Management Of Bronchiolitis Research Articles

37 Improving Bronchiolitis Management at B.C. Children’s Hospital: Standardizing Care Through a Pre-printed Order

Abstract Introduction/Background Bronchiolitis is the most common cause of hospital admissions during the first year of life. There is significant variation in the management of this disease. Despite supportive care being the hallmark of treatment, investigations and other treatments are commonly prescribed. Standardizing care for bronchiolitis leads to decreased resource utilization and improved patient outcomes. Pre-printed orders can standardize care and improve compliance with evidence-based medicine. Objectives To determine whether a pre-printed order (PPO) would influence length of stay and specific medication use (corticosteroids, antibiotics, bronchodilators) for patients admitted to B.C. Children’s Hospital (BCCH) with a diagnosis of bronchiolitis. Design/Methods We implemented a pre-printed order (PPO) for inpatient management of bronchiolitis at B.C. Children’s Hospital (BCCH), then conducted a retrospective chart review of children admitted to BCCH with a discharge diagnosis of bronchiolitis. We compared primary and secondary outcomes between the pre-PPO (November 24, 2017 to December 31, 2019) and post-PPO (September 22, 2021 to April 12, 2022) periods. The primary outcome was length of stay (LOS) in days, and secondary outcomes included the prescription of specific medications. Results A total of 584 patients were included in the retrospective chart review: 436 patients were from the pre-PPO period and 148 patients were from the post-PPO period. There was no difference in the LOS between the pre-PPO and post-PPO periods: median LOS was 3.00 days (2.00 to 5.00 days) and 3.00 days (2.00 to 5.00 days) in the pre- and post-PPO periods, respectively (p = 0.88). There was a decrease in prescribed antibiotics, from 36.7% to 24.7% (OR = 0.56, 95% CI = 0.37 to 0.86, p = 0.01). Additionally, there was a decrease in prescribed salbutamol, from 41.5% to 29.3% (OR = 0.58, 95% CI = 0.39 to 0.87, p = 0.01). There was no significant difference in rates of PICU admission between the pre- and post-PPO periods (23.6% vs. 26.4%, OR = 1.16, 95% CI = 0.75 to 1.76, p = 0.5). Conclusion The implementation of a PPO for inpatient management of bronchiolitis did not affect length of stay or PICU admissions. However, there was significant reduction in prescribed antibiotics and salbutamol (both reduced in the post-PPO period). Our results suggest that a pre-printed order can improve antimicrobial stewardship and reduce unnecessary medication use, when managing a common paediatric disease. Graph Example for antibiotic/salbutamol and PICU

Management Practices for Standard-Risk and High-Risk Patients With Bronchiolitis.

Management guidelines for bronchiolitis advocate for supportive care and exclude those with high-risk conditions. We aim to describe and compare the management of standard-risk and high-risk patients with bronchiolitis. This retrospective study examined patients <2 years of age admitted to the general pediatric ward with an International Classification of Diseases, 10th Revision discharge diagnosis code of bronchiolitis or viral syndrome with evidence of lower respiratory tract involvement. Patients were defined as either standard- or high-risk on the basis of previously published criteria. The frequencies of diagnostic and therapeutic interventions were compared. We included 265 patients in this study (122 standard-risk [46.0%], 143 high-risk [54.0%]). Increased bronchodilator use was observed in the standard-risk group (any albuterol dosing, standard-risk 65.6%, high-risk 44.1%, P = .003). Increased steroid use was observed in the standard-risk group (any steroid dosing, standard-risk 19.7%, high-risk 14.7%, P = .018). Multiple logistic regression revealed >3 doses of albuterol, hypertonic saline, and chest physiotherapy use to be associated with rapid response team activation (odds ratio [OR] >3 doses albuterol: 8.36 [95% confidence interval (CI): 1.99-35.10], P = .048; OR >3 doses hypertonic saline: 13.94 [95% CI: 4.32-44.92], P = .001); OR percussion and postural drainage: 5.06 [95% CI: 1.88-13.63], P = .017). A varied approach to the management of bronchiolitis in both standard-risk and high-risk children occurred institutionally. Bronchodilators and steroids continue to be used frequently despite practice recommendations and regardless of risk status. More research is needed on management strategies in patients at high-risk for severe disease.

