Twenty-one-year follow-up revealed guideline-concordant and non-concordant trends in intensive care of bronchiolitis.

To evaluate the management of bronchiolitis in the paediatric intensive care unit (PICU) before and after publication of the national bronchiolitis guidelines in June 2015. All infants treated between 2016-2020 for bronchiolitis in the PICU of Tampere University Hospital at < 12 months of age were included. The data were retrospectively collected from electronic patient records. The current results reflecting the post-guideline era were compared with previously published results for the pre-guideline 2000-2015 period. These two studies used identical protocols. Forty-six infants treated in the PICU were included. During the post-guideline era, inhaled adrenaline was given to 26 (57%), salbutamol to 7 (15%), and hypertonic saline inhalations to 35 (75%) patients. Forty-three patients (94%) received high-flow oxygen therapy (HFOT). Seventeen patients (37%) were treated with nasal continuous positive airway pressure (CPAP) and 4 (9%) with mechanical ventilation. CONCLUSION: When post-guideline years were compared with pre-guideline years, the use of bronchodilators decreased in agreement, but the use of inhaled saline increased in disagreement with the guidelines. The use of respiratory support increased, evidently because of an introduction of the non-invasive HFOT treatment modality. WHAT IS KNOWN: • Oxygen supplementation and respiratory support, when needed, are the cornerstones of bronchiolitis treatment. • Medicines are frequently given to infants with bronchiolitis, especially if intensive care is needed, although evidence of their effectiveness is lacking. WHAT IS NEW: • Nearly all (94%) infants who needed intensive care were treated with HFOT and 37% with nasal CPAP, and finally, only 9% were intubated, which reflects the effectiveness of non-invasive techniques. • When pre- and post-guideline eras were compared, use of racemic adrenaline decreased from 84 to 57%, but use of hypertonic saline increased up to 75%, which disagrees with the current guidelines.

Multicenter cohort study on duration of antiarrhythmic medication for supraventricular tachycardia in infants.

Antiarrhythmic medication (AM) is commonly used to prevent supraventricular tachycardia (SVT) recurrence in infants. Our aim was to determine whether a shorter duration of AM is sufficient to prevent atrioventricular reentrant tachycardia (AVRT) recurrence and evaluate risk factors for recurrence of SVT after discontinued AM.This multicenter cohort study included all infants diagnosed with SVT in the five university hospitals in Finland between 2005 and 2017. Those diagnosed between 2005 and 2012 received AM for 12 months (group 1), and those diagnosed between 2013 and 2017 received AM for 6 months (group 2). A total of 278 infants presented with AVRT (group 1, n = 181; group 2, n = 97), and the median AM duration was 12.0 months (interquartile range [IQR] 11.4-13.4) and 7.0 months (IQR 6.0-10.2), respectively. Propranolol was the most frequently used first-line AM (92% and 95%). Recurrence-free survival rates were over 88% until 12 months after AM prophylaxis in both groups, without any statistically significant difference between them. Independent risk factors for recurrence of SVT after discontinuation of AM were need of combination AM (HR 2.2, 95% CI 1.14-4.20), Wolff-Parkinson-White (WPW) syndrome (HR 2.4, 95% CI 1.25-4.59), and age over 1 month at admission (HR 2.2, 95% CI 1.12-4.48).    Conclusion: Shortening AM duration in infants from 12 to 6 months does not seem to lead to more frequent SVT recurrence. The risk factors for recurrence of SVT were WPW syndrome, need of combination AM, and age over 1 month.

Review shows substantial variations in the use of medication for infant bronchiolitis between and within countries.

