Practice variation in the management of children hospitalized with bronchiolitis: A Canadian perspective

Suctioning in the management of bronchiolitis: A prospective observational study

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.

Oxygen Saturation Targets in Infants Hospitalized With Bronchiolitis: A Multicenter Cohort Study

OBJECTIVES

To examine 2 hospital oxygen saturation target policies and clinical outcomes in infants hospitalized with bronchiolitis.

METHODS

This multicenter cohort study used data collected from a randomized clinical trial of infants aged 4 weeks to 24 months, hospitalized with bronchiolitis at children's and community hospitals from 2016 to 2019. We modeled the association between hospital oxygen saturation target policy, either 90% while awake and 88% while asleep (90%/88%) or 90% while awake and asleep (90%/90%), and clinical outcomes.

RESULTS

A total of 162 infants were enrolled at 4 hospitals using a 90%/88% oxygen saturation target and 67 infants at 2 hospitals using a 90%/90% target policy. No significant differences between the 90%/88% group and 90%/90% groups were observed for time to discharge (adjusted hazard ratio, 0.83; 95% confidence interval [CI], 0.61-1.14; P = .25), initiation of supplemental oxygen (adjusted odds ratio [aOR], 0.98; 95% CI, 0.47-2.02; P = .95), time to discontinuation of supplemental oxygen (adjusted hazard ratio, 0.75; 95% CI, 0.44-1.27; P = .28), revisits (aOR, 1.38; 95% CI, 0.52-3.71; P = .52), and parent days missed from work (aOR, 2.41; 95% CI, 0.90-6.41; P = .08). Three infants in the 90%/88% group and none in the 90%/90% group were transferred to the ICU.

CONCLUSIONS

Among infants hospitalized with bronchiolitis, clinical outcomes were similar between a hospital oxygen saturation target policy of 90% while awake and 88% while asleep compared with 90% while awake and asleep. These findings may inform the design of future trials of oxygen saturation targets in bronchiolitis hospital care.

Duration of monitoring after cessation of oxygen therapy in infants with bronchiolitis

AIM

There is no evidence for how long bronchiolitis patients should be observed after coming off oxygen therapy and wide practice variation exists. We aimed to investigate whether it is safe to discharge bronchiolitis patients 4 h after cessation of oxygen therapy.

METHODS

A retrospective single-centre cohort study of 884 infants (n = 462 in 2018 vs. n = 422 in 2019) aged 0-24 months admitted with bronchiolitis in 2018 and 2019 was conducted after implementation of a bronchiolitis protocol recommending discharge home 4 h post-cessation of oxygen therapy in 2019. We compared the rate of readmissions and Clinical Reviews/Rapid Responses in the pre- and post-exposure cohorts.

RESULTS

There was a significant reduction in median (interquartile range (IQR)) time to discharge post oxygen cessation by 87 min (510 (370-1033) min versus 423 (273-904) min; P < 0.001) and in median (IQR) length of stay by 6.7 h (2.11 (1.54-2.97) days vs. 1.83 (1.17-2.71) days; P < 0.001). There was no significant difference between readmissions in 2018 compared to 2019 (0.6% vs. 1.4%; P = 0.317). In 2018, there were two Clinical Reviews and in 2019 there were two Rapid Responses post-cessation of oxygen. There were 89 patients discharged within 4 h of cessation of oxygen therapy (n = 18 in 2018 vs. n = 71 in 2019; P < 0.001) with no readmissions, Clinical Reviews or Rapid Responses in the 2019 cohort.

CONCLUSIONS

This study demonstrates that patients can be discharged 4 h after cessation of supplemental oxygen without increased risk of adverse events.

Protocol-Driven Initiation and Weaning of High-Flow Nasal Cannula for Patients With Bronchiolitis: A Quality Improvement Initiative

OBJECTIVES

Bronchiolitis is the most common cause for nonelective infant hospitalization in the United States with increasing utilization of high-flow nasal cannula (HFNC). We standardized initiation and weaning of HFNC for bronchiolitis and quantified the impact on outcomes. Our specific aim was to reduce hospital and ICU length of stay (LOS) by 10% between two bronchiolitis seasons after implementation.

DESIGN

A quality improvement (QI) project using statistical process control methodology.