Evaluating the efficacy of corticosteroids and bronchodilators in the management of paediatric bronchiolitis

Background: Bronchiolitis, a standard lower tract infection in young children, poses significant challenges in terms of diagnosis and management. Corticosteroids and bronchodilators are often prescribed to manage this condition, despite limited evidence supporting their efficacy. This study aimed to judge the effectiveness of corticosteroids and bronchodilators within the management of paediatric bronchiolitis. Objective: to see the clinical efficacy of corticosteroids and bronchodilators in improving respiratory symptoms and reducing hospitalization rates among paediatric patients with bronchiolitis. Study Settings and Sample Size: This study was conducted at different centres including Department of Paediatrics, Social Security MNCH Hospital, Dera Ghazi Khan, Punjab and Sahara Medical College Narowal, Punjab in the period from October, 2022 to March, 2023 enrolling 300 children aged 1 month to 2 years with a clinical diagnosis of bronchiolitis. Methods: Participants were randomly assigned to at least one of three treatment groups: corticosteroids (n=100), bronchodilators (n=100), or placebo (n=100). the first outcome was improvement within the Respiratory Distress Assessment Instrument (RDAI) score. Secondary outcomes included hospitalization rates, length of hospital stay, and adverse events. Results: Children within the corticosteroid group experienced a significantly greater improvement in RDAI scores compared to the placebo group (p&lt;0.001).

Factors associated with salbutamol overuse in bronchiolitis.

Numerous studies have shown that quality improvement methods can reduce the use of medications in the management of bronchiolitis. Our objective is to identify factors related to the overuse of salbutamol in the treatment of bronchiolitis before and after an improvement initiative. Observational study of sociodemographic and clinical factors associated with the use of salbutamol in children diagnosed with bronchiolitis. This was a secondary analysis of a prospective cohort study conducted at 135 primary care (PC) centers and eight pediatric emergency departments (ED) in the Osakidetza/Basque Health Service (Spain) in two epidemic seasons between which a bronchiolitis integrated care pathway (BICP) had been implemented: pre-intervention season from October 2018 to March 2019 and post-intervention season from October 2019 to March 2020. Generalized linear mixed models were used to estimate association of studied variables on use of salbutamol over the two seasons. Four thousand one hundred thirty-four ED attendances and 8573 PC visits were included, of which 1936 (46.8%). And 4067 (47.4%) occurred in the post-intervention period respectively. Six independent risk factors were associated with overuse of salbutamol in both seasons: age ≥ 1year, aOR 2.32 (2.01 to 2.68) in PC centers, and aOR 6.84 (4.98 to 9.39) in EDs; being seen in the last third of the bronchiolitis season, aOR 1.82 (1.51 to 2.18) in PC centers and aOR 1.78 (1.19 to 2.64) in EDs; making more than one visit to the PC center, aOR 4.18 (3.32 to 5.27) or the ED, aOR 2.06 (1.59 to 2.66); being seen by a general practitioner, aOR 1.97 (1.58 to 2.46) in PC centers; and having a more severe episode, aOR 3.01 (1.89 to 4.79) in EDs. Conclusion:There are factors associated with salbutamol overuse in children diagnosed with bronchiolitis in PC and emergency settings that persist after the deployment of quality improvement initiatives. What is Known: • Quality improvement initiatives have been shown to decrease the use of non-evidence-based treatments and testing in bronchiolitis. • The magnitude and pattern of change in the use of medications linked to the quality improvement initiatives are not uniform across the same health service. What is New: • Children diagnosed with bronchiolitis ≥ 1year of age, seen in the last third of the bronchiolitis season, attending more than once, treated by a general practitioner, and/or with more severe episodes are more likely to be treated with salbutamol. • These factors may remain present despite the implementation of improvement initiatives focused on reducing the use of medications in the management of bronchiolitis.

Intensivists' Reported Management of Critical Bronchiolitis: More Data and New Guidelines Needed.

