Infants with severe respiratory syncytial virus needed less ventilator time with nasal continuous airways pressure then invasive mechanical ventilation

Safety and effectiveness of bubble continuous positive airway pressure as respiratory support for bronchiolitis in a pediatric ward

The results of several clinical trials suggest that continuous positive airway pressure (CPAP) for acute bronchiolitis can be more effective than high-flow nasal cannula (HFNC). The use of HFNC involved a minimum reduction (5%) in admissions to the pediatric intensive care unit (PICU) in our hospital. Our main aim was to evaluate its safety and effectiveness as respiratory support for patients with bronchiolitis in a pediatric general ward. A secondary goal was to compare the admissions to PICU and the invasive mechanical ventilation (IMV) rate of patients treated with HFNC and those treated with HFNC/b-CPAP during the 2018-2019 and 2019-2020 epidemic seasons, respectively. Two prospective single-centre observational studies were performed. For the main aim, a cohort study (CS1) was carried out from 1st of November 2019 to 15th of January 2020. Inclusion criteria were children aged up to 3 months with bronchiolitis treated with b-CPAP support when HFNC failed. Epidemiological and clinical parameters were collected before and 60 min after the onset of CPAP and compared between the responder (R) and non-responders (NR) groups. NR was the group that required PICU admission. One hundred fifty-eight patients were admitted to the ward with bronchiolitis and HFNC. Fifty-seven out of one hundred fifty-eight required b-CPAP. No adverse events were observed. Thirty-two out of fifty-seven remained in the general ward (R-group), and 25/57 were admitted to PICU (NR-group). There were statistically significant differences in respiratory rate (RR) and heart rate (HR) between both groups before and after the initiation of b-CPAP, but the multivariable models showed that the main differences were observed after 60 min of therapy (lower HR, RR, BROSJOD score and FiO2 in the R-group). For the secondary aim, another cohort study (CS2) was performed comparing data from a pre-b-CPAP bronchiolitis season (1st of November 2018 to 15th January 2019) and the b-CPAP season (2019-2020). Inclusion criteria in pre-b-CPAP season were children aged up to 3 months admitted to the same general ward with moderate-severe bronchiolitis and with HFNC support. Admissions to PICU during the CPAP season were significantly reduced, without entailing an increase in the rate of IMV.

CONCLUSION

The implementation of b-CPAP for patients with bronchiolitis in a pediatric ward, in whom HFNC fails, is safe and effective and results in a reduction in PICU admissions.

WHAT IS KNOWN

• Bronchiolitis is one of the most frequent respiratory infections in children and one of the leading causes of hospitalization in infants. • Several studies suggest that the use of continuous positive airway pressure (CPAP) for acute bronchiolitis can be more effective than the high flow nasal cannula (HFNC). CPAP is a non-invasive ventilation (NIV) therapy used in patients admitted to pediatric intensive care unit (PICU) with progressive moderate-severe bronchiolitis. There is little experience in the literature on the use of continuous positive airway pressure (CPAP) for acute bronchiolitis in a general ward.

WHAT IS NEW

• CPAP could be safely and effectively used as respiratory support in young infants with moderate-severe bronchiolitis in a general ward and it reduced the rate of patients who required PICU admission. • Patients' heart and respiratory rate and their FiO2 needs in the first 60 minutes may help to decide whether or not to continue the CPAP therapy in a general ward.

The Effects and Safety of Continuous Positive Airway Pressure in Children with Bronchiolitis: A Systematic Review and Meta-Analysis

OBJECTIVES

To evaluate the effects and safety of continuous positive airway pressure (CPAP) for initial respiratory management of bronchiolitis.

METHODS

PubMed, EMBASE, Cochrane Library, CNKI, Wanfang data and CQ VIP were searched until 17 June 2020. Randomized controlled trials (RCTs) which investigated the effect of CPAP for bronchiolitis were included.

RESULTS

Twenty-seven RCTs met the eligibility criteria. In the comparison of CPAP versus standard oxygen therapy, CPAP can reduce the length of stay (LOS) in hospital, respiratory rate (RR), PaCO2, heart rate, mechanical ventilation and increase PaO2, but the SpO2 and PH were not improved. In the comparison of CPAP versus high-flow nasal cannula, CPAP can reduce treatment failure, but the PICU LOS, Incidence of intubation, RR, Modified Woods Clinical Asthma Score were not decreased. Treatment failure may be less in helmet comparing with the mask though there was no quantitative analysis.

CONCLUSION

CPAP for the initial respiratory management significantly benefit children with bronchiolitis, the delivery of CPAP by helmet may be a better choice. More high-quality research is needed to confirm the conclusion.

