prevention and management of acute bronchiolitis of children under two years of age

Acute bronchiolitis is the most common cause of hospitalization in the first year of life. Primary prevention and supportive care are key. Here, we aimed to design and assess the psychometric properties of a parent-focused questionnaire on prevention and management of acute bronchiolitis at home in children under two years of age. For the design of the questionnaire, we conducted a literature search on prevention strategies and risk factors for bronchiolitis. An expert committee evaluated the content of the new questionnaire using the Content Validity Index and estimated the internal consistency reliability with Cronbach's alpha. A 26-item questionnaire divided into four dimensions (Risk factors, Signs and symptoms, Prevention, Care and pharmacological support) was created. The normalized score fell in the range between -50 and +50; a positive score was interpreted as presence of good knowledge, attitudes, and habits. Each of the 26 items obtained a Content Validity Index score > 0.80 and the global score was 0.90. The global internal consistency was a = 0.77, with differences between individual scores of the different dimensions of the questionnaire. The Parental knowledge, attitude, and practice questionnaire on prevention and management of acute bronchiolitis at home obtained an excellent Content Validity Index score by the expert committee and an acceptable internal consistency. Our questionnaire may reinforce the weak knowledge areas regarding the measures to apply.

The Tree-in-Bud Has Many Roots: Aetiology and Management of Acute Bronchiolitis in Adults

The Tree-in-Bud Has Many Roots: Aetiology and Management of Acute Bronchiolitis in Adults

THE EFFECT OF INTRAVENOUS MAGNESIUM SULFATE ON CHILDREN ADMITTED WITH ACUTE BRONCHIOLITIS IN A TERTIARY CARE HOSPITAL

Objective: To assess the efficacy of using intravenous Magnesium Sulfate along with the conventional treatment in the management of acute bronchiolitis
 Study Design: Quasi-experimental study.
 Place and Duration of Study: Pediatrics department in Sandeman Provincial Hospital, Quetta, from Jan to Jul 2019.
 Methodology: The study was approved by institutional ethical committee of Combined Military Hospital, Peshawar. Children, 2 months to 2 years of age, with acute bronchiolitis having clinical severity score of ≥5, presenting to the OPD and emergency department were enrolled in the study after getting informed consent from the guardian. They were randomly assigned group A receiving intravenous Magnesium Sulfate and group B receiving placebo along with the conventional treatment for both. Data was analysed with SPSS-21.
 Results: Total 108 patients were included in the study with 54 (50%) in group A and 54 (50%) in group B. Mean age in the study was 12.02 ± 6.421 months. Mean age in group A and B was 11.17 ± 6.40 and 12.87 ± 6.38 months respectively. Out of 108 patients 50 (46.3%) were males while 58 (53.7%) were females. There was statistically significant difference in the efficacy of treatment between two groups with values being 48 (88.9%) and 37 (68.5%) for Magnesium Sulfate and control groups respectively (p=0.01).
 Conclusion: From a clinical point of view, intravenous Magnesium Sulfate combined with conventional treatment is more effective than conventional treatment alone in the management of acute bronchiolitis.

Management of Acute Bronchiolitis, Guidelines Vs Practice; An Inner-City Community Hospital Experience

Management of Acute Bronchiolitis, Guidelines Vs Practice; An Inner-City Community Hospital Experience

Impact of Guidelines Publication on Acute Bronchiolitis Management: 10-Year Experience from a Tertiary Care Center in Italy.

Bronchiolitis is the most common lower respiratory tract infection in infants. According to evidence-based guidelines, diagnosis is clinical, there is no need for routine use of laboratory or instrumental tests and therapy is primarily supportive, based on oxygen and adequate fluid supplementation. Nevertheless, unnecessary diagnostic tests and pharmacological treatments are still very common. The aim of this retrospective cohort study was to evaluate how the management of bronchiolitis has changed in the last ten years in a Tertiary Care Center in Italy, assessing adherence to national guidelines. Considering the publication of the Italian inter-society consensus document in 2014, we compared patients admitted in the prior four epidemic seasons with patients admitted in the latter six epidemic seasons. The comparison between the two groups showed a significant reduction in the prescription of systemic corticosteroids (58.9% vs. 41.8%, p < 0.001), nebulized epinephrine (73.8% vs. 38.3%, p < 0.001) and antibiotics (59.5% vs. 42.3%, p < 0.001), together with a drastic decrease in the use of chest X-ray (92.2% vs. 54.4%, p < 0.001). On the contrary, the use of inhaled salbutamol remained substantially stable over time (39.4% vs. 37.6%, p = 0.505). Despite the encouraging results, further efforts are needed to limit the prescription of ineffective therapies like antibiotics and inhaled salbutamol.

