[Bronchiolitis treated with mechanical ventilation: prognosis factors and outcome in a series of 135 children]

Respiratory and pharmacological management in severe acute bronchiolitis: Were clinical guidelines not written for critical care?

PURPOSE

The treatment applied for children admitted to the pediatric intensive care unit (PICU) for severe acute bronchiolitis may differ from general recommendations. The first objective of our study was to describe the treatments offered to these children in a Spanish tertiary PICU. The second objective was to analyse the changes in management derived from the publication of the American Academy of Pediatrics (AAP) bronchiolitis guideline in 2014.

METHODS

This was a retrospective-prospective observational study conducted during two epidemic waves (2014-2015 and 2015-2016). The AAP guidelines were distributed and taught to PICU staff between both epidemic waves.

RESULTS

A total of 138 children were enrolled (78 male). In the first period, 78 children were enrolled. The median age was 1.8 months (IQR 1.1-3.6). There were no differences between the management in the two periods, except for the use of high-flow oxygen therapy (HFOT); its use increased in the second period. Overall, 83% of patients received non-invasive ventilation or HFOT. Children older than 12 months received HFOT exclusively. In comparison, continuous positive airway pressure and bi-level positive airway pressure were used less during the period 2015-2016 (P=0.036). Regarding pharmacological therapy, 70% of patients received antibiotics, 23% steroids, 33% salbutamol, 31% adrenaline, and 7% hypertonic saline. The mortality rate was zero.

CONCLUSIONS

Our PICU did not follow the AAP recommendations. There were no differences between the two periods, except in the use of HFOT. All children older than 12 months received HFOT exclusively. The rate of using invasive mechanical ventilation was also low.

Prospective Multicentre Study on the Epidemiology and Current Therapeutic Management of Severe Bronchiolitis in Spain

Objective. To determine the epidemiology and therapeutic management of patients with severe acute bronchiolitis (AB) admitted to paediatric intensive care units (PICUs) in Spain. Design. Descriptive, prospective, multicentre study. Setting. Sixteen Spanish PICUs. Patients. Patients with severe AB who required admission to any of the participating PICUs over 1 year. Interventions. Both epidemiological variables and medical treatment received were recorded. Results. A total of 262 patients were recruited; 143 were male (54.6%), with median age of 1 month (0–23). Median stay in the PICU was 7 days (1–46). Sixty patients (23%) received no nebuliser treatment, while the rest received a combination of inhalation therapies. One-quarter of patients (24.8%) received corticosteroids and 56.5% antibiotic therapy. High-flow oxygen therapy was used in 14.3% and noninvasive ventilation (NIV) was used in 75.6%. Endotracheal intubation was required in 24.4% of patients. Younger age, antibiotic therapy, and invasive mechanical ventilation (IMV) were risk factors that significantly increased the stay in the PICU. Conclusions. Spanish PICUs continue to routinely use nebulised bronchodilator treatment and corticosteroid therapy. Despite NIV being widely used in this condition, intubation was required in one-quarter of cases. Younger age, antibiotic therapy, and IMV were associated with a longer stay in the PICU.

Heliox inhalation therapy for bronchiolitis in infants

BACKGROUND

Bronchiolitis is the leading cause of hospitalisation among infants in high-income countries. Acute viral bronchiolitis is associated with airway obstruction and turbulent gas flow. Heliox, a mixture of oxygen and the inert gas helium, may improve gas flow through high-resistance airways and decrease the work of breathing. In this review, we selected trials that objectively assessed the effect of the addition of heliox to standard medical care for acute bronchiolitis.

OBJECTIVES

To assess heliox inhalation therapy in addition to standard medical care for acute bronchiolitis in infants with respiratory distress, as measured by clinical endpoints (in particular the rate of endotracheal intubation, the rate of emergency department discharge, the length of treatment for respiratory distress) and pulmonary function testing (mainly clinical respiratory scores).

SEARCH METHODS

We searched CENTRAL (2015, Issue 2), MEDLINE (1966 to March week 3, 2015), EMBASE (1974 to March 2015), LILACS (1982 to March 2015) and the National Institutes of Health (NIH) website (May 2009).

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs of heliox in infants with acute bronchiolitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality.

