acute respiratory illnesses in children
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Acute Respiratory Illnesses in Children
Derek Zhorne, MDClinical Assistant Professor of Pediatrics
Pediatric Hospitalist
Disclosures
I have no actual or potential conflicts in relation to this presentation.
I will be referring to some industry products in regards to non-invasive respiratory support options for pediatric patients.
Objectives
Discuss the diagnostic evaluation and management of bronchiolitis & community-acquired pneumonia
Discuss non-invasive respiratory support for these conditions
Review some of the commonly encountered diagnostic & therapeutic dilemmas
Bronchiolitis
▪ Most common cause of hospitalization among infants during the 1st year of life
▪ 1 in 5 infants of each birth year cohort require outpatient medical attention during the first year of life for RSV
▪ ~ 100,000 bronchiolitis
admissions / year in
the US for estimated
cost of $1.73 billion
https://www.morethanacold.co.uk/Illustration by: Hélène Desputeaux
Bronchiolitis – Clinical Features
“A young child (0 – 18 months old) with
bronchiolitis typically presents during the winter
months after 2-4 days of low-grade fever, nasal
congestion, rhinorrhea and sxs of lower respiratory
tract infection as manifested by grunting, nasal
flaring, intercostal / subcostal / supraclavicular
retractions, inspiratory crackles and expiratory
wheezing.”
- NEJM 2016
Bronchiolitis – Pathophysiology
ReferenceRossi GA, Silvestri M, Colin AA. Viral Bronchiolitis in Children. N Engl J Med. 2016;374(18):1792-3
Bronchiolitis - Microbiology
▪ Many viruses that infect the respiratory system cause
similar signs and symptoms
▪ Seasonality of viral infections is relevant
Virus Frequency (%)
Respiratory Syncytial Virus 50-80
Human rhinovirus 5-25
Parainfluenza virus 5-25
Human metapneumovirus 5-10
Coronavirus 5-10
Adenovirus 5-10
Influenza virus 1-5
Enterovirus 1-5
Bronchiolitis – Microbiology
▪ nucleic acid amplification tests ↑ detection of viruses…
▪ “co-infections” with multiple viruses are frequently seen
Studies have shown that at least 1 respiratory virus
can be found in up to 30% of children < 6 years old who
have no respiratory symptoms.
1) Asymptomatic colonization
2) Incubation before clinical infection
3) Prolonged viral shedding post-infection
Bronchiolitis – RSV
▪ Enveloped single-stranded RNA virus of the
Paramyxoviridae family.
▪ RSV reinfection occurs throughout life, despite induction
of both antibody and T-cell responses after primary
infection
▪ Poor understanding of the mechanisms limiting the
induction of long-lasting immunity has delayed the
development of an effective vaccine
Bronchiolitis – Clinical Course
▪ Variable and dynamic
▪ Proper assessment requires serial exams over a
period of observation – after nasal suctioning
ReferenceFlorin TA, Plint AC, Zorc JJ. Viral bronchiolitis. Lancet. 2017;389(10065):211-24.
Bronchiolitis – High Risk Patients
▪ Infants <3 months old
▪ Hx of prematurity (<32 weeks)
▪ Chronic Lung Disease
▪ Immunodeficiency
▪ Congenital Heart Disease
▪ Neuromuscular Disorders
Apnea in Bronchiolitis
▪ Apnea is a life-threatening complication of bronchiolitis
▪ Incidence of apnea has varied from 1-24% in different studies
Retrospective cohort study of ~700 infants hospitalized with bronchiolitis
• Inpatient apnea identified in 19 patients (2.7%, 95% CI: 1.7 - 4.3%)
All patients who had apnea were identified by the following 3 “high-risk” criteria:
1. Born full-term (≥ 37 weeks) and currently < 1 month old
2. Born preterm (<37 weeks) and < 50 weeks postmenstrual age
3. Child’s parents or a clinician had witnessed apnea before admission
ReferenceWillwerth BM, Harper MB, Greenes DS. Identifying hospitalized infants who have bronchiolitis and are at high risk for apnea. Ann Emerg Med. 2006;48(4):441-7.
Caffeine for the Treatment of Apnea in
Bronchiolitis?
