The Role of Viral Coinfection in Bronchiolitis Treated With High-Flow Nasal Cannula at Pediatric Emergency Department During 2 Consecutive Seasons: An Observational Study

The Impact of Viral Co-Infection in Children Treated With Respiratory Support Due to Lower Respiratory Tract Infections. An Observational Study

OBJECTIVE

To investigate the effect of viral co-infections on treatment length and treatment failure in children with lower respiratory tract infections (LRTI) supported with continuous positive airway pressure (CPAP) or high-flow nasal cannula oxygenation therapy (HFNC).

METHODS

Patients aged 0-5 years hospitalized with viral LRTI and in need of respiratory support between August 1 and December 31, 2021, were retrospectively evaluated by patient chart audits.

RESULTS

A total of 148 children (median age 10.1 [IQR 2.2-17.6] months) were included. Of this, 98 children were treated with HFNC and 50 with CPAP. Five children were transferred to the pediatric intensive care unit. In 17 children, HFNC treatment failed, leading to a shift to CPAP. The median treatment length was 90.6 (IQR 61-136) h. A total of 93 children were mono-infected: 66 with respiratory syncytial virus (RSV), 14 with rhino/enterovirus (REV), 11 with metapneumovirus (MPV), 1 with adenovirus (AV), and 1 with coronavirus. Fourteen children were co-infected with either RSV, REV or MPV and AV or parainfluenza virus (PIV). A total of 41 children were infected with both RSV and REV, RSV and MPV, MPV and REV, or all three viruses. Co-infections with RSV, MPV, and/or REV were independent predictors of treatment failure with HFNC (p < 0.05) and length of treatment (p < 0.01), whereas co-infections with AV or PIV had no effect.

CONCLUSION

In children with viral LRTI, the combination of RSV/REV/MPV had an impact on treatment length and failure with HFNC, whereas co-infections with either RSV, REV or MPV, and AV or PIV had not.

Occult Serious Bacterial Infections in Neonates and Infants Up to Three Months of Age with Bronchiolitis: Are Invasive Cultures Required?

(1) Background: The literature reports a low risk of serious bacterial infections (SBIs) in febrile infants presenting with bronchiolitis or respiratory syncytial virus infection, but current microbiological techniques have a higher accuracy. (2) Methods: We assessed the risk of SBIs in neonates and infants with bronchiolitis from 2021 to 2023. We also evaluated C-reactive protein, procalcitonin, and leukocyte values. (3) Results: We included 242 infants. Blood cultures (BCs) were performed in 66/242 patients, with a positivity rate of 9.1% (including one BC with Staphylococcus hominis, considered as a contaminant). The cerebrospinal fluid culture was performed in 6/242 patients, and the results were all negative. Infection markers did not discriminate infants with positive BCs from those with negative ones. (4) Conclusions: Blood cultures should be performed in neonates and young infants with bronchiolitis fever, as the sepsis risk is not negligible. Conversely, our proposed algorithm is to wait for the respiratory panel results before decision-making for a lumbar puncture. Further studies are needed to understand lumbar puncture requirements.

Are lung ultrasound features more severe in infants with bronchiolitis and coinfections?

Background

The lung ultrasound (LUS) score can be a useful tool to predict the need for respiratory support and the length of hospital stay in infants with bronchiolitis.

Objective

To compare lung ultrasound features in neonates and infants up to three months of age with bronchiolitis to determine whether LUS scores (range 0-36) differ in infants with coinfections or not.

Methods

Neonates and infants younger than three months admitted to neonatal units from October 2022 to March 2023, who underwent lung ultrasound evaluation on admission, were included in this retrospective study.

Results

We included 60 patients who underwent LUS evaluation at admission. Forty-two infants (70.0%) had a single viral infection. Eighteen infants (30.0%) had a coinfection: fifteen infants (25.0%) had more than one virus at PCR; one infant (1.7%) had both a viral coinfection and a viral-bacteria coinfection; two infants (3.3%) had viral-bacteria coinfection. Infants with a single viral infection and those with coinfections had similar LUS scores globally and in different lung zones. An LUS score higher than 8 was identified to significantly predict the need for any respiratory support (p = 0.0035), whereas an LUS score higher than 13 was identified to significantly predict the need for mechanical ventilation (p = 0.024).