Agreements and controversies of national guidelines for bronchiolitis: Results from an Italian survey.

IntroductionSignificant variations in the management of bronchiolitis are often recorded, and, in parallel, to recommend a univocal clinical approach is challenging and still questioned. This study is aimed to evaluate the diagnostic and therapeutic management of bronchiolitis in children adopted by Italian pediatricians following the national guidelines.Material and MethodsA survey study was designed and carried out by sending an email an open‐ended questionnaire developed by an expert panel of the Scientific Board of the Italian Society of Pediatric Allergology and Immunology (SIAIP). Questions were designed according to the national intersociety consensus document on treatment and prevention of bronchiolitis in newborns and infants.ResultsOverall, 234 pediatricians were taking part in the study. When diagnosing bronchiolitis, only 44.01% (103/234) of participants correctly followed the national guidelines. All participants (100%) would perform laboratory tests and/or radiological exams. 44.01% administered oxygen (O2) when O2 saturation was minor than 92%. About the therapeutic regimen, marked discrepancies between national guidelines and recorded answers were reported. Indications for hospital admission and discharge criteria were in line with the national guidelines.ConclusionsThere is a significant practice variation in the management of acute bronchiolitis among Italian physicians. Some wrong attitudes need to be further discouraged, such use of diagnostic procedures and therapeutic approaches. Further research is urgently required to define the best management of patients with bronchiolitis and implement strategies to standardize care and improve the quality of care.

Pediatricians' Attitude in Management of Acute Bronchiolitis: Did Guidelines Overcome Practices?

Background: Acute bronchiolitis is one of the most common diseases of early childhood. There are many recent changes in the treatment of acute bronchiolitis. The aim of this study is to evaluate treatment approaches to acute bronchiolitis among clinicians and to observe compliance with clinical guidelines. Materials and Methods: Our study was designed as a multicenter cross-sectional descriptive study. A cohort of pediatric residents, fellows, and attendants were surveyed with a questionnaire including general and occupational characteristics of pediatricians and treatment choices in acute bronchiolitis. Results: A total of 713 questionnaires were collected. Most commonly applied treatment among pediatricians was inhaled salbutamol, followed by intravenous hydration, hypertonic saline, and inhaled steroid. Most commonly preferred treatment in the management of mild bronchiolitis was oral hydration and inhaled salbutamol in severe bronchiolitis. Conclusion: Although recent guidelines for the treatment of acute bronchiolitis does not support the use of many different therapies, pediatricians still tend to use them, especially bronchodilators, corticosteroids, and antibiotics.

Comparative efficacy of nebulization with 3% hypertonic saline and 0.9% normal saline in the management of acute bronchiolitis

Background: There is a dearth of therapeutic modalities for the management of bronchiolitis in children. Objective: The objective of the study was to compare the improvement in clinical severity scores and the length of hospital stay (LOS) among children with bronchiolitis nebulized with either 3% hypertonic saline (HS) or 0.9% normal saline (NS). Materials and Methods: A total of 360 hospitalized patients of age 1–24 months, diagnosed as a case of acute bronchiolitis of moderate severity, were randomized to receive either 4 ml of 3% HS (Group A) or 4 ml of 0.9% NS (Group B) along with 1.5 mg of epinephrine in each arm, at 4 hourly intervals till the patients were ready for discharge. Appropriate statistical analysis was carried out using the collected data. Results: All the baseline characteristics were similar in both the groups. There was a significant (p=0.0011) reduction of 13 h (12.2%), i.e., from 4 days 23 h in Group B (NS) to 4 days 10 h in Group A in the mean LOS and significant difference (p=0.0001) in the clinical severity score was noted from the 2nd day onward in Group A as compared to Group B. No adverse events were observed or reported by the treating medical team or the patients’ caregiver in both the study groups. Conclusion: Nebulization with 3% HS is superior to 0.9% NS nebulization in infants with clinically diagnosed acute bronchiolitis.

Cost-effectiveness of the utilization of "good practice" or the lack thereof according to a bronchiolitis evidence-based clinical practice guideline.