A Cochrane review and meta-analysis of 6 RCTs showed that methylxanthines (i.e., theophylline or caffeine)
are effective in treating apnea of prematurity
▪ ↓ # of apnea events
▪ ↓ need for mechanical ventilation
Proposed mechanism of action
- increased central respiratory drive
- increasing chemoreceptor sensitivity to carbon dioxide
- improved skeletal muscle contraction
Assessment:
Single center RCT enrolled 90 infants diagnosed with viral bronchiolitis who presented to a pediatric ER with
history of apnea or observed apnea
Patient: Infants ≤ 4 months old with bronchiolitis
Intervention: IV dose of caffeine (25 mg/kg in 15 ml D5W)
Comparison: 15 ml normal saline
Outcome(s): time until a 24-hour apnea-free period
Mean duration to a 24-hour apnea-free period was 28.1 hrs (caffeine group) vs. 29.1 hours (placebo group).
Recommendation
A single dose of caffeine citrate did not significantly reduce apnea episodes associated with bronchiolitis
NNT = 452
ReferenceAlansari K, Toaimah FH, Khalafalla H, El Tatawy LA, Davidson BL, Ahmed W. Caffeine for the Treatment of Apnea in Bronchiolitis: A Randomized Trial. J Pediatr. 2016;177:204-11.e3.
Bronchiolitis – Supportive Therapies
No available treatment shortens the
course of bronchiolitis or hastens the
resolution of symptoms
Bronchiolitis – Supportive Therapies
NOT Recommended
• short-acting β2-agonists
• racemic epinephrine
• systemic glucocorticoids
• ribavirin
• chest physiotherapy
• antibiotics
• Testing for viral causes*
• Chest X-ray*
2014 AAP
Clinical Practice Guideline
• Nasal saline drops and suctioning
• Supplemental oxygen to keep SpO2 >90%
• IV or NG fluids if unable to maintain hydration orally
• May consider nebulized hypertonic saline if hospitalized (RCTs with inconsistent findings)
Bronchiolitis – Supportive Therapies
Standard Nasal Cannula (“Low Flow”)
• 100% oxygen through bubbler humidifier at rate of 0 – 4 LPM
• FiO2 varies from 25-40% depending on RR, TV and extent of mouth breathing
• Flow > 2 LPM is irritating to nares unless heated & humidified
Heated, Humidified High Flow Nasal Cannula (HFNC)
• Heated and humidified oxygen via special devices at rates up to 8 LPM in infants and 60 LPM in adults
• Better tolerated than face mask in terms of comfort
• ↓ RR, work of breathing and better oxygenation
High Flow Nasal Cannula
• Provides low-level positive pressure (PEEP) and aids in lung recruitment
• Provides CO2 “washout” of respiratory physiologic dead space
• Warmth and humidity keep secretions moist and improve mucociliary clearance
RAM Cannula & CPAP
• Designed by neonatologist for use in premies as
alternative to nasal CPAP
• Has softer, thinner walled prongs with larger nasal prong
inner diameter → results in lower airflow resistance with
reduced nasal trauma
Does this child have pneumonia?
Case 1
18 month old male with no significant
PMHx presents to PCP with 1 day
history of fever and cough. Parents
report decreased PO intake for past
24 hours. Attends daycare.
Vital Signs: Temp 38.5°C, RR 48,
SpO2 93% on room air
Exam: Awake, alert with no signs of
respiratory distress. He has diffuse
crackles (R > L) with no wheezes.
Other findings from his exam are
normal.
Case 2
2 year old female with no significant
PMHx presents to PCP with 4 days of
fever and cough. Parents report
decreased PO intake for the past 24
hours and they have noticed difficulty
breathing. Attends daycare.
Vital Signs: Temp 38.5°C, RR 35,
SpO2 93% on room air
Exam: Awake, alert with no signs of
respiratory distress. She has
crackles in right lower posterior chest.
Other findings from her examination
are normal.
Community-Acquired Pneumonia (CAP)
• Pneumonia is the single greatest cause of death in children worldwide
• In the developed world, the annual incidence of pneumonia is ~3-4 cases per 100 children <5 years old
• There is no universally accepted and practical reference standard for diagnosis of pediatric CAP
ReferenceWalker CLF, Rudan I, Liu L, Nair H, Theodoratou E, Bhutta ZA, et al. Global burden of childhood pneumonia and diarrhoea. Lancet. 2013;381(9875):1405-16.
