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Scheller LL, Crandall CN, Carlin KE, Lein MA, DiBlasi RM. Clinical Features of Patients With Bronchiolitis Prior to the Initiation of Noninvasive Respiratory Support. Respir Care 2025. [PMID: 40028881 DOI: 10.1089/respcare.11922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2025]
Abstract
Background: Effective management of infants hospitalized with bronchiolitis depends on clinician assessment of disease severity. Although environmental and demographic risk factors help identify severe cases, there is limited research on specific clinical and physiological characteristics associated with respiratory deterioration. This study aimed to identify physiologic variables and clinical parameters associated with respiratory deterioration in hospitalized infants with bronchiolitis. Methods: A single-center retrospective cohort study included previously healthy infants <2 years of age hospitalized for bronchiolitis. The primary outcome measure, deterioration, was defined as respiratory distress requiring noninvasive (including high-flow nasal cannula) or invasive respiratory support within 48 h of admission. A multivariable logistic regression analysis with preselected factors was used to assess the odds of deterioration. Variables included sex, age, affect and behavior, nasopharyngeal suctioning, number, location of retractions, SpO2/FIO2 (S/F ratio), breathing frequency, pulse rate, and respiratory severity score. A secondary analysis assessed retraction locations. Results: Of the 584 eligible patients, 154 (26%) experienced a deterioration event and required noninvasive or invasive respiratory support. Respiratory score (odds ratio [OR] 1.9 [95% CI 1.5-2.4]), total number of retractions (OR: 2.5 [95% CI 1.6-3.8]), S/F ratio (OR: 1.0 [95% CI 0.99-0.998), pulse rate (OR: 1.0 [95% CI 1.0-1.1]), nasopharyngeal suctioning (OR: 5.5 [95% CI 2.6-11.7]), and positive affect and behavior descriptors (OR: 0.3 [95% CI 0.1-0.7]) were associated with deterioration. Age, sex, negative affect and behavior descriptors, and breathing frequency were not statistically significant. Conclusions: These variables may be used to design predictive algorithms that alert clinicians of impending respiratory deterioration in infants with bronchiolitis.
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Affiliation(s)
- Lindsey L Scheller
- Ms Scheller, Crandall, Lein, and Mr. DiBlasi are affiliated with Seattle Children's Hospital, Seattle, Washington, USA
| | - Coral N Crandall
- Ms Scheller, Crandall, Lein, and Mr. DiBlasi are affiliated with Seattle Children's Hospital, Seattle, Washington, USA
| | - Kristen E Carlin
- Mrs Carlin is affiliated with Seattle Children's Research Institute, Seattle, Washington, USA
- Mrs Carlin is affiliated with Biostatistics, Epidemiology, and Analytics for Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Missy A Lein
- Ms Scheller, Crandall, Lein, and Mr. DiBlasi are affiliated with Seattle Children's Hospital, Seattle, Washington, USA
| | - Robert M DiBlasi
- Ms Scheller, Crandall, Lein, and Mr. DiBlasi are affiliated with Seattle Children's Hospital, Seattle, Washington, USA
- Mr DiBlasi is affiliated with Center for Respiratory Biology and Therapeutics, SCRI, Seattle, Washington, USA
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2
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Hedland JL, Chang TP, Schmidt AR, Festekjian A. Suctioning in the management of bronchiolitis: A prospective observational study. Am J Emerg Med 2024; 82:57-62. [PMID: 38795425 DOI: 10.1016/j.ajem.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 05/28/2024] Open
Abstract
BACKGROUND Bronchiolitis accounts for a considerable number of Emergency Department (ED) visits by infants each year and is the leading cause of respiratory infection in children 2 years of age and younger. Suctioning remains one of the main supportive treatments, but suctioning practices of nasal aspiration and deep suctioning vary among practitioners in bronchiolitis management. Our objective was to explore associations between suction type and respiratory distress, oxygen saturation, and markers of respiratory compromise such as airway escalation, disposition, ED length of stay (LOS), and outpatient outcomes. METHODS This was a prospective observational study on infants (aged 2-23 months) in a pediatric ED with bronchiolitis from September 2022 to April 2023. Infants with tracheostomies, muscular weakness, and non-invasive positive pressure ventilation were excluded. Infants were grouped into nasal aspiration, deep suctioning, or combination groups. Mean differences in respiratory scores (primary outcome) and oxygen saturation were measured at three timepoints: pre-suction, 30 and 60 min post-suction. Escalation to airway adjuncts, disposition, and ED LOS were also recorded. Discharged families were contacted for phone call interviews. RESULTS Of 121 enrolled infants (nasal aspiration n = 31, deep suctioning n = 68, combination n = 22), 48% (n = 58) were discharged, and 90% (n = 52) completed the study call. There was no interaction between suction type and timepoint (p = 0.63) and no effect between suction type and respiratory score (p = 0.38). However, timepoint did have an effect on respiratory score between 0 and 30 min post-suction (p = 0.01) and between 0 and 60 min post-suction (p < 0.001). Admitted infants received more deep suctioning or a combination of suctioning compared to those discharged (p = 0.005). Suction type had no effect on oxygen saturation, airway adjunct escalation, length of stay, or outpatient outcomes (p > 0.11). CONCLUSIONS There was no difference in respiratory scores or outpatient outcomes between suction types. Deep suctioning may not be needed in all infants with bronchiolitis.
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Affiliation(s)
- July Lee Hedland
- Division of Emergency and Transport Medicine Children's Hospital Los Angeles, Los Angeles, USA.
| | - Todd P Chang
- Division of Emergency and Transport Medicine Children's Hospital Los Angeles, Los Angeles, USA
| | - Anita R Schmidt
- Division of Emergency and Transport Medicine Children's Hospital Los Angeles, Los Angeles, USA
| | - Ara Festekjian
- Division of Emergency and Transport Medicine Children's Hospital Los Angeles, Los Angeles, USA
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3
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Smith JA, Stone BS, Shin J, Yen K, Reisch J, Fernandes N, Cooper MC. Association of outcomes in point-of-care lung ultrasound for bronchiolitis in the pediatric emergency department. Am J Emerg Med 2024; 75:22-28. [PMID: 37897916 DOI: 10.1016/j.ajem.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/26/2023] [Accepted: 10/06/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND Acute bronchiolitis (AB) is the most common lower respiratory tract infection in infants. Objective scoring tools and plain film radiography have limited application, thus diagnosis is clinical. The role of point-of-care lung ultrasound (LUS) is not well established. OBJECTIVE We sought to characterize LUS findings in infants presenting to the pediatric ED diagnosed with AB, and to identify associations between LUS and respiratory support (RS) at 12 and 24 h, maximum RS during hospitalization, disposition, and hospital length of stay (LOS). METHODS Infants ≤12 months presenting to the ED and diagnosed with AB were enrolled. LUS was performed at the bedside by a physician. Lungs were divided into 12 segments and scanned, then scored and summated (min. 0, max. 36) in real time accordingly: 0 - A lines with <3 B lines per lung segment. 1 - ≥3 B lines per lung segment, but not consolidated. 2 - consolidated B lines, but no subpleural consolidation. 3 - subpleural consolidation with any findings scoring 1 or 2. Chart review was performed for all patients after discharge. RS was categorized accordingly: RS (room air), low RS (wall O2 or heated high flow nasal cannula <1 L/kg), and high RS (heated high flow nasal cannula ≥1 L/kg or positive pressure). RESULTS 82 subjects were enrolled. Regarding disposition, the mean (SD) LUS scores were: discharged 1.18 (1.33); admitted to the floor 4.34 (3.62); and admitted to the ICU was 10.84 (6.54). For RS, the mean (SD) LUS scores at 12 h were: no RS 1.56 (1.93), low RS 4.34 (3.51), and high RS 11.94 (6.17). At 24 h: no RS 2.11 (2.35), low RS 4.91 (3.86), and high RS 12.64 (6.48). Maximum RS: no RS 1.22 (1.31), low RS 4.11 (3.61), and high RS 10.45 (6.16). Mean differences for all dispositions and RS time points were statistically significant (p < 0.05, CI >95%). The mean (SD) hospital LOS was 84.5 h (SD 62.9). The Pearson correlation coefficient (r) comparing LOS and LUS was 0.489 (p < 0.0001). CONCLUSION Higher LUS scores for AB were associated with increased respiratory support, longer LOS, and more acute disposition. The use of bedside LUS in the ED may assist the clinician in the management and disposition of patient's diagnosed with AB.
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Affiliation(s)
- Jaron A Smith
- University of Texas Southwestern, Department of Pediatrics, Division of Emergency Medicine, Children's Medical Center, Dallas, TX, USA.
| | - Bethsabee S Stone
- University of Texas Southwestern, Department of Pediatrics, Division of Emergency Medicine, Children's Medical Center, Dallas, TX, USA.
| | - Jiwoong Shin
- University of Texas Southwestern, Department of Pediatrics, Division of Emergency Medicine, Children's Medical Center, Dallas, TX, USA.
| | - Kenneth Yen
- University of Texas Southwestern, Department of Pediatrics, Division of Emergency Medicine, Children's Medical Center, Dallas, TX, USA.
| | - Joan Reisch
- University of Texas Southwestern, School of Public Health, Division of Statistics, Dallas, TX, USA.
| | - Neil Fernandes
- University of Texas Southwestern, Department of Radiology, Division of Pediatric Radiology, Children's Medical Center, Dallas, TX, USA.
| | - Michael C Cooper
- University of Texas Southwestern, Department of Pediatrics, Division of Emergency Medicine, Children's Medical Center, Dallas, TX, USA.
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Jurlina Bs A, Maul T, Hunsaker Bs P, Steffen Bs M, Gawaskar Bs S, Sarandria J, Glass TF, Blake K, Alexander K, Rivera-Sepulveda A. Changes in Bronchiolitis Characteristics During the COVID-19 Pandemic: A Description of Pediatric Emergency Department Visits in a Community Hospital, 2019-2021. Clin Pediatr (Phila) 2024; 63:73-79. [PMID: 37872735 PMCID: PMC11061886 DOI: 10.1177/00099228231208941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
A retrospective, cross-sectional study of children with bronchiolitis aged 1 to 24 months during an ED visit between 2019 and 2021 was performed. Chi-square or Kruskal-Wallis was used to compare groups. The gamma coefficient was used to measure the association of variables through time. Bronchiolitis cases decreased by 75% from 2019 to 2020 and rose back to prepandemic levels by 2021. Radiographs (gamma -0.443), steroids (gamma -0.298), and bronchodilators (gamma -0.414) decreased during the study period (P < .001). Laboratory studies (gamma 0.032), viral testing (gamma 0.097), antibiotic use (gamma -0.069), and respiratory support (gamma 0.166) were unchanged. The decrease in steroids and bronchodilators was related to a clinical pathway that discouraged their use. Respiratory support remained unchanged. The COVID-19 pandemic (2019-2021) seems to have had little effect on the severity or resource utilization associated with bronchiolitis but may have unraveled a potential bronchiolitis phenotype that may have been more prominent during the pandemic.
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Affiliation(s)
- Anna Jurlina Bs
- College of Medicine, University of Central Florida, Orlando, FL, USA
| | - Timothy Maul
- Department of Cardiac Surgery, Nemours Children's Hospital, Orlando, FL, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | | | - John Sarandria
- Division of Hospitalist Medicine, Nemours Children's Health, Orlando, FL, USA
| | - Todd F Glass
- Division of Emergency Medicine and Urgent Care, Nemours Children's Health, Orlando, FL, USA
| | | | - Kenneth Alexander
- Division of Infectious Diseases, Nemours Children's Hospital, Orlando, FL, USA
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Hernández-Villarroel AC, Ruiz-García A, Manzanaro C, Echevarría-Zubero R, Bote-Gascón P, Gonzalez-Bertolin I, Sainz T, Calvo C, Bueno-Campaña M. Lung Ultrasound: A Useful Prognostic Tool in the Management of Bronchiolitis in the Emergency Department. J Pers Med 2023; 13:1624. [PMID: 38138851 PMCID: PMC10745017 DOI: 10.3390/jpm13121624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 11/01/2023] [Accepted: 11/13/2023] [Indexed: 12/24/2023] Open
Abstract
Lung ultrasound, a non-invasive bedside technique for assessing paediatric patients with acute respiratory diseases, is becoming increasingly widespread. The aim of this prospective, observational cohort study was to evaluate the effectiveness of a clinical ultrasound score in assessing infants with acute bronchiolitis in the emergency department and its ability to accurately identify patients at a higher risk of clinical deterioration. Infants under 6 months of age with clinical symptoms compatible with acute bronchiolitis were enrolled and underwent clinical and lung ultrasound evaluations. The study included 50 patients, the median age of which was 2.2 months (IQR: 1-5), and the primary outcome was respiratory support. Infants requiring invasive or non-invasive ventilation showed higher scores (5 points [IQR: 3.5-5.5] vs. 2.5 [IQR: 1.5-4]). The outcome had an AUC of 0.85 (95%CI: 0.7-0.98), with a sensitivity of 87%, specificity of 64%, and negative predictive value of 96.4% for a score <3.5 points. Children who scored ≥3.5 points were more likely to require respiratory support within the next 24 h (estimated event-free survival of 82.9% compared to 100%, log-rank test p-value = 0.02). The results suggest that integrating lung ultrasound findings into clinical scores when evaluating infants with acute bronchiolitis could be a promising tool for improving prognosis.
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Affiliation(s)
- Aiza C. Hernández-Villarroel
- Department of Paediatrics and Neonatology, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain; (A.C.H.-V.); (A.R.-G.); (C.M.)
| | - Alicia Ruiz-García
- Department of Paediatrics and Neonatology, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain; (A.C.H.-V.); (A.R.-G.); (C.M.)
| | - Carlos Manzanaro
- Department of Paediatrics and Neonatology, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain; (A.C.H.-V.); (A.R.-G.); (C.M.)
| | - Regina Echevarría-Zubero
- Department of Paediatrics and Neonatology, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain; (A.C.H.-V.); (A.R.-G.); (C.M.)
| | - Patricia Bote-Gascón
- Paediatric Emergency Department, Hospital Universitario La Paz, 28046 Madrid, Spain; (P.B.-G.); (I.G.-B.)
| | - Isabel Gonzalez-Bertolin
- Paediatric Emergency Department, Hospital Universitario La Paz, 28046 Madrid, Spain; (P.B.-G.); (I.G.-B.)
| | - Talía Sainz
- Department of Paediatrics, Tropical and Infectious Diseases, Hospital Universitario La Paz, 28046 Madrid, Spain; (T.S.); (C.C.)
- IdiPAZ Research Institute, Translational Research Network for Paediatric Infectious Diseases (RITIP), 28029 Madrid, Spain
- Centre for Biomedical Research in Infectious Diseases (CIBERINFEC), 28029 Madrid, Spain
- Department of Paediatrics, Autonomous University of Madrid, 28029 Madrid, Spain
| | - Cristina Calvo
- Department of Paediatrics, Tropical and Infectious Diseases, Hospital Universitario La Paz, 28046 Madrid, Spain; (T.S.); (C.C.)
