Management Of Bronchiolitis Research Articles

Emergency Department Management of Bronchiolitis in the United States

The aim of this study was to examine differences between general and pediatric emergency departments (PEDs) in adherence to the American Academy of Pediatrics bronchiolitis management guidelines. We conducted a nationally representative study of ED visits by infants younger than 24 months with bronchiolitis from 2002 to 2011 using the National Hospital Ambulatory Medical Care Survey. Diagnostic testing (complete blood counts, radiographs) and medication use (albuterol, corticosteroids, antibiotics and intravenous fluids) in general emergency departments (GEDs) were compared with those in PEDs before and after 2006 American Academy of Pediatrics guideline publication. Weighted percentages were compared, and logistic regression evaluated the association between ED type and resource use. Of more than 2.5 million ED visits for bronchiolitis from 2002 to 2011, 77.3% occurred in GEDs. General emergency departments were more likely to use radiography (62.7% vs 42.1%; adjusted odds ratio [aOR], 2.4; 95% confidence interval [CI], 1.4-4.1), antibiotics (41.3% vs 18.8%; aOR, 2.8; 95% CI, 1.5-5.2), and corticosteroids (24.3% vs 12.5%; aOR, 2.1; 95% CI, 1.0-4.5) compared with PEDs. Compared with preguideline, after guideline publication PEDs had a greater decrease in radiography use (-19.7%; 95% CI, -39.3% to -0.03%) compared with GEDs (-12.2%; 95% CI, -22.3% to -2.1%), and PEDs showed a significant decline in corticosteroid use (-12.4%; 95% CI, -22.1% to -2.8%), whereas GEDs showed no significant decline (-4.6%; 95% CI, -13.5% to 4.3%). The majority of ED visits for bronchiolitis in the United States occurred in GEDs, yet GEDs had increased use of radiography, corticosteroids, and antibiotics and did not show substantial declines with national guideline publication. Given that national guidelines discourage the use of such tests and treatments in the management of bronchiolitis, efforts are required to decrease ED use of these resources in infants with bronchiolitis, particularly in GEDs.

Comparison of CPAP and HFNC in Management of Bronchiolitis in Infants and Young Children.

Continuous positive airway pressure (CPAP) has been used in infants with bronchiolitis for decades. Recently, high flow nasal cannula (HFNC) therapy was introduced We conducted a retrospective study of treatment with CPAP vs. HFNC between 2013 and 2015, comparing the development in respiratory rate, fraction of inspired oxygen (FiO2) and heart rate, treatment failure, duration of treatment, and length of hospital stay. A sample size of 49 children were included. Median age was 1.9 months. Median baseline pCO2 was 7.4 kPa in both groups, respiratory rate per minute was 57 vs. 58 (CPAP vs. HFNC). Respiratory rate decreased faster in the CPAP group (p < 0.05). FiO2 decreased in the CPAP group and increased in the HFNC group during the first 12 h, whereafter it decreased in both groups. (p < 0.01). Heart rate development was similar in both groups. Twelve children (55%) changed systems from HFNC to CPAP due to disease progression. There was no difference in length of treatment, hospital stay, or transmission to intensive care unit between the groups. CPAP was more effective than HFNC in decreasing respiratory rate (RR) and FiO2. No differences were observed in length of treatment or complications. Further studies should be conducted to compare the efficacy of the two treatments of bronchiolitis, preferably through prospective randomized trials.

Management of bronchiolitis in infants: key clinical questions

Abstract Bronchiolitis is the most common lower respiratory tract infection in infants. It is a seasonal illness and remains the leading cause of hospitalisation of infants worldwide. Respiratory syncytial virus (RSV) is responsible for approximately 70% of cases. Infants present with coryzal symptoms progressing to a cough and respiratory distress. A mild pyrexia and reduced feeding are common. Bronchiolitis is a clinical diagnosis and investigations are often of limited value. The management of bronchiolitis remains a contentious issue with a wide variation in practice. Recently here has been a significant shift in favour of minimally invasive, supportive therapy as the cornerstone of management. This typically involves minimal handling, nasopharyngeal suction, oxygen supplementation and optimising hydration. There is little evidence to support the use of pharmacological agents in managing of bronchiolitis. Palivizumab, a monoclonal antibody targeting RSV, can be administered to high risk patients in an attempt to reduce admission rates.

