bronchiolitis, updates on management - uvmhealth.org · bronchiolitis by age 2 more than 1/3 of...
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V A L E R I E R I S S , M D / M P H
Bronchiolitis, Updates on Management
Disclosures
I have no financial disclosures to report
Outline
Overview of bronchiolitis
Review 2014 AAP guidelines
Viral testing
Variability in practice
Pulse oximetry
HFNC
Enteral feeding
Bronchiolitis
By age 2 more than 1/3 of children have experienced bronchiolitis
About 10% of children with bronchiolitis are hospitalized Between 2 and 6% of all children with bronchiolitis require care in an
ICU
16% of all infant hospitalizations (< 2 years)
8% of hospitalized children with bronchiolitis have high risk medical conditions
In-hospital mortality in 2009 estimated at 0.03% (3/10,000)
Hospital cost in 2009 estimated at $1.73 billion
Pathophysiology
2014 AAP Guidelines
Children 1 month – 23 months of age Children with many co-morbidities excluded
Increasing number of patients with significant co-morbidities admitted annually
Do: Suction! Give IV vs. NG fluids (more to come) Consider O2 therapy (more to come)
Don’t: No CXR No Albuterol trials No epinephrine (other than potentially as rescue medication in severe disease) No oral steroids No antibiotics No chest PT No hypertonic saline (well…we don’t think so)
Variability in Care
22-75% order CBC
36-85% order CXR
19-91% bronchodilators
8-44% corticosteroids
17-43% antibiotics
38-93% IV
Variability in Care - CPAP
Variability in Care - Intubation
Prediction of Disease Severity
Hospitalization
Apnea
NIPPV
Mechanical Ventilation
ECMO
Chest X-Ray
No evidence to support routine use of CXR:
Risks: Unnecessary antibiotic use
CXR findings do not correlate with disease severity
Risk of bacterial pneumonia is low
Consider if increased pre-test probability for bacterial pneumonia:
> 2 days of fever
Asymmetric chest exam
No clinical improvement
Unusually high O2 need
Hypertonic Saline
? Shorten hospital stays: AAP 2014 consider if expected LOS > 3 days
Increased number of negative studies since 2014
2015 Pediatrics – no difference in LOS, clinical worsening, or 7-day readmission
2013 – AE 8.9% in HS vs. 3.9% in NS
2017 – French trial stopped early due to 4/61 with “severe” adverse events
2017 – comparison of three wards, hypertonic saline associated with longer period of desaturations and hospital stays
Viral Testing
Common culprits: RSV (73%)
Rhino (26%)
Influenza (1%)
Coronavirus (7%)
Human Metapneumovirus (7%)
Parainfluenza (3%)
Enterovirus (5%)
Adenovirus (8%)
M. pneumoniae (1%)
B. pertussis (0.2%)
Co-infections 30%
Viral Testing
Prognosis:
Rhinovirus may have shorter course of disease, may have a different phenotype associated with repeated wheezing
No difference in risk of apnea
Studies mixed with regard to LOS and severity associated with different pathogens
Rhino +/- co-infection with any organism other than RSV MAY have shorter LOS than RSV (although variable results)
Does not appear to impact risk of CPAP/need for intubation (although variable results)
Combined RSV/rhinovirus MAY have a longer LOS and a more severe course, but not clear at this point
Viral Testing
Not routinely recommended
Consider if: Need for cohorting
Uncertain clinical diagnosis
Age < 2 months
To assess for influenza
Recommended for: Patient with hospital acquired infection
High risk patients (immune-compromised, chronic lung/heart disease)
Child on Palivizumab (concern for breakthrough infection)
Pulse Oximetry
Healthy babies have oxygen desaturation events
Increased admissions since introduction
12.9/1000 to 31.2/1000 children under 1 year of age
90% vs. 94% SpO2 as cutoff- decreased LOS with no increased AE
Pulse Oximetry
Pulse Oximetry
Pulse Oximetry
Is there harm? Increased length of stay
Increased by 1.6 days in one study, a second showed that 58% of pts had increased LOS due to perceived oxygen need by 2.75 days (average LOS in this study was 72 hours)
Increased admissions Adverse events during hospital stay up to 10/100 Expensive ($600 million – $1.73 billion a year on bronchiolitis admissions in US)
Benefits? Some evidence that lower oxygen saturations in CHD (90-94%) associated with
worse long term neurodevelopment outcome Some evidence that mild hypoxemia in other chronic conditions (COPD and
Asthma) does not have detrimental effects on neuro-cognitive outcomes No identified impact on neuro-cognitive outcomes in children with mild or
moderate OSA older than 6 months
Choosing wisely campaign – one of five recommendations from 2013 was to avoid continuous pulse ox in children admitted for respiratory illness who are not using supplemental oxygen
Changes in Interventions for Bronchiolitis 2000 - 2009
High Flow Nasal Cannula
Possibly decreases intubation rates, but VERY unclear
Decreases need for escalation of care?