Conclusion

In our small cohort of neonates and infants younger than three months hospitalized with bronchiolitis, we found no statistically significant differences in the LUS score on admission between patients with a single viral infection and those with multiple infections.

High-Flow Oxygen and Other Noninvasive Respiratory Support Therapies in Bronchiolitis: Systematic Review and Network Meta-Analyses

OBJECTIVES

We present a systematic review on the effectiveness of noninvasive respiratory support techniques in bronchiolitis.

DATA SOURCES

Systematic review with pairwise meta-analyses of all studies and network meta-analyses of the clinical trials.

STUDY SELECTION

Patients below 24 months old with bronchiolitis who require noninvasive respiratory support were included in randomized controlled trials (RCTs), non-RCT, and cohort studies in which high-flow nasal cannula (HFNC) was compared with conventional low-flow oxygen therapy (LFOT) and/or noninvasive ventilation (NIV).

DATA EXTRACTION

Emergency wards and hospitalized patients with bronchiolitis.

DATA SYNTHESIS

A total of 3,367 patients were analyzed in 14 RCTs and 8,385 patients in 14 non-RCTs studies. Only in nonexperimental studies, HFNC is associated with a lower risk of invasive mechanical ventilation (MV) than NIV (odds ratio, 0.49; 95% CI, 0.42-0.58), with no differences in experimental studies. There were no differences between HFNC and NIV in other outcomes. HFNC is more effective than LFOT in reducing oxygen days and treatment failure. In the network meta-analyses of clinical trials, NIV was the most effective intervention to avoid invasive MV (surface under the cumulative ranking curve [SUCRA], 57.03%) and to reduce days under oxygen therapy (SUCRA, 79.42%), although crossover effect estimates between interventions showed no significant differences. The included studies show methodological heterogeneity, but it is only statistically significant for the reduction of days of oxygen therapy and length of hospital stay.

CONCLUSIONS

Experimental evidence does not suggest that high-flow oxygen therapy has advantages over LFOT as initial treatment nor over NIV as a rescue treatment.

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

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.

Time to Say Goodbye to Bronchiolitis, Viral Wheeze, Reactive Airways Disease, Wheeze Bronchitis and All That

The diagnosis and management of infants and children with a significant viral lower respiratory tract illness remains the subject of much debate and little progress. Over the decades various terms for such illnesses have been in and fallen out of fashion or have evolved to mean different things to different clinicians. Terms such as "bronchiolitis," "reactive airways disease," "viral wheeze," and many more are used to describe the same condition and the same term is frequently used to describe illnesses caused by completely different dominant pathologies. This lack of clarity is due, in large part, to a failure to understand the basic underlying inflammatory and associated processes and, in part, due to the lack of a simple test to identify a condition such as asthma. Moreover, there is a lack of insight into the fact that the same pathology can produce different clinical signs at different ages. The consequence is that terminology and fashions in treatment have tended to go around in circles. As was noted almost 60 years ago, amongst pre-school children with a viral LRTI and airways obstruction there are those with a "viral bronchitis" and those with asthma. In the former group, a neutrophil dominated inflammation response is responsible for the airways' obstruction whilst amongst asthmatics much of the obstruction is attributable to bronchoconstriction. The airways obstruction in the former group is predominantly caused by airways secretions and to some extent mucosal oedema (a "snotty lung"). These patients benefit from good supportive care including supplemental oxygen if required (though those with a pre-existing bacterial bronchitis will also benefit from antibiotics). For those with a viral exacerbation of asthma, characterized by bronchoconstriction combined with impaired b-agonist responsiveness, standard management of an exacerbation of asthma (including the use of steroids to re-establish bronchodilator responsiveness) represents optimal treatment. The difficulty is identifying which group a particular patient falls into. A proposed simplified approach to the nomenclature used to categorize virus associated LRTIs is presented based on an understanding of the underlying pathological processes and how these contribute to the physical signs.