Diagnosis & Management of Bronchiolitis in Children: An Update

Diagnosis & Management of Bronchiolitis in Children: An Update

High flow nasal cannula (HFNC) versus nasal continuous positive airway pressure (nCPAP) for the initial respiratory management of acute viral bronchiolitis in young infants: a multicenter randomized controlled trial (TRAMONTANE study).

Nasal continuous positive airway pressure (nCPAP) is currently the gold standard for respiratory support for moderate to severe acute viral bronchiolitis (AVB). Although oxygen delivery via high flow nasal cannula (HFNC) is increasingly used, evidence of its efficacy and safety is lacking in infants. A randomized controlled trial was performed in five pediatric intensive care units (PICUs) to compare 7cmH2O nCPAP with 2L/kg/min oxygen therapy administered with HFNC in infants up to 6months old with moderate to severe AVB. The primary endpoint was the percentage of failure within 24h of randomization using prespecified criteria. To satisfy noninferiority, the failure rate of HFNC had to lie within 15% of the failure rate of nCPAP. Secondary outcomes included success rate after crossover, intubation rate, length of stay, and serious adverse events. From November 2014 to March 2015, 142 infants were included and equally distributed into groups. The risk difference of -19% (95% CI -35 to -3%) did not allow the conclusion of HFNC noninferiority (p=0.707). Superiority analysis suggested a relative risk of success 1.63 (95% CI 1.02-2.63) higher with nCPAP. The success rate with the alternative respiratory support, intubation rate, durations of noninvasive and invasive ventilation, skin lesions, and length of PICU stay were comparable between groups. No patient had air leak syndrome or died. In young infants with moderate to severe AVB, initial management with HFNC did not have a failure rate similar to that of nCPAP. This clinical trial was recorded in the National Library of Medicine registry (NCT 02457013).

Predictors of Inappropriate Use of Diagnostic Tests and Management of Bronchiolitis.

Background The aim of the present study was to determine predictors of inappropriate use of diagnostic tests and management of bronchiolitis in a population of hospitalized infants. Methods In an analytical cross-sectional study, we determined independent predictors of the inappropriate use of diagnostic tests and management of bronchiolitis in a population of hospitalized infants. We defined a composite outcome score as the main outcome variable. Results Of the 303 included patients, 216 (71.3%) experienced an inappropriate use of diagnostic tests and treatment of bronchiolitis. After controlling for potential confounders, it was found that atopic dermatitis (OR 5.30; CI 95% 1.14–24.79; p = 0.034), length of hospital stay (OR 1.48; CI 95% 1.08–2.03; p = 0.015), and the number of siblings (OR 1.92; CI 95% 1.13–3.26; p = 0.015) were independent predictors of an inappropriate use of diagnostic tests and treatment of the disease. Conclusions Inappropriate use of diagnostic tests and treatment of bronchiolitis was a highly prevalent outcome in our population of study. Participants with atopic dermatitis, a longer hospital stay, and a greater number of siblings were at increased risk for inappropriate use of diagnostic tests and management of the disease.

Diagnosis, prevention, and management of bronchiolitis in children: review of current controversies.

Viral bronchiolitis is a common and costly condition among young children worldwide, contributing to high medical expenditures in industrialized countries and significant mortality in low-income countries. Much research has focused on therapy for this disease entity, though the standard of care remains merely supportive. Current areas of active research include the nuances of defining bronchiolitis, a deeper exploration of causative viruses, the role and development of preventive strategies, and associated long-term outcomes. This review aims to explore relevant recent literature, and particularly to focus on active areas of uncertainty and controversy.

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.