- IdiPAZ Research Institute, Translational Research Network for Paediatric Infectious Diseases (RITIP), 28029 Madrid, Spain
- Centre for Biomedical Research in Infectious Diseases (CIBERINFEC), 28029 Madrid, Spain
- Department of Paediatrics, Autonomous University of Madrid, 28029 Madrid, Spain
| | - Mercedes Bueno-Campaña
- Department of Paediatrics and Neonatology, Hospital Universitario Fundación Alcorcón, 28922 Madrid, Spain; (A.C.H.-V.); (A.R.-G.); (C.M.)
- IdiPAZ Research Institute, Translational Research Network for Paediatric Infectious Diseases (RITIP), 28029 Madrid, Spain
- Centre for Biomedical Research in Infectious Diseases (CIBERINFEC), 28029 Madrid, Spain
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6
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Ajayi OO, Ajufo A, Ekpa QL, Alabi PO, Babalola F, Omar ZTO, Ekanem M, Ezuma-Ebong C, Ogunshola OS, Akahara DE, Manandhar S, Okobi OE. Evaluation of Bronchiolitis in the Pediatric Population in the United States of America and Canada: A Ten-Year Review. Cureus 2023; 15:e43393. [PMID: 37706121 PMCID: PMC10495256 DOI: 10.7759/cureus.43393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2023] [Indexed: 09/15/2023] Open
Abstract
Bronchiolitis is a well-known viral infection among the pediatric population, significantly impacting hospitalization rates. The COVID-19 pandemic profoundly affected respiratory viral infections, including bronchiolitis, as various mitigation measures were implemented. In this study, we analyzed bronchiolitis cases during the pandemic and post-pandemic period, aiming to identify changes in management guidelines and their incidence and management over the last 10 years. Moreover, we explored the relationship between bronchiolitis and COVID-19, a virus that gained rapid notoriety worldwide. By analyzing data from pediatric populations in Canada and the USA, we sought to understand the role of varying seasons in the peak periods of bronchiolitis infections. The comprehensive review's results will provide valuable insights into bronchiolitis dynamics within the context of the COVID-19 pandemic. Our aim is to better comprehend the interplay between bronchiolitis, COVID-19, and seasonal variations, ultimately contributing to a deeper understanding of this respiratory viral infection and informing future management strategies. Furthermore, these findings can assist healthcare professionals in preparing for and responding to potential fluctuations in bronchiolitis cases in the post-pandemic era.
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Affiliation(s)
- Olamide O Ajayi
- Internal Medicine, Obafemi Awolowo College of Health Sciences, Olabisi Onabanjo University, Sagamu, NGA
| | - Afomachukwu Ajufo
- Internal Medicine and Pediatrics, All Saints University, Roseau, DMA
| | - Queen L Ekpa
- General Practice, Conestoga College, Kitchener, CAN
| | - Peace O Alabi
- Pediatrics, University of Abuja Teaching Hospital, Abuja, NGA
| | - Funmilola Babalola
- Epidemiology and Public Health, Texas Department of State Health Services, San Antonio, USA
| | | | - Medara Ekanem
- General Medicine, Babcock University Teaching Hospital, Ogun, NGA
| | | | | | | | | | - Okelue E Okobi
- Family Medicine, Larkin Community Hospital Palm Springs Campus, Miami, USA
- Family Medicine, Medficient Health Systems, Laurel, USA
- Family Medicine, Lakeside Medical Center, Belle Glade, USA
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7
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De Rose DU, Maddaloni C, Martini L, Braguglia A, Dotta A, Auriti C. Comparison of three clinical scoring tools for bronchiolitis to predict the need for respiratory support and length of stay in neonates and infants up to three months of age. Front Pediatr 2023; 11:1040354. [PMID: 36873647 PMCID: PMC9983816 DOI: 10.3389/fped.2023.1040354] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 01/30/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Bronchiolitis severity can be assessed using different clinical scores. Some of the most used are the Wang Bronchiolitis Severity Score (WBSS), the Kristjansson Respiratory Score (KRS), and the Global Respiratory Severity Score (GRSS), calculated on the vital parameters and the clinical conditions. OBJECTIVE To assess which of the three clinical scores better predicts the need for respiratory support and length of hospital stay in neonates and infants younger than three months, admitted to neonatal units for bronchiolitis. METHODS Neonates and infants younger than three months admitted to neonatal units from October 2021 to March 2022 were included in this retrospective study. The scores were calculated in all patients soon after admission. RESULTS Ninety-six patients (of whom 61 neonates) admitted for bronchiolitis were included in the analysis. Median WBSS at admission was 4.00 (interquartile range, IQR 3.00-6.00), median KRS was 4.00 (IQR 3.00-5.00), and median GRSS 4.90 (IQR 3.89-6.10). We found significant differences in all three scores between infants who needed respiratory support (72.9%) and those who did not (27.1%) (p < 0.001). A value >3 for WBSS, > 3 for KRS, and >3.8 for GRSS were accurate in predicting the need for respiratory support, with a sensitivity of 85.71%, 75.71%, and 93.75% and a specificity of 80.77%, 92.31%, and 88.24%, respectively. The three infants who required mechanical ventilation had a median WBSS of 6.00 (IQR 5.00-6.50), a KRS of 7.00 (IQR 5.00-7.00), and a GRSS of 7.38 (IQR 5.59-7.39). The median length of stay was 5 days (IQR 4-8). All three scores were significantly correlated with the length of stay, although with a low correlation coefficient: WBSS with an r2 of 0.139 (p < 0.001), KRS with an r2 of 0.137 (p < 0.001), and GRSS with an r2 of 0.170 (p < 0.001). CONCLUSION Clinical scores WBSS, KRS, and GRSS calculated on admission accurately predict the need for respiratory support and the length of hospital stay in neonates and infants younger than three months with bronchiolitis. The GRSS score seems to better discriminate the need for respiratory support than the others.
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Affiliation(s)
| | - Chiara Maddaloni
- Neonatal Intensive Care Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Ludovica Martini
- Neonatal Intensive Care Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Annabella Braguglia
- Neonatal Sub-Intensive Care Unit and Follow-up, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Andrea Dotta
- Neonatal Intensive Care Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Cinzia Auriti
- Neonatal Intensive Care Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
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8
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Acute bronchiolitis: Experience of home oxygen therapy in “Hospital at Home” care from 2012 to 2014. Arch Pediatr 2022; 29:610-614. [DOI: 10.1016/j.arcped.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 02/14/2022] [Accepted: 08/04/2022] [Indexed: 11/05/2022]
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9
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Makrinioti H, Maggina P, Lakoumentas J, Xepapadaki P, Taka S, Megremis S, Manioudaki M, Johnston SL, Tsolia M, Papaevangelou V, Papadopoulos NG. Recurrent Wheeze Exacerbations Following Acute Bronchiolitis-A Machine Learning Approach. FRONTIERS IN ALLERGY 2022; 2:728389. [PMID: 35387034 PMCID: PMC8974688 DOI: 10.3389/falgy.2021.728389] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/29/2021] [Indexed: 01/01/2023] Open
Abstract
Introduction: Acute bronchiolitis is one of the most common respiratory infections in infancy. Although most infants with bronchiolitis do not get hospitalized, infants with hospitalized bronchiolitis are more likely to develop wheeze exacerbations during the first years of life. The objective of this prospective cohort study was to develop machine learning models to predict incidence and persistence of wheeze exacerbations following the first hospitalized episode of acute bronchiolitis. Methods: One hundred thirty-one otherwise healthy term infants hospitalized with the first episode of bronchiolitis at a tertiary pediatric hospital in Athens, Greece, and 73 age-matched controls were recruited. All patients/controls were followed up for 3 years with 6-monthly telephone reviews. Through principal component analysis (PCA), a cluster model was used to describe main outcomes. Associations between virus type and the clusters and between virus type and other clinical characteristics and demographic data were identified. Through random forest classification, a prediction model with smallest classification error was identified. Primary outcomes included the incidence and the number of caregiver-reported wheeze exacerbations. Results: PCA identified 2 clusters of the outcome measures (Cluster 1 and Cluster 2) that were significantly associated with the number of recurrent wheeze episodes over 3-years of follow-up (Chi-Squared, p < 0.001). Cluster 1 included infants who presented higher number of wheeze exacerbations over follow-up time. Rhinovirus (RV) detection was more common in Cluster 1 and was more strongly associated with clinical severity on admission (p < 0.01). A prediction model based on virus type and clinical severity could predict Cluster 1 with an overall error 0.1145 (sensitivity 75.56% and specificity 91.86%). Conclusion: A prediction model based on virus type and clinical severity of first hospitalized episode of bronchiolitis could predict sensitively the incidence and persistence of wheeze exacerbations during a 3-year follow-up. Virus type (RV) was the strongest predictor.
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Affiliation(s)
- Heidi Makrinioti
- West Middlesex University Hospital, Chelsea and Westminster Foundation Trust, Isleworth, United Kingdom.,Centre for Paediatrics and Child Health, Imperial College London, London, United Kingdom
| | - Paraskevi Maggina
- Allergy and Clinical Immunology Laboratory, Second Department of Pediatrics, National and Kapodistrian University of Athens (NKUA), School of Medicine, P. and A. Kyriakou Children's Hospital, Athens, Greece
| | - John Lakoumentas
- Allergy and Clinical Immunology Laboratory, Second Department of Pediatrics, National and Kapodistrian University of Athens (NKUA), School of Medicine, P. and A. Kyriakou Children's Hospital, Athens, Greece
| | - Paraskevi Xepapadaki
- Allergy and Clinical Immunology Laboratory, Second Department of Pediatrics, National and Kapodistrian University of Athens (NKUA), School of Medicine, P. and A. Kyriakou Children's Hospital, Athens, Greece
| | - Stella Taka
- Allergy and Clinical Immunology Laboratory, Second Department of Pediatrics, National and Kapodistrian University of Athens (NKUA), School of Medicine, P. and A. Kyriakou Children's Hospital, Athens, Greece
| | - Spyridon Megremis
- Division of Evolution, Infection and Genomics, University of Manchester, Manchester, United Kingdom
| | - Maria Manioudaki
- Allergy and Clinical Immunology Laboratory, Second Department of Pediatrics, National and Kapodistrian University of Athens (NKUA), School of Medicine, P. and A. Kyriakou Children's Hospital, Athens, Greece
| | - Sebastian L Johnston
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Maria Tsolia
- Second Department of Pediatrics, National and Kapodistrian University of Athens (NKUA), School of Medicine, P. and A. Kyriakou Children's Hospital, Athens, Greece
| | - Vassiliki Papaevangelou
- Third Department of Paediatrics, Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos G Papadopoulos
- Allergy and Clinical Immunology Laboratory, Second Department of Pediatrics, National and Kapodistrian University of Athens (NKUA), School of Medicine, P. and A. Kyriakou Children's Hospital, Athens, Greece.,Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, United Kingdom
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10
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Nagakura A, Morikawa Y, Takasugi N, Funakoshi H, Miura Y, Ota T, Shimizu A, Shimizu K, Shirane S, Hataya H. Oxygen saturation targets in pediatric respiratory disease. Pediatr Int 2022; 64:e15129. [PMID: 35616158 DOI: 10.1111/ped.15129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 12/09/2021] [Accepted: 01/11/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The present study aimed to assess the appropriate oxygen saturation target in patients with pediatric respiratory diseases by lowering the oxygen saturation target from SpO2 94% to 90%. No previous study has explored appropriate oxygen saturation targets in respiratory diseases other than bronchiolitis. METHODS The present, prospective, single-arm intervention trial enrolled pediatric inpatients with bronchiolitis, bronchitis, pneumonia, and asthma. The oxygen saturation target was lowered from SpO2 94% to 90% after the patients' general condition improved. The patients continued to be observed for 12 h after achieving SpO2 94%. The duration from the first cut-off point (SpO2 90% for 12 h without oxygen) to the second cut-off point (SpO2 94% for 12 h) was then evaluated. RESULTS In total, 248 patients completed the study. Patients with bronchiolitis, bronchitis, pneumonia, and asthma had an interval between the two cut-off points of 23.9, 15.5, 19.1, and 13.8 h, respectively, (mean 17.2 h; 95% confidence interval 15.0-19.5). CONCLUSIONS In generally healthy children, setting the oxygen saturation target at SpO2 90% after confirming improvement in their general condition was safe. The time required for increasing SpO2 from 90% to 94% was longest in the patients with bronchiolitis.
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Affiliation(s)
- Akito Nagakura
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yoshihiko Morikawa
- Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Nao Takasugi
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hanako Funakoshi
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yoko Miura
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Tomomi Ota
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Ayumi Shimizu
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Keisuke Shimizu
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Shoichiro Shirane
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hiroshi Hataya
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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11
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Rivera-Sepúlveda A, García-Rivera E, Castro M, Soto F. Risk Factors Associated With Bronchiolitis in Puerto Rican Children. Pediatr Emerg Care 2021; 37:e1593-e1599. [PMID: 32530834 PMCID: PMC7728621 DOI: 10.1097/pec.0000000000002130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to identify frequency, severity, and risk factors associated with bronchiolitis in Puerto Rican children. METHODS A cross-sectional was study performed at 4 emergency departments of Puerto Rico's metropolitan area, between June 2014 and May 2015. We included children younger than 24 months, with a clinical diagnosis of bronchiolitis, who were born and living in Puerto Rico at the time of recruitment. A physician-administered questionnaire inquiring about the patient's medical, family, and social history and a bronchiolitis severity assessment were performed. Daily weather conditions were monitored, and aeroallergens were collected with an air sample and precision weather station within the metropolitan area to evaluate environmental factors. RESULTS We included 600 patients for 12 months. More than 50% of the recruited patients had a previous episode of bronchiolitis, of which 40% had been hospitalized. Older age (odds ratio [OR], 18.3; 95% confidence interval [CI], 9.2-36.5), male sex (OR, 1.6; 95% CI, 1.1-2.4), history of asthma (OR, 8.9; 95% CI, 3.6-22), allergic rhinitis (OR, 3.6; 95% CI, 1.8-7.4), and smoke exposure by a caretaker (OR, 2.3; 95% CI, 1.2-4.4) were predictors of bronchiolitis episodes. Bronchiolitis episodes were associated with higher severity score (P = 0.040), increased number of atopic factors (P < 0.001), and higher number of hospitalizations (P < 0.001). CONCLUSIONS This study identifies Puerto Rican children who may present a severe clinical course of disease without traditional risk factors. Atopy-related factors are associated with frequency and severity of bronchiolitis. Puerto Rican children present risk factors related to atopy earlier in life, some of which may be modified to prevent the subsequent development of asthma.