Existing bronchiolitis guidelines do not reflect the needs of infants admitted to the PICU. This study aimed to identify PICU providers' reported practice variations and explore the need for critical bronchiolitis clinical guidelines. Cross-sectional electronic survey available in English, Spanish, and Portuguese between November 2020 and March 2021, distributed via research networks from North and Latin America, Asia, and Australia/New Zealand. A total of 657 PICU providers responded, including 344 English, 204 Spanish, and 109 Portuguese. PICU providers indicated frequently using (≥25% of time) diagnostic modalities for nonintubated and intubated patients on PICU admission (complete blood count [75%-97%], basic metabolic panel [64%-92%], respiratory viral panel [90%-95%], chest x-ray [83%-98%]). Respondents also reported regularly (≥25% of time) prescribing β-2 agonists (43%-50%), systemic corticosteroids (23%-33%), antibiotics (24%-41%), and diuretics (13%-41%). Although work of breathing was the most common variable affecting providers' decision to initiate enteral feeds for nonintubated infants, hemodynamic status was the most common variable for intubated infants (82% of providers). Most respondents agreed it would be beneficial to have specific guidelines for infants with critical bronchiolitis who are requiring both noninvasive (91% agreement) and invasive (89% agreement) respiratory support. PICU providers report performing diagnostic and therapeutic interventions for infants with bronchiolitis more frequently than recommended by current clinical guidelines, with interventions occurring more frequently for infants requiring invasive support. More clinical research is needed to inform the creation of evidence-based guidelines specifically for infants with critical bronchiolitis.

Application of POCUS lung ultrasound in infants with bronchiolitis: a prospective study

BACKGROUND: Acute bronchiolitis is a viral infection of the lower respiratory tract typical of the pediatric age and of the winter season. It represents the leading cause of hospitalization in the first year of life in industrialized countries. Several authoritative scientific societies have issued guidelines for the diagnostic and therapeutic management of bronchiolitis, and they limit the use of radiological imaging in the diagnosis of the pathology, which is mostly clinical.METHODS: For this reason, in the light of the amount of work published in the literature on the application of lung ultrasound in the diagnosis and follow-up of pneumonia, the idea of its use in the integrated evaluation of patients with clinical suspicion has gained ground of bronchiolitis and especially POCUS. This study has the following objectives: 1) verify the existence of a clinical-ultrasound correlation; 2) ability of the clinical score and the ultrasound score to predict the need for ventilatory support; 3) compare point-of-care lung ultrasound and chest X-ray.RESULTS: This work adds to the numerous studies already published which have investigated the potential of lung ultrasound performed by clinicians in cases of bronchiolitis, beyond now validated contexts, such as the evaluation of pleural effusions and pneumothorax.CONCLUSIONS: The advantages of LUS are considerable: safe, rapid, accurate, simple, executable and repeatable technique at the patient’s bed, free from exposure to ionizing radiation and, therefore, it would be desirable to spread it more widely in the pediatric field.

Factors associated with nonadherence to the American Academy of Pediatrics 2014 bronchiolitis guidelines: A retrospective study.

The latest guideline from the American Academy of Pediatrics for the management of bronchiolitis has helped reduce unnecessary interventions and costs. However, data on patients still receiving interventions are missing. In patients with acute bronchiolitis whose management was assessed and compared with current achievable benchmarks of care, we aimed to identify factors associated with nonadherence to guideline recommendations. In this single-centre retrospective study the management of bronchiolitis pre-guideline (Period 1: 2010 to 2012) was compared with two periods post-guideline (Period 2: 2015 to 2016, early post-guideline; and Period 3: 2017 to 2018, late post-guideline) in otherwise healthy infants aged less than 1 year presenting at the Children's University Hospitals of Geneva (Switzerland). Post-guideline, bronchodilators were more frequently administered to older (>6 months; OR 25.8, 95%CI 12.6-52.6), and atopic (OR 3.5, 95%CI 1.5-7.5) children with wheezing (OR 5.4, 95%CI 3.3-8.7). Oral corticosteroids were prescribed more frequently to older (>6 months; OR 5.2, 95%CI 1.4-18.7) infants with wheezing (OR 4.9, 95% CI 1.3-17.8). Antibiotics and chest X-ray were more frequently prescribed to children admitted to the intensive care unit (antibiotics: OR 4.2, 95%CI 1.3-13.5; chest X-ray: OR 19.4, 95%CI 7.4-50.6). Latest prescription rates were all below the achievable benchmarks of care. In summary, following the latest American Academy of Pediatrics guideline, older, atopic children with wheezing and infants admitted to the intensive care unit were more likely to receive nonevidence-based interventions during an episode of bronchiolitis. These patient profiles are generally excluded from bronchiolitis trials, and therefore not specifically covered by the current guideline. Further research should focus on the benefit of bronchiolitis interventions in these particular populations.