215 Confirmation of Racial/Ethnic Disparities in the Management of Severe Bronchiolitis

Bronchiolitis is the #1 cause of hospitalization among infants in the U.S. and is associated with an increased risk of asthma. In an earlier multicenter study (Santiago et al. J Hosp Med 2014; 9: 565-572), we reported three racial/ethnic differences in the management of severe bronchiolitis: 1) ED/clinic albuterol use, 2) inpatient diagnostic imaging, and 3) prescription of inhaled corticosteroids at discharge. In the current study, we examine if racial/ethnic differences persist in a new multicenter severe bronchiolitis cohort. We enrolled infants (age <1y) with severe bronchiolitis between 2011 and 2014 at 17 teaching hospitals across 13 states in the 35th Multicenter Airway Research Collaboration (MARC-35) study. In total, 1016 infants had a structured interview and chart review during their bronchiolitis hospitalization. Race/ethnicity was assigned based on the guardian’s response to U.S. Census questions: Hispanic (y/n) and Race (eg, white, black, Asian - mark all that apply). Infants were categorized into three groups: non-Hispanic white (NHW), non-Hispanic black (NHB), or Hispanic. For analytical reasons, we excluded 39 infants who could not be categorized into these groups. This resulted in a total of 977 (96%) infants in our analytical dataset. Multivariable logistic regression was used to examine the independent association between race/ethnicity and diagnostic imaging, ED/clinic and inpatient treatment (albuterol, corticosteroids), management (intensive care interventions and length-of-stay), discharge on corticosteroids, and bronchiolitis relapse within three weeks. Among 977 infants, 430 (44%) were NHW, 239 (24%) were NHB, and 308 (32%) were Hispanic. The median age at enrollment was 3.2 months; 60% were male and 60% had public health insurance. Most infants tested positive for RSV (81%) and did not have a breathing problem before enrollment (80%); the median hospital length-of-stay was 2 days. In multivariable analyses, with NHW infants as reference group, we focused on three previously reported differences (Figure). We did not confirm the previously reported difference for ED/clinic albuterol across the three groups. We did confirm the other two findings, with NHB infants less likely to receive chest x-rays during hospitalization (OR: 0.64; 95% CI: 0.45-0.93), and Hispanic infants more likely to be discharged on corticosteroids (OR: 1.91; 95% CI: 1.05-3.48). We again found no significant racial/ethnic differences for all other outcomes: inpatient corticosteroid use, hospital length of stay, intensive care interventions, or worsening of bronchiolitis requiring medical treatment after discharge. We confirmed racial/ethnic differences for two practices (inpatient diagnostic imaging and prescription of corticosteroids at discharge); neither is recommended by the 2014 American Academy of Pediatrics guidelines for treatment of bronchiolitis. The causes of these management differences remain unclear, but they support implementation of care pathways for severe bronchiolitis to reduce disparities in care.

Consensus conference on the appropriateness of palivizumab prophylaxis in respiratory syncytial virus disease.

Respiratory syncytial virus infection represents a clinical burden among young children under 24 months. Palivizumab is the only drug licensed in Italy for the prevention of serious lower respiratory tract disease requiring hospitalization caused by respiratory syncytial virus in children at high risk. However recommendations for palivizumab prophylaxis are heterogeneous. Not all the published documents agree about the clinical indications of palivizumab; this could lead to different clinical practices and concerns about the appropriateness of prophylaxis. These issues and the lack of evidence about palivizumab prophylaxis efficacy in specific medical conditions brought on the idea of a consensus conference on the current recommendations for the management and prevention of bronchiolitis, in order to share useful indications. The goal was to perform a review of the evidence regarding the efficacy and the safety of palivizumab and give recommendations in order to harmonize its use. A structured and validated method to conduct the consensus process was adopted. The consensus conference recommends palivizumab prophylaxis in infants born before 29 weeks and younger than 12 months at the start of the epidemic season. According to evidence from literature and experts' opinion, palivizumab prophylaxis is not recommended in preterm infants of gestational age ≥29 weeks, without co-morbidity (i.e., cardiac, bronchopulmonary diseases). The experts identified some clinical rare conditions for which the decision of prophylaxis should be entrusted to the specialists. The evaluation of the appropriateness of palivizumab prophylaxis in the single patient should be documented by the specialists. Pediatr Pulmonol. 2016;51:1088-1096. © 2016 Wiley Periodicals, Inc.

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?

Do we need more tools in the management of bronchiolitis or are only oxygen, salt water and a cool head required?

Do we need more tools in the management of bronchiolitis or are only oxygen, salt water and a cool head required?