Respiratory Syncytial Virus-Associated Acute Lower Respiratory Infections in Children With Bronchopulmonary Dysplasia: Systematic Review and Meta-Analysis

BACKGROUND

Respiratory syncytial virus (RSV) is among the most important causes of acute lower respiratory tract infection (ALRI) in young children. We assessed the severity of RSV-ALRI in children less than 5 years old with bronchopulmonary dysplasia (BPD).

METHODS

We searched for studies using EMBASE, Global Health, and MEDLINE. We assessed hospitalization risk, intensive care unit (ICU) admission, need for oxygen supplementation and mechanical ventilation, and in-hospital case fatality (hCFR) among children with BPD compared with those without (non-BPD). We compared the (1) length of hospital stay (LOS) and (2) duration of oxygen supplementation and mechanical ventilation between the groups.

RESULTS

Twenty-nine studies fulfilled our inclusion criteria. The case definition for BPD varied substantially in the included studies. Risks were higher among children with BPD compared with non-BPD: RSV hospitalization (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.7-4.2; P < .001), ICU admission (OR, 2.9; 95% CI, 2.3-3.5; P < .001), need for oxygen supplementation (OR, 4.2; 95% CI, .5-33.7; P = .175) and mechanical ventilation (OR, 8.2; 95% CI, 7.6-8.9; P < .001), and hCFR (OR, 12.8; 95% CI, 9.4-17.3; P < .001). Median LOS (range) was 7.2 days (4-23) (BPD) compared with 2.5 days (1-30) (non-BPD). Median duration of oxygen supplementation (range) was 5.5 days (0-21) (BPD) compared with 2.0 days (0-26) (non-BPD). The duration of mechanical ventilation was more often longer (>6 days) in those with BPD compared with non-BPD (OR, 11.9; 95% CI, 1.4-100; P = .02).

CONCLUSIONS

The risk of severe RSV disease is considerably higher among children with BPD. There is an urgent need to establish standardized BPD case definitions, review the RSV prophylaxis guidelines, and encourage more specific studies on RSV infection in BPD patients, including vaccine development and RSV-specific treatment.

Respiratory support for infants with bronchiolitis, a narrative review of the literature

Bronchiolitis is a common viral disease that significantly affects infants less than 12 months of age. The purpose of this review is to present a review of the current knowledge of the uses of respiratory support in the management of infants with bronchiolitis presenting to hospital. We electronically searched MEDLINE, Cochrane, CINAHL and EMBASE (inception to 25th March 2018), to manually search for clinical trials that address the management strategies for respiratory support of infants with bronchiolitis. We identified 120 papers who met the inclusion criteria, of which 33 papers were relevant for this review with only nine randomized controlled trials. This review demonstrated that non-invasive respiratory support reduced the need for escalation of therapy, particularly the proportion of intubations required for infants with bronchiolitis. Additionally, clear economic benefits have been demonstrated when non-invasive ventilation has been used. The potential early use of non-invasive respiratory supports such as nasal high flow therapy and non-invasive ventilation may have an impact on health care costs and reduction in ICU admissions and intubation rates. High-grade evidence demonstrates safety and quality of high flow therapy in general ward settings.

Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC)

Purpose

Much of the common practice in paediatric mechanical ventilation is based on personal experiences and what paediatric critical care practitioners have adopted from adult and neonatal experience. This presents a barrier to planning and interpretation of clinical trials on the use of specific and targeted interventions. We aim to establish a European consensus guideline on mechanical ventilation of critically children.

Methods

The European Society for Paediatric and Neonatal Intensive Care initiated a consensus conference of international European experts in paediatric mechanical ventilation to provide recommendations using the Research and Development/University of California, Los Angeles, appropriateness method. An electronic literature search in PubMed and EMBASE was performed using a combination of medical subject heading terms and text words related to mechanical ventilation and disease-specific terms.

Results

The Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) consisted of a panel of 15 experts who developed and voted on 152 recommendations related to the following topics: (1) general recommendations, (2) monitoring, (3) targets of oxygenation and ventilation, (4) supportive measures, (5) weaning and extubation readiness, (6) normal lungs, (7) obstructive diseases, (8) restrictive diseases, (9) mixed diseases, (10) chronically ventilated patients, (11) cardiac patients and (12) lung hypoplasia syndromes. There were 142 (93.4%) recommendations with “strong agreement”. The final iteration of the recommendations had none with equipoise or disagreement.

Conclusions

These recommendations should help to harmonise the approach to paediatric mechanical ventilation and can be proposed as a standard-of-care applicable in daily clinical practice and clinical research.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-017-4920-z) contains supplementary material, which is available to authorized users.

Variability of Care in Infants with Severe Bronchiolitis: Less-Invasive Respiratory Management Leads to Similar Outcomes

OBJECTIVE

To compare the management of children with severe bronchiolitis requiring intensive care (based on duration of ventilatory support and duration of pediatric intensive care unit [PICU] stay) in 2 countries with differing pediatric transport and PICU organizations.