MAIN RESULTS

We included seven trials involving 447 infants younger than two years with respiratory distress secondary to viral bronchiolitis. All children were recruited from a paediatric intensive care unit (PICU; 378 infants), except in one trial (emergency department; 69 infants). All children were younger than two (under nine months in two trials and under three months in one trial). Positive tests for respiratory syncytial virus (RSV) were required for inclusion in five trials. The two other trials were carried out in the bronchiolitis seasons. Seven different protocols were used for inhalation therapy with heliox.When heliox was used in the PICU, we observed no significant reduction in the rate of intubation: risk ratio (RR) 2.73 (95% confidence interval (CI) 0.96 to 7.75, four trials, 408 infants, low quality evidence). When heliox inhalation was used in the emergency department, we observed no increase in the rate of discharge: RR 0.51 (95% CI 0.17 to 1.55, one trial, 69 infants, moderate quality evidence).There was no decrease in the length of treatment for respiratory distress: mean difference (MD) -0.19 days (95% CI -0.56 to 0.19, two trials, 320 infants, moderate quality evidence). However, in the subgroup of infants who were started on nasal continuous positive airway pressure (nCPAP) right from the start, because of severe respiratory distress, heliox therapy reduced the length of treatment: MD -0.76 days (95% CI -1.45 to -0.08, one trial, 21 infants, low quality evidence). No adverse events related to heliox inhalation were reported.We found that infants treated with heliox inhalation had a significantly lower mean clinical respiratory score in the first hour after starting treatment when compared to those treated with air or oxygen inhalation: MD -1.04 (95% CI -1.60 to -0.48, four trials, 138 infants, moderate quality evidence). This outcome had statistical heterogeneity, which remained even after removing the study using a standard high-concentration reservoir mask. Several factors may explain this heterogeneity, including first the limited number of patients in each trial, and the wide differences in the baseline severity of disease between studies, with the modified Wood Clinical Asthma Score (m-WCAS) in infants treated with heliox ranging from less than two to more than seven.

AUTHORS' CONCLUSIONS

Current evidence suggests that the addition of heliox therapy may significantly reduce a clinical score evaluating respiratory distress in the first hour after starting treatment in infants with acute RSV bronchiolitis. We noticed this beneficial effect regardless of which heliox inhalation protocol was used. Nevertheless, there was no reduction in the rate of intubation, in the rate of emergency department discharge, or in the length of treatment for respiratory distress. Heliox could reduce the length of treatment in infants requiring CPAP for severe respiratory distress. Further studies with homogeneous logistics in their heliox application are needed. Inclusion criteria must include a clinical severity score that reflects severe respiratory distress to avoid inclusion of children with mild bronchiolitis who may not benefit from heliox inhalation. Such studies would provide the necessary information as to the appropriate place for heliox in the therapeutic schedule for severe bronchiolitis.

Initiation de la ventilation non invasive aux urgences pédiatriques dans les bronchiolites sévères du nourrisson

Introduction

La ventilation non invasive (VNI) dans les bronchiolites sévères du nourrisson s’est développée rapidement en réanimation et au service mobile d’urgence et réanimation pédiatrique (Smur) depuis 2003. Les objectifs de cette étude sont de vérifier les indications de mise sous VNI utilisées aux urgences pédiatriques d’Ambroise-Paré en les comparant à celles utilisées en réanimation et de confirmer l’efficacité de cette technique aux urgences pédiatriques.

Méthodes et population

Étude rétrospective sur 31 nourrissons ventilés par VNI pour bronchiolite sévère aux urgences pédiatriques de l’hôpital Ambroise-Paré (92) des hivers 2009 à 2011.

Résultats

La population étudiée était composée de 16 % d’anciens prématurés sans hypotrophie ni antécédent notable et âgés d’en moyenne deux mois au moment de la bronchiolite. Le pourcentage de bronchiolites apnéisantes (seule indication de VNI selon la conférence de consensus de 2006) était de 17 %. Au moins deux indications de recours à la VNI ont été retrouvées pour chaque patient. Cinquante-huit pour cent des nourrissons étaient transférés plus de deux heures après la mise sous VNI, avec une amélioration constatée sur la fréquence respiratoire (FR), la saturation, la PCO₂ et le pH (p < 0,001) et sans complications aux urgences. La VNI a été poursuivie en réanimation dans 84 % des cas. La durée moyenne de VNI était de 2,7 jours, celle d’hospitalisation en réanimation de 4,2 jours.