Potentially increases patient comfort
Some studies suggest decreased respiratory rates and heart rates
No difference in length of stay or length of O2 need
Low complication rates
McKiernan Journal of Pediatrics 2010
McKiernan Journal of Pediatrics 2010
Schibler et al. Intensive Care Medicine 2011
HFNC Prevents Escalation of Care?
NEJM 2018
NEJM 2018
High Flow Nasal Cannula at UVM
Started November 15 on the floor:
Have re-worked guidelines twice
Data to date:
38 total children eligible for HFNC on the floor (< 48 months old, not intubated on arrival or en route)
28 primary diagnosis bronchiolitis
4 primary diagnosis asthma
29 admitted to hospital floor
9 had HFNC initiated on floor
20 initiated in ED
Flow ranged 4-15L on initiation, average 1.2L/kg/min
Average age 9 months
Children Transferred to PICU
18/29 children transferred to PICU
6 remained on HFNC and required no additional therapy
10 were transitioned to CPAP
1 was intubated due to apnea
1 month old ex-33 week infant, admitted for observation, on RA on hospital floor, had code called due to apnea and was started on HFNC in PICU.
Would have been admitted to hospital floor last year as well
Enteral Feeding in Bronchiolitis
Concern for aspiration based on historical results
NPO status associated with increased LOS
LFNC
No different in LOS or adverse events associated with NG feeds
Offer option of NG feeding to families, similar outcomes, decreased tries at placement
IV vs. NG Hydration
Enteral Feeding in Bronchiolitis
Concern for aspiration based on historical results
NPO status associated with increased LOS
LFNC
No different in LOS or adverse events associated with NG feeds
Offer option of NG feeding to families, similar outcomes, decreased tries at placement
HFNC
There are some AE related to oral/NG feeding
No clear predictors of who will have AE
Generally well-tolerated
Adverse Events with PO Feeding in HFNC
This Season at UVM
HFNC on the floor for select patients
Selective use of viral swabs for clinical utility (specifically consider during influenza season and for infants < 2 months when considering sepsis rule out, or for unclear diagnosis)
Consider NG for hydration rather than IV
Spot check SpO2
Otherwise continue to follow 2014 AAP guidelines, suction, hydration, oxygen support
Precautions
Nosocomial RSV Spread in PICU Managed by Re-enforcing Droplet Precautions
Decrease of Nosocomial RSV Infections with Introduction of Droplet Precautions
References
Amir Kugelman, MD1, Karine Raibin, MD1, Husein Dabbah, MD2, Irina Chistyakov, MD1, Isaac Srugo, MD1, Lea Even, MD2, Nurit Bzezinsky, RN1, and Arieh Riskin, MD1 Intravenous Fluids versus Gastric-Tube Feeding in Hospitalized Infants with Viral Bronchiolitis: A Randomized, Prospective Pilot Study Journal of Pediatrics Vol. 162, No. 3 Todd A Florin, Amy C Plint, Joseph J ZorcViral bronchiolitis Lancet 2017; 389: 211–24