A clustering approach to identify severe bronchiolitis profiles in children

ObjectiveAlthough bronchiolitis is generally considered a single disease, recent studies suggest heterogeneity. We aimed to identify severe bronchiolitis profiles using a clustering approach.MethodsWe analysed data from two prospective, multicentre cohorts...

Can Hospitalization Precipitate Toxic Stress?

* Abbreviation: ACE — : adverse childhood experience During morning rounds, I introduced myself to the parent of a patient with bronchiolitis. As trainees, we are taught the medical management of bronchiolitis and how to set families’ expectations for the course of illness. However, we are not taught how to help families cope with the stress of a hospitalization. As we entered the room to discuss her child’s illness, the mother was on edge. Although her son was due to feed, she firmly requested that we let him sleep. Then she glanced at the textbook in her lap, remarking that her child was finally comfortable. Although she had not slept herself, she needed to catch up with her schoolwork. This interaction prompted our team to consider whether this mother’s stress, the challenge she felt juggling her son’s illness with her own responsibilities, was affecting her son’s clinical course. Could the stress of this hospitalization be toxic to her? To this family? The 2012 American Academy of Pediatrics Policy Statement called on pediatricians to screen for and act on factors that could precipitate toxic stress responses.1 The report introduced positive, tolerable, and toxic physiologic responses to stress.1 Events that trigger positive and tolerable stress may elevate the body’s physiologic response system, but buffers such as social supports make the biological response mild and brief, preventing harm. Events that trigger positive stress provide the opportunity “to observe, learn, and practice healthy, adaptive responses.”2 Alternatively, … Address correspondence to Anita N. Shah, DO, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 9016, Cincinnati, OH 45229. E-mail: anita.shah{at}cchmc.org

NICE guidelines on bronchiolitis: a robust appraisal of current evidence.

Bronchiolitis is common in infants. Oxygen therapy, fluids and occasionally respiratory support remain the mainstay of treatment. The NICE guidelines are expected to streamline the management of bronchiolitis and minimize potentially harmful interventions. Further research to find other useful therapies is necessary.

Acute viral bronchiolitis in South Africa: Intensive care management for severe disease

It is estimated that 2 - 3% of children will be hospitalised with viral bronchiolitis during their first year of life, and a small proportion of them will have a severe course of the disease, requiring intensive care and ventilatory support. In South Africa, 20% of children admitted to a paediatric intensive care unit (PICU) had positive respiratory viral isolates (especially respiratory syncytial virus), with symptomatic respiratory disease. Rapid laboratory-based diagnosis using multiplex polymerase chain reaction is recommended to reduce overall antibiotic use in the PICU and neonatal ICU (NICU) and improve the targeted use of antibiotics (antibiotic stewardship). The mainstay of bronchiolitis management in the PICU and NICU is supportive, comprising fluid management, oxygen supplementation and/or respiratory ventilatory support, and antipyretics if needed. Non-invasive nasal continuous positive airway pressure and high-flow nasal cannula oxygen therapy are increasingly being used in children with severe bronchiolitis, and may reduce the need for intubation. Infants with bronchiolitis may have a variety of clinical presentations, which may require different ventilatory approaches. Children may present predominantly with apnoeas, air trapping and wheeze, atelectasis and parenchymal disease (in acute respiratory distress syndrome), or a combination of these. Lung-protective ventilation, using a low tidal volume pressure-limited approach, is essential to limit ventilator-induced lung injury.

Acute viral bronchiolitis in South Africa: Strategies for management and prevention

Management of acute viral bronchiolitis is largely supportive. There is currently no proven effective therapy other than oxygen for hypoxic children. The evidence indicates that there is no routine benefit from inhaled, rapid short-acting bronchodilators, adrenaline or ipratropium bromide for children with acute viral bronchiolitis. Likewise, there is no demonstrated benefit from routine use of inhaled or oral corticosteroids, inhaled hypertonic saline nebulisation, montelukast or antibiotics. The last should be reserved for children with severe disease, when bacterial co-infection is suspected. Prevention of respiratory syncytial virus (RSV) disease remains a challenge. A specific RSV monoclonal antibody, palivizumab, administered as an intramuscular injection, is available for children at risk of severe bronchiolitis, including premature infants, young children with chronic lung disease, immunodeficiency, or haemodynamically significant congenital heart disease. Prophylaxis should be commenced at the start of the RSV season and given monthly during the season. The development of an RSV vaccine may offer a more effective alternative to prevent disease, for which the results of clinical trials are awaited. Education of parents or caregivers and healthcare workers about diagnostic and management strategies should include the following: bronchiolitis is caused by a virus; it is seasonal; it may start as an upper respiratory tract infection with low-grade fever; symptoms are cough and wheeze, often with fast breathing; antibiotics are generally not needed; and the condition is usually self limiting, although symptoms may occur for up to four weeks in some children.