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Affiliation(s)
| | | | - Mario Castro
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St Louis, MO
| | - Fernando Soto
- Department of Emergency Medicine, School of Medicine, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico
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12
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Kubota J, Hirano D, Okabe S, Yamauchi K, Kimura R, Numata H, Suzuki T, Kakegawa D, Ito A. Utility of the Global Respiratory Severity Score for predicting the need for respiratory support in infants with respiratory syncytial virus infection. PLoS One 2021; 16:e0253532. [PMID: 34197495 PMCID: PMC8248615 DOI: 10.1371/journal.pone.0253532] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 06/07/2021] [Indexed: 11/18/2022] Open
Abstract
Background Respiratory syncytial virus (RSV) is a common cause of acute respiratory infection in children. One of the most important strategies for treatment of an RSV infection is to decide whether the patient needs respiratory support. This study aimed to assess the validity and clinical benefit of the Global Respiratory Severity Score (GRSS) and the Wang bronchiolitis severity score (WBSS) for clinical decision-making regarding providing respiratory support (high-flow nasal cannula, nasal continuous positive airway pressure, or ventilator) in infants with an RSV infection. Study design and methods This retrospective cohort study enrolled 250 infants aged under 10 months who were admitted to Atsugi City Hospital with an RSV infection between January 2012 and December 2019. The utility of these scores was evaluated for assessing the need for respiratory support through decision curve analysis by calculating the optimal GRSS and WBSS cut-offs for predicting the need for respiratory support. Results Twenty-six infants (10.4%) received respiratory support. The optimal cut-offs for the GRSS and the WBSS were 4.52 and 7, respectively. Decision curve analysis suggested that the GRSS was a better predictive tool than the WBSS if the probability of needing respiratory support was 10–40%. Conclusions The GRSS was clinically useful in determining the need for respiratory support in infants aged under 10 months with an RSV infection.
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Affiliation(s)
- Jun Kubota
- Department of Pediatrics, Atsugi City Hospital, Kanagawa, Japan.,Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan
| | - Daishi Hirano
- Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan
| | - Shiro Okabe
- Department of Pediatrics, Atsugi City Hospital, Kanagawa, Japan.,Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan
| | - Kento Yamauchi
- Department of Pediatrics, Atsugi City Hospital, Kanagawa, Japan.,Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan
| | - Rena Kimura
- Department of Pediatrics, Atsugi City Hospital, Kanagawa, Japan.,Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan
| | - Haruka Numata
- Department of Pediatrics, Atsugi City Hospital, Kanagawa, Japan.,Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan
| | - Takayuki Suzuki
- Department of Pediatrics, Atsugi City Hospital, Kanagawa, Japan.,Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan
| | - Daisuke Kakegawa
- Department of Pediatrics, Atsugi City Hospital, Kanagawa, Japan.,Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan
| | - Akira Ito
- Department of Pediatrics, Atsugi City Hospital, Kanagawa, Japan.,Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan
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13
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Wang L, Chu CY, McCall MN, Slaunwhite C, Holden-Wiltse J, Corbett A, Falsey AR, Topham DJ, Caserta MT, Mariani TJ, Walsh EE, Qiu X. Airway gene-expression classifiers for respiratory syncytial virus (RSV) disease severity in infants. BMC Med Genomics 2021; 14:57. [PMID: 33632195 PMCID: PMC7908785 DOI: 10.1186/s12920-021-00913-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 02/19/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND A substantial number of infants infected with RSV develop severe symptoms requiring hospitalization. We currently lack accurate biomarkers that are associated with severe illness. METHOD We defined airway gene expression profiles based on RNA sequencing from nasal brush samples from 106 full-tem previously healthy RSV infected subjects during acute infection (day 1-10 of illness) and convalescence stage (day 28 of illness). All subjects were assigned a clinical illness severity score (GRSS). Using AIC-based model selection, we built a sparse linear correlate of GRSS based on 41 genes (NGSS1). We also built an alternate model based upon 13 genes associated with severe infection acutely but displaying stable expression over time (NGSS2). RESULTS NGSS1 is strongly correlated with the disease severity, demonstrating a naïve correlation (ρ) of ρ = 0.935 and cross-validated correlation of 0.813. As a binary classifier (mild versus severe), NGSS1 correctly classifies disease severity in 89.6% of the subjects following cross-validation. NGSS2 has slightly less, but comparable, accuracy with a cross-validated correlation of 0.741 and classification accuracy of 84.0%. CONCLUSION Airway gene expression patterns, obtained following a minimally-invasive procedure, have potential utility for development of clinically useful biomarkers that correlate with disease severity in primary RSV infection.
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Affiliation(s)
- Lu Wang
- Department of Biostatistics and Computational Biology, University of Rochester School Medicine, Rochester, NY, USA
| | - Chin-Yi Chu
- Department of Pediatrics, University of Rochester School Medicine, Rochester, NY, USA
| | - Matthew N McCall
- Department of Biostatistics and Computational Biology, University of Rochester School Medicine, Rochester, NY, USA
| | | | - Jeanne Holden-Wiltse
- Department of Biostatistics and Computational Biology, University of Rochester School Medicine, Rochester, NY, USA
| | - Anthony Corbett
- Department of Biostatistics and Computational Biology, University of Rochester School Medicine, Rochester, NY, USA
| | - Ann R Falsey
- Department of Medicine, University of Rochester School Medicine, Rochester, NY, USA
- Department of Medicine, Rochester General Hospital, Rochester, NY, USA
| | - David J Topham
- Department of Microbiology and Immunology, University of Rochester School Medicine, Rochester, NY, USA
| | - Mary T Caserta
- Department of Pediatrics, University of Rochester School Medicine, Rochester, NY, USA
| | - Thomas J Mariani
- Department of Pediatrics, University of Rochester School Medicine, Rochester, NY, USA.
| | - Edward E Walsh
- Department of Medicine, University of Rochester School Medicine, Rochester, NY, USA.
- Department of Medicine, Rochester General Hospital, Rochester, NY, USA.
| | - Xing Qiu
- Department of Biostatistics and Computational Biology, University of Rochester School Medicine, Rochester, NY, USA.
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14
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Buendia JA, Guerrero Patino D. Importance of respiratory syncytial virus as a predictor of hospital length of stay in bronchiolitis. F1000Res 2021; 10:110. [PMID: 35903216 PMCID: PMC9277196 DOI: 10.12688/f1000research.40670.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2021] [Indexed: 09/01/2024] Open
Abstract
IIntroduction : Bronchiolitis is the leading cause of hospitalization in children. Estimate potentially preventable variables that impact the length of hospital stay are a priority to reduce the costs associated with this disease. This study aims to identify clinical variables associated with length of hospital stay of bronchiolitis in children in a tropical middle-income country Methods: We conducted a retrospective cohort study in 417 infants with bronchiolitis in tertiary centers in Colombia. All medical records of all patients admitted to the emergency department were reviewed. To identify factors independently associated we use negative binomial regression model, to estimate incidence rate ratios (IRR) and adjust for potential confounding variables Results : The median of the length of hospital stay was 3.68 days, with a range of 0.74 days to 29 days, 138 (33.17%) of patients have a hospital stay of 5 or more days. After modeling and controlling for potential confounders age <6 months, comorbidities (CHD or neurological), BPD, chest indrawing, RSV isolation, and C-reactive protein were independent predictors of LOS Conclusions : Our results show that in infants with bronchiolitis, RSV isolation, age <6 months, comorbidities (CHD or neurological), BPD, chest indrawing, and C-reactive protein were independent predictors of LOS. As a potentially modifiable risk factor, efforts to reduce the probability of RSV infection can reduce the high medical cost associates with prolonged LOS in bronchiolitis.
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Affiliation(s)
- Jefferson Antonio Buendia
- Pharmacology and Toxicology Department, Pharmacology and Toxicology Research Group, Faculty of Medicine, Universidad de Antioquia., Medellín, Antioquia, 053212, Colombia
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15
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Buendia JA, Guerrero Patino D. Importance of respiratory syncytial virus as a predictor of hospital length of stay in bronchiolitis. F1000Res 2021; 10:110. [PMID: 35903216 PMCID: PMC9277196 DOI: 10.12688/f1000research.40670.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2021] [Indexed: 09/01/2024] Open
Abstract
Introduction: Bronchiolitis is the leading cause of hospitalization in children. Estimate potentially preventable variables that impact the length of hospital stay are a priority to reduce the costs associated with this disease. This study aims to identify clinical variables associated with length of hospital stay of bronchiolitis in children in a tropical middle-income country Methods: We conducted a retrospective cohort study in 417 infants with bronchiolitis in tertiary centers in Colombia. All medical records of all patients admitted to the emergency department were reviewed. To identify factors independently associated we use negative binomial regression model, to estimate incidence rate ratios (IRR) and adjust for potential confounding variables Results: The median of the length of hospital stay was 3.68 days, with a range of 0.74 days to 29 days, 138 (33.17%) of patients have a hospital stay of 5 or more days. After modeling and controlling for potential confounders age <6 months, comorbidities (CHD or neurological), BPD, chest indrawing, RSV isolation, and C-reactive protein were independent predictors of LOS Conclusions: Our results show that in infants with bronchiolitis, RSV isolation, age <6 months, comorbidities (CHD or neurological), BPD, chest indrawing, and C-reactive protein were independent predictors of LOS. As a potentially modifiable risk factor, efforts to reduce the probability of RSV infection can reduce the high medical cost associates with prolonged LOS in bronchiolitis.
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Affiliation(s)
- Jefferson Antonio Buendia
- Pharmacology and Toxicology Department, Pharmacology and Toxicology Research Group, Faculty of Medicine, Universidad de Antioquia., Medellín, Antioquia, 053212, Colombia
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16
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Buendia JA, Guerrero Patino D. Importance of respiratory syncytial virus as a predictor of hospital length of stay in bronchiolitis. F1000Res 2021; 10:110. [PMID: 35903216 PMCID: PMC9277196 DOI: 10.12688/f1000research.40670.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction : Bronchiolitis is the leading cause of hospitalization in children. Estimate potentially preventable variables that impact the length of hospital stay are a priority to reduce the costs associated with this disease. This study aims to identify clinical variables associated with length of hospital stay of bronchiolitis in children in a tropical middle-income country Methods: We conducted a retrospective cohort study in 417 infants with bronchiolitis in tertiary centers in Colombia. All medical records of all patients admitted through the emergency department were reviewed. To identify factors independently associated we use negative binomial regression model, to estimate incidence rate ratios (IRR) and adjust for potential confounding variables Results : The median of the length of hospital stay was 3.68 days, with a range of 0.74 days to 29 days, 138 (33.17%) of patients have a hospital stay of 5 or more days. After modeling and controlling for potential confounders age <6 months, comorbidities (CHD or neurological), BPD, chest indrawing, detection of RSV, and C-reactive protein were independent predictors of LOS Conclusions : Our results show that in infants with bronchiolitis, detection of RSV, age <6 months, comorbidities (CHD or neurological), BPD, chest indrawing, and C-reactive protein were independent predictors of LOS. As a potentially modifiable risk factor, efforts to reduce the probability of RSV infection can reduce the high medical cost associates with prolonged LOS in bronchiolitis.
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Affiliation(s)
- Jefferson Antonio Buendia
- Pharmacology and Toxicology Department, Pharmacology and Toxicology Research Group, Faculty of Medicine, Universidad de Antioquia., Medellín, Antioquia, 053212, Colombia
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17
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Buendia JA, Guerrero Patino D. Importance of respiratory syncytial virus as a predictor of hospital length of stay in bronchiolitis. F1000Res 2021; 10:110. [PMID: 35903216 PMCID: PMC9277196 DOI: 10.12688/f1000research.40670.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2021] [Indexed: 09/01/2024] Open
Abstract
Introduction : Bronchiolitis is the leading cause of hospitalization in children. Estimate potentially preventable variables that impact the length of hospital stay are a priority to reduce the costs associated with this disease. This study aims to identify clinical variables associated with length of hospital stay of bronchiolitis in children in a tropical middle-income country Methods: We conducted a retrospective cohort study in 417 infants with bronchiolitis in tertiary centers in Colombia. All medical records of all patients admitted to the emergency department were reviewed. To identify factors independently associated we use negative binomial regression model, to estimate incidence rate ratios (IRR) and adjust for potential confounding variables Results : The median of the length of hospital stay was 3.68 days, with a range of 0.74 days to 29 days, 138 (33.17%) of patients have a hospital stay of 5 or more days. After modeling and controlling for potential confounders age <6 months, comorbidities (CHD or neurological), BPD, chest indrawing, RSV isolation, and C-reactive protein were independent predictors of LOS Conclusions : Our results show that in infants with bronchiolitis, RSV isolation, age <6 months, comorbidities (CHD or neurological), BPD, chest indrawing, and C-reactive protein were independent predictors of LOS. As a potentially modifiable risk factor, efforts to reduce the probability of RSV infection can reduce the high medical cost associates with prolonged LOS in bronchiolitis.
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Affiliation(s)
- Jefferson Antonio Buendia
- Pharmacology and Toxicology Department, Pharmacology and Toxicology Research Group, Faculty of Medicine, Universidad de Antioquia., Medellín, Antioquia, 053212, Colombia
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18
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Havdal LB, Nakstad B, Fjærli HO, Ness C, Inchley C. Viral lower respiratory tract infections-strict admission guidelines for young children can safely reduce admissions. Eur J Pediatr 2021; 180:2473-2483. [PMID: 33834273 PMCID: PMC8285352 DOI: 10.1007/s00431-021-04057-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 03/13/2021] [Accepted: 03/29/2021] [Indexed: 01/11/2023]
Abstract
Viral lower respiratory tract infection (VLRTI) is the most common cause of hospital admission among small children in high-income countries. Guidelines to identify children in need of admission are lacking in the literature. In December 2012, our hospital introduced strict guidelines for admission. This study aims to retrospectively evaluate the safety and efficacy of the guidelines. We performed a single-center retrospective administrative database search and medical record review. ICD-10 codes identified children < 24 months assessed at the emergency department for VLRTI for a 10-year period. To identify adverse events related to admission guidelines implementation, we reviewed patient records for all those discharged on primary contact followed by readmission within 14 days. During the study period, 3227 children younger than 24 months old were assessed in the ED for VLRTI. The proportion of severe adverse events among children who were discharged on their initial emergency department contact was low both before (0.3%) and after the intervention (0.5%) (p=1.0). Admission rates before vs. after the intervention were for previously healthy children > 90 days 65.3% vs. 53.3% (p<0.001); for healthy children ≤ 90 days 85% vs. 68% (p<0.001); and for high-risk comorbidities 74% vs. 71% (p=0.5).Conclusion: After implementation of admission guidelines for VLRTI, there were few adverse events and a significant reduction in admissions to the hospital from the emergency department. Our admission guidelines may be a safe and helpful tool in the assessment of children with VLRTI. What is Known: • Viral lower respiratory tract infection, including bronchiolitis, is the most common cause of hospitalization for young children in the developed world. Treatment is mainly supportive, and hospitalization should be limited to the cases in need of therapeutic intervention. • Many countries have guidelines for the management of the disease, but the decision on whom to admit for inpatient treatment is often subjective and may vary even between physicians in the same hospital. What is New: • Implementation of admission criteria for viral lower respiratory tract infection may reduce the rate of hospital admissions without increasing adverse events.