Perspectives of Health Care Personnel on the Benefits of Bronchiolitis Interventions.

Many interventions in bronchiolitis are low-value or poorly studied. Inpatient bronchiolitis management is multidisciplinary, with varying degrees of registered nurse (RN) and respiratory therapist (RT) autonomy. Understanding the perceived benefit of interventions for frontline health care personnel may facilitate deimplementation efforts. Our objective was to examine perceptions surrounding the benefit of common inpatient bronchiolitis interventions. We conducted a cross-sectional survey of inpatient pediatric RNs, RTs, and physicians/licensed practitioners (P/LPs) (eg, advanced-practice practitioners) from May to December of 2021 at 9 university-affiliated and 2 community hospitals. A clinical vignette preceded a series of inpatient bronchiolitis management questions. A total of 331 surveys were analyzed with a completion rate of 71.9%: 76.5% for RNs, 57.4% for RTs, and 71.2% for P/LPs. Approximately 54% of RNs and 45% of RTs compared with 2% of P/LPs believe albuterol would be "extremely or somewhat likely" to improve work of breathing (P < .001). Similarly, 52% of RNs, 32% of RTs, and 23% of P/LPs thought initiating or escalating oxygen in the absence of hypoxemia was likely to improve work of breathing (P < .001). Similar differences in perceived benefit were observed for steroids, nebulized hypertonic saline, and deep suctioning, but not superficial nasal suctioning. Hospital type (community versus university-affiliated) did not impact the magnitude of these differences. Variation exists in the perceived benefit of several low-value or poorly studied bronchiolitis interventions among health care personnel, with RNs/RTs generally perceiving higher benefit. Deimplementation, educational, and quality improvement efforts should be designed with an interprofessional framework.

A progress update on the implementation of a multi-faceted intervention to spread and scale bronchiolitis appropriate care in Alberta

Background: Acute viral bronchiolitis is among the most common illnesses seen in the emergency department (ED) and is the leading cause of infant hospitalization in Canada. Successful implementation of an audit and feedback (A&amp;F) intervention at the Alberta Children’s Hospital (ACH) reduced use of low-value interventions and tests for bronchiolitis. Opportunities to improve bronchiolitis management are likely also present in other urban and rural settings. This project will spread and scale the work completed at ACH to 16 sites across Alberta focusing on children under one-year diagnosed with bronchiolitis who managed both in ED and inpatient settings.&#x0D; &#x0D; Methods: Site implementation included two key aspects:&#x0D; &#x0D; Audit &amp; Feedback (A&amp;F) – review practice data, facilitated discussion with clinicians and their teams, and identify enablers and barriers to practice change.&#x0D; &#x0D; The seasonality of bronchiolitis cases (November to April) helped inform the frequency of A&amp;F feedback reports: mid-season (February) and end-of-season (April)&#x0D; Clinical dashboards are being developed within the new clinical information system – ConnectCare - that will provide teams with real-time feedback on potential practice change.&#x0D; &#x0D; &#x0D; Site Specific Implementation Plan – Resources are tailored to fit site needs including the use of posters, handouts and practice guidelines; utilization of order sets; and staff and family education resources.&#x0D; &#x0D; The bronchiolitis initiative is eligible for Continuing Medical Education accreditation through a newly developed easy-to-navigate web-based tool, My Practice Improvement – MyPI. An Education Working Group consisting of patient and family advisors was developed. Family resources included a QR code handout to a “How to suction your baby’s nose” instructional video to help parents/families care for their child at home. The HEAL handout provided links to additional resources for families. Family centred care participants were consulted on the development of a family resource: “Bronchiolitis: A roadmap from admission until discharge”.&#x0D; &#x0D; Evaluation Methods: The primary objective of the study is a 25% absolute reduction in chest radiograph use. Chest x-rays utilization can be readily obtained from administrative data at all sites in the project. Return visits to the ED within 72 hours of discharge will be monitored as a balancing measure to assess potential unintended consequences of de-implementing low-value tests and interventions in the ED. The provincial rollout of ConnectCare and tableau dashboard integration will enable a broader array of tests and treatments that are used in the management of bronchiolitis to be reported. The spread and scale of this project has now engaged with ED sites in non-tertiary settings in urban and rural areas where patient demographics and resource availability could pose additional challenges. Providing education and resources for these sites is one way to ensure equitable healthcare access for all Albertans.&#x0D; &#x0D; Results: Six facilities implemented rollout from September to November 2021 with a total of 151 physicians attending the A&amp;F sessions. Chest x-ray use at sites that had a 2021 session compared to sites with a planned session in 2022 revealed a decrease after one bronchiolitis season. A difference in difference analysis between the two groups demonstrated that sites with a 2021 session had a -14.3% (95%CI -21.4 to -7.1) decrease in chest x-ray use. As of November 17, 2022, there have been 12 A&amp;F sessions attended by 255 physicians, nurses and respiratory therapists.&#x0D; &#x0D; Advice and Lessons Learned: &#x0D; &#x0D; Capacity for scale and spread intiatives should be accounted for early in planning processes. We brought on two additional medical leads to facilitate sessions in fall 2022 due to an increase in the number of sites involved. Without the additional assistance, the success of roll out may have been jeopardized.&#x0D; Flexibility is key. Several sites across the province are continuing to deal with staffing shortages and recent high volumes of influenza, RSV and COVID are putting EDs over capacity. Sites have demonstrated incredible flexibility with engagement and session availabiltiy despite these circumstances. We changed session dates to help balance workloads as some sites had ConnectCare implementation concurrent with the start of the bronchiolitis season.&#x0D;