CAP - Diagnosis
Depends on who you ask
World Health Organization (WHO)
British Thoracic Society Infectious Disease Society of America (IDSA)
Cough or difficulty breathing and age-adjusted tachypnea
2 – 11 mo: RR ≥ 50 1 – 5 yo: RR ≥ 40 ≥ 5 yo: RR ≥ 20
Persistent or repetitive fever > 38.5 or 101.3 with chest retractions and increased respiratory rate
Presence of signs and symptoms of pneumonia in a previously healthy child caused by an infection that has been acquired outside the hospital
CAP – Clinical Features
CharacteristicFrequency in children with radiographic evidence of
pneumonia
Symptom
Cough 95%
Abnormal temperature
91%
Anorexia 75%
Dyspnea 70%
Chest wall retractions
55%
Radiographic Findings
Consolidation 58%
Alveolar or interstitial infiltrate
51%
Pleural effusion 13%
Adapted from Jain S, Williams DJ, Arnold SR, et al. Community-acquired pneumonia requiring hospitalization among U.S. children. NEJM2015;372(9).
• Signs / Symptoms
– Fever
– Cough
– Tachypnea
– Dyspnea
– Chest pain (adolescents)
– Abdominal pain
– Crackles / Rales
– Diminished breath sounds
– Wheezing
– Grunting (infants)
– Nasal flaring
– Chest wall retractions (infants)
– Hypoxemia
CAP - Pathophysiology
Anatomic & Mechanical Barriers
- Upper respiratory tract nasal hairs & turbinate architecture to trap particles
- Mucociliary clearance of secretions
- Epiglottic reflex to prevent aspiration and cough to expel things that may be aspirated
- Complex respiratory airway branching
Humoral Immunity
- Secretory IgA is major immunoglobulin produced in upper airways and has antibacterial / antiviral activity
- IgG and IgM enter airways via transudation from blood and opsonize bacteria, activate complement and neutralize toxins.
Phagocytic Cells
- Alveolar macrophages are first line of cellular defense.
- Interstitial macrophages
- Intravascular macrophages
Cell-Mediated Immunity
- Lymphocytes play critical role in producing antibodies, cytotoxic activity and cytokine production to fight off viruses and intracellular microorganisms.
PNEUMONIA
Invasion of lower respiratory tract by a pathogenic organism
that alters, inhibits or overwhelms these host defenses
CAP - Microbiology
• Historically, CAP was largely considered a bacterial process– Streptococcus pneumoniae
– Haemophilus influenzae, type b
– Streptococcus pyogenes
– Staphylococcus aureus
• Molecular diagnostics for viral respiratory pathogens have increased awareness of viral causes of CAP
ReferenceJain S, Williams DJ, Arnold SR, et al. Community-acquired pneumonia requiring hospitalization among U.S. children. NEJM 2015;372(9).
Vaccines1987 – Hib
2000 – PCV72010 – PCV13
CAP - Microbiology
ReferenceJain S, Williams DJ, Arnold SR, et al. Community-acquired pneumonia requiring hospitalization among U.S. children. NEJM 2015;372(9).
Community-Acquired Pneumonia Requiring
Hospitalization among U.S. Children
ReferenceJain S, Williams DJ, Arnold SR, et al. Community-acquired pneumonia requiring hospitalization among U.S. children. NEJM 2015;372(9).
DESIGN:
Prospective population-based surveillance study. Eligible for study if <18 years old and…
1) hospitalized with CAP between Jan 2010 – June 2012
2) resided in 1 of 22 counties which comprised the study catchment areas of participating children’s hospitals (Nashville, Memphis, Salt Lake City)
3) had a CXR performed within 72 hrs before or after admission
RESULTS:
2,638 children were enrolled in the EPIC study.
Of the patients who had both radiographic evidence of pneumonia and blood / respiratory specimens available for bacterial + viral testing…
- Either viral or bacterial pathogen detected 81% cases
- Viral pathogen detected 73% cases
- Bacterial pathogen detected 15% cases
- Both viral + bacterial pathogen detected 7% of cases
Community-Acquired Pneumonia Requiring
Hospitalization among U.S. Children
ReferenceJain S, Williams DJ, Arnold SR, et al. Community-acquired pneumonia requiring hospitalization among U.S. children. NEJM 2015;372(9).
