Bronchiolitis: in-patient focus

Bronchiolitis in Infants; Five Years' Experience of a Teaching Hospital

Background

Bronchiolitis is a clinical syndrome affecting the lower respiratory tract of infants and toddlers <2 years old. Variability in clinical profile and response to therapy in children with Bronchiolitis calls for studying the different clinical aspects of local patient population.

Aim

The goal of our study is to determine the clinical presentation, past medical history, hospitalization course and prognosis in children below two years of age who have been hospitalized in King Fahad University Hospital over the last five years.

Materials and Methods

A retrospective chart review based on electronic health records of all Bronchiolitis-related hospitalization of infants and toddlers below two years of age, covering the period between January 1, 2015, to April 26, 2020.

Results

Out of a total of 446 children <2 years of age, 202 were female (45.4%), and 243 were male (54.6%). Although the length of hospital stay was almost equal between the sexes, there was a significant (p-value=0.01) increase in length of intensive care unit stay among females compared to males. Furthermore, there was a significant prolongation in the duration of ventilator usage among females (p value = 0.062). Out of fifty-five patients admitted to the ICU, 83.63% of them were 12 months of age and below.

Conclusion

Our results show a significant increase in length of ICU and ventilator use among females compared to males. It also shows that infants younger than 12 months account for most ICU admissions. These findings, among many others, may help pediatricians formulate a better diagnostic and therapeutic pathways.

Manifestations and Risk Factors in Children Hospitalized with Respiratory Syncytial Virus Infection

Background: Acute lower respiratory infection (ALRI) is one of the main causes of morbidity and mortality in children under five years of age, and the respiratory syncytial virus (RSV) remains its leading etiological factor. Although RSV infections occur in all age groups, the most severe course is observed among children. The clinical manifestations include both mild upper respiratory infections and severe infections of the lower tract, such as bronchiolitis and pneumonia that can lead to hospitalization and severe complications, including respiratory failure. Objectives: The study aimed to evaluate the manifestations of RSV infection in hospitalized children younger than 18 months of age and predictors of disease severity, as well as their comparison with the same age group hospitalized due to ALRI of different etiology. Methods: A retrospective analysis was performed on medical records of 448 children hospitalized due to ALRI. The analysis was performed on the total study group and subgroups of children with positive and negative results of the nasal swab for RSV detection. In each group, clinical data, laboratory test results, and imaging results were analyzed. Results: The most common manifestation was pneumonia (n = 82; 63.08%). Otitis media was observed mainly in children under six months of age with lowered inflammatory markers (P < 0.05), conjunctivitis in those with a positive family history of allergies (P < 0.05), and pneumonia in children under six months of age, with lower blood oxygen saturation and inflammatory markers, features of acidosis, and fever-free course (P < 0.05). Respiratory failure affected 13 children (10%). However, no predictors of this complication were noted. Conclusions: As pneumonia was the most common manifestation in children with both RSV-positive and RSV-negative ALRI, it seems advisable to perform the imaging of the lungs on admission and carefully monitor the child’s condition during hospitalization. In both groups, special attention should be paid to the youngest children with low inflammatory markers on hospital admission, increased clinical symptoms, and family history of allergies. Nevertheless, widely known risk factors of RSV infection itself do not reflect the risk of developing pneumonia or respiratory failure in its course.

Risk Factors and Clinical Determinants in Bronchiolitis of Infancy

OBJECTIVES

The aims of this study was to demonstrate the viral pathogens, to evaluate the clinical prognosis, risk factors for recurrence, severity of acute viral bronchiolitis episodes among pediatric patients.

MATERIALS AND METHODS

Our study included 101 children aged between 2 months and 2 years diagnosed with clinical bronchiolitis between September 2011 and April 2012. The demographics and clinical, laboratory, and radiological results of the patients were recorded. Nasopharyngeal swab samples were collected and analyzed through polymerase chain reaction (PCR) method. The patients were followed up for at least one year for new episodes, existence of wheezing, frequency of pulmonary infections, and progression of asthma.

RESULTS

In half of the patients, determinants were indicated through the PCR method, with the most frequent being respiratory syncytial virus (44%). The frequency of bronchiolitis was higher in prematures (p<0.005). There was a relationship between crowded family structure and the existence of wheezing (p=0.003), increased recurrence (p=0.014), and need for inhaler treatment (p=0.014). The frequency was higher in patients living in urban cities (p<0.001), in houses with heating stoves (p=0.001), and in houses with smokers (p=0.001). Patients living in houses with heating stoves had more severe episodes (p=0.018). Recurrent wheezing and the need for regular inhaler usage were positively correlated with high API scores (p=0.008 and p=0.002, respectively).