Conclusion

L’utilisation de la VNI aux urgences pédiatriques est une procédure simple, permettant une prise en charge précoce, avant transfert en réanimation, des bronchiolites sévères du nourrisson et permettant une amélioration clinique et gazométrique de leur insuffisance respiratoire.

Burden of respiratory syncytial virus infection in young children

Respiratory syncytial virus (RSV) is the most frequent and important cause of lower respiratory tract infection in infants and children. It is a seasonal virus, with peak rates of infection occurring annually in the cold season in temperate climates, and in the rainy season, as temperatures fall, in tropical climates. High risk groups for severe RSV disease include infants below six mo of age, premature infants with or without chronic lung disease, infants with hemodynamically significant congenital heart disease, infants with immunodeficiency or cystic fibrosis, and infants with neuromuscular diseases. Mortality rates associated with RSV infection are generally low in previous healthy infants (below 1%), but increase significantly in children with underlying chronic conditions and comorbidities. Following early RSV lower respiratory tract infection, some patients experience recurrent episodes of wheezing mimicking early childhood asthma with persistence of lung function abnormalities until adolescence. There is currently no RSV vaccine available, but promising candidate vaccines are in development. Palivizumab, a monoclonal RSV antibody that is the only tool for immunoprophylaxis in high-risk infants, lowers the burden of RSV infection in certain carefully selected patient groups.

Palivizumab in preventing respiratory syncytial virus-related hospitalization in high-risk infants

Respiratory syncytial virus (RSV) causes seasonal epidemics (winter or wet-season) of serious lower respiratory tract infections in young infants with subsequent increased frequency of recurrent wheezing during early childhood. Palivizumab is a humanized monoclonal antibody that provides immunoprophylaxis against RSV when administered monthly over the RSV season. It significantly reduced hospitalizations in high-risk infants including preterm infants with and without bronchopulmonary dysplasia and infants with hemodynamically significant congenital heart disease. Since its license in 1998, approximately 36 methodologically different economic studies have been performed to prove cost-effectiveness of the product. The majority of cost-effectiveness analyses revealed costs of palivizumab exceeding anticipated savings from reduced RSV hospitalizations. A minority of studies performed cost-effectiveness analyses using incremental cost-effectiveness ratios as costs per quality-adjusted life-year gained. The wide variability in the results of economic studies with estimates ranging from cost savings to incremental costs of a high order of magnitude with its use is discussed, in the light of the continuing burden of RSV disease, the limited treatment modalities, and the continuing research for a vaccine.

Role of real-time reverse transcription polymerase chain reaction for detection of respiratory viruses in critically ill children with respiratory disease: Is it time for a change in algorithm?

OBJECTIVES

To identify the respiratory viral pathogens associated with acute lower respiratory tract infection in critically ill pediatric patients by using real-time reverse transcription-polymerase chain reaction, and compare results with those of direct fluorescence antibody assay testing.

DESIGN

Observational cohort study.

SETTING

Pediatric intensive care unit at a tertiary care academic hospital.

PATIENTS

Pediatric patients admitted to the pediatric intensive care unit with severe respiratory symptoms consistent with viral lower respiratory tract infection.

INTERVENTIONS

None.

MEASUREMENTS

Respiratory samples of pediatric patients admitted to the pediatric intensive care unit with severe respiratory symptoms between January 2008 and July 2009 were tested with direct fluorescence antibody assay and real-time reverse transcription-polymerase chain reaction.

MAIN RESULTS

At least one viral agent was detected in 70.5% of specimens by real-time reverse transcription-polymerase chain reaction and in 16.5% by direct fluorescence antibody assay (p < .001). Real-time reverse transcription-polymerase chain reaction increased the total viral yield five-fold compared to direct fluorescence antibody assay. Rhinovirus was the most commonly identified virus (41.6%). For viruses included in the direct fluorescence antibody assay panel, direct fluorescence antibody assay had a sensitivity of 0.42 (95% confidence interval 0.25-0.61) and a specificity of 1 (95% confidence interval 0.86-1.00) compared with real-time reverse transcription-polymerase chain reaction. Coinfections were not uncommon, in particular with rhinovirus, and these patients tended to have higher mortality.