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Affiliation(s)
- Lise Beier Havdal
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Sykehusveien 25, 1478, Nordbyhagen, Norway. .,Division of Paediatric and Adolescent Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Britt Nakstad
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Hans Olav Fjærli
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Sykehusveien 25, 1478, Nordbyhagen, Norway
| | - Christian Ness
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Sykehusveien 25, 1478, Nordbyhagen, Norway
| | - Christopher Inchley
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Sykehusveien 25, 1478, Nordbyhagen, Norway
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Stollar F, Glangetas A, Luterbacher F, Gervaix A, Barazzone-Argiroffo C, Galetto-Lacour A. Frequency, Timing, Risk Factors, and Outcomes of Desaturation in Infants With Acute Bronchiolitis and Initially Normal Oxygen Saturation. JAMA Netw Open 2020; 3:e2030905. [PMID: 33355677 PMCID: PMC7758807 DOI: 10.1001/jamanetworkopen.2020.30905] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Little is known about the natural course of oxygen desaturation in acute bronchiolitis. Information on risk factors associated with desaturation as well as the time to desaturation in infants with bronchiolitis could help physicians better treat these infants before deciding whether to hospitalize them. OBJECTIVE To prospectively determine the frequency of desaturation in infants with bronchiolitis, along with the time to desaturation and risk factors associated with desaturation, and to compare infants who were hospitalized with those discharged home and evaluate risk factors for rehospitalization. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted during the 2017 to 2018 and 2018 to 2019 respiratory syncytial virus seasons in a tertiary care pediatric emergency department in Switzerland. Included individuals were 239 otherwise-healthy infants aged younger than 1 year, diagnosed with acute bronchiolitis and oxygen saturation of 90% or more on arrival. Data were analyzed from July 2019 to October 2020. EXPOSURES After receiving triage care, study participants admitted to the emergency department were equipped with a pulse oximeter to continuously record oxygen saturation (Spo2 levels), regardless of subsequent hospitalization or discharge home. MAIN OUTCOMES AND MEASURES The primary outcome was desaturation (ie, Spo2 < 90%) during the first 36 hours. RESULTS Of 239 infants enrolled, with a median (interquartile range [IQR]) age of 3.9 (1.5-6.5) months, 116 (48.5%) were boys and desaturation occurred in 165 infants (69.0%). Median (IQR) time to desaturation was 3.6 (1.8-9.4) hours. The rate of desaturation was similar between infants hospitalized and those discharged home (137 of 200 infants [68.5%] vs 28 of 39 infants [71.8%]; difference, -3.3%; 95% CI, -18.8% to 12.2%; P = .85). A more severe initial clinical presentation with moderate or severe retractions was the only independent risk factor associated with desaturation (odds ratio, 2.73; 95% CI, 1.49 to 5.02; P = .001). Of 39 infants discharged home, 22 infants (56.4%) experienced major desaturations. However, infants with desaturations, including those with major desaturations, had rates of rehospitalization similar to those of infants without desaturations (8 of 28 infants [28.5%] vs 3 of 11 infants [27.3%]; difference, 1.2%; 95% CI, -29.9% to 32.5; P > .99). CONCLUSIONS AND RELEVANCE These findings suggest that rates of desaturation in infants with acute bronchiolitis were high and similar between infants who were hospitalized and those discharged home. A more severe initial clinical presentation was the only risk factor associated with desaturation. However, for infants discharged home, desaturation was not a risk factor associated with rehospitalization.
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Affiliation(s)
- Fabiola Stollar
- General Pediatric Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Alban Glangetas
- Pediatric Emergency Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Fanny Luterbacher
- Pediatric Emergency Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Alain Gervaix
- Pediatric Emergency Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Constance Barazzone-Argiroffo
- Pediatric Pulmonology Unit, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Annick Galetto-Lacour
- Pediatric Emergency Division, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
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20
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Nonoyama ML, Kukreti V, Papaconstantinou E, D'cruz RR. Assessing physical and respiratory distress in children with bronchiolitis admitted to a community hospital emergency department: A retrospective chart review. CANADIAN JOURNAL OF RESPIRATORY THERAPY : CJRT = REVUE CANADIENNE DE LA THERAPIE RESPIRATOIRE : RCTR 2019; 55:16-20. [PMID: 31297441 PMCID: PMC6591780 DOI: 10.29390/cjrt-2018-021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Introduction Bronchiolitis is a leading cause of infant hospitalization with wide variation in its diagnosis and management, especially in smaller community hospitals. The objective of this study is to describe children admitted to a community-based hospital emergency department (ED) for bronchiolitis and explore alternate assessments of illness severity. Methods A retrospective chart review (January to September 2014) of 100 children, < 2 years old and meeting International Classification of Diseases 10 for bronchiolitis. Outcomes included demographics, symptoms, and interventions. In addition, the Respiratory Distress Assessment Instrument (RDAI) score was calculated using documented assessments of wheezing and retractions. Descriptive and comparative statistics were completed with p < 0.05 considered significant. Results The mean (standard deviation) age 10.6 (8.4) months, n = 41 females. Sixty-seven percent had a chest X-ray (CXR), 17% oral antibiotics, 65% bronchodilators, and 19% oral steroids; 19% were admitted in hospital. There was a significant difference in RDAI score between those given oral antibiotics (mean (95% CI), 6.35 (4.96–7.75)) versus not (4.70 (4.20–5.20)), p = 0.01. Those who received a CXR had a significantly higher oxygen flowrate (1.4 (0.6–2.1) litres per minute (lpm)) and worse physical appearance (tri-pod position, head bobbing) versus those who did not (0.15 (–0.05 to 0.35) lpm), p = 0.002 and p = 0.04, respectively. Conclusions A large number of children admitted to a community-based ED for bronchiolitis received unnecessary CXR and medications. Assessing physical and respiratory distress may be more effective at determining illness severity compared with radiological or laboratory testing. Local clinical practice guidelines may aid in optimal management of bronchiolitis for community-based EDs.
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Affiliation(s)
- Mika L Nonoyama
- Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Canada.,Department of Respiratory Therapy, Hospital for Sick Children, Toronto, Canada.,Department of Physical Therapy and Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
| | | | - Efrosini Papaconstantinou
- Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Canada.,University of Ontario Institute of Technology-Canadian Memorial Chiropractic College Centre for Disability Prevention and Rehabilitation, Oshawa and Toronto, Canada
| | - Rayona Raymond D'cruz
- Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Canada
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21
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Bueno-Campaña M, Sainz T, Alba M, Del Rosal T, Mendez-Echevarría A, Echevarria R, Tagarro A, Ruperez-Lucas M, Herrreros ML, Latorre L, Calvo C. Lung ultrasound for prediction of respiratory support in infants with acute bronchiolitis: A cohort study. Pediatr Pulmonol 2019; 54:873-880. [PMID: 30838805 DOI: 10.1002/ppul.24287] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 01/31/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Respiratory tract infections are among the most common causes of morbidity and mortality worldwide. Acute bronchiolitis (AB) is the leading cause of hospital admission among infants. Clinical scores have proven to be inaccurate in predicting prognosis. Our aim was to build a score based on findings of lung ultrasound (LU) performed at admission, to stratify patients at risk of needing respiratory support (non-invasive and invasive ventilation). STUDY DESIGN Prospective, multicenter study including infants <6 months of age admitted with AB. Point-of-care LU was performed on admission, and a score was calculated based on ultrasound findings (presence and localization of B lines, B line confluence and/or consolidations) and clinical data. Main outcome was need of respiratory support. RESULTS A total of 145 patients were included in the study, with a median age of 1.7 months [IQR: 1.2-2.8], 47.6% were female. Mean duration of symptoms prior to admission was 3.1 days (SD 1.8). Fifty-six patients (39%) required non-invasive ventilation (NIV), 14 (9.7%) were transferred to PICU, and 3 needed invasive ventilation (3/145). Identification of at least one posterior consolidation >1 cm was the main factor associated to NIV (RR 4.4; [CI95%1.8-10.8]) The LU score built according to the findings on admission showed an AUC: 0.845(CI95%:0.78-0.91). A score ≥3.5 showed a sensitivity of 89.1% (CI95%:78.2-94.9%) and specificity of 56% (CI95%: 45.3-66.1%) CONCLUSIONS: Among infants below 6 months of age admitted with AB, point-of-care LU was a helpful tool to identify patients at risk of needing respiratory support.
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Affiliation(s)
- Mercedes Bueno-Campaña
- Department of Pediatrics and Neonatology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Talía Sainz
- Department of Pediatrics, Tropical and Infectious Diseases, Hospital Universitario La Paz and IdiPAZ Research Institute, Madrid, Spain.,Translational Research Network for Pediatric Infectious Diseases (RITIP), Madrid, Spain
| | - Maria Alba
- Department of Pediatrics and Neonatology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Teresa Del Rosal
- Department of Pediatrics, Tropical and Infectious Diseases, Hospital Universitario La Paz and IdiPAZ Research Institute, Madrid, Spain.,Translational Research Network for Pediatric Infectious Diseases (RITIP), Madrid, Spain
| | - Ana Mendez-Echevarría
- Department of Pediatrics, Tropical and Infectious Diseases, Hospital Universitario La Paz and IdiPAZ Research Institute, Madrid, Spain.,Translational Research Network for Pediatric Infectious Diseases (RITIP), Madrid, Spain
| | - Regina Echevarria
- Department of Pediatrics and Neonatology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Alfredo Tagarro
- Translational Research Network for Pediatric Infectious Diseases (RITIP), Madrid, Spain.,Department of Pediatrics, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain.,Universidad Europea de Madrid, Madrid, Spain
| | - Marta Ruperez-Lucas
- Department of Pediatrics and Neonatology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Maria L Herrreros
- Department of Pediatrics, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - Libertad Latorre
- Department of Pediatrics, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - Cristina Calvo
- Department of Pediatrics, Tropical and Infectious Diseases, Hospital Universitario La Paz and IdiPAZ Research Institute, Madrid, Spain.,Translational Research Network for Pediatric Infectious Diseases (RITIP), Madrid, Spain.,TEDDY Network Member (European Network of Excellence for Pediatric Clinical Research), Bari, Italy
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22
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Chen DY, Zee ED, Gildengorin G, Fong EW. A pilot study of heated and humidified low flow oxygen therapy: An assessment in infants with mild and moderate bronchiolitis (HHOT AIR study). Pediatr Pulmonol 2019; 54:620-627. [PMID: 30887708 DOI: 10.1002/ppul.24267] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 12/19/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND Heated and humidified high flow nasal cannula oxygen therapy has been used in children with severe bronchiolitis. No data exists in children with mild to moderate bronchiolitis requiring lower flows of heated and humidified oxygen therapy. METHODS We conducted a prospective, randomized pilot study of standard dry oxygen (control) versus heated and humidified low flow nasal cannula (HHLFNC), <4 liters per minute (LPM) oxygen, (treatment) in healthy children ≤24 months old with bronchiolitis. Clinical assessments were made using Respiratory Distress Assessment Instrument (RDAI), respiratory rate (RR), and oxygen saturation. RESULTS Thirty-two children were enrolled (16 participants in each group). There was no significant difference in mean RDAI over time between groups. There was a significant difference in mean RDAI over time within control group, at hour 12, and treatment group, at hour 1, compared to baseline. RDAI in the treatment group was overall lower over time compared to control group. There was no significant difference in mean RR over time between or within groups, between mean length of stay and duration of oxygen requirement. Subgroup analyses showed lower RDAI in subjects that had RSV infection, male gender, and non-black race. CONCLUSIONS The use of HHLFNC oxygen therapy may provide more comfort and may result in more rapid improvements in RDAI compared to standard dry oxygen therapy over time. HHFLNC is safe and well tolerated compared to standard dry oxygen. Larger studies are needed to assess the clinical efficacy of HHLFNC oxygen therapy.
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Affiliation(s)
- Diana Y Chen
- Department of Pediatrics, Division of Pediatric Pulmonology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Eric D Zee
- Department of Pediatrics, Division of Pulmonology, Stanford University School of Medicine, Palo Alto, California
| | - Ginny Gildengorin
- Department of Statistics, UCSF Benioff Children's Hospital, Oakland, California
| | - Edward W Fong
- Department of Pediatrics, Section of Pediatric Pulmonology, Kapiolani Medical Center for Women and Children, Honolulu, Hawaii
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23
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Luo G, Stone BL, Nkoy FL, He S, Johnson MD. Predicting Appropriate Hospital Admission of Emergency Department Patients with Bronchiolitis: Secondary Analysis. JMIR Med Inform 2019; 7:e12591. [PMID: 30668518 PMCID: PMC6362392 DOI: 10.2196/12591] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 11/27/2018] [Accepted: 12/12/2018] [Indexed: 11/13/2022] Open
Abstract
Background In children below the age of 2 years, bronchiolitis is the most common reason for hospitalization. Each year in the United States, bronchiolitis causes 287,000 emergency department visits, 32%-40% of which result in hospitalization. Due to a lack of evidence and objective criteria for managing bronchiolitis, clinicians often make emergency department disposition decisions on hospitalization or discharge to home subjectively, leading to large practice variation. Our recent study provided the first operational definition of appropriate hospital admission for emergency department patients with bronchiolitis and showed that 6.08% of emergency department disposition decisions for bronchiolitis were inappropriate. An accurate model for predicting appropriate hospital admission can guide emergency department disposition decisions for bronchiolitis and improve outcomes, but has not been developed thus far. Objective The objective of this study was to develop a reasonably accurate model for predicting appropriate hospital admission. Methods Using Intermountain Healthcare data from 2011-2014, we developed the first machine learning classification model to predict appropriate hospital admission for emergency department patients with bronchiolitis. Results Our model achieved an accuracy of 90.66% (3242/3576, 95% CI: 89.68-91.64), a sensitivity of 92.09% (1083/1176, 95% CI: 90.33-93.56), a specificity of 89.96% (2159/2400, 95% CI: 88.69-91.17), and an area under the receiver operating characteristic curve of 0.960 (95% CI: 0.954-0.966). We identified possible improvements to the model to guide future research on this topic. Conclusions Our model has good accuracy for predicting appropriate hospital admission for emergency department patients with bronchiolitis. With further improvement, our model could serve as a foundation for building decision-support tools to guide disposition decisions for children with bronchiolitis presenting to emergency departments. International Registered Report Identifier (IRRID) RR2-10.2196/resprot.5155
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Affiliation(s)
- Gang Luo
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States
| | - Bryan L Stone
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Flory L Nkoy
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Shan He
- Care Transformation, Intermountain Healthcare, Salt Lake City, UT, United States
| | - Michael D Johnson
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
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24
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Mittal S, Marlowe L, Blakeslee S, Zieniuk G, Doshi S, Gray BJ, Bowen M, Oleaga L, Carbone K, Aumaier BL, Taylor A, Joffe M. Successful Use of Quality Improvement Methodology to Reduce Inpatient Length of Stay in Bronchiolitis Through Judicious Use of Intermittent Pulse Oximetry. Hosp Pediatr 2019; 9:73-78. [PMID: 30606774 DOI: 10.1542/hpeds.2018-0023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES The American Academy of Pediatrics 2014 bronchiolitis guidelines recommend against the routine use of continuous pulse oximetry (CPO) because it has been implicated in prolonging the length of stay (LOS). At our institution, infants admitted with bronchiolitis were monitored by using CPO during the entire hospital stay and intermittent desaturations <90% appeared to delay discharge. This quality improvement initiative was designed to reduce the LOS by decreasing the use of CPO in stable infants with nonsevere bronchiolitis. METHODS The quality improvement project was implemented on the inpatient units of 2 community hospitals during the 2016 and 2017 bronchiolitis seasons. In cycle 1 (January 2016 to April 2016), the bronchiolitis pathway from the associated quaternary children's hospital was used to (1) limit the use of CPO to patients with severe bronchiolitis and those at high risk for apnea or severe disease, (2) discontinue CPO as patients improved and stabilized, and (3) standardize discharge criteria. In cycle 2 (November 2016 to April 2017), the clinical pathway was adopted. The main outcome measure was LOS, measured from the time of the admission order to the time of the discharge order. Process measures included compliance with the interventions. RESULTS The project included 373 patients, 180 preintervention and 193 postintervention. The average LOS decreased by 20 hours, from 53 hours at baseline to 33 hours in cycle 2. No adverse events were noted, and there was no significant change in the number of emergency department revisits and readmissions within 7 days. CONCLUSIONS In our study, LOS was successfully reduced in bronchiolitis patients by using a clinical pathway that limited CPO to patients with severe bronchiolitis and those at risk for severe disease or apnea.