CONCLUSION

Prematurity, exposure to smoking, living in a crowded house with heating stoves, and an urban life are the risk factors for frequent bronchiolitis. The API can be used to predict the recurrence of bronchiolitis.

Efficacy of 3% hypertonic saline in bronchiolitis: A meta-analysis

A meta-analysis was performed to analyze the efficacy of 3% hypertonic saline (HS) in bronchiolitis. Pubmed and MEDLINE databases were searched for relevant articles. A total of 2 authors selected the articles according to the inclusion criteria and then data were carefully extracted. Weighted mean difference (WMD) with 95% confidence interval (95% CI) values were used to pool continuous data, including length of stay and clinical severity score (CSS). Relative risk (RR) with 95% CI was calculated to determine the association between 3% HS and re-admission. The pooled data revealed that infants treated with 3% HS exhibited shorter durations of hospitalization compared with those treated with normal saline (NS; WMD=-0.43; 95% CI=-0.70, -0.15). Subgroup analysis examining the combination of HS or NS with additional medication demonstrated that 3% HS with epinephrine significantly decreased the length of hospital stay, with a WMD=-0.62 (95% CI=-0.90, -0.33). The results indicated a lower CSS score in the 3% HS group compared with the NS group (SMD=-0.80; 95% CI=-1.06, -0.54). The pooled outcome indicated a beneficial effect of 3% HS on decreasing re-admission rates compared with NS (RR=0.93; 95% CI=0.70, 1.23). No potential publication bias was observed (Begg's, P=0.133; Egger's, P=0.576). In conclusion, 3% HS was demonstrated to be a more successful therapy compared with NS for infants with bronchiolitis.

IV Magnesium Sulfate for Bronchiolitis: A Randomized Trial

BACKGROUND

The goal of this study was to determine if IV magnesium, useful for severe pediatric asthma, reduces time to medical readiness for discharge in patients with bronchiolitis when added to supportive care.

METHODS

We compared a single dose of 100 mg/kg of IV magnesium sulfate vs placebo for acute bronchiolitis. Patients received bronchodilator therapy, nebulized hypertonic saline, and 5 days of dexamethasone if there was eczema and/or a family history of asthma. Time to medical readiness for discharge was the primary efficacy outcome. Bronchiolitis severity scores and need for infirmary or hospital admission and for clinic revisits within 2 weeks were secondary outcomes. Cardiorespiratory instability onset was the safety outcome.

RESULTS

A total of 162 previously healthy infants diagnosed with bronchiolitis aged 22 days to 17.6 months (median, 3.7 months) were enrolled. Approximately one-half of patients had eczema and/or a family history of asthma; 86.4% had positive findings on nasopharyngeal virus swabs. Geometric mean time until medical readiness for discharge was 24.1 h (95% CI, 20.0-29.1) for the 78 magnesium-treated patients and 25.3 h (95% CI, 20.3-31.5) for the 82 patients receiving placebo (ratio, 0.95 [95% CI, 0.52-1.80]; P = .91). Mean bronchiolitis severity scores over time were similar for the two groups. The frequency of clinic visits in the subsequent 2 weeks (33.8% and 27.2%, respectively) was also similar. Fifteen magnesium recipients (19.5%) vs five placebo recipients (6.2%) were readmitted to the infirmary or hospital within 2 weeks (P = .016). No acute cardiorespiratory side effects were reported.

CONCLUSIONS

IV magnesium did not provide benefit for patients with acute bronchiolitis and may be harmful.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT02145520; URL: www.clinicaltrials.gov.

Clinical and laboratory characteristics of viral lower respiratory tract infections in preschool children

Background

Viral lower respiratory tract infections are the leading cause of hospitalizations in preschool children. Clinical pictures of different viral causes are not well characterized. The aim of this study was to establish the differences in clinical and laboratory characteristics between the different viral causes of lower respiratory tract infections in preschool children.

Methods

We included 278 preschool children hospitalized because of lower respiratory tract infection. White blood cell count and C-reactive protein values were determined and chest X-ray was performed in most patients. Polymerase chain reaction assay was used for the detection of viral pathogens from nasopharyngeal swab.