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.

Evaluation of targeted implementation interventions for reducing investigations and therapies in infants with bronchiolitis.

To evaluate the impact of locally adapted targeted implementation interventions on bronchiolitis management through reduction in ineffective investigation and therapies within emergency departments. A multi-centred, quality improvement study in four different grades of hospitals in Western Australia that provide paediatric emergency and inpatient care. All hospitals incorporated an adapted implementation intervention package for infants under 1 year with bronchiolitis. The proportion whose care complied with guideline recommendations to not receive investigations and therapies of minimal benefit were compared to pre-intervention care in a previous bronchiolitis season. A total of 457 infants in 2019 (pre-intervention) and 443 in 2021 (post-intervention) were included, with mean age of 5.6 months (SD 3.2, 2019; SD 3.0, 2021). In 2019, compliance was 78.1% versus 85.6% in 2021, RD 7.4 (95% CI -0.6; 15.5). The strongest evidence was reduced salbutamol use (compliance improvement: 88.6% to 95.7%, RD 7.1 95% CI (1.7; 12.4)). Hospitals initially at <80% compliance demonstrated greatest improvements (Hospital 2: 95 (78.5%) to 108 (90.8%) RD 12.2 95% CI (3.3; 21.2); Hospital 3: 67 (62.6%) to 63 (76.8%) RD 14.2 95% CI (1.3; 27.2)). Targeted site-adapted implementation interventions resulted in improvement in compliance with guideline recommendations, particularly for those hospitals with initial low compliance. Maximising benefits through guidance on how to adapt and effectively use interventions will enhance sustainable practice change.

EFFICACY OF ORAL PREDNISOLONE IN MANAGEMENT OF BRONCHIOLITIS: A PLACEBO-CONTROLLED STUDY

Acute bronchiolitis is a common and deadly condition in infants described as a respiratory infection due to inflammatory obstruction of bronchioles. This study was designed to assess prednisolone's efficacy in treating bronchiolitis in children aged &gt;2 years.&#x0D; A retrospective study was conducted in the Department of peadiatrics in different hospitals from February 2022- February 2023. A total of 80 children aged &gt; 2 years with acute bronchiolitis were included in the study. The patients were divided into groups A and B. Group A (n=40) was administered salbutamol combined with prednisolone, and Group B (n=40) was administered salbutamol alone. The outcomes of both treatments were evaluated.&#x0D; The average age in group A and B was 6.9± 4.5 months and 5.5 ± 3.9 months, respectively. 65 patients (81.2%) belonged to middle-class families, and 20 (25%) came from crowded households. 10 patients (12.5%) had a preterm delivery, and 12 (15%) had low birth weight. A significant difference was observed in Group A after 3 days of treatment (p &lt;0.05), and a reduction in hospital stay was also noted (p&lt;0.001) in contrast with Group B. Based on the results, it can be concluded that the prednisolone is an effective drug in the management of bronchiolitis by reducing hospital stay and disease severity in children &gt; 2 years.