STUDY DESIGN

This was a prospective observational care study in 2 PICUs of tertiary care university hospitals, 1 in France and 1 in Canada. All children with bronchiolitis who required admission to the PICU between November 1, 2013, and March 31, 2014, were included.

RESULTS

A total of 194 children were included. Baseline characteristics and illness severity were similar at the 2 sites. There was a significant difference between centers in the use of invasive ventilation (3% in France vs 26% in Canada; P < .0001). The number of investigations performed from admission to emergency department presentation and during the PICU stay was significantly higher in Canada for both chest radiographs and blood tests (P < .001). The use of antibiotics was significantly higher in Canada both before (60% vs 28%; P < .001) and during (72% vs 33%; P < .0001) the PICU stay. The duration of ventilatory support, median length of stay, and rate of PICU readmission were similar in the 2 centers.

CONCLUSION

Important differences in the management of children with severe bronchiolitis were observed during both prehospital transport and PICU treatment. Less invasive management resulted in similar outcomes with in fewer complications.

Outcomes for Children Receiving Noninvasive Ventilation as the First-Line Mode of Mechanical Ventilation at Intensive Care Admission: A Propensity Score-Matched Cohort Study

Supplemental Digital Content is available in the text.

Objectives:

To compare outcomes of children receiving noninvasive ventilation with those receiving invasive ventilation as first-line mode of mechanical ventilation following unplanned intensive care admission.

Design:

Propensity score-matched cohort study analyzing data prospectively collected by the Pediatric Intensive Care Audit Network over 8 years (2007–2014).

Setting:

Thirty-one PICUs in the United Kingdom and Ireland; twenty-one of whom submitted Pediatric Critical Care Minimum Dataset data for the entire study period.

Patients:

Children consecutively admitted to study PICUs. Planned admissions following surgery, unplanned admissions from other hospitals, those on chronic ventilation, and those who did not receive mechanical ventilation on the day of PICU admission were excluded.

Interventions:

Use of noninvasive ventilation, rather than invasive ventilation, as the first-line mode of mechanical ventilation.

Measurements and Main Results:

PICU mortality, length of ventilation, length of PICU stay, and ventilator-free days at day 28. During the study period, there were 151,128 PICU admissions. A total of 15,144 admissions (10%) were eligible for analysis once predefined exclusion criteria were applied: 4,804 (31.7%) received “noninvasive ventilation first,” whereas 10,221 (67.5%) received “invasive ventilation first”; 119 (0.8%) admissions could not be classified. Admitting PICU site explained 6.5% of the variation in first-line mechanical ventilation group (95% CI, 2.0–19.0%). In propensity score-matched analyses, receiving noninvasive ventilation first was associated with a significant reduction in mortality by 3.1% (95% CI, 1.7–4.6%), length of ventilation by 1.6 days (95% CI, 1.0–2.3), and length of PICU stay by 2.1 days (95% CI, 1.3–3.0), as well as an increase in ventilator-free days at day 28 by 3.7 days (95% CI, 3.1–4.3).

Conclusions:

Use of noninvasive ventilation as first-line mode of mechanical ventilation in critically ill children admitted to PICU in an unplanned fashion may be associated with significant clinical benefits. Further high-quality evidence regarding optimal patient selection and timing of initiation of noninvasive ventilation could lead to less variability in clinical care between institutions and improved patient outcomes.

Influenza and other respiratory viruses: standardizing disease severity in surveillance and clinical trials

INTRODUCTION

Influenza-Like Illness is a leading cause of hospitalization in children. Disease burden due to influenza and other respiratory viral infections is reported on a population level, but clinical scores measuring individual changes in disease severity are urgently needed. Areas covered: We present a composite clinical score allowing individual patient data analyses of disease severity based on systematic literature review and WHO-criteria for uncomplicated and complicated disease. The 22-item ViVI Disease Severity Score showed a normal distribution in a pediatric cohort of 6073 children aged 0-18 years (mean age 3.13; S.D. 3.89; range: 0 to 18.79). Expert commentary: The ViVI Score was correlated with risk of antibiotic use as well as need for hospitalization and intensive care. The ViVI Score was used to track children with influenza, respiratory syncytial virus, human metapneumovirus, human rhinovirus, and adenovirus infections and is fully compliant with regulatory data standards. The ViVI Disease Severity Score mobile application allows physicians to measure disease severity at the point-of care thereby taking clinical trials to the next level.

High flow nasal cannula (HFNC) versus nasal continuous positive airway pressure (nCPAP) for the initial respiratory management of acute viral bronchiolitis in young infants: a multicenter randomized controlled trial (TRAMONTANE study)

PURPOSE

Nasal continuous positive airway pressure (nCPAP) is currently the gold standard for respiratory support for moderate to severe acute viral bronchiolitis (AVB). Although oxygen delivery via high flow nasal cannula (HFNC) is increasingly used, evidence of its efficacy and safety is lacking in infants.