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Affiliation(s)
- Shraddha Mittal
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lauren Marlowe
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Gregory Zieniuk
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Samir Doshi
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bobbi Jo Gray
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Melissa Bowen
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Leslie Oleaga
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kelly Carbone
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - April Taylor
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mark Joffe
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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25
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Gjengstø Hunderi JO, Lødrup Carlsen KC, Rolfsjord LB, Carlsen K, Mowinckel P, Skjerven HO. Parental severity assessment predicts supportive care in infant bronchiolitis. Acta Paediatr 2019; 108:131-137. [PMID: 29889987 DOI: 10.1111/apa.14443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 05/14/2018] [Accepted: 06/07/2018] [Indexed: 11/25/2022]
Abstract
AIM In infants with acute bronchiolitis, the precision of parental disease severity assessment is unclear. We aimed to determine if parental assessment at the time of hospitalisation predicted the use of supportive care, and subsequently determine the likelihood that the infant with acute bronchiolitis would receive supportive care. METHODS From the Bronchiolitis ALL south-east Norway study, we included all 267, 0-12 month old, infants with acute bronchiolitis whose parents at the time of hospitalisation completed a three-item visual analogue scale (VAS) concerning Activity, Feeding and Illness. Respiratory rate, oxygen saturation (SpO2 ) and use of supportive care were recorded daily. By multivariate logistic regression analyses we included significant predictors available at hospital admission to predict the use of supportive care. RESULTS The parental Activity, Feeding and Illness VAS scores significantly predicted supportive care with odds ratios of 1.23, 1.26 and 1.36, respectively. The prediction algorithm included parental Feeding and Illness scores, SpO2 , gender and age, with an area under the curve of 0.76 (95% CI 0.69, 0.81). A positive likelihood ratio of 2.1 gave the highest combined sensitivity of 81% and specificity of 61%. CONCLUSION Parental assessment at hospital admission moderately predicted supportive care treatment in infants with acute bronchiolitis.
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Affiliation(s)
- Jon Olav Gjengstø Hunderi
- Department of Pediatrics and Adolescent Medicine Østfold Hospital Trust Sarpsborg Norway
- Division of Pediatric and Adolescent Medicine Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Karin C. Lødrup Carlsen
- Division of Pediatric and Adolescent Medicine Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Leif Bjarte Rolfsjord
- Institute of Clinical Medicine University of Oslo Oslo Norway
- Department of Pediatrics Innlandet Hospital Trust Elverum Norway
| | - Kai‐Håkon Carlsen
- Division of Pediatric and Adolescent Medicine Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Petter Mowinckel
- Division of Pediatric and Adolescent Medicine Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Håvard Ove Skjerven
- Division of Pediatric and Adolescent Medicine Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
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26
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Luo G, Johnson MD, Nkoy FL, He S, Stone BL. Appropriateness of Hospital Admission for Emergency Department Patients with Bronchiolitis: Secondary Analysis. JMIR Med Inform 2018; 6:e10498. [PMID: 30401659 PMCID: PMC6246976 DOI: 10.2196/10498] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 10/08/2018] [Indexed: 12/18/2022] Open
Abstract
Background Bronchiolitis is the leading cause of hospitalization in children under 2 years of age. Each year in the United States, bronchiolitis results in 287,000 emergency department visits, 32%-40% of which end in hospitalization. Frequently, emergency department disposition decisions (to discharge or hospitalize) are made subjectively because of the lack of evidence and objective criteria for bronchiolitis management, leading to significant practice variation, wasted health care use, and suboptimal outcomes. At present, no operational definition of appropriate hospital admission for emergency department patients with bronchiolitis exists. Yet, such a definition is essential for assessing care quality and building a predictive model to guide and standardize disposition decisions. Our prior work provided a framework of such a definition using 2 concepts, one on safe versus unsafe discharge and another on necessary versus unnecessary hospitalization. Objective The goal of this study was to determine the 2 threshold values used in the 2 concepts, with 1 value per concept. Methods Using Intermountain Healthcare data from 2005-2014, we examined distributions of several relevant attributes of emergency department visits by children under 2 years of age for bronchiolitis. Via a data-driven approach, we determined the 2 threshold values. Results We completed the first operational definition of appropriate hospital admission for emergency department patients with bronchiolitis. Appropriate hospital admissions include actual admissions with exposure to major medical interventions for more than 6 hours, as well as actual emergency department discharges, followed by an emergency department return within 12 hours ending in admission for bronchiolitis. Based on the definition, 0.96% (221/23,125) of the emergency department discharges were deemed unsafe. Moreover, 14.36% (432/3008) of the hospital admissions from the emergency department were deemed unnecessary. Conclusions Our operational definition can define the prediction target for building a predictive model to guide and improve emergency department disposition decisions for bronchiolitis in the future.
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Affiliation(s)
- Gang Luo
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States
| | - Michael D Johnson
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Flory L Nkoy
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Shan He
- Homer Warner Research Center, Intermountain Healthcare, Murray, UT, United States
| | - Bryan L Stone
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
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27
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Freire G, Kuppermann N, Zemek R, Plint AC, Babl FE, Dalziel SR, Freedman SB, Atenafu EG, Stephens D, Steele DW, Fernandes RM, Florin TA, Kharbanda A, Lyttle MD, Johnson DW, Schnadower D, Macias CG, Benito J, Schuh S. Predicting Escalated Care in Infants With Bronchiolitis. Pediatrics 2018; 142:peds.2017-4253. [PMID: 30126934 DOI: 10.1542/peds.2017-4253] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Early risk stratification of infants with bronchiolitis receiving airway support is critical for focusing appropriate therapies, yet the tools to risk categorize this subpopulation do not exist. Our objective was to identify predictors of "escalated care" in bronchiolitis. We hypothesized there would be a significant association between escalated care and predictors in the emergency department. We subsequently developed a risk score for escalated care. METHODS We conducted a retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was escalated care (ie, hospitalization with high-flow nasal cannula, noninvasive or invasive ventilation, or intensive care admission). The predictors evaluated were age, prematurity, day of illness, poor feeding, dehydration, apnea, nasal flaring and/or grunting, respiratory rate, oxygen saturation, and retractions. RESULTS Of 2722 patients, 261 (9.6%) received escalated care. Multivariable predictors of escalated care were oxygen saturation <90% (odds ratio [OR]: 8.9 [95% confidence interval (CI) 5.1-15.7]), nasal flaring and/or grunting (OR: 3.8 [95% CI 2.6-5.4]), apnea (OR: 3.0 [95% CI 1.9-4.8]), retractions (OR: 3.0 [95% CI 1.6-5.7]), age ≤2 months (OR: 2.1 [95% CI 1.5-3.0]), dehydration (OR 2.1 [95% CI 1.4-3.3]), and poor feeding (OR: 1.9 [95% CI 1.3-2.7]). One of 217 (0.5%) infants without predictors received escalated care. The risk score ranged from 0 to 14 points, with the estimated risk of escalated care from 0.46% (0 points) to 96.9% (14 points). The area under the curve was 85%. CONCLUSIONS We identified variables measured in the emergency department predictive of escalated care in bronchiolitis and derived a risk score to stratify risk of this outcome. This score may be used to aid management and disposition decisions.
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Affiliation(s)
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, School of Medicine, University of California, Davis, Sacramento, California
| | - Roger Zemek
- Division of Pediatric Emergency Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Amy C Plint
- Division of Pediatric Emergency Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Franz E Babl
- Emergency Department, Royal Children's Hospital, Murdoch Children's Research Institute, Parkville, Australia.,University of Melbourne, Melbourne, Australia
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Hospital and the University of Auckland, Auckland, New Zealand
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Departments of Pediatrics, Alberta Children's Hospital Research Institute, Cumming School of Medicine, Calgary University, Calgary, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Derek Stephens
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Dale W Steele
- Department of Pediatric Emergency Medicine, Hasbro Children's Hospital and Departments of Emergency Medicine, Pediatrics, and Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
| | - Ricardo M Fernandes
- Department of Pediatrics, Hospital de Santa Maria and Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
| | - Todd A Florin
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Anupam Kharbanda
- Department of Pediatric Emergency Medicine, Children's Hospital of Minnesota, Minneapolis, Minnesota
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children and Faculty of Health and Applied Life Sciences, University of the West of England, Bristol, United Kingdom
| | - David W Johnson
- Sections of Pediatric Emergency Medicine, and Physiology and Pharmacology, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, Calgary University, Calgary, Canada
| | - David Schnadower
- Department of Pediatric Emergency Medicine, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Charles G Macias
- Department of Pediatric Emergency Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas; and
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Spain
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, and .,Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
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28
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Golan-Tripto I, Goldbart A, Akel K, Dizitzer Y, Novack V, Tal A. Modified Tal Score: Validated score for prediction of bronchiolitis severity. Pediatr Pulmonol 2018; 53:796-801. [PMID: 29655288 DOI: 10.1002/ppul.24007] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 03/14/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To further validate the use of the Modified Tal Score (MTS), a clinical tool for assessing bronchiolitis severity, by physicians with varying experience and training levels, and to determine the ability of the MTS to predict bronchiolitis severity. METHODS This prospective cohort study included infants of <12 months of age who were diagnosed with bronchiolitis and assessed via MTS. We calculated the intra-class correlation coefficient (ICC) among four groups of raters: group 1, board-certified pediatric pulmonologists; group 2, board-certified pediatricians; group 3, senior pediatric residents; and group 4, junior pediatric residents. Clinical outcomes were determined as length of oxygen support and length of stay (LOS). We assessed MTS's prediction of these outcomes. Relative risk (RR) for clinical severity was calculated via a Generalized Linear Model. RESULTS Twenty-four physicians recorded a total of 600 scores for 50 infants (average age 5 ± 3 months; 56% male). The ICC values with group 1 as a reference were 0.92, 0.87, and 0.83, for groups 2, 3, and 4, respectively (P < 0.001). RR for oxygen support required was; 1.33 (CI 1.12-1.57), 1.26 (1.1-1.46), 1.26 (1.06-1.5), and 1.21 (0.93-1.58) for groups 1, 2, 3, and 4, respectively. RR for LOS was; 1.15 (CI 0.97-1.37), 1.19 (1.03-1.38), 1.18 (1.0-1.39), and 1.18 (0.93-1.51) for groups 1, 2, 3, and 4, respectively. CONCLUSION The MTS is a simple and valid scoring system for evaluating infants with acute bronchiolitis, among different physician groups. The first score upon admission is a fair predictor of oxygen requirement at 48 h, and LOS at 72 h.
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Affiliation(s)
- Inbal Golan-Tripto
- Department of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel.,Pediatric Pulmonary Unit, Soroka University Medical Center, Beer Sheva, Israel
| | - Aviv Goldbart
- Department of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel.,Pediatric Pulmonary Unit, Soroka University Medical Center, Beer Sheva, Israel
| | - Khaled Akel
- Department of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel
| | - Yotam Dizitzer
- Clinical Research Center, Soroka University Medical Center, Beer Sheva, Israel
| | - Victor Novack
- Clinical Research Center, Soroka University Medical Center, Beer Sheva, Israel.,Department of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Asher Tal
- Department of Pediatrics, Soroka University Medical Center, Beer Sheva, Israel.,Pediatric Pulmonary Unit, Soroka University Medical Center, Beer Sheva, Israel
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29
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Abstract
Bronchiolitis is the number one cause of hospitalization in infants during the first year of life. Clinical guidelines recommend primarily supportive care and discourage use of pharmacotherapies and diagnostics. However, there continues to be widespread use of non-recommended therapies and variation in the use of therapeutic interventions among hospitals in the United States. Here we review evidence-based management of this common disease in order to optimize resource utilization, decrease healthcare costs, and decrease unnecessary hospitalization. Current evidence does not support the routine use of chest radiographs, viral testing or laboratory evaluation in children with bronchiolitis. In addition, routine administration of bronchodilators, including albuterol and nebulized epinephrine, corticosteroids and hypertonic saline are not recommended for infants and children with bronchiolitis. Intravenous or nasogastric hydration and nutritional support, supplemental oxygen, and respiratory support are recommended. Standardization of bronchiolitis care with evidence based institutional clinical pathways spanning ED to inpatient care can help optimize resource utilization while simultaneously improving care of bronchiolitis and reducing hospital length of stays and costs.