Major Findings of the EPIC Study
1. Pathogen (viral or bacteria) was detected in 81% of children– viruses alone were detected in 66% of children
2. Most commonly detected pathogens were viruses– RSV 28%
– Rhinovirus 27%
– Human metapneumovirus 13%
– Adenovirus 11%
3. Typical bacterial accounted for 8% of CAP overall– Streptococcus pneumoniae 5%
– Staphylococcus aureus 1%
– Streptococcus pyogenes 1%
4. Atypical bacteria was much more common in older children– Mycoplasma pneumoniae detected in 19% of children > 5 yo compared to only 3% in
younger children
Community-Acquired Pneumonia Requiring
Hospitalization among U.S. Children
ReferenceJain S, Williams DJ, Arnold SR, et al. Community-acquired pneumonia requiring hospitalization among U.S. children. NEJM 2015;372(9).
Children ≤ 4 years old had virus as sole pathogen in ~50% of cases and concurrent viral detection in an additional 15-25% of cases
Etiology of CAP by Age
< 3 months 3 months – 5 years > 5 years
Viral Pathogens
RSV RSV Influenza
Influenza Influenza Adenovirus
Parainfluenza Parainfluenza Human metapneumovirus
Human metapneumovirus Human metapneumovirus Rhinovirus
Bacterial Pathogens
Group B streptococcus Streptococcus pneumoniae Mycoplasma pneumoniae
Gram-negative bacilli Mycoplasma pneumoniae Streptococcus pneumoniae
Streptococcus pneumoniae Staphylococcus aureus Staphylococcus aureus
Bordetella pertussis Streptococcus pyogenes (GAS) Streptococcus pyogenes (GAS)
Chlamydia trachomatis Haemophilus influenza type b Haemophilus influenza type b
Complications Associated with CAP
Pulmonary
Pleural effusion or empyema
Lung abscess
Bronchopleural fistula
Necrotizing pneumonia
Acute respiratory failure
Metastatic Disease
Meningitis
CNS abscess
Pericarditis
Endocarditis
Osteomyelitis
Septic arthritis
Systemic
SIRS → Sepsis
Hemolytic Uremic syndrome
Right upper lobe lung abscess
ReferencePabary R, Balfour-Lynn I. Complicated pneumonia in children. Breathe 2013;9(3)210-222.
Necrotizing Pneumonia a) CXR, Day #1c) CXR, Day #8
ReferencePabary R, Balfour-Lynn I. Complicated pneumonia in children. Breathe 2013;9(3)210-222.
CAP – Viral or Bacterial?
• Significant overlap in clinicalsymptoms
• Typical CXR findings DO NOTdistinguish between viral and bacterial causes
• Acute-phase reactants (ESR, CRP, PCT) cannot be used as sole determinant to distinguish between viral and bacterial causes
CAP – Diagnostic Testing
Recommended Actions
- Pulse oximetry should be performed.
- Obtain respiratory viral testing.
Choose Wisely:
- Do not obtain blood culture in a nontoxic, fully immunized child
- CXR is not necessary at initial visit. Obtain if significant respiratory distress or hypoxemic.
- Blood culture and CBC rarely change treatment course
Outpatient (limited testing)
Recommended Actions
- Pulse oximetry should be performed.
- Obtain respiratory viral testing.
- Blood cultures should be obtained in hospitalized children with moderate-severe CAP
- CBC, ESR, CRP may provide useful information for clinical management.
- CXR (PA + lateral) should be obtained in all hospitalized children with CAP.
Inpatient
CAP – Treatment
In children < 5 yo, the majority of CAP will be due to viral pathogens and no antibiotic treatment is indicated.
1st line Therapy: Amoxicillin x 7 - 10 days
Alternative(s) 2nd / 3rd Gen Cephalosporin
Outpatient
1st line Therapy: Ampicillin
Not fully immunized, severe disease
→ substitute a 3rd Generation Cephalosporin
→ + Vancomycin or Clindamycin if concern for Staphylococcus aureus
Inpatient
What about Mycoplasma pneumoniae?
• Frequent cause of CAP in school-aged children and adolescents
• What does a positive PCR test for Mycoplasma mean?
– The CDC EPIC Study showed Mycoplasma pneumoniae was detected in 8% of children with pneumonia and fewer than 1% of controls
– A cross-sectional, observational study from the Netherlands found higher rates of Mycoplasma pneumoniae in asymptomatic children
• Azithromycin is largely ineffective against other bacterial causes of CAP but is the 2nd most commonly prescribed antibiotic in outpatient pediatrics.