Results

Pneumonia was present in 71.4 % of all coronavirus infections, 35.1 % of all respiratory syncytial virus infections, and 13.0 % of all rhinovirus infections. Coronavirus (p = 0.03) and respiratory syncytial virus (p < 0.01) were retrospectively shown to be associated with the presence of pneumonia and rhinovirus (p < 0.01) with the absence of pneumonia. Wheezing was present in 81.5 % of all rhinovirus infections and in only 33.3 % of all adenovirus infections. Rhinovirus (p < 0.01) was associated with the presence of wheezing and adenovirus (p = 0.05) with the absence of wheezing. In adenovirus infections mean C-reactive protein value was 72.4 mg/L and white blood cell count 19.000/µl, both significantly higher than in other viruses (p < 0.01).

Conclusions

Clinical and laboratory characteristics of viral lower respiratory tract infections significantly differ. With the advance of viral detection methods and increase of knowledge it becomes possible to characterize different respiratory viral infections and to improve the differential diagnosis.

Respiratory Tract Infections

Respiratory tract infections are among the most common and important problems in clinical medicine. The approach to these infections begins with a basic understanding of the pathophysiology of the respiratory tract and how immune defences interact with pathogens. A number of distinct clinical syndromes can be defined which help physicians and clinical microbiologists develop a differential diagnosis of potential infecting pathogens. The type and severity of infection is often modulated by the medical characteristics of the patient, circumstances surrounding infection, geography and environmental exposures. Multiple laboratory test methodologies are available to aid clinical diagnosis and close communication between clinicians and laboratory personnel can optimise the efficiency and cost-effectiveness of diagnosis. Molecular testing for respiratory viruses has become widely used in the clinical setting and will expand to include other pathogens of the respiratory tract.

Oral dexamethasone for bronchiolitis: a randomized trial

OBJECTIVE

Determine whether dexamethasone treatment added to salbutamol reduces time to readiness for discharge in patients with bronchiolitis and possible asthma.

METHODS

We compared efficacy and safety of dexamethasone, 1 mg/kg, then 0.6 mg/kg for 4 more days, with placebo for acute bronchiolitis in patients with asthma risk, as determined by eczema or a family history of asthma in a first-degree relative. All patients received inhaled salbutamol. Time to readiness for discharge was the primary efficacy outcome.

RESULTS

Two hundred previously healthy infants diagnosed with bronchiolitis, median age 3.5 months, were enrolled. Five placebo recipients needed admission to intensive care unit during infirmary treatment (P = .02). Among 100 dexamethasone recipients, geometric mean time to readiness for discharge was 18.6 hours (95% confidence interval [CI], 14.9 to 23.1 hours); among 90 control patients, 27.1 hours (95% CI, 21.8 to 33.8 hours). The ratio, 0.69 (95% CI, 0.51 to 0.93), revealed a mean 31% shortening of duration to readiness for discharge favoring dexamethasone (P = .015). Twenty-two dexamethasone and 19 control patients were readmitted to the short stay infirmary in the week after discharge (P = .9). No hospitalizations or side effects were reported during 7 days of surveillance.

CONCLUSIONS

Dexamethasone with salbutamol shortened time to readiness for infirmary discharge during bronchiolitis episodes in patients with eczema or a family history of asthma in a first-degree relative. Infirmary and clinic visits in the subsequent week occurred similarly for the 2 groups.

Evaluation of viral load in infants hospitalized with bronchiolitis caused by respiratory syncytial virus

The relationship between viral load, disease severity and antiviral immune activation in infants suffering from respiratory syncytial virus (RSV)-associated bronchiolitis has not been well identified. The main objective of this study was to determine the existence of a correlation between RSV load and disease severity and also between different clinical markers and mRNA levels of the interferon stimulated gene (ISG)56 in infants hospitalized for bronchiolitis. We also evaluated whether viral load tended to be persistent over the course of the RSV infection. The levels of RSV-RNA were quantified in nasopharyngeal washings, collected from 132 infants infected with RSV as a single (90.15%) or as a dual infection with other respiratory viruses (9.85%). Results indicated that viral load was positively related to the clinical severity of bronchiolitis, the length of hospital stay, the levels of glycemia and the relative gene expression of ISG56, whereas an inverse correlation was observed with the levels of hemoglobin. We also found that the RSV load significantly decreased between the first and second nasopharingeal washings sample in most subjects. These results suggest that infants with high RSV load on hospital admission are more likely to have both more severe bronchiolitis and a higher airway activation of antiviral immune response.