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Affiliation(s)
| | - Joanna Cohen
- Children’s National Medical Center in Washington, D.C
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30
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Robledo-Aceves M, Moreno-Peregrina MDJ, Velarde-Rivera F, Ascencio-Esparza E, Preciado-Figueroa FM, Caniza MA, Escobedo-Melendez G. Risk factors for severe bronchiolitis caused by respiratory virus infections among Mexican children in an emergency department. Medicine (Baltimore) 2018; 97:e0057. [PMID: 29489664 PMCID: PMC5851717 DOI: 10.1097/md.0000000000010057] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Severe bronchiolitis is the most common reason for hospitalization among children younger than 2 years. This study analyzed the prevalence of community-acquired respiratory virus infection and the risk factors for hospitalization of Mexican children with severe bronchiolitis treated in an Emergency department.This retrospective study included 134 children 2 years or younger with severe viral bronchiolitis, and 134 healthy age-matched controls. The study period was September 2012 to January 2015. We determined the viral etiology and coinfections with multiple viruses and compared the risk factors detected in children with severe viral bronchiolitis with those in the control group.A total of 153 respiratory viruses in these 134 patients, single or mixed infections, were identified: respiratory syncytial virus (RSV) type A or B was the most frequently detected (23.6% and 17.6%, respectively), followed by rhinovirus (RV; 16.3%) and parainfluenza virus (PIV) type 3 (12.4%). Coinfections of 2 respiratory viruses were found in 14.2% of cases; all cases had either RSV type A or B with another virus, the most common being parainfluenza virus or rhinovirus. Exposure to cigarette smoking was independently associated with hospitalization for severe bronchiolitis (OR, 3.5; 95% CI, 1.99-6.18; P = .0001), and having completed the vaccination schedule for their age was a protective factor against adverse outcome (OR, 0.55; 95% CI, 0.35-0.87; P = .010).RSV is a common infection among young children with severe bronchiolitis; thus, developing a vaccine against RSV is essential. Campaigns to reinforce the importance of avoiding childhood exposure to cigarette smoke are also needed.
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Affiliation(s)
| | | | | | | | | | - Miguela A. Caniza
- Departments of Infectious Diseases and Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Griselda Escobedo-Melendez
- Pediatrics Hematology and Oncology Department, Infectious Diseases Clinic, Civil Hospital of Guadalajara Dr. Juan I. Menchaca
- Research Institute in Childhood and Adolescent Cancer, University of Guadalajara, Guadalajara, Jalisco, Mexico
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Improving the Care of Children with Acute Respiratory Distress Across the Continuum of Care. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Sarkar M, Sinha R, Roychowdhoury S, Mukhopadhyay S, Ghosh P, Dutta K, Ghosh S. Comparative Study between Noninvasive Continuous Positive Airway Pressure and Hot Humidified High-flow Nasal Cannulae as a Mode of Respiratory Support in Infants with Acute Bronchiolitis in Pediatric Intensive Care Unit of a Tertiary Care Hospital. Indian J Crit Care Med 2018. [PMID: 29531447 PMCID: PMC5842462 DOI: 10.4103/ijccm.ijccm_274_17] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Early initiation of appropriate noninvasive respiratory support is utmost important intervention to avoid mechanical ventilation in severe bronchiolitis. Aim This study aims to compare noninvasive continuous positive airway pressure (nCPAP) and hot humidified high-flow nasal cannulae (HHHFNC) as modes of respiratory support in infants with severe bronchiolitis. Methods Prospective, randomized, open-label pilot study done in a tertiary-care hospital Pediatric Intensive Care Unit (PICU). Participants: 31 infants (excluding neonates) clinically diagnosed with acute bronchiolitis having peripheral capillary oxygen saturation (SpO2) <92% (with room air oxygen); Respiratory Distress Assessment Index (RDAI) ≥11. Intervention: nCPAP (n = 16) or HHHFNC (n = 15), initiated at enrollment. Primary outcome: Reduction of need of mechanical ventilation assessed by improvements in (i) SpO2% (ii) heart rate (HR); respiratory rate; (iii) partial pressure of carbon dioxide; (iv) partial pressure of oxygen; (v) COMFORT Score; (vi) RDAI from preintervention value. Secondary outcome: (i) total duration of noninvasive ventilation support; (ii) PICU length of stay; and (iii) incidence of nasal injury (NI). Results Mean age was 3.41 ± 1.11 months (95% confidence interval 2.58-4.23). Compared to nCPAP, HHHFNC was better tolerated as indicated by better normalization of HR (P < 0.001); better COMFORT Score (P < 0.003) and lower incidence of NI (46.66% vs. 75%; P = 0.21). Improvements in other outcome measures were comparable for both groups. For both methods, no major patient complications occurred. Conclusion HHHFNC is an emerging alternative to nCPAP in the management of infants with acute bronchiolitis.
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Affiliation(s)
- Mihir Sarkar
- Department of Pediatrics, Medical College and Hospital, Kolkata, West Bengal, India
| | - Rajasree Sinha
- Department of Pediatrics, Medical College and Hospital, Kolkata, West Bengal, India
| | | | | | - Pramit Ghosh
- Department of Community Medicine, Medical College and Hospital, Kolkata, West Bengal, India
| | - Kalpana Dutta
- Department of Pediatrics, Medical College and Hospital, Kolkata, West Bengal, India
| | - Shibarjun Ghosh
- Department of Pediatrics, Medical College and Hospital, Kolkata, West Bengal, India
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Rivas-Juesas C, Rius Peris J, García A, Madramany A, Peris M, Álvarez L, Primo J. A comparison of two clinical scores for bronchiolitis. A multicentre and prospective study conducted in hospitalised infants. Allergol Immunopathol (Madr) 2018. [PMID: 28629673 DOI: 10.1016/j.aller.2017.01.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND There are a number of clinical scores for bronchiolitis but none of them are firmly recommended in the guidelines. METHOD We designed a study to compare two scales of bronchiolitis (ESBA and Wood Downes Ferres) and determine which of them better predicts the severity. A multicentre prospective study with patients <12 months with acute bronchiolitis was conducted. Each patient was assessed with the two scales when admission was decided. We created a new variable "severe condition" to determine whether one scale afforded better discrimination of severity. A diagnostic test analysis of sensitivity and specificity was made, with a comparison of the AUC. Based on the optimum cut-off points of the ROC curves for classifying bronchiolitis as severe we calculated new Se, Sp, LR+ and LR- for each scale in our sample. RESULTS 201 patients were included, 66.7% males and median age 2.3 months (IQR=1.3-4.4). Thirteen patients suffered bronchiolitis considered to be severe, according to the variable severe condition. ESBA showed a Se=3.6%, Sp=98.1%, and WDF showed Se=46.2% and Sp=91.5%. The difference between the two AUC for each scale was 0.02 (95%CI: 0.01-0.15), p=0.72. With new cut-off points we could increase Se and Sp for ESBA: Se=84.6%, Sp=78.7%, and WDF showed Se=92.3% and Sp=54.8%; with higher LR. CONCLUSIONS None of the scales studied was considered optimum for assessing our patients. With new cut-off points, the scales increased the ability to classify severe infants. New validation studies are needed to prove these new cut-off points.
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Hendaus MA, Nassar S, Leghrouz BA, Alhammadi AH, Alamri M. Parental preference and perspectives on continuous pulse oximetry in infants and children with bronchiolitis. Patient Prefer Adherence 2018; 12:483-487. [PMID: 29662305 PMCID: PMC5892958 DOI: 10.2147/ppa.s152880] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE The purpose of the study was to investigate parental preference of continuous pulse oximetry in infants and children with bronchiolitis. MATERIALS AND METHODS A cross-sectional prospective study was conducted at Hamad Medical Corporation in Qatar. Parents of infants and children <24 months old and hospitalized with bronchiolitis were offered an interview survey. RESULTS A total of 132 questionnaires were completed (response rate 100%). Approximately 90% of participants were 20-40 years of age, and 85% were females. The mean age of children was 7.2±5.8 months. Approximately eight in ten parents supported the idea of continuous pulse oximetry in children with bronchiolitis. Almost 43% of parents believed that continuous pulse-oximetry monitoring would delay their children's hospital discharge. Interestingly, approximately 85% of caregivers agreed that continuous pulse oximetry had a good impact on their children's health. In addition, around one in two of the participants stated that good bedside examinations can obviate the need for continuous pulse oximetry. Furthermore, 80% of parents believed that continuous pulse-oximetry monitoring would give the health-care provider a good sense of security regarding the child's health. Finally, being a male parent was associated with significantly increased risk of reporting unnecessary fatigue, attributed to the sound of continuous pulse oximetry (P=0.031). CONCLUSION Continuous pulse-oximetry monitoring in children with bronchiolitis was perceived as reassuring for parents. Involving parents in decision-making is considered essential in the better management of children with bronchiolitis or any other disease. The first step to decrease continuous pulse oximetry will require provider education and change as well. Furthermore, we recommend proper counseling for parents, emphasizing that medical technology is not always essential, but is a complementary mode of managing a disease.
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Affiliation(s)
- Mohamed A Hendaus
- Department of Pediatrics, Section of Academic General Pediatrics, Sidra Medicine, Doha, Qatar
- Department of Clinical Pediatrics, Weill Cornell Medicine, Doha, Qatar
- Correspondence: Mohamed A Hendaus, Department of Pediatrics, Sidra Medicine, Al Al Luqta Street, PO BOX 26999, Doha, Qatar, Tel +974 4003 6559, Fax +974 4443 9571, Email
| | - Suzan Nassar
- Department of Pediatrics, Hamad General Corporation, Doha, Qatar
| | | | - Ahmed H Alhammadi
- Department of Pediatrics, Section of Academic General Pediatrics, Sidra Medicine, Doha, Qatar
- Department of Clinical Pediatrics, Weill Cornell Medicine, Doha, Qatar
| | - Mohammed Alamri
- Pediatric Emergency Center, Hamad General Corporation, Doha, Qatar
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Rodríguez-Martínez CE, Sossa-Briceño MP, Nino G. Systematic review of instruments aimed at evaluating the severity of bronchiolitis. Paediatr Respir Rev 2018; 25:43-57. [PMID: 28258885 PMCID: PMC5557708 DOI: 10.1016/j.prrv.2016.12.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 11/27/2016] [Accepted: 12/13/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE No recent studies have performed a systematic review of all available instruments aimed at evaluating the severity of bronchiolitis. The objective of the present study was to perform a systematic review of instruments aimed at evaluating the severity of bronchiolitis and to evaluate their measurement properties. METHODS A systematic search of the literature was performed in order to identify studies in which an instrument for evaluating the severity of bronchiolitis was described. Instruments were evaluated based on their reliability, validity, utility, endorsement frequency, restrictions in range, comprehension, and lack of ambiguity. RESULTS A total of 77 articles, describing a total of 32 different instruments were included in the review. The number of items included in the instruments ranged from 2 to 26. Upon analyzing their content, respiratory rate turned out to be the most frequently used item (in 26/32, 81.3% of the instruments), followed by wheezing (in 25/32, 78.1% of the instruments). In 18 (56.3%) instruments, there was a report of at least one of their measurement properties, mainly reliability and utility. Taking into consideration the information contained in the instruments, as well as their measurement properties, one was considered to be the best one available. CONCLUSIONS Among the 32 instruments aimed at evaluating the severity of bronchiolitis that were identified and systematically examined, one was considered to be the best one available. However, there is an urgent need to develop better instruments and to validate them in a more comprehensive and proper way.
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Affiliation(s)
- Carlos E. Rodríguez-Martínez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia,Department of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Bogota, Colombia,Research Unit, Military Hospital of Colombia, Bogota, Colombia
| | - Monica P. Sossa-Briceño
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia
| | - Gustavo Nino
- Division of Pediatric Pulmonary, Sleep Medicine and Integrative Systems Biology. Center for Genetic Research, Children’s National Medical Center, George Washington University, Washington, D.C
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Schuh S, Babl FE, Dalziel SR, Freedman SB, Macias CG, Stephens D, Steele DW, Fernandes RM, Zemek R, Plint AC, Florin TA, Lyttle MD, Johnson DW, Gouin S, Schnadower D, Klassen TP, Bajaj L, Benito J, Kharbanda A, Kuppermann N. Practice Variation in Acute Bronchiolitis: A Pediatric Emergency Research Networks Study. Pediatrics 2017; 140:peds.2017-0842. [PMID: 29184035 DOI: 10.1542/peds.2017-0842] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Studies characterizing hospitalizations in bronchiolitis did not identify patients receiving evidence-based supportive therapies (EBSTs). We aimed to evaluate intersite and internetwork variation in receipt of ≥1 EBSTs during the hospital management of infants diagnosed with bronchiolitis in 38 emergency departments of pediatric emergency research networks in Canada, the United States, Australia, New Zealand, the United Kingdom, Ireland, Spain, and Portugal. We hypothesized that there would be significant variation, adjusted for patient characteristics. METHODS Retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was that hospitalization occurred with EBST (ie, parenteral fluids, oxygen, or airway support). RESULTS Out of 3725 participants, 1466 (39%) were hospitalized, and 1023 out of 1466 participants (69.8%) received EBST. The use of EBST varied by site (P < .001; range 6%-99%, median 23%), but not by network (P = .2). Significant multivariable predictors and their odds ratios (ORs) were as follows: age (0.9), oxygen saturation (1.3), apnea (3.4), dehydration (3.2), nasal flaring and/or grunting (2.4), poor feeding (2.1), chest retractions (1.9), and respiratory rate (1.2). The use of pharmacotherapy and radiography varied by network and site (P < .001), with respective intersite ranges 2% to 79% and 1.6% to 81%. Compared with Australia and New Zealand, the multivariable OR for the use of pharmacotherapy in Spain and Portugal was 22.7 (95% confidence interval [CI]: 4.5-111), use in Canada was 11.5 (95% CI: 3.7-36), use in the United States was 6.8 (95% CI: 2.3-19.8), and use in the United Kingdom was 1.4 (95% CI: 0.4-4.2). Compared with United Kingdom, OR for radiography use in the United States was 4.9 (95% CI 2.0-12.2), use in Canada was 4.9 (95% CI 1.9-12.6), use in Spain and Portugal was 2.4 (95% CI 0.6-9.8), and use in Australia and New Zealand was 1.8 (95% CI 0.7-4.7). CONCLUSIONS More than 30% of infants hospitalized with bronchiolitis received no EBST. The hospital site was a source of variation in all study outcomes, and the network also predicted the use of pharmacotherapy and radiography.