METHODS

A randomized controlled trial was performed in five pediatric intensive care units (PICUs) to compare 7 cmH₂O nCPAP with 2 L/kg/min oxygen therapy administered with HFNC in infants up to 6 months old with moderate to severe AVB. The primary endpoint was the percentage of failure within 24 h of randomization using prespecified criteria. To satisfy noninferiority, the failure rate of HFNC had to lie within 15% of the failure rate of nCPAP. Secondary outcomes included success rate after crossover, intubation rate, length of stay, and serious adverse events.

RESULTS

From November 2014 to March 2015, 142 infants were included and equally distributed into groups. The risk difference of -19% (95% CI -35 to -3%) did not allow the conclusion of HFNC noninferiority (p = 0.707). Superiority analysis suggested a relative risk of success 1.63 (95% CI 1.02-2.63) higher with nCPAP. The success rate with the alternative respiratory support, intubation rate, durations of noninvasive and invasive ventilation, skin lesions, and length of PICU stay were comparable between groups. No patient had air leak syndrome or died.

CONCLUSION

In young infants with moderate to severe AVB, initial management with HFNC did not have a failure rate similar to that of nCPAP. This clinical trial was recorded in the National Library of Medicine registry (NCT 02457013).

Non-invasive ventilation in paediatric critical care

Non-invasive ventilation (NIV) is a well recognised and increasingly prevalent intervention in the paediatric critical care setting. In the acute setting NIV is used to provide respiratory support in a flexible manner that avoids a requirement for endotracheal intubation or tracheostomy, with the aim of avoiding the complications of invasive ventilation. This article will explore the physiological benefits, complications and epidemiology of the different modes of NIV including continuous positive airway pressure (CPAP), non-invasive positive pressure ventilation (NIPPV) and high-flow nasal cannula oxygen (HFNC). The currently available equipment and patient interfaces will be described, and the practical aspects of using NIV clinically will be explored. The current evidence for use of NIV in different clinical settings will be discussed, drawing on adult and neonatal as well as paediatric literature.

Neurally adjusted ventilator assist (NAVA) reduces asynchrony during non-invasive ventilation for severe bronchiolitis

BACKGROUND

To determine the prevalence of main inspiratory asynchrony events during non-invasive intermittent positive-pressure ventilation (NIV) for severe bronchiolitis. Ventilator response time and asynchrony were compared in neurally adjusted ventilator assist (NAVA) and in pressure assist/control (PAC) modes.

METHODS

This prospective physiological study was performed in a university hospital's paediatric intensive care unit and included 11 children (aged 35.2 ± 23 days) with respiratory syncytial virus bronchiolitis with failure of nCPAP. Patients received NIV for 2 hr in PAC mode followed by 2 hr in NAVA mode. Electrical activity of the diaphragm and pressure curves were recorded for 10 min. Trigger delay, main asynchronies (auto-triggering, double triggering, or non-triggered breaths) were analyzed, and the asynchrony index was calculated for each period.

RESULTS

The asynchrony index was lower during NAVA than during PAC (3 ± 3% vs. 38 ± 21%, P < 0.0001), and the trigger delay was shorter (43.9 ± 7.2 vs. 116.0 ± 38.9 ms, P < 0.0001). Ineffective efforts were significantly less frequent in NAVA mode (0.54 ± 1.5 vs. 21.8 ± 16.5 events/min, P = 0.01). Patient respiratory rates were similar, but the ventilator rate was higher in NAVA than in PAC mode (59.5 ± 17.9 vs. 49.8 ± 8.5/min, P = 0.03). The TcPCO2 baselines values (64 ± 12 mmHg vs. 62 ± 9 mmHg during NAVA, P = 0.30) were the same and their evolution over the 2 hr study period (-6 ± 10 mmHg vs. -12 ± 17 mmHg during NAVA, P = 0.36) did not differ.

CONCLUSION

Patient-ventilator inspiratory asynchronies and trigger delay were dramatically lower in NAVA mode than in PAC mode during NIV in infants with severe bronchiolitis.

Non-invasive ventilation is useful in paediatric intensive care units if children are appropriately selected and carefully monitored

Non-invasive ventilation (NIV) is commonly used in paediatric intensive care units (PICUs) for respiratory failure. This review aims to improve paediatricians' understanding of NIV, by specifying technical or practical considerations, giving advice about selecting patients and presenting pertinent published data about NIV in different circumstances.

CONCLUSION

NIV is useful in PICUs if children are appropriately selected and carefully monitored. Technological advances and future clinical research will improve its use and success rate in PICU.