Elizabeth Kepreotes, Bruce Whitehead, John Attia, Christopher Oldmeadow, Adam Collison, Andrew Searles, Bernadette Goddard, Jodi Hilton, Mark Lee, Joerg Mattes High- flow warm humidified oxygen versus standard low- flow nasal cannula oxygen for moderate bronchiolitis (HFWHO RCT): an open, phase 4, randomised controlled trial Lancet 2017; 369: 930–39
Steve Cunningham, Aryelly Rodriguez, Tim Adams, Kathleen A Boyd, Isabella Butcher, Beth Enderby, Morag MacLean, Jonathan McCormick, James Y Paton, Fiona Wee, Huw Thomas, Kay Riding, Steve W Turner, Chris Williams, Emma McIntosh, Steff C Lewis, for the Bronchiolitis of Infancy Discharge Study (BIDS) group*
Oxygen saturation targets in infants with bronchiolitis (BIDS): a double-blind, randomised, equivalence trial Lancet 2015; 386: 1041–48
Ed Oakley, MBBS, FACEM1, Sonny Bata, MD1, Sharmila Rengasamy, MBBS1, David Krieser, MBBS, FRACP2, John Cheek, MBBS, FACEM3, Kim Jachno, PG Dip4, and Franz E. Babl, MD, MPH, FRACP, FAAP, FACEP1
Nasogastric Hydration in Infants with Bronchiolitis Less Than 2 Months of Age J Pediatr 2016;178:241-5
Gordana Mlinaric -Galinovic a,*, Dijana Varda-Brkic bNosocomial respiratory syncytial virus infections in children’s wards Diagnostic Microbiology and Infectious Disease
37 (2000) 237–246
Ricardo A QuinonezWhen technology creates uncertainty: pulse oximetry and overdiagnosis of hypoxaemia in bronchiolitis BMJ 2017;358:j3850 doi: 10.1136/bmj.j3850 (Published 2017 August 16)
Franklin et al. Early high flow nasal cannula therapy in bronchiolitis, a prospective randomised control trial (protocol): A Paediatric Acute Respiratory Intervention Study (PARIS) BMC Pediatrics (2015) 15:183 DOI 10.1186/s12887-015-0501-x
Patricia A. Abboud, MD; Patrick J. Roth, BS, RRT, RCP; Cheryl L. Skiles, RN, BSN; Adrienne Stol , MSPH; Mark E. Rowin, MD Predictors of failure in infants with viral bronchiolitis treated with high- ow, high-humidity nasal cannula therapy* Pediatr Crit Care Med 2012 Vol. 13, No. 6
Previously Healthy Infants May Have Increased Risk of Aspiration During Respiratory Syncytial Viral Bronchiolitis PEDIATRICS Vol. 104 No. 6 December 1999
A. Schibler et al. Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery Intensive Care Med (2011) 37:847–852 DOI 10.1007/s00134-011-2177-5
Charles G. Macias, MD, MPH; Jonathan M. Mansbach, MD, MPH; Erin S. Fisher, MD; Mark Riederer, MD; Pedro A. Piedra, MD; Ashley F. Sullivan, MS, MPH;Janice A. Espinola, MPH; Carlos A. Camargo, Jr., MD, DrPH
Variability in Inpatient Management of Children Hospitalized With Bronchiolitis Academic Pediatrics Volume 15, Number 1 January–February 2015
References
Grewal, S. (2013). A comparison of nebulized 3% hypertonic saline and epinephrine versus nebulized normal saline and epinephrine in the treatment of acute bronchiolitis. Http://isrctn.org/>. doi:10.1186/isrctn66632312
Shmueli, E., Berger, T., Herman, Y. A., Chodick, G., Rom, E., Bilavsky, E., . . . Prais, D. (2017). Real-life comparison of three general paediatric wards showed similar outcomes for children with bronchiolitis despite different treatment regimens. Acta Paediatrica,106(9), 1507-1511. doi:10.1111/apa.13921