CONCLUSIONS

Direct fluorescence antibody assay testing is a suboptimal method for the detection of respiratory viruses in critically ill children with lower respiratory tract infection. Given the importance of a prompt and accurate viral diagnosis for this group of patients, we suggest that real-time reverse transcription-polymerase chain reaction becomes part of the routine diagnostic algorithm in critically ill children when a viral etiology is suspected, even if conventional tests yield a negative result.

Paediatric intensive care admissions for respiratory syncytial virus bronchiolitis in France: results of a retrospective survey and evaluation of the validity of a medical information system programme

The purpose of this study was to describe the characteristics of patients with bronchiolitis admitted to a paediatric intensive care unit (PICU), and to evaluate a national registry of hospitalizations (Programme de Médicalisation des Systèmes d'Information; PMSI) as a potential source of epidemiological data. Of the 49 French PICUs invited to take part in a retrospective survey of children aged <2 years who were hospitalized during the 2005–2006 epidemic season, 24 agreed to participate. Overall, 467 children were enrolled: 75% were aged <2 months, 76% had positive respiratory syncytial virus (RSV) tests, 34·9% required non-invasive ventilation, 36·6% were mechanically ventilated, and six infants died. The main neonatal characteristics were: prematurity (31·9%), respiratory disease (16·5%), congenital heart disease (6·4%), receiving mechanical ventilation (11·6%), and bronchopulmonary dysplasia at day 28 (3·8%). For bronchiolitis episode, the kappa coefficient between the survey and PMSI data was good only for mechanical ventilation (0·63) and the death rate (0·86).

[Consensus conference on acute bronchiolitis (VI): prognosis of acute bronchiolitis. Review of scientific evidence]

We present a review of the evidence on prognosis of acute bronchiolitis, risk factors for severe forms, symptom or severity scores and risk of post-bronchiolitis asthma. Documented risk factors of long stay or PICU admission in hospitalized patients are: bronchopulmonary dysplasia and/or chronic lung disease, prematurity, congenital heart disease and age less than 3 months. Other less well documented risk factors are: tobacco exposure, history of neonatal mechanical ventilation, breastfeeding for less than 4 months, viral co-infection and other chronic diseases. There are several markers of severity: toxic appearance, tachypnea, hypoxia, atelectasis or infiltrate on chest radiograph, increased breathing effort, signs of dehydration, tachycardia and fever. Although we have some predictive models of severity, none has shown sufficient predictive validity to recommend its use in clinical practice. While there are different symptom or severity scores, none has proven to be valid or accurate enough to recommend their preferable application in clinical practice. There seems to be a consistent and strong association between admission due to bronchiolitis and recurrent episodes of wheezing in the first five years of life. However it is unclear whether this association continues in subsequent years, as there are discordant data on the association between bronchiolitis and asthma.

Heliox inhalation therapy for bronchiolitis in infants

BACKGROUND

Acute viral bronchiolitis is associated with airway obstruction and turbulent gas flow. Heliox, a mixture of oxygen and the inert gas helium, may improve gas flow through high-resistance airways and decrease the work of breathing.

OBJECTIVES

To assess heliox in addition to standard medical care for acute bronchiolitis in infants.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 2), which includes the Cochrane Acute Respiratory Infections (ARI) Group's Specialised Register, MEDLINE (1966 to June 2009), EMBASE (June 2009), LILACS (May 2009) and the NIH web site (May 2009).

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs of heliox in infants with acute bronchiolitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. We pooled data from individual trials.

MAIN RESULTS

We included four trials involving 84 infants under two years of age with respiratory distress secondary to bronchiolitis caused by respiratory syncytial virus (RSV) and requiring paediatric intensive care unit (PICU) hospitalisation. We found that infants treated with heliox inhalation had a significantly lower mean clinical respiratory score in the first hour after starting treatment when compared to those treated with air or oxygen inhalation (mean difference (MD) -1.15, 95% confidence interval (CI) -1.98 to -0.33, P = 0.006, n = 69). There was no clinically significant reduction in the rate of intubation (risk ratio (RR) 1.38, 95% CI 0.41 to 4.56, P = 0.60, n = 58), in the need for mechanical ventilation (RR 1.11, 95% CI 0.36 to 3.38, P = 0.86, n = 58), or in the length of stay in a PICU (MD = -0.15 days, 95% CI -0.92 to 0.61, P = 0.69, n = 58). No adverse events related to heliox inhalation were reported.