Twenty-one-year follow-up revealed guideline-concordant and non-concordant trends in intensive care of bronchiolitis

To evaluate the management of bronchiolitis in the paediatric intensive care unit (PICU) before and after publication of the national bronchiolitis guidelines in June 2015. All infants treated between 2016–2020 for bronchiolitis in the PICU of Tampere University Hospital at < 12 months of age were included. The data were retrospectively collected from electronic patient records. The current results reflecting the post-guideline era were compared with previously published results for the pre-guideline 2000–2015 period. These two studies used identical protocols. Forty-six infants treated in the PICU were included. During the post-guideline era, inhaled adrenaline was given to 26 (57%), salbutamol to 7 (15%), and hypertonic saline inhalations to 35 (75%) patients. Forty-three patients (94%) received high-flow oxygen therapy (HFOT). Seventeen patients (37%) were treated with nasal continuous positive airway pressure (CPAP) and 4 (9%) with mechanical ventilation.Conclusion: When post-guideline years were compared with pre-guideline years, the use of bronchodilators decreased in agreement, but the use of inhaled saline increased in disagreement with the guidelines. The use of respiratory support increased, evidently because of an introduction of the non-invasive HFOT treatment modality.What is Known:• Oxygen supplementation and respiratory support, when needed, are the cornerstones of bronchiolitis treatment.• Medicines are frequently given to infants with bronchiolitis, especially if intensive care is needed, although evidence of their effectiveness is lacking.What is New:• Nearly all (94%) infants who needed intensive care were treated with HFOT and 37% with nasal CPAP, and finally, only 9% were intubated, which reflects the effectiveness of non-invasive techniques.• When pre- and post-guideline eras were compared, use of racemic adrenaline decreased from 84 to 57%, but use of hypertonic saline increased up to 75%, which disagrees with the current guidelines.

Comparative evaluation of high flow oxygen therapy versus low flow oxygen therapy in the management of acute moderate bronchiolitis

Background: Acute bronchiolitis is the most common respiratory tract infection in young children. Despite the high prevalence, no consensus exists on management. Hence the present study was conducted to find out the efficacy of high flow oxygen therapy (HFNC) versus low flow oxygen therapy in the management of acute moderate bronchiolitis. Methods: Prospective randomized controlled study of 100 children aged between 2 months to 24 months with signs and symptoms of acute moderate bronchiolitis were admitted to Indira Gandhi Institute of Child Health, Bangalore from January 2018 to June 2019 formed the study group, they were randomised into 2 groups, group A received high flow oxygen therapy and group B received low flow oxygen therapy. Results: Out of 100 children enrolled in the study, 50 children (group A) received high flow oxygen therapy and 50 children (group B) received low flow oxygen therapy. At 24 hours the mean severity score for group A was 0.46±077 and group B was 1.86±0.86 (p&lt;0.001). Maximum improvement in O2 saturation was observed in group A compared to group B. The duration of hospital stay was shorter (2-3 days) in group A with a mean of 2.20 days and was longer (4-5 days) in group B with a mean value of 3.84 days which was statistically significant (p&lt;0.001). Conclusions: Children with acute bronchiolitis treated with heated humidified high flow oxygen (HFNC) had early improvement in the clinical severity score, reduced duration of oxygen requirement and decrease in the length of hospital stay. Hence heated humidified high flow oxygen (HFNC) is an effective and safe modality of treatment for children with acute moderate bronchiolitis compared to low flow oxygen therapy (p&lt;0.0001).

Epidemiology and clinical course of bronchiolitis in hospitalized children in tertiary care hospital in Kashmir