SETTING

Tertiary-care children's hospital with 24 PICU and 48 acute care pediatric beds.

PATIENTS

Children less than 24 months old with bronchiolitis without other respiratory diagnoses or underlying cardiac, respiratory, or neuromuscular disorders between December 2017 and November 2018 (baseline), and December 2018 and February 2020 (postintervention).

INTERVENTIONS

Interventions included development of an HFNC protocol with initiation and weaning guidelines, modification of protocol and respiratory assessment classification, education, and QI rounds with a focus on efficient HFNC weaning, transfer, and/or discharge.

MEASUREMENTS AND MAIN RESULTS

A total of 223 children were included (96 baseline and 127 postintervention). The primary outcome metric, average LOS per patient, decreased from 4.0 to 2.8 days, and the average ICU LOS per patient decreased from 2.8 to 1.9 days. The secondary outcome metric, average HFNC treatment hours per patient, decreased from 44.0 to 36.3 hours. The primary and secondary outcomes met criteria for special cause variation. Balancing measures included ICU readmission rates, 30-day readmission rates, and adverse events, which were not different between the two periods.

CONCLUSIONS

A standardized protocol for HFNC management for patients with bronchiolitis was associated with decreased hospital and ICU LOS, less time on HFNC, and no difference in readmissions or adverse events.

Patient, Provider, and Health Care System Characteristics Associated With Overuse in Bronchiolitis

BACKGROUND AND OBJECTIVES

The American Academy of Pediatrics recommends against the routine use of β-agonists, corticosteroids, antibiotics, chest radiographs, and viral testing in bronchiolitis, but use of these modalities continues. Our objective for this study was to determine the patient, provider, and health care system characteristics that are associated with receipt of low-value services.

METHODS

Using the Virginia All-Payers Claims Database, we conducted a retrospective cross-sectional study of children aged 0 to 23 months with bronchiolitis (code J21, International Classification of Diseases, 10th Revision) in 2018. We recorded medications within 3 days and chest radiography or viral testing within 1 day of diagnosis. Using Poisson regression, we identified characteristics associated with each type of overuse.

RESULTS

Fifty-six percent of children with bronchiolitis received ≥1 form of overuse, including 9% corticosteroids, 17% antibiotics, 20% β-agonists, 26% respiratory syncytial virus testing, and 18% chest radiographs. Commercially insured children were more likely than publicly insured children to receive a low-value service (adjusted prevalence ratio [aPR] 1.21; 95% confidence interval [CI]: 1.15-1.30; P < .0001). Children in emergency settings were more likely to receive a low-value service (aPR 1.24; 95% CI: 1.15-1.33; P < .0001) compared with children in inpatient settings. Children seen in rural locations were more likely than children seen in cities to receive a low-value service (aPR 1.19; 95% CI: 1.11-1.29; P < .0001).

CONCLUSIONS

Overuse in bronchiolitis remains common and occurs frequently in emergency and outpatient settings and rural locations. Quality improvement initiatives aimed at reducing overuse should include these clinical environments.

Parent Experiences Caring for a Child With Bronchiolitis: A Qualitative Study

Background:

Bronchiolitis is an acute lower respiratory infection, with significant impacts on children and families and strains on the health care system. Understanding parents’ experiences and information needs caring for a child with bronchiolitis is crucial to highlight misconceptions or issues contributing to the high burden. The objective of this qualitative study was to describe parents’ experiences caring for a child with bronchiolitis.

Methods:

Qualitative description guided this study. Participants were recruited from the Stollery Children’s Hospital emergency department (ED), a specialized pediatric ED in a major Canadian urban center. Semi-structured interviews were conducted with 15 parents.

Results:

Five major themes were identified: (a) their children’s symptoms and behaviors, (b) bronchiolitis affects the entire family, (c) factors influencing parent’s decision to go to ED, (d) ED experience for parents and their children, and (e) bronchiolitis treatment and management. Interviews revealed bronchiolitis has significant effects on both children and families and parents are generally unaware of bronchiolitis symptoms, treatment, and management.

Conclusions:

Our study highlights that parents have knowledge deficits when it comes to recognizing the presence and severity of bronchiolitis symptoms. Parents would benefit from having more evidence-based resources to enhance their knowledge about the nature of bronchiolitis.