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Affiliation(s)
- Suzanne Schuh
- Division of Paediatric Emergency Medicine and.,The Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Franz E Babl
- Emergency Department, Royal Children's Hospital, Murdoch Children's Research Institute, and University of Melbourne, Melbourne, Australia
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Hospital, and University of Auckland, Auckland, New Zealand
| | | | - Charles G Macias
- Pediatric Emergency Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Derek Stephens
- The Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Dale W Steele
- Section of Pediatric Emergency Medicine, Hasbro Children's Hospital and Section of Pediatric Emergency Medicine, Rhode Island Hospital, Providence, Rhode Island
| | - Ricardo M Fernandes
- Department of Pediatrics, Hospital de Santa Maria and Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
| | - Roger Zemek
- Division of Pediatric Emergency Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Amy C Plint
- Division of Pediatric Emergency Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Todd A Florin
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Mark D Lyttle
- Pediatric Emergency Department, Bristol Royal Hospital for Children and Faculty of Health and Life Sciences, University of the West of England, Bristol, United Kingdom
| | - David W Johnson
- Sections of Pediatric Emergency Medicine.,Emergency Medicine, and.,Physiology and Pharmacology, Department of Pediatrics, Alberta Children's Hospital Research Institute and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Serge Gouin
- Centre hospitalier universitaire Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - David Schnadower
- Pediatric Emergency Medicine, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Terry P Klassen
- Manitoba Institute of Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lalit Bajaj
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Bizkaia, Spain
| | - Anupam Kharbanda
- Emergency Department, Children's Hospital of Minnesota, Minneapolis, Minnesota; and
| | - Nathan Kuppermann
- Departments of Emergency Medicine and.,Pediatrics, Davis School of Medicine, University of California, Sacramento, California
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Rivera-Sepulveda A, Garcia-Rivera EJ. Epidemiology of bronchiolitis: a description of emergency department visits and hospitalizations in Puerto Rico, 2010-2014. Trop Med Health 2017; 45:24. [PMID: 29021713 PMCID: PMC5623968 DOI: 10.1186/s41182-017-0064-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 08/11/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Little is known about the epidemiology of bronchiolitis as a clinical diagnosis and its impact on emergency department visits and hospitalizations in tropical and semitropical regions. We described the epidemiology of bronchiolitis emergency visits and hospitalizations, its temporal trend and geographic distribution in Puerto Rico between 2010 and 2014. METHODS We performed a retrospective descriptive analysis of a representative sample of privately insured children with bronchiolitis from January 2010 to December 2014. Data was provided by the largest private health insurer in Puerto Rico and identified children < 24 months of age with bronchiolitis by International Classification of Diseases, Ninth Revision code 466, 466.11, and 466.19. Chi-square and one-way ANOVA compared sex, age, diagnosis, and severity across the years. Joinpoint Poisson regression analysis evaluated the temporal trend distribution of bronchiolitis hospitalizations per calendar year. A P value less than 0.05 was statistically significant. RESULTS During the study period, the annual proportion of emergency department visits and hospitalizations due to bronchiolitis increased from 3 to 5%, and 26 to 38%, respectively. The annual incidence rate of hospitalizations was 3.2 per 1000 privately insured children < 24 months. Non-RSV bronchiolitis was the most frequent diagnosis (51%). Hospitalizations occurred year-round, but increased significantly from August through December. Most children hospitalized resided in the metropolitan San Juan (35%) and surrounding urban areas. Total hospital charges decreased from $3.78 to $3.74 million, with an average cost per hospitalization of $4320.12 (11.3% increase; P = 0.0015). CONCLUSIONS This is the first study that evaluates the epidemiological characteristics of bronchiolitis in a primarily Hispanic population, living in a tropical country, and using data from a privately insured population. We found a small but significant increase in proportion of emergency visits and hospitalizations. Temporal trend shows year-round hospitalizations with an earlier seasonal peak and longer duration, consistent with Puerto Rico's seasonal rainfall throughout the study period. Further studies are needed to elucidate whether this epidemiologic pattern can also be seen in publicly insured children and whether Hispanic ethnicity is a risk factor for increased hospitalizations or is related to health disparities in the US healthcare system.
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Affiliation(s)
- Andrea Rivera-Sepulveda
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Saint Louis University School of Medicine, 1402 S. Grand Boulevard – Glennon Hall, Room 2717, 63104 Saint Louis, MO USA
- School of Health Professions, University of Puerto Rico Medical Sciences Campus, and School of Medicine, San Juan, Puerto Rico
| | - Enid J. Garcia-Rivera
- School of Health Professions, University of Puerto Rico Medical Sciences Campus, and School of Medicine, San Juan, Puerto Rico
- Endowed Health Services, University of Puerto Rico School of Medicine, Medical Sciences Campus, San Juan, Puerto Rico
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Chong SL, Teoh OH, Nadkarni N, Yeo JG, Lwin Z, Ong YKG, Lee JH. The modified respiratory index score (RIS) guides resource allocation in acute bronchiolitis. Pediatr Pulmonol 2017; 52:954-961. [PMID: 28114728 DOI: 10.1002/ppul.23663] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 11/14/2016] [Accepted: 12/15/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVE Bronchiolitis is a common disease in early childhood with increasing healthcare utilization. We aim to study how well a simple and improved respiratory score (the modified Respiratory Index Score [RIS]) would perform when predicting for a warranted admission. METHODS This is an observational prospective study, from June 2015 to December 2015 in a paediatric emergency department (ED) of a large tertiary hospital in Singapore. We included children aged less than 2 years old, presenting with typical symptoms and signs of bronchiolitis but excluded children with four or more previous wheezes, a gestation of <35 weeks, and known cardiopulmonary disease. We also performed a sensitivity analysis for children presenting with their first wheeze. We defined a warranted admission as a composite of: The need for airway intervention, intravenous hydration, and a hospital stay of 2 days or more. RESULTS Among 1,818 patients, the median age was 10.8 months (IQR 7.2-15.9). The median modified RIS score was 4.0 (IQR 3.0-5.0). A total of 19 (1.0%) children required respiratory support, 101 (5.6%) received intravenous hydration, and 571 (31.4%) required a hospital stay of 2 days or more. After adjusting for age and duration of illness, a modified RIS score of >4 predicted significantly for a warranted admission (adjusted Odds Ratio: 3.28, 95% confidence interval: 2.62-4.12). The association remained significant among children presenting with their first wheeze. CONCLUSIONS This simple respiratory tool predicts for the need for respiratory support, intravenous hydration, and a significant hospital stay of 2 days or more. Pediatr Pulmonol. 2017; 52:954-961. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Oon Hoe Teoh
- Department of Paediatrics, Respiratory Medicine Service, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Nivedita Nadkarni
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Joo Guan Yeo
- Division of Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Zaw Lwin
- Department of Emergency Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Yong-Kwang Gene Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
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Caserta MT, Qiu X, Tesini B, Wang L, Murphy A, Corbett A, Topham DJ, Falsey AR, Holden-Wiltse J, Walsh EE. Development of a Global Respiratory Severity Score for Respiratory Syncytial Virus Infection in Infants. J Infect Dis 2017; 215:750-756. [PMID: 28011907 DOI: 10.1093/infdis/jiw624] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 12/16/2016] [Indexed: 11/13/2022] Open
Abstract
Background Respiratory syncytial virus (RSV) infection in infants has recognizable clinical signs and symptoms. However, quantification of disease severity is difficult, and published scores remain problematic. Thus, as part of a RSV pathogenesis study, we developed a global respiratory severity score (GRSS) as a research tool for evaluating infants with primary RSV infection. Methods Previously healthy infants <10 months of age with RSV infections representing the spectrum of disease severity were prospectively evaluated. Clinical signs and symptoms were collected at 3 time points from hospitalized infants and those seen in ambulatory settings. Data were also extracted from office, emergency department, and hospital records. An unbiased data-driven approach using factor analysis was used to develop a GRSS. Results A total of 139 infants (84 hospitalized and 55 nonhospitalized) were enrolled. Using hospitalization status as the output variable, 9 clinical variables were identified and weighted to produce a composite GRSS. The GRSS had an area under the receiver operator curve of 0.961. Construct validity was demonstrated via a significant correlation with length of stay (r = 0.586, P < .0001). Conclusions Using routine clinical variables, we developed a severity score for infants with RSV infection that should be useful as an end point for investigation of disease pathogenesis and as an outcome measure for therapeutic interventions.
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Affiliation(s)
- Mary T Caserta
- Division of Infectious Diseases, Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Xing Qiu
- Department of Biostatistics and Computational Biology, New York Influenza Center of Excellence at the University of Rochester Medical Center, Rochester, NY, USA
| | - Brenda Tesini
- Division of Infectious Diseases, Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Lu Wang
- Department of Biostatistics and Computational Biology, New York Influenza Center of Excellence at the University of Rochester Medical Center, Rochester, NY, USA.,Center for Vaccine Biology and Immunology, University of Rochester, Rochester, New York, USA
| | - Amy Murphy
- Division of Infectious Diseases, Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Anthony Corbett
- Department of Biostatistics and Computational Biology, New York Influenza Center of Excellence at the University of Rochester Medical Center, Rochester, NY, USA
| | - David J Topham
- Center for Vaccine Biology and Immunology, University of Rochester, Rochester, New York, USA
| | - Ann R Falsey
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA.,Department of Medicine, Rochester General Hospital, New York, USA
| | - Jeanne Holden-Wiltse
- Department of Biostatistics and Computational Biology, New York Influenza Center of Excellence at the University of Rochester Medical Center, Rochester, NY, USA
| | - Edward E Walsh
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA.,Department of Medicine, Rochester General Hospital, New York, USA
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40
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Carr SB, Main E. Acute bronchiolitis-Should we be doing more? Pediatr Pulmonol 2017; 52:279-280. [PMID: 28221735 DOI: 10.1002/ppul.23642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 10/22/2016] [Accepted: 11/03/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Siobhan B Carr
- Department of Paediatric Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London
| | - Eleanor Main
- Physiotherapy Department in Respiratory, Critical Care and Anaesthesia, UCL Great Ormond Street Institute of Child Health, London
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Fretzayas A, Moustaki M. Etiology and clinical features of viral bronchiolitis in infancy. World J Pediatr 2017; 13:293-299. [PMID: 28470580 PMCID: PMC7090852 DOI: 10.1007/s12519-017-0031-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 11/18/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Bronchiolitis is a common lower respiratory tract infection in infancy. The aim of this review is to present the clinical profile of viral bronchiolitis, the different culprit viruses and the disease severity in relation to the viral etiology. DATA SOURCES Databases including PubMed and Google Scholar were searched for articles about the clinical features of bronchiolitis and its viral etiology. The most relevant articles to the scope of this review were analyzed. RESULTS Currently there are two main definitions for bronchiolitis which are not identical, the European definition and the American one. The most common viral pathogen that causes bronchiolitis is respiratory syncytial virus which was identified in 1955; now many other viruses have been implicated in the etiology of bronchiolitis such as rhinovirus, adenovirus, metapneumovirus, and bocavirus. Several studies have attempted to investigate the correlation of bronchiolitis severity with the type of detected virus or viruses. However, the results were not consitent. CONCLUSIONS For the time being, the diagnosis of bronchiolitis remains clinical. The isolation of the responsible respiratory pathogens does not seem to confer to the prognosis of the disease severity.
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Affiliation(s)
- Andrew Fretzayas
- 3rd Department of Pediatrics, "Attikon" University Hospital, Athens University, School of Medicine, 1 Rimini str, Haidari, 12462, Athens, Greece.
| | - Maria Moustaki
- 0000 0001 2155 0800grid.5216.03rd Department of Pediatrics, “Attikon” University Hospital, Athens University, School of Medicine, 1 Rimini str, Haidari, 12462 Athens, Greece
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Gold JM, Hall M, Shah SS, Thomson J, Subramony A, Mahant S, Mittal V, Wilson KM, Morse R, Mussman GM, Hametz P, Montalbano A, Parikh K, Ishman S, O'Neill M, Berry JG. Long length of hospital stay in children with medical complexity. J Hosp Med 2016; 11:750-756. [PMID: 27378587 DOI: 10.1002/jhm.2633] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 05/19/2016] [Accepted: 05/27/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Hospitalizations of children with medical complexity (CMC) account for one-half of hospital days in children, with lengths of stays (LOS) that are typically longer than those for children without medical complexity. The objective was to assess the impact of, risk factors for, and variation across children's hospitals regarding long LOS (≥10 days) hospitalizations in CMC. METHODS A retrospective study of 954,018 CMC hospitalizations, excluding admissions for neonatal and cancer care, during 2013 to 2014 in 44 children's hospitals. CMC were identified using 3M's Clinical Risk Group categories 6, 7, and 9, representing children with multiple and/or catastrophic chronic conditions. Multivariable regression was used to identify demographic and clinical characteristics associated with LOS ≥10 days. Hospital-level risk-adjusted rates of long LOS generated from these models were compared using a covariance test of the hospitals' random effect. RESULTS Among CMC, LOS ≥10 days accounted for 14.9% (n = 142,082) of all admissions and 61.8% ($13.7 billion) of hospital costs. The characteristics most strongly associated with LOS ≥10 days were use of intensive care unit (ICU) (odds ratio [OR]: 3.5, 95% confidence interval [CI]: 3.4-3.5), respiratory complex chronic condition (OR: 2.7, 95% CI: 2.6-2.7), and transfer from another medical facility (OR: 2.1, 95% CI: 2.0-2.1). After adjusting for severity, there was significant (P < 0.001) variation in the prevalence of LOS ≥10 days for CMC across children's hospitals (range, 10.3%-21.8%). CONCLUSIONS Long hospitalizations for CMC are costly. Their prevalence varies significantly by type of chronic condition and across children's hospitals. Efforts to reduce hospital costs in CMC might benefit from a focus on prolonged LOS. Journal of Hospital Medicine 2016;11:750-756. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Jessica M Gold
- Department of Pediatrics, New York-Presbyterian Morgan Stanley Children's Hospital and Columbia University Medical Center, New York, New York.
| | - Matt Hall
- Department of Pediatrics, Children's Hospital Association, Overland Park, Kansas
- Department of Pediatrics, Children's Mercy Hospitals and Clinics and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Samir S Shah
- Department of Otolaryngology, Head & Neck Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Joanna Thomson
- Department of Otolaryngology, Head & Neck Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Anupama Subramony
- Department of Pediatrics, Cohen Children's Medical Center, Northwell Health, New Hyde Park, New York
| | - Sanjay Mahant
- Department of Pediatrics, Division of Pediatric Medicine, Department of Pediatrics and Institute for Health Policy, Management and Evaluation, University of Toronto, and SickKids Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vineeta Mittal
- Department of Pediatrics, Children's Medical Center and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Karen M Wilson
- Department of Pediatrics, Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, Colorado
| | - Rustin Morse
- Department of Pediatrics, Children's Medical Center and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Grant M Mussman
- Department of Otolaryngology, Head & Neck Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Patricia Hametz
- Department of Pediatrics, New York-Presbyterian Morgan Stanley Children's Hospital and Columbia University Medical Center, New York, New York
| | - Amanda Montalbano
- Department of Pediatrics, Children's Mercy Hospitals and Clinics and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Kavita Parikh
- Department of Pediatrics, Children's National Medical Center and George Washington School of Medicine, Washington, DC
| | - Stacey Ishman
- Department of Otolaryngology, Head & Neck Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Margaret O'Neill
- Department of Pediatrics, Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jay G Berry
- Department of Pediatrics, Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Stollar F, Gervaix A, Argiroffo CB. Safely Discharging Infants with Bronchiolitis from an Emergency Department: A Five Step Guide for Pediatricians. PLoS One 2016; 11:e0163217. [PMID: 27690359 PMCID: PMC5045212 DOI: 10.1371/journal.pone.0163217] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 09/06/2016] [Indexed: 11/24/2022] Open
Abstract
Recent publications have established the pulse oxygen saturation (SpO2) threshold of 90% for the hospitalization and discharge of infant patients with bronchiolitis. However, there is no clear recommendation regarding the Emergency Department (ED) observation period necessary before allowing safe home discharge for patients with SpO2 above 90%-92%. Our primary aims were to evaluate the risk factors associated with delayed desaturation in infants with SpO2 ≥ 92% on arrival at the ED as well as the ED observation period necessary before allowing safe home discharge. A secondary aim was to identify the risk factors for ED readmission. Of 581 episodes of bronchiolitis in patients < 1 year old admitted to the ED, only 47 (8%) had SpO2 < 92% on arrival there, although 106 (18%) exhibited a delayed desaturation (to < 92%) during ED observation. Female sex, age < 3 months old, ED readmission, more severe initial clinical presentation, and higher pCO2 level (> 6KPa) were risk factors for delayed desaturation with OR varying from 1.7 to 7.5. In patients < 3 months old, mean desaturation occured later than in older patients [6.0 hours (IQR 3.0–14.0) vs. 3.0 hours (IQR 2.0–6.0), P = 0.0018]. In 95% of patients with a delayed desaturation this decrease occurred within 25 hours for patients < 3 months old and within 11 hours for patients ≥ 3 months old. In patients < 3 months old with respiratory rates above the normal range for their age the desaturation occurred earlier than in patients < 3 months with normal respiratory rates [4.4 hours (IQR 3.0–11.7) vs. 14.6 hours (IQR 7.6–22.2), P = 0.037]. Based on the present study’s results, we propose a five step guide for pediatricians on discharging children with bronchiolitis from the ED. By using the threshold of an 11 hour ED observation period for patients ≥ 3 months old and a 25 hour period for patients < 3 months old we are able to detect 95% of the patients with bronchiolitis who are at risk of delayed desaturation.