AIM: Meta-analyses of randomised controlled trials on infant bronchiolitis do not support medication. We summarised the current data and evaluated the real-life use of medication for infants treated for bronchiolitis in hospitals, including paediatric wards, emergency departments and paediatric intensive care units (PICU). METHODS: We searched PubMed for studies published from 2009 to 2018 that provided data on the real-life use of adrenaline, salbutamol, corticosteroids or antibiotics for infants hospitalised for bronchiolitis. RESULTS: The review identified 10 such studies and showed substantial variations in medication for infant bronchiolitis between different countries and even between different hospitals in the same country. A multi-centre study including 38 hospitals in eight countries reported that a mean of 29% infants admitted for bronchiolitis received drugs without any research-based evidence on their effectiveness, ranging from 9% in Australia and New Zealand to 58% in Spain and Portugal. In addition, an American prospective multi-centre study of 16 PICUs reported that bronchodilators were used by a mean of 60%, corticosteroids by 33% and antibiotics by 63%. Other studies reported that higher ages and a history of wheezing increased the use of medication. CONCLUSION: There were substantial variations in bronchiolitis treatment between, and within, different countries.

The change in management of bronchiolitis in the intensive care unit between 2000 and 2015.

This case-control study evaluated interventions for bronchiolitis in relation to time in the pediatric intensive care unit (PICU) during a 16-year surveillance period. Together, 105 infants aged < 12 months were treated for bronchiolitis in the PICU, and for them, we selected 210 controls admitted for bronchiolitis closest to cases. We collected data on treatments in the PICU, at the ward and in the emergency department for three periods: years 2000-2005, 2006-2010, and 2011-2015. Median hospital length of stay for PICU patients were 7 days (interquartile range 5-12), 5 days (4-8) and 8 days (4-12.5, p = 0.127), respectively. By time, the use of inhaled beta-agonist (68 vs. 44 vs. 38%, p = 0.019) and systemic corticosteroids (29 vs. 15 vs. 5%, p = 0.019) decreased, but that of racemic adrenaline (59 vs. 78 vs. 84%, p = 0.035) and hypertonic saline (0 vs. 0 vs. 54%, p < 0.001) inhalations increased in the PICU. Similar changes were seen at the ward. In the PICU, non-invasive ventilation therapies increased significantly, but intubation rates did not decline.Conclusion: Beta-agonists and systemic corticosteroids were used less by time in intensive care for infant bronchiolitis, but the use of hypertonic saline and racemic adrenaline increased, though their effectiveness has been questioned. What is Known: • Until now, studies have shown which treatments do not work in bronchiolitis, and so, there is no consensus how infants with bronchiolitis should be treated. In particular, there is no consensus on different interventions in intensive care for bronchiolitis. What is New: • During 2000-2015, treatments with inhaled beta-agonists and systemic corticosteroids decreased but treatments with racemic adrenaline and hypertonic saline inhalations increased in intensive care for bronchiolitis. Similar changes were seen at the ward. Though non-invasive ventilation therapies increased, the intubation rate did not decline.

National treatment guidelines decreased the use of racemic adrenaline for bronchiolitis in four Finnish university hospitals.

AIM: Inhaled racemic adrenaline was used for bronchiolitis in many hospitals in Finland prior to new national current care guidelines for bronchiolitis in 2014, which limited its recommendations to on-demand rescue therapy. We studied the drug's use before and after the new guidelines to gauge changes in prescribing habits. METHODS: This 2012-2016 study analysed how many 0.5 mL doses of racemic adrenaline were used for children by emergency rooms, paediatric wards and paediatric intensive care units at four university hospitals and estimated drug and staff costs. RESULTS: There were substantial differences in the yearly consumption of racemic adrenaline between the hospitals before and after the bronchiolitis guidelines were published, with reductions in drug costs and staff time. The overall use more than halved during the study period, particularly in two hospitals where baseline consumptions were highest, but not in a third where baseline consumption was already low. In the fourth, the baseline consumption was modest and there was a constant decrease during the study years. CONCLUSION: The current care guidelines for bronchiolitis had some impact on clinical practice, as the overall use of racemic adrenaline more than halved, but considerable differences remained in the four study hospitals after their publication.

Using high-flow nasal cannulas for infants with bronchiolitis admitted to paediatric wards is safe and feasible.