Nebulized 5% or 3% hypertonic or 0.9% saline for treating acute bronchiolitis in infants

OBJECTIVE

To compare the efficacy and safety of 5%, 3%, and 0.9% saline solution for treating acute bronchiolitis in the prehospital setting.

STUDY DESIGN

This was a double-blind trial including consecutive infants aged <18 months treated in an urban urgent care setting. A total of 165 patients were randomized to receive nebulized 5%, 3%, or 0.9% (normal) saline with epinephrine every 4 hours. The primary efficacy outcome was bronchiolitis severity score improvement at 48 hours (chi2 analysis). Scores and oxygen saturation immediately before and after each treatment were recorded to assess safety.

RESULTS

A total of 187 previously healthy infants (median age, 3.1 months) diagnosed with bronchiolitis were enrolled. Positivity for respiratory syncytial virus was similar in the 3 treatment groups (mean, 56%). At 48 hours, the mean severity score for the 5% saline group was 3.69+/-1.09, and that for the 0.9% saline group was 4.12+/-1.11 (P=.04; difference, 0.43, 95% confidence interval for the difference, 0.02-0.88). The mean severity score for the 3% saline group was intermediate at 4.00+/-1.22. Revisit rates after discharge were similar in the 3 treatment groups. No adverse reactions or other safety concerns were identified.

CONCLUSIONS

Nebulization with 5% hypertonic saline is safe, can be widely generalizable, and may be superior to current treatment for early outpatient treatment of bronchiolitis.

Haemophilusinfluenzae type b conjugate vaccine for preventing pneumonia in infants hospitalized for bronchiolitis: a case-control study

BACKGROUND

Haemophilus influenzae type b (Hib) conjugate vaccine reduces the risk of pneumonia in infants.

OBJECTIVE

To determine the effect of Hib conjugate vaccine (HibCV) on the prevention of pneumonia as a complication among infants hospitalized for bronchiolitis.

METHODS

This record-based case-control study was conducted at The Children's Hospital "Dr. Ovidio Aliaga U" in La Paz, Bolivia during 2003 and 2004. Cases were infants hospitalized for bronchiolitis under 1 year of age who developed radiological pneumonia during hospitalization. Controls were patients who had good clinical progress without the use of antibiotics. Pneumonia was defined by alveolar consolidation on chest X-ray that justified the use of antibiotics.

RESULTS

Eighty patients were studied (16 cases and 64 controls). Their median age was 4.5 months. Demographic and clinical features were similar in both groups, except for a higher proportion of vomiting (56.3% vs. 28.1%; p<0.05) in the case group. The percentage of unvaccinated infants was significantly higher in cases (68.8% vs. 26.6%; p<0.05) and the length of hospital stay longer (8.5+/-5.4 vs. 3.1+/-2.2 days; p<0.05). There was a strong association between unvaccinated infants and the occurrence of pneumonia as a complication (odds ratio 6.1, 95% confidence interval 1.8-20.1; p<0.01).

CONCLUSIONS

Unvaccinated infants admitted for bronchiolitis have a higher risk of radiologically confirmed pneumonia. Larger studies are needed to validate these results and reconsider the burden of Hib infection among infants in less developed countries.

Pharmacokinetics and safety of montelukast oral granules in children 1 to 3 months of age with bronchiolitis

The single-dose pharmacokinetics of montelukast 4-mg oral granules and tolerability of daily administration of 2 different doses of montelukast (4 mg and 8 mg given once daily for 7 days) versus placebo were evaluated in 12 infants 1 to 3 months of age with bronchiolitis or a history of bronchiolitis and asthma-like symptoms. The population area under the concentration-time curve estimate after a single 4-mg dose of montelukast was 13 195.7 +/- 2309.8 (standard error) ng.hr/mL, 3.6 times higher than historical values in infants 3 to 24 months of age. Six patients had 10 total clinical adverse experiences; none was considered serious or drug related. Three patients had transient drug-related increases in aspartate aminotransferase (montelukast 8 mg [n = 2]; placebo [n = 1]). Despite increased systemic exposure after administration of a single dose of montelukast 4-mg oral granules in infants 1 to 3 months of age compared with that in pediatric patients 3 to 24 months of age, administration of montelukast at 4 and 8 mg once daily for 7 days in 1- to 3-month-old infants was generally well tolerated.