Background: Bronchiolitis is the commonest lower respiratory tract infection in children &lt; 2 years of age and is responsible for the majority of their pediatrician visits and hospital admission during the winter season. The aim of this study was to describe the epidemiological data, seasonal trends, clinical characteristics, and outcomes of children admitted with bronchiolitis in pediatric hospital GMC Srinagar. Methods: This was a retrospective observational study in children less than 2 years of age admitted in department of pediatrics in GMC Srinagar. Data were collected through review of the medical records of patients with a diagnosis of bronchiolitis on discharge and analyzed through SPSS 20. Results: A total of 228 infants were enrolled in the study. The majority were males (60.08%). The median age on admission was 5.5 months, exclusive breastfeeding was the mode of feeding in majority and 8.77% were ex-preterm. Respiratory syncytial virus (RSV) was identified in majority (103) and admission peak was from October to March. Most of the patients presented on day 3 of the illness. Most patients 45.17% were having feeding difficulties and chest auscultation was normal in about 22% of the children. Oxygen supplementation was administered to 85.52% of the children. The 32 children (14.03%) required admission to PICU. Mechanical ventilation was required in 6 children (18.75%). No death occurred in infants while in the hospital. Conclusions: RSV has been found to be the main responsible virus. Management of bronchiolitis is usually symptomatic as recommended by most of the guidelines.

Different Pediatric Acute Care Settings Influence Bronchiolitis Management: A 10-Year Retrospective Study

Bronchiolitis is the main cause of hospitalization in infants. Diagnosis is clinical, and treatment is based on hydration and oxygen therapy. Nevertheless, unnecessary diagnostic tests and pharmacological treatments are still very common. This retrospective study aimed to evaluate whether the setting of bronchiolitis care influences diagnostic and therapeutic choices. The management of 3201 infants, referred to our Italian Tertiary Care Center for bronchiolitis between 2010 and 2020, was analyzed by comparing children discharged from the pediatric emergency department (PEDd group) undergoing short-stay observation (SSO group) and hospitalization. Antibiotic use in PEDd, SSO, and ward was 59.3% vs. 51.6% vs. 49.7%, respectively (p < 0.001); inhaled salbutamol was mainly administered in PEDd and during SSO (76.1% and 82.2% vs. 38.3% in ward; p < 0.001); the use of corticosteroids was higher during SSO and hospitalization (59.6% and 49.1% vs. 39.0% in PEDd; p < 0.001); inhaled adrenaline was administered mostly in hospitalized infants (53.5% vs. 2.5% in SSO and 0.2% in PEDd; p < 0.001); chest X-ray use in PEDd, SSO, and ward was 30.3% vs. 49.0% vs. 70.5%, respectively (p < 0.001). In a multivariate analysis, undergoing SSO was found to be an independent risk factor for the use of systemic corticosteroid and salbutamol; being discharged at home was found to be a risk factor for antibiotic prescription; undergoing SSO and hospitalization resulted as independent risk factors for the use of CXR. Our study highlights that different pediatric acute care settings could influence the management of bronchiolitis. Factors influencing practice may include a high turnover of PED medical staff, personal reassurance, and parental pressure.

Clinical practice guidelines: management of severe bronchiolitis in infants under 12months old admitted to a pediatric critical care unit.

We present guidelines for the management of infants under 12months of age with severe bronchiolitis with the aim of creating a series of pragmatic recommendations for a patient subgroup that is poorly individualized in national and international guidelines. Twenty-five French-speaking experts, all members of the Groupe Francophone de Réanimation et Urgence Pédiatriques (French-speaking group of paediatric intensive and emergency care; GFRUP) (Algeria, Belgium, Canada, France, Switzerland), collaborated from 2021 to 2022 through teleconferences and face-to-face meetings. The guidelines cover five areas: (1) criteria for admission to a pediatric critical care unit, (2) environment and monitoring, (3) feeding and hydration, (4) ventilatory support and (5) adjuvant therapies. The questions were written in the Patient-Intervention-Comparison-Outcome (PICO) format. An extensive Anglophone and Francophone literature search indexed in the MEDLINE database via PubMed, Web of Science, Cochrane and Embase was performed using pre-established keywords. The texts were analyzed and classified according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. When this method did not apply, an expert opinion was given. Each of these recommendations was voted on by all the experts according to the Delphi methodology. This group proposes 40 recommendations. The GRADE methodology could be applied for 17 of them (3 strong, 14 conditional) and an expert opinion was given for the remaining 23. All received strong approval during the first round of voting. These guidelines cover the different aspects in the management of severe bronchiolitis in infants admitted to pediatric critical care units. Compared to the different ways to manage patients with severe bronchiolitis described in the literature, our original work proposes an overall less invasive approach in terms of monitoring and treatment.