AUTHORS' CONCLUSIONS

Current evidence suggests that the addition of heliox therapy may significantly reduce a clinical score evaluating respiratory distress in the first hour after starting treatment in infants with acute RSV bronchiolitis. Nevertheless, there was no reduction in the rate of intubation, in the need for mechanical ventilation, or in the length of PICU stay. Further studies with homogeneous logistics in their heliox application are needed. Such studies would provide necessary information as to the appropriate place for heliox in the therapeutic schedule for severe bronchiolitis.

Severe respiratory syncytial virus (RSV) infection in infants with neuromuscular diseases and immune deficiency syndromes

Respiratory syncytial virus (RSV) is an important cause of lower respiratory tract infection (LRTI) in infants and children. There is growing evidence of severe RSV disease in infants with neuromuscular diseases and immune deficiency syndromes. Factors predisposing to a more severe course of RSV disease in neuromuscular diseases include the impaired ability to clear secretions from the airways due to ineffective cough, respiratory muscle weakness, high prevalence of gastro-oesophageal reflux and swallowing dysfunction which leads to aspiration. Similarly, pulmonary disease is a common presenting feature and complication of T-cell immunodeficiency. Infants with severe congenital and acquired immune deficiency syndromes may demonstrate prolonged viral shedding in RSV LRTI and are reported to have increased morbidity and mortality associated with RSV infection. Although not indicated in most guideline statements, palivizumab prophylaxis for these uncommon underlying conditions is under consideration by clinicians. Prospective studies are needed to determine the burden of RSV disease in these children.

Non-invasive ventilation as primary ventilatory support for infants with severe bronchiolitis

OBJECTIVE

To report our experience of non-invasive ventilation (NIV) as primary ventilatory support strategy in infants admitted for severe bronchiolitis.

DESIGN AND SETTING

Retrospective study in a paediatric intensive care unit of an university hospital.

PATIENTS

Infants aged less than 12 months, admitted for bronchiolitis during 2003-2004 and 2004-2005 winter epidemics.

INTERVENTION

NIV was used as the primary ventilatory support during the second winter (NIV period), whereas invasive ventilation (IV) was the only support employed during the first winter (IV period). NIV consisted in either continuous positive airway pressure (CPAP from 5 to 10 cmH(2)O) or bilevel positive airway pressure (inspiratory pressure from 12 to 18 cmH(2)O) with a nasal mask.

RESULTS

During the IV period, 53 infants were included, compared to 27 during the NIV period. The two groups did not differ in age or in number of premature births. Children in NIV group had less apnoea on admission. The intubation rate was reduced during NIV period (p < 0.001). No children had ventilator-associated pneumonia (VAP) during NIV period compared to nine during IV period (p < 0.05). In the NIV group, 10 infants (37%) required supplemental oxygen for more than 8 days compared to 33 children (65%) in IV group (p < 0.05). The length of hospital stay and the duration of ventilation were similar.

CONCLUSIONS

In this retrospective study, the use of NIV decreased the rate of ventilator associated pneumonia and reduced the duration of oxygen requirement without prolonging the hospital stay.

High frequency oscillatory ventilation for respiratory failure due to RSV bronchiolitis

OBJECTIVE

To describe the time course of high frequency oscillatory ventilation (HFOV) in respiratory syncytial virus (RSV) bronchiolitis.

DESIGN

Retrospective charts review.

SETTING

A tertiary paediatric intensive care unit.

PATIENTS AND PARTICIPANTS

Infants with respiratory failure due to RSV infection.

INTERVENTION

HFOV.