What about Mycoplasma pneumoniae?
• Studies have failed to consistently demonstrate
a benefit of using macrolide therapy in children
with pneumonia.
• However, existing clinical practice guidelines still
recommend macrolide antibiotics for treatment
of children (school-aged and adolescents) in an
outpatient setting. - IDSA 2011
ReferenceKatz SE, Williams DJ. Pediatric Community-Acquired Pneumonia in the United States: Changing Epidemiology, Diagnostic and Therapeutic Challenges, and Areas for Future Research. Infect Dis Clin North Am. 2018;32(1):47-63.
“Secondary” Bacterial Pneumonia
Child with viral URI symptoms.
Begins to show clear clinical improvement.
Abrupt worsening of clinical status.
Bacterial Superinfection
Presence of a preceding viral respiratory tract infection is an important risk
factor in the pathogenesis of bacterial pneumonia.
Chest X-ray*
Public health evidence of this viral-bacterial interplay
-Severe pneumococcal pneumonia has been associated with outbreaks of influenza
-Pneumococcal vaccines decrease the morbidity of influenza infections
Does this child have pneumonia?
Case 1
18 month old male with no significant
PMHx presents to PCP with 1 day
history of fever and cough. Parents
report decreased PO intake for past
24 hours. Attends daycare.
Vital Signs: Temp 38.5°C, RR 48,
SpO2 93% on room air
Exam: Awake, alert with no signs of
respiratory distress. He has diffuse
crackles (R > L) with no wheezes.
Other findings from his exam are
normal.
Case 2
2 year old female with no significant
PMHx presents to PCP with 4 days of
fever and cough. Parents report
decreased PO intake for the past 24
hours and they have noticed difficulty
breathing. Attends daycare.
Vital Signs: Temp 38.5°C, RR 35,
SpO2 93% on room air
Exam: Awake, alert with no signs of
respiratory distress. She has
crackles in right lower posterior chest.
Other findings from her examination
are normal. Dx: BronchiolitisNo CXR, no labs. Flu PCR (if winter) Teach family nasal saline / suctioningAnticipatory guidance
Dx: Pneumonia (mild) No CXR, no labs. Flu PCR (if winter) No antibiotics as < 5 yo
Take Home Points
Bronchiolitis
• Influenza testing during appropriate season
• Supportive cares only nasal suctioning fluid hydration supplemental oxygen
• Do not order CXR
• Do not administer albuterol or racemic epinephrine in the office (unless admitting to the hospital)
Community-Acquired Pneumonia
• Limited outpatient evaluation is appropriate for mild disease (pulse ox + respiratory viral testing).
• Viruses > > > Bacteria as cause of CAP in children
• Concerns whether treating Mycoplasma pneumoniae with a macrolide is effective at all
• 1st line treatment should be 7 – 10 days of Amoxicillin
Bibliography
[1] Florin TA, Plint AC, Zorc JJ. Viral bronchiolitis. Lancet. 2017;389(10065):211-24.
[2] Ralston SL, Lieberthal AS, Meissner HC. Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. 2014;134(5):e1474-e1502. Pediatrics. 2015;136(4):782.
[3] Higdon MM, Le T, O'Brien KL, Murdoch DR, Prosperi C, Baggett HC, et al. Association of C-Reactive Protein With Bacterial and Respiratory Syncytial Virus-Associated Pneumonia Among Children Aged <5 Years in the PERCH Study. Clin Infect Dis. 2017;64(suppl_3):S378-s86.
[4] Rossi GA, Silvestri M, Colin AA. Viral Bronchiolitis in Children. N Engl J Med. 2016;374(18):1792-3.
[5] Jansen RR, Wieringa J, Koekkoek SM, Visser CE, Pajkrt D, Molenkamp R, et al. Frequent detection of respiratory viruses without symptoms: toward defining clinically relevant cutoff values. J Clin Microbiol. 2011;49(7):2631-6.
[6] Hasegawa K, Linnemann RW, Avadhanula V, Mansbach JM, Piedra PA, Gern JE, et al. Detection of respiratory syncytial virus and rhinovirus in healthy infants. BMC Res Notes. 2015;8:718.