International variation in evidence-based emergency department management of bronchiolitis: a retrospective cohort study

ObjectivesWe aimed to evaluate the international variation in the use of evidence-based management (EBM) in bronchiolitis. We hypothesised that management consistent with full-EBM practices is associated with the research network...

Managing Bronchiolitis in Pediatric Patients: Current Evidence

Background: Acute bronchiolitis is an inflammatory process affecting small airways. Although most cases are self-limiting, it is still one of the most common causes of hospitalization below 24 months of age. Treatment is mainly supportive. The purpose of this narrative review was to look for recent evidence in the management of bronchiolitis. Methods: PubMed, EMBASE, Global Health, MEDLINE, SCOPUS, and Cochrane database searches were performed using keywords such as bronchiolitis, management, bronchodilators, nebulized epinephrine, corticosteroids, and hypertonic saline. Systematic reviews, original articles, and clinical practice guidelines with evidence for bronchiolitis management were included during our search. We excluded guidelines and clinical trials which solely focused on high-risk children, articles by a single author, and trials that are not part of a clinical practice guideline. Discussion: The safety and efficacy of various therapies for bronchiolitis such as bronchodilators, epinephrine, hypertonic saline, and corticosteroid were analyzed. Bronchodilators have not shown consistent benefits in bronchiolitis and may be tried in the selected population. Current evidence does not suggest routine use of nebulized epinephrine in bronchiolitis except as rescue therapy in selected cases. Hypertonic saline showed positive results in some studies but questions still remain regarding its effectiveness in all. Recent trials also do not support the use of systemic or inhaled corticosteroids in bronchiolitis. Conclusion: In conclusion, there is no strong evidence to routinely recommend the use of bronchodilator, epinephrine, hypertonic saline, or corticosteroids in acute bronchiolitis. Supportive care still remains the mainstay of therapy for bronchiolitis.

76 Understanding practice change around intermittent versus continuous pulse oximetry in infants hospitalized with bronchiolitis: a multi-centre qualitative study

Abstract Background Bronchiolitis is the most common reason for hospitalization in infants and is cumulatively costly for the healthcare system. Trial evidence and national guidelines support the routine use of intermittent pulse oximetry in stabilized (no oxygen supplementation) infants with bronchiolitis. However, continuous pulse oximetry use is common. Objectives To understand the barriers and facilitators important to de-implementing continuous pulse oximetry and implementing intermittent pulse oximetry in stabilized infants hospitalized with bronchiolitis. Design/Methods From December 2018 to January 2020, participants were recruited from six Ontario hospitals (3 community and 3 paediatric hospitals) in a multi-centre qualitative study. Focus groups were conducted with staff paediatricians, paediatric residents, nurses, and respiratory therapists. Interviews were conducted with caregivers of infants recently hospitalized with bronchiolitis. Participants' beliefs, attitudes, and experiences related to pulse oximetry use in bronchiolitis management were explored. Recordings were transcribed and analyzed using thematic analysis via NVivo software to understand barriers and facilitators to practice change. These were then mapped to the domains and the constructs of the Consolidated Framework for Implementation Research (CFIR). Results 67 individuals from six hospitals participated. Themes relevant to understanding barriers and facilitators to de-implementing continuous and implementing intermittent monitoring were identified. Healthcare professionals emphasized the importance of identifying and understanding who is responsible for bedside monitoring practice (physician vs. nurses). Clinical experience, knowledge of guidelines (international and local practice), importance relative to competing priorities, and the tensions amongst team members due to practice variation all influenced monitoring practice. Nurses held beliefs around the advantages of intermittent monitoring (e.g., reduced alarm fatigue, facilitation of timely discharges and reduced workload). Clinicians identified ways to clarify indications for ongoing continuous monitoring (e.g., based on clinical risk factors such as medical complexity, prematurity, and age), vs. indications to transition to intermittent monitoring (e.g., established oral feeding, sleeping without desaturations, and off supplemental oxygen). Caregivers did not express a clear preference for monitoring type, but described the stress of having a child admitted to hospital with an emphasis on the need for clear communication around the interpretation of monitors, management decisions, and care transitions. Conclusion In this multi-centre qualitative study of clinicians and caregivers, we identified barriers and facilitators that are important to de-implementing continuous monitoring and implementing intermittent monitoring. Understanding professional roles, clarity around local practice standards and supporting families' understanding of pulse oximetry monitoring practices are essential for practice change.