Management of Bronchiolitis in Community Hospitals in Ontario: a Multicentre Cohort Study.

Bronchiolitis is the leading cause of hospital admission for infants, but few studies have examined management of this condition in community hospital settings. We reviewed the management of children with bronchiolitis presenting to community hospitals in Ontario. We retrospectively reviewed a consecutive cohort of infants less than 12 months old with bronchiolitis who presented to 28 Ontario community hospitals over a two-year period. Bronchiolitis was defined as first episode of wheezing associated with signs of an upper respiratory tract infection during respiratory syncytial virus season. Of 543 eligible children, 161 (29.7%, 95% Confidence Interval (CI) 22.3 to 37.0%) were admitted to hospital. Hospital admission rates varied widely (Interquartile Range 0%-40.3%). Bronchodilator use was widespread in the emergency department (ED) (79.7% of patients, 95% CI 75.0 to 84.5%) and on the inpatient wards (94.4% of patients, 95% CI 90.2 to 98.6%). Salbutamol was the most commonly used bronchodilator. At ED discharge 44.7% (95% CI 37.5 to 51.9%) of patients were prescribed a bronchodilator medication. Approximately one-third of ED patients (30.8%, 95% CI 22.7 to 38.8%), 50.3% (95% CI 37.7 to 63.0%) of inpatients, and 23.5% (95% CI 14.4 to 32.7) of patients discharged from the ED were treated with corticosteroids. The most common investigation obtained was a chest x-ray (60.2% of all children; 95% CI 51.9 to 68.5%). Infants with bronchiolitis receive medications and investigations for which there is little evidence of benefit. This suggests a need for knowledge translation strategies directed to community hospitals.

Best practice in the prevention and management of paediatric respiratory syncytial virus infection.

Respiratory syncytial virus (RSV) infection is ubiquitous with almost all infants having been infected by 2 years of age and lifelong repeated infections common. It is the second largest cause of mortality, after malaria, in infants outside the neonatal period and causes up to 200,000 deaths per year worldwide. RSV results in clinical syndromes that include upper respiratory tract infections, otitis media, bronchiolitis (up to 80% of cases) and lower respiratory tract disease including pneumonia and exacerbations of asthma or viral-induced wheeze. For the purposes of this review we will focus on RSV bronchiolitis in infants in whom the greatest disease burden lies. For infants requiring hospital admission, the identification of the causative respiratory virus is used to direct cohorting or isolation and infection control procedures to minimize nosocomial transmission. Nosocomial RSV infections are associated with poorer clinical outcomes, including increased mortality, the need for mechanical ventilation and longer length of hospital stay. Numerous clinical guidelines for the management of infants with bronchiolitis have been published, although none are specific for RSV bronchiolitis. Ribavirin is the only licensed drug for the specific treatment of RSV infection but due to drug toxicity and minimal clinical benefit it has not been recommended for routine clinical use. There is currently no licensed vaccine to prevent RSV infection but passive immunoprophylaxis using a monoclonal antibody, palivizumab, reduces the risk of hospitalization due to RSV infection by 39-78% in various high-risk infants predisposed to developing severe RSV disease. The current management of RSV bronchiolitis is purely supportive, with feeding support and oxygen supplementation until the infant immune system mounts a response capable of controlling the disease. The development of a successful treatment or prophylactic agent has the potential to revolutionize the care and outcome for severe RSV infections in the world's most vulnerable infants.

Quality Improvement Initiative to Decrease the Use of Bronchodilators in the Management of Bronchiolitis

Quality Improvement Initiative to Decrease the Use of Bronchodilators in the Management of Bronchiolitis