MEASUREMENTS AND RESULTS

Pattern of lung disease, ventilatory settings, blood gases, infant's vital parameters, sedation and analgesia during the periods of conventional mechanical ventilation (CMV, 6 infants), after initiation of HFOV (HFOVi, 9 infants), in the middle of its course (HFOVm), at the end (HFOVe) and after extubation (Post-Extub) were compared. All infants showed a predominant overexpanded lung pattern. Mean airway pressure was raised from a mean (SD) 12.5 (2.0) during CMV to 18.9 (2.7) cmH(2)O during HFOVi (P < 0.05), then decreased to 11.1(1.3) at HFOVe (P < 0.05). Mean FiO(2) was reduced from 0.68 (0.18) (CMV) to 0.59 (0.14) (HFOVi) then to 0.29 (0.06) (P < 0.05) at HFOVe and mean peak to peak pressure from 44.9 (12.4) cmH(2)O (HFOVi) to 21.1 (7.7) P < 0.05 (HFOVe) while mean (SD) PaCO(2) showed a trend to decrease from 72 (22) (CMV) to 47 (8) mmHg (HFVOe) and mean infants respiratory rate a trend to increase from 20 (11) (HFOVi) to 34 (14) (HFOVe) breaths/min. With usual doses of sedatives and opiates, no infant was paralysed and all were extubated to CPAP or supplemental oxygen after a mean of 120 h.

CONCLUSION

RSV induced respiratory failure with hypercapnia can be managed with HFOV using high mean airway pressure and large pressure swings while preserving spontaneous breathing.

[Severe bronchiolitis. Epidemiology and clinical course of 284 patients]

INTRODUCTION

Bronchiolitis is the leading cause of hospital admission and a frequent cause of pediatric intensive care unit (PICU) admission among infants during the winter months. The objective of this study was to analyze the characteristics and clinical course of patients admitted to the PICU for bronchiolitis.

PATIENTS AND METHOD

We performed a descriptive, observational study by clinical chart review of all patients admitted to the PICU for severe bronchiolitis from November 1994 to March 2006.

RESULTS

A total of 284 patients were included. Most were admitted during December and January and 74% had respiratory syncytial virus (RSV) infection. At least one risk factor for severe disease was present in 68% of the patients: the most frequent risk factor was age < 6 weeks (45%), followed by prematurity (30%). Mechanical ventilation was required in 64 of the 284 patients (24%). Mortality was 1.8% and was associated with chronic pre-existing illness (p < 0.001). The factors associated with a greater risk of mechanical ventilation and a longer PICU stay were the association of two or more risk factors (42/284; 15%), the presence of apnea (73/284; 25.7%), and images of pulmonary consolidation or atelectasis on admission chest X-ray (157/284; 55%).

CONCLUSIONS

Most patients admitted for severe bronchiolitis to the PICU are healthy infants whose principal risk factor is young age. The main predictors of severe clinical course during PICU stay are the association of two or more risk factors, the presence of apnea, and pulmonary consolidation on admission chest X-ray. Bronchiolitis-associated mortality is low and is associated with pre-existing chronic illness.

Place de la ventilation non invasive nasale dans la prise en charge des broncho-alvéolites sévères

OBJECTIVE

Usefulness of nasal continuous positive airway pressure (NCPAP) in severe acute bronchiolitis has been checked. The objective of this descriptive study was to evaluate the feasibility, safety and risk factors of NCPAP failure.

POPULATION AND METHODS

One hundred and forty-five infants were hospitalised in our intensive care unit during the 2 last epidemics (2003-2004, 2004-2005). Among them, 121 needed a respiratory support, either invasive ventilation (N=68) or NCPAP (N=53).

RESULTS

General characteristics were similar during the 2 periods. Percentage of NCPAP failure, defined by tracheal intubation requirement during the stay in paediatric intensive care unit, was quite similar during the 2 periods (25%), but number of NCPAP increased twofold. Whatever the evolution was in the NCPAP group, we observed a significant decrease in respiratory rate (60+/-16 vs 47.5+/-13.7 cycle/min., P<0.001) and PaCO2 (64.3+/-13.8 vs 52.6+/-11.7 mmHg, P=0.001) during NCPAP. Only PRISM calculated at day 1 and initial reduction of PaCO2 were predictive of NCPAP failure. Percentage of ventilator associated pneumonia was similar (22%) between the invasive ventilation group and infants who where intubated because of failure of NCPAP. Duration of respiratory support and stay were reduced in the NCPAP group (P<0.002).

CONCLUSION

NCPAP appears to be a safe alternative to immediate intubation in infants with severe bronchiolitis.