Early Halt of a Randomized Controlled Study with 3% Hypertonic Saline in Acute Bronchiolitis.Ania Carsin Emilie Sauvaget Violaine Bresson Karine Retornaz Maria Cabrera Elisabeth Jouve Romain Truillet Emmanuelle Bosdure Jean-Christophe DubusRespiration. , 2017, Vol.94(3), p.251-257
Hospital Pediatrics August 2017, VOLUME 7 / ISSUE 8. Multicenter Observational Study of the Use of Nebulized Hypertonic Saline to Treat Children Hospitalized for Bronchiolitis From 2008 to 2014. Joshua Davis, Amy D. Thompson, Jonathan M. Mansbach, Pedro A. Piedra, Kohei Hasegawa, Ashley F. Sullivan, Janice A. Espinola, Carlos A. Camargo, Jr
Pediatrics. February 2017, VOLUME 139 / ISSUE 2. Update on Pediatric OveruseEric R. Coon, Paul C. Young, Ricardo A. Quinonez, Daniel J. Morgan, Sanket S. Dhruva, Alan R. Schroeder
Silver AH, Esteban-Cruciani N, Azzarone G, et al. 3% Hypertonic Saline Versus Normal Saline in Inpatient Bronchiolitis: A Randomized Controlled Trial. Pediatrics.2015;136(6):1036–1043pmid:26553190
Kohei Hasegawa, MD, MPH,a,b Yusuke Tsugawa, MD, MPH,b,c,d David F.M. Brown, MD,a,b Jonathan M. Mansbach, MD, MPH,a,e and Carlos A. Camargo Jr, MD, DrPHa,bTrends in Bronchiolitis Hospitalizations in the United States, 2000-2009. (2013). Pediatrics, 132(1). doi:10.1542/peds.2012-3877dRalston et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics 2014;134:e1474–e1502
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Elizabeth Eby Halvorson, MD,1 Nicole Chandler, MD,2 Rebecca Neiberg, MS,3 and Sean E. Ervin, MD, PhD1 Association of NPO Status and Type of Nutritional Support on Weight and Length of Stay in Infants Hospitalized With Bronchiolitis. Hospital Pediatrics; 4 (3), 2013. www.hospitalpediatrics.org
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Effect of Oxygen Supplementation on Length of Stay for Infants Hospitalized With Acute Viral BronchiolitisStefan Unger and Steve Cunningham
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David Isaacs, Harriet Dickson, Chris O'Callaghan, Richard Sheaves, Andrew Winter, E Richard Moxon. Handwashing and cohorting in prevention of hospital acquired infections with respiratory syncytial virus. Archives of Disease in Childhood. 1991;66:227-231
Sara Mayfield,1,2 Fiona Bogossian,2 Lee O’Malley1 and Andreas Schibler1,3 High-flow nasal cannula oxygen therapy for infants with bronchiolitis: Pilot study Journal of Paediatrics and Child Health 50 (2014) 373–378
Tuomas Jartti, MD,* Matilda Aakula, BM,* Jonathan M. Mansbach, MD, MPH,† Pedro A. Piedra, MD,‡ Eija Bergroth, MD,§ Petri Koponen, MD,¶ Juho E. Kivisto , MD,¶** Ashley F. Sullivan, MS, MPH,‖ Janice A. Espinola, MPH,‖ Sami Remes, MD,§ Matti Korppi, MD,¶ and Carlos A. Camargo, Jr., MD, DrPH‖ Hospital Length-of-stay Is Associated With Rhinovirus Etiology of Bronchiolitis Pediatr Infect Dis J 2014;33:829–834
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Questions
Risk Factors for Failing HFNC
Risk Factors for Failing HFNC