The aim of the present study was to determine the cost-effectiveness of the utilization of "good practice" according to a bronchiolitis clinical practice guideline (CPG) in a population of infants hospitalized for acute bronchiolitis. A decision-analysis model was developed in order to estimate the cost-effectiveness of the utilization of "good practice" compared with the lack of use of "good practice" according to a bronchiolitis evidence-based CPG. The effectiveness parameters and costs of the model were obtained from electronic medical records. The main outcome was the readmission of the patients within 10days of post discharge. Compared with lack of "good practice," the utilization of "good practice" in the diagnosis and management of patients with bronchiolitis was associated with both fewer patients readmitted within 10days of post discharge (0.88 vs 0.99 on average per patient) and lower costs (US$1529.3 versus $1709.1 average cost per patient), thus leading to dominance. Results were robust to deterministic and probabilistic sensitivity analyses. Compared with lack of "good practice," the utilization of "good practice" in the diagnosis and management of acute bronchiolitis according to a bronchiolitis CPG is a dominant strategy because it involves both fewer patients readmitted within 10days of post discharge and lower costs.

The role of nebulized hypertonic saline in the management of acute bronchiolitis

Background Acute bronchiolitis is the most frequent lower respiratory tract infection in infants and the most frequent cause of hospitalization in this age group. It places enormous strains on pediatric inpatient services and pediatric ICUs, and despite the growing understanding of its pathogenesis, currently available therapies have failed to show consistent benefit, and supportive care remains the mainstay of bronchiolitis therapy. It is suggested that hypertonic saline nebulization may be useful in making secretions less viscous and promoting their excretion, thereby resulting in clinical improvement, and over the past decade, a growing number of randomized trials have suggested that early and repeated doses of nebulized 3% hypertonic saline improve clinical outcomes in hospitalized children compared with 0.9% normal saline. Objectives The current study aimed to study the safety and efficacy of nebulized 3% hypertonic saline in hospitalized infants with a clinical diagnosis of bronchiolitis. Patients and methods This double-blind, randomized controlled trial was conducted on 110 infants who were admitted to Alexandria University Children’s Hospital with a clinical diagnosis of acute bronchiolitis. The diagnosis of bronchiolitis was based on clinical evaluation. Patients were randomly allocated into two groups: one group received nebulized 3% hypertonic saline with 2.5-mg salbutamol at intervals of 4 h, whereas the second group received nebulized 0.9% normal saline with 2.5-mg salbutamol at intervals of 4 h. Results There was no significant difference in the clinical severity score between the two studied groups in all days of admission, except for mild improvement on the second and third days of admission, yet it was not sufficient enough to make the patients eligible for discharge. Furthermore, there was no significant difference in length of hospital stay among infants who received hypertonic saline. Complications of nebulized hypertonic saline, namely, vomiting, agitation, exacerbation of cough, cyanosis, and apnea, were similar to normal saline. Conclusion The use of nebulized 3% hypertonic saline in hospitalized infants with bronchiolitis is considered safe, but when compared with 0.9% normal saline, it did not improve the clinical severity score nor shorten the length of hospital stay in hospitalized infants with bronchiolitis.

Role of Antibiotic in Treatment of Bronchiolitis

Background: Acute bronchiolitis is a viral respiratory illness of infants and young children. It is characterized by coryzal symptoms followed by rapid onset of cough, wheeze, fever, tachypnea, chest recession and crepitation with radiological evidence of hyperinflation. Bronchiolitis occurs in first 2 years of age and is usually caused by respiratory syncytial virus. Objective: To find out the effectiveness of antibiotic in treatment of bronchiolitis.Methods: It was a randomized controlled trial carried out in Department of Paediatrics, Rajshahi Medical College Hospital, Rajshahi. 200 acute bronchiohtis patient admitted into paediatric ward of Rajshahi Medical College Hospital who fulfill inclusion criteria. Then relevant history and physical examination findings were recorded in data sheet. The even numbered patient was selected as control group and odd numbered patients as intervention group. The control group was receive supportive management and intervention group was receive lnj. Ceftriaxone 75mg/kg/day in for 5 days along with supportive management.Results: This study it was observed that bronchiolitis was more common in male. The age for peak incidence (75%) of bronchiolitis was 2-6 months. About 59% children presented with fever and all of them recovered from fever quickly before leaving hospital. At the time of admission 43% children had feeding difficulty, which improved steadily and similarly in both the groups. For days hours after admission 16% of antibiotic group and 15% of without antibiotic group had similar chest indrawing. Cough was the most common starting symptoms. None of the cases showed cyanosis and at the time of admission total 91% children had SpO2 &lt;95%, after 4 days of admission 33%of antibiotic group and 14% of without antibiotic group still had SpO2 &lt;95% but during discharge none of them had hypoxia. After 4 days of admission 17% of antibiotic group and 14% of without antibiotic group had crepitation and 6 days after discharge 1(1%) child of without antibiotic group and 2(2%) from antibiotic group still had crepitation. It was observed that hypertranslucency in 74% and hyperinflation in 64% in cases.Conclusion: This study shows antibiotics have no role in acute bronchiolitis management. Further multicenter study with larger sample size is recommended.TAJ 2013; 26: 43-47

A Comparative Study to Assess the Effectivenesss of Nebulised 3% Hypertonic Saline, 0.9% Normal Saline and Salbutalmol in Management of Acute Bronchiolitis

A Comparative Study to Assess the Effectivenesss of Nebulised 3% Hypertonic Saline, 0.9% Normal Saline and Salbutalmol in Management of Acute Bronchiolitis

Radiographie de thorax et bronchiolite aiguë : des indications en diminution ?