[7] Self WH, Williams DJ, Zhu Y, Ampofo K, Pavia AT, Chappell JD, et al. Respiratory Viral Detection in Children and Adults: Comparing Asymptomatic Controls and Patients With Community-Acquired Pneumonia. J Infect Dis. 2016;213(4):584-91.
[8] Schroeder AR, Mansbach JM, Stevenson M, Macias CG, Fisher ES, Barcega B, et al. Apnea in children hospitalized with bronchiolitis. Pediatrics. 2013;132(5):e1194-201.
[9] Willwerth BM, Harper MB, Greenes DS. Identifying hospitalized infants who have bronchiolitis and are at high risk for apnea. Ann Emerg Med. 2006;48(4):441-7.
[10] Alansari K, Toaimah FH, Khalafalla H, El Tatawy LA, Davidson BL, Ahmed W. Caffeine for the Treatment of Apnea in Bronchiolitis: A Randomized Trial. J Pediatr. 2016;177:204-11.e3.
[11] Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53(7):e25-76.
[12] Rambaud-Althaus C, Althaus F, Genton B, D'Acremont V. Clinical features for diagnosis of pneumonia in children younger than 5 years: a systematic review and meta-analysis. Lancet Infect Dis. 2015;15(4):439-50.
[13] Katz SE, Williams DJ. Pediatric Community-Acquired Pneumonia in the United States: Changing Epidemiology, Diagnostic and Therapeutic Challenges, and Areas for Future Research. Infect Dis Clin North Am. 2018;32(1):47-63.
[14] Messinger AI, Kupfer O, Hurst A, Parker S. Management of Pediatric Community-acquired Bacterial Pneumonia. Pediatr Rev. 2017;38(9):394-409.
[15] Shah SN, Bachur RG, Simel DL, Neuman MI. Does This Child Have Pneumonia?: The Rational Clinical Examination Systematic Review. JAMA. 2017;318(5):462-71.
[16] Federico MJ, Baker CD, Deboer EM, Halbower AC, Kupfer O, Martiniano SL, et al. Respiratory Tract & Mediastinum. In: Hay JWW, Levin MJ, Deterding RR, Abzug MJ, editors. Current Diagnosis & Treatment: Pediatrics, 24e. New York, NY: McGraw-Hill Education; 2018.
[17] Liu L, Oza S, Hogan D, Perin J, Rudan I, Lawn JE, et al. Global, regional, and national causes of child mortality in 2000-13, with projections to inform post-2015 priorities: an updated systematic analysis. Lancet. 2015;385(9966):430-40.
[18] Walker CLF, Rudan I, Liu L, Nair H, Theodoratou E, Bhutta ZA, et al. Global burden of childhood pneumonia and diarrhoea. Lancet. 2013;381(9875):1405-16.
[19] Jain S, Williams DJ, Arnold SR, Ampofo K, Bramley AM, Reed C, et al. Community-acquired pneumonia requiring hospitalization among U.S. children. N Engl J Med. 2015;372(9):835-45.
[20] Abboud PA, Roth PJ, Skiles CL, Stolfi A, Rowin ME. Predictors of failure in infants with viral bronchiolitis treated with high-flow, high-humidity nasal cannula therapy*. Pediatr Crit Care Med. 2012;13(6):e343-9.
[21] Kelly GS, Simon HK, Sturm JJ. High-flow nasal cannula use in children with respiratory distress in the emergency department: predicting the need for subsequent intubation. Pediatr Emerg Care. 2013;29(8):888-92.
[22] Sinha IP, McBride AK, Smith R, Fernandes RM. CPAP and High-Flow Nasal Cannula Oxygen in Bronchiolitis. Chest. 2015;148(3):810-23.
[23] Schibler A, Pham TM, Dunster KR, Foster K, Barlow A, Gibbons K, et al. Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery. Intensive Care Med. 2011;37(5):847-52.
[24] Mikalsen IB, Davis P, Oymar K. High flow nasal cannula in children: a literature review. Scand J Trauma Resusc Emerg Med. 2016;24(1):93.
[25] Milesi C, Essouri S, Pouyau R, Liet JM, Afanetti M, Portefaix A, et al. 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). Intensive Care Med. 2017;43(2):209-16.
[26] Franklin D, Babl FE, Schlapbach LJ, Oakley E, Craig S, Neutze J, et al. A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. N Engl J Med. 2018;378(12):1121-31.
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