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Affiliation(s)
- Fabiola Stollar
- General Pediatric Division, Children’s Hospital, University Hospitals of Geneva, Geneva, Switzerland
- * E-mail:
| | - Alain Gervaix
- Pediatric Emergency Division, Children’s Hospital, University Hospitals of Geneva, Geneva, Switzerland
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McCallum GB, Chatfield MD, Morris PS, Chang AB. Risk factors for adverse outcomes of Indigenous infants hospitalized with bronchiolitis. Pediatr Pulmonol 2016; 51:613-23. [PMID: 26575201 PMCID: PMC7167668 DOI: 10.1002/ppul.23342] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 10/18/2015] [Accepted: 11/01/2015] [Indexed: 11/06/2022]
Abstract
BACKGROUND Hospitalized bronchiolitis imposes a significant burden among infants, particularly among Indigenous children. Traditional or known risk factors for severe disease are well described, but there are limited data on risks for prolonged hospitalization and persistent symptoms. Our aims were to determine factors (clinical and microbiological) associated with (i) prolonged length of stay (LOS); (ii) persistent respiratory symptoms at 3 weeks; (iii) bronchiectasis up to ∼24 months post-hospitalisation; and (iv) risk of respiratory readmissions within 6 months. METHODS Indigenous infants hospitalized with bronchiolitis were enrolled at Royal Darwin Hospital between 2008 and 2013. Standardized forms were used to record clinical data. A nasopharyngeal swab was collected at enrolment to identify respiratory viruses and bacteria. RESULTS The median age of 232 infants was 5 months (interquartile range 3-9); 65% male. On multivariate regression, our 12 point severity score (including accessory muscle use) was the only factor associated with prolonged LOS but the effect was modest (+3.0 hr per point, 95%CI: 0.7, 5.1, P = 0.01). Presence of cough at 3 weeks increased the odds of bronchiectasis (OR 3.0, 95%CI: 1.1, 7.0, P = 0.03). Factors associated with respiratory readmissions were: previous respiratory hospitalization (OR 2.3, 95%CI: 1.0, 5.4, P = 0.05) and household smoke (OR 2.6, 95%CI: 1.0, 6.3, P = 0.04). CONCLUSION Increased severity score is associated with prolonged LOS in Indigenous children hospitalized with bronchiolitis. As persistent symptoms at 3 weeks post-hospitalization are associated with future diagnosis of bronchiectasis, optimising clinical care beyond hospitalization is needed to improve long-term respiratory outcomes for infants at risk of respiratory disease. Pediatr Pulmonol. 2016;51:613-623. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Gabrielle B McCallum
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, 0811, Northern Territory, Australia
| | - Mark D Chatfield
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, 0811, Northern Territory, Australia
| | - Peter S Morris
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, 0811, Northern Territory, Australia
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Anne B Chang
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, 0811, Northern Territory, Australia
- Queensland Children's Medical Research Institute, Children's Health Queensland, Queensland University of Technology, Brisbane, Queensland, Australia
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Luo G, Stone BL, Johnson MD, Nkoy FL. Predicting Appropriate Admission of Bronchiolitis Patients in the Emergency Department: Rationale and Methods. JMIR Res Protoc 2016; 5:e41. [PMID: 26952700 PMCID: PMC4802105 DOI: 10.2196/resprot.5155] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 01/07/2016] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND In young children, bronchiolitis is the most common illness resulting in hospitalization. For children less than age 2, bronchiolitis incurs an annual total inpatient cost of $1.73 billion. Each year in the United States, 287,000 emergency department (ED) visits occur because of bronchiolitis, with a hospital admission rate of 32%-40%. Due to a lack of evidence and objective criteria for managing bronchiolitis, ED disposition decisions (hospital admission or discharge to home) are often made subjectively, resulting in significant practice variation. Studies reviewing admission need suggest that up to 29% of admissions from the ED are unnecessary. About 6% of ED discharges for bronchiolitis result in ED returns with admission. These inappropriate dispositions waste limited health care resources, increase patient and parental distress, expose patients to iatrogenic risks, and worsen outcomes. Existing clinical guidelines for bronchiolitis offer limited improvement in patient outcomes. Methodological shortcomings include that the guidelines provide no specific thresholds for ED decisions to admit or to discharge, have an insufficient level of detail, and do not account for differences in patient and illness characteristics including co-morbidities. Predictive models are frequently used to complement clinical guidelines, reduce practice variation, and improve clinicians' decision making. Used in real time, predictive models can present objective criteria supported by historical data for an individualized disease management plan and guide admission decisions. However, existing predictive models for ED patients with bronchiolitis have limitations, including low accuracy and the assumption that the actual ED disposition decision was appropriate. To date, no operational definition of appropriate admission exists. No model has been built based on appropriate admissions, which include both actual admissions that were necessary and actual ED discharges that were unsafe. OBJECTIVE The goal of this study is to develop a predictive model to guide appropriate hospital admission for ED patients with bronchiolitis. METHODS This study will: (1) develop an operational definition of appropriate hospital admission for ED patients with bronchiolitis, (2) develop and test the accuracy of a new model to predict appropriate hospital admission for an ED patient with bronchiolitis, and (3) conduct simulations to estimate the impact of using the model on bronchiolitis outcomes. RESULTS We are currently extracting administrative and clinical data from the enterprise data warehouse of an integrated health care system. Our goal is to finish this study by the end of 2019. CONCLUSIONS This study will produce a new predictive model that can be operationalized to guide and improve disposition decisions for ED patients with bronchiolitis. Broad use of the model would reduce iatrogenic risk, patient and parental distress, health care use, and costs and improve outcomes for bronchiolitis patients.
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Affiliation(s)
- Gang Luo
- School of Medicine, Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States.
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Abstract
Infants admitted to health-care centers with acute bronchiolitis are frequently monitored with a pulse oximeter, a noninvasive method commonly used for measuring oxygen saturation. The decision to hospitalize children with bronchiolitis has been largely influenced by pulse oximetry, despite its questionable diagnostic value in delineating the severity of the illness. Many health-care providers lack the appropriate clinical fundamentals and limitations of pulse oximetry. This deficiency in knowledge might have been linked to changes in the management of bronchiolitis. The aim of this paper is to provide the current evidence on the role of pulse oximetry in bronchiolitis. We discuss the history, fundamentals of operation, and limitations of the apparatus. A search of the Google Scholar, Embase, Medline, and PubMed databases was carried out for published articles covering the use of pulse oximetry in bronchiolitis.
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Affiliation(s)
- Mohamed A Hendaus
- Department of Pediatrics, General Pediatrics Division, Hamad Medical Corporation, Doha, Qatar ; Weill-Cornell Medical College, Doha, Qatar
| | - Fatima A Jomha
- School of Pharmacy, Lebanese International University, Khiara, Lebanon
| | - Ahmed H Alhammadi
- Department of Pediatrics, General Pediatrics Division, Hamad Medical Corporation, Doha, Qatar ; Weill-Cornell Medical College, Doha, Qatar
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Clinical Endpoints for Respiratory Syncytial Virus Prophylaxis Trials in Infants and Children in High-income and Middle-income Countries. Pediatr Infect Dis J 2015; 34:1086-92. [PMID: 26121204 DOI: 10.1097/inf.0000000000000813] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Respiratory syncytial virus (RSV) continues to cause significant clinical and economic burden around the world. Historically, RSV-associated hospitalization was used as a primary endpoint for RSV prophylaxis trials in infants. However, because of the changing epidemiology and healthcare system landscape, this endpoint has become a critical bottleneck on the pathway to licensure for new therapeutics. A panel of 7 RSV experts was convened (Chicago, IL, May 22, 2014) to evaluate the challenges of defining RSV prevention endpoints for clinical trials and to develop endpoints that are clinically meaningful while minimizing subjectivity and bias to achieve sufficient consistency of response for regulatory approval. Particular consideration was given to the ability to collect data systematically and consistently in countries with different healthcare practices and systems, while capturing the greatest proportion of disease impact. The group consensus was that a clinically meaningful primary endpoint could include medically attended RSV illness in settings beyond RSV-associated hospitalizations alone, in particular, a composite reduction in hospitalization, emergency room or urgent care center visits because of an RSV respiratory infection. Relevant secondary endpoints included reductions in RSV lower respiratory tract infection, RSV-related intensive care unit rates, subsequent recurrent wheezing or asthma and direct and indirect costs.
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Lin JA, Madikians A. From bronchiolitis guideline to practice: A critical care perspective. World J Crit Care Med 2015; 4:152-158. [PMID: 26261767 PMCID: PMC4524812 DOI: 10.5492/wjccm.v4.i3.152] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 06/12/2015] [Accepted: 07/14/2015] [Indexed: 02/06/2023] Open
Abstract
Acute viral bronchiolitis is a leading cause of admission to pediatric intensive care units, but research on the care of these critically ill infants has been limited. Pathology of viral bronchiolitis revealed respiratory obstruction due to intraluminal debris and edema of the airways and vasculature. This and clinical evidence suggest that airway clearance interventions such as hypertonic saline nebulizers and pulmonary toilet devices may be of benefit, particularly in situations of atelectasis associated with bronchiolitis. Research to distinguish an underlying asthma predisposition in wheezing infants with viral bronchiolitis may one day lead to guidance on when to trial bronchodilator therapy. Considering the paucity of critical care research in pediatric viral bronchiolitis, intensive care practitioners must substantially rely on individualization of therapies based on bedside clinical assessments. However, with the introduction of new diagnostic and respiratory technologies, our ability to support critically ill infants with acute viral bronchiolitis will continue to advance.
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Fernandes RM, Plint AC, Terwee CB, Sampaio C, Klassen TP, Offringa M, van der Lee JH. Validity of bronchiolitis outcome measures. Pediatrics 2015; 135:e1399-408. [PMID: 25986025 DOI: 10.1542/peds.2014-3557] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The Respiratory Distress Assessment Instrument (RDAI) and Respiratory Assessment Change Score (RACS) are frequently used in bronchiolitis clinical trials, but evidence is limited on their measurement properties. We investigated their validity, reliability, and responsiveness. METHODS We included data from up to 1765 infants with bronchiolitis enrolled in 2 studies conducted in pediatric emergency departments. We assessed RDAI construct validity by testing hypotheses of associations with physiologic measures (respiratory rate, oxygen saturation) and with constructs related to hospitalization, using correlation coefficients, and multivariable analysis. RDAI/RACS responsiveness was evaluated by using anchors of change based on these constructs; measures of responsiveness included the area under the curve. RDAI test-retest agreement and interrater reliability were evaluated by using limits of agreement and intraclass correlation coefficients. RESULTS Baseline RDAI scores were weakly correlated with respiratory rate (r = 0.38, P < .001), and scores increased in lower oxygen saturation categories (P < .001). Higher RDAI scores were associated with hospitalization (odds ratio: 1.36; 95% confidence interval: 1.26-1.47); scores differed between participants who were discharged, admitted, or stayed in the emergency department (P < .001). Our hypotheses were met, but the magnitude of associations was below our predefined thresholds. RDAI test-retest limits of agreement were -3.80 to 3.64 (20% of the range), whereas interrater reliability was good (intraclass correlation coefficient = 0.93). Formulated hypotheses for responsiveness were confirmed, with moderate responsiveness (area under the curve: RDAI, 0.64-0.70; RACS, 0.72). CONCLUSIONS RDAI has poor to moderate construct validity, with good discriminative properties but considerable test-retest measurement error. The RDAI and RACS are responsive measures of respiratory distress in bronchiolitis but do not encompass all determinants of disease severity.
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Affiliation(s)
- Ricardo M Fernandes
- Department of Pediatrics, Santa Maria Hospital, Lisbon Academic Medical Centre, Lisbon, Portugal; Clinical Pharmacology Unit, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal;
| | - Amy C Plint
- University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Caroline B Terwee
- Department of Epidemiology and Biostatistics and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, Netherlands
| | - Cristina Sampaio
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
| | - Terry P Klassen
- Manitoba Institute of Child Health, University of Manitoba, Winnipeg, Canada
| | - Martin Offringa
- ChildHealth Evaluative Sciences, Hospital for Sick Children, Toronto, Canada; and
| | - Johanna H van der Lee
- Division of Woman and Child, Pediatric Clinical Research Office, Academic Medical Centre, Amsterdam, Netherlands
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Peeler A, Fulbrook P, Kildea S. The experiences of parents and nurses of hospitalised infants requiring oxygen therapy for severe bronchiolitis: A phenomenological study. J Child Health Care 2015; 19:216-28. [PMID: 24154843 DOI: 10.1177/1367493513503587] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Bronchiolitis is a major cause of children's admission to hospital. The study aim was to describe the experiences of parents who had, or nurses who cared for, a child admitted to hospital for severe bronchiolitis requiring oxygen therapy. A descriptive phenomenological approach was used to interview 12 mothers and 12 nurses. The findings were clustered into three domains: fear, parent-child interaction and technical caring. The mothers found the experience to be extremely frightening, based on their fear that their child could die. This was compounded by their lack of knowledge and understanding about what was happening and their inability to fulfil their mothering role. Although nurses recognised that parents were anxious, they did not seem to appreciate fully the depth of fear and emotion that mothers were experiencing and tended to describe procedural aspects of their role. The mothers' relationship with their child was focused upon physical contact and the desire to comfort their child. Their ability to do so was significantly impacted upon by the method of oxygen delivery to their child. For nurses, although they recognised the psychosocial dimension, their emphasis was on health and safety aspects of oxygen therapy, both for the child and themselves.
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Affiliation(s)
| | - Paul Fulbrook
- Australian Catholic University; The Prince Charles Hospital, Australia
| | - Sue Kildea
- Australian Catholic University; Mater Mothers' Hospital, Australia
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