A management protocol for infants hospitalized for acute bronchiolitis, established after the study conducted in our unit in 2012, recommends a chest X-ray when the clinical course is unusual or if a differential diagnosis is suspected. The goal of this study was to evaluate professional practices after the introduction of this new management protocol. Retrospective descriptive study in two pediatric units from October 2013to March 2015, including infants (0-23months) hospitalized for their first episode of acute bronchiolitis without any underlying chronic condition. Overall, 599infants were included (median age, 3.7months, 54% boys). Nearly six out of ten (n=355, 59.3%) had at least one chest radiograph (38.5% fewer than in 2012). It was abnormal in 96.3% of cases, revealing distension and/or bronchial wall thickening (56.7%), focal opacity (23.5%), or atelectasis (19.5%). An X-ray was performed out of the recommendations in 42.5% of cases. The chest X-ray result led to management changes in 52infantswith prescription of antibiotics for pneumonia (86.5%) and allowed the diagnosis of heart disease in one case (0.2%). Management of acute bronchiolitis (X-ray and antibiotics) was statistically different between the two pediatric units. This protocol led to a significant decrease in the number of chest X-rays. However, many are still performed out of the recommendations, resulting in an increase of antibiotic use for pneumonia. The decrease in use of chest X-rays in acute bronchiolitis for hospitalized infants was significant but remains insufficient.

Is it urgent to update the Spanish clinical practice guidelines for acute bronchiolitis management?

Is it urgent to update the Spanish clinical practice guidelines for acute bronchiolitis management?

ASSESSMENT OF HEMATOLOGICAL PARAMETERS, ACID-BASE STATUS AND ARTERIAL BLOOD GAS TEST BEFORE AND AFTER TREATMENT OF ACUTE BRONCHIOLITIS IN CHILDREN

Objective: The purpose of our retrospective study was to investigate the necessity of some laboratory testing in patients with acute bronchiolitis before and after treatment. Methods: We have taken blood samples of all children puncturing the cubital vein, and analyzed it using the Colter appliances-automatic counter blood count, for analyzes of a number of erythrocytes, leukocytes, platelets, differential blood count, Hct, Hb. CRP concentration in serum of patients determined by laser nephelometry with CardioPhase® high sensitivity C-reactive protein (hsCRP). For assessment of acid-base status and arterial blood gas analysis were used ABL5 and ABL700 Radiometer Copenhagen. We monitored the following parameters: pH, pCO2, HCO3-, total CO2, base excess, pO2, SpO2. Results: There was a significant improvement of hypoxemia after management of acute bronchiolitis in the form of a significant increase in average values of pO2 and SpO2 after treatment of acute bronchiolitis. The average value of the number of leukocytes and value of CRP in children were significantly decreased before and after management of acute bronchiolitis. There was no significant difference in duration of hospitalization in term and preterm newborns. Conclusion: No routine diagnostic tests are used routinely. However, there is an improvement of hypoxemia after management of acute bronchiolitis in children.

Comparison of the efficacies of normal saline versus hypertonic saline in the management of acute bronchiolitis'

Background: The aim of this study was to compare the efficacies of saline solutions of different concentrations used for the management of infants with mild to moderate bronchiolitis. Methods: A retrospective chart review of 46 children, aged 1-24 months, diagnosed with acute bronchiolitis was performed. The patients were separated into 2 groups: normal saline and 3% hypertonic saline. Length of hospital stay, modified respiratory assessment score (MRAS) at admission, at 48 hours of admission and at discharge were compared. Results: MRAS evaluated at admission, at 48 hours after admission and at discharge and length of hospital stay did not reveal significant difference between the two groups (p>0.05). Conclusions: Comparison of two different treatments, salbutamol applied in combination with either normal saline or 3% hypertonic saline, did not reveal any statistically significant differences with respect to symptomatic improvement or length of hospital stay.

Current Management of Acute Bronchiolitis: An Evidence-Based Approach

Current Management of Acute Bronchiolitis: An Evidence-Based Approach