AIM: Using a high-flow nasal cannula (HFNC) for infant bronchiolitis is increasingly common, but insufficiently studied. In this retrospective study, we examined the outcomes of HFNC and compared infants who did and did not respond to this oxygen delivery method. METHODS: This 2012-2015 study of six Finnish hospitals focused on 88 infants under 12 months who received HFNC: 53 on paediatric wards and 35 in paediatric intensive care units (PICUs). We reviewed patient files for underlying factors, clinical parameters and HFNC treatment. The treatment failed if the patient was transferred to another respiratory support. RESULTS: We found HFNC treatment was successful in 76 (86%) infants, including all 53 on the paediatric wards and 23/35 PICU patients. The responders' heart rates were significantly lower, and their oxygen saturation was significantly higher at 60 minutes after HFNC treatment started and then stayed relatively constant. Their respiratory rate was only significantly lower after 360 minutes. In non-responders, the respiratory rate initially decreased but was higher at 180 and 360 minutes after the start of HFNC. CONCLUSION: We found preliminary evidence that oxygen support needs and heart rate were useful early predictors of HFNC therapy success in infants hospitalised with bronchiolitis, but respiratory rate was not.

Low age, low birthweight and congenital heart disease are risk factors for intensive care in infants with bronchiolitis.

AIM: This study evaluated the incidence and risk factors for intensive care and respiratory support in infant bronchiolitis. METHODS: This retrospective descriptive case-control study focused on 105 patients treated in the paediatric intensive care unit (PICU) and 210 controls treated in the emergency department or on the paediatric ward in Tampere University Hospital in Finland between 2000 and 2015. Statistically significant risk factors in nonadjusted analyses were included in the adjusted logistic regression. RESULTS: The average age-specific annual incidence of bronchiolitis requiring PICU admission under the age of 12 months was 1.5/1000/year (range 0.18-2.59). Independently, significant risk factors for PICU admission were as follows: being less than two months old with an adjusted odds ratio (aOR) of 11.5, birthweight of <2000 g (aOR of 15.9), congenital heart disease (CHD) (aOR of 15.9), apnoea (aOR of 7.2) and the absence of wheezing (aOR of 2.2). Significant risk factors for needing respiratory support were a birthweight of <2000 g, an age of less than two months and CHD. CONCLUSION: Less than 0.1% of infants under the age of 12 months were admitted to the PICU for bronchiolitis. Low age, low birthweight or prematurity and CHD were independently significant risk factors for both intensive care and respiratory support.

Diagnosis and treatment of bronchiolitis in Finnish and Swedish children's hospitals.

AIM: There is no widely accepted consensus on the diagnosis and treatment of bronchiolitis. This study describes current practices in Finnish and Swedish hospitals. METHODS: A questionnaire on the diagnosis and treatment of bronchiolitis in children below 2 years of age was sent to all Finnish and Swedish hospitals providing inpatient care for children. All 22 Finnish hospitals answered, covering 100% of the <12-month-old population and 21 of the 37 Swedish hospitals responded, covering 74%. RESULTS: The mean upper age limit for bronchiolitis was 12.7 months in Finnish hospitals and 12.5 months in Swedish hospitals. In both, laboured breathing, chest retractions and fine crackles were highlighted as the main clinical findings, followed by prolonged expiration. The mean value for the lowest acceptable saturation in room air was 94% in Finnish hospitals and 93% in Swedish hospitals. The most important factors influencing hospitalisation were young age, desaturation and inability to take oral fluids. Finnish doctors preferred intravenous routes, and Swedish doctors preferred nasogastric tubes for supplementary feeding. The first-line drug therapy was inhaled racemic adrenaline in Finland and inhaled levo-adrenaline in Sweden. CONCLUSION: The diagnosis and treatment of bronchiolitis is fairly similar in Finnish and Swedish hospitals.

Salbutamol with metered dose inhalers with spacers - an established emergency treatment for preschool wheeze.

AIMS: Metered dose inhalers (MDI) with spacers were implemented to treat preschool wheeze in the emergency room (ER) and hospital in 2006 in our children's hospital. The implementation at day time happened successfully within 4 months, but not at night time. The objective of the present study was to check the treatment mode, hospitalization rate and length of hospital stay (LOS) 4 years later. METHODS: The present retrospective hospital chart review was identical to the review 4 years earlier, including data collection on treatment mode in 1- to-5-year-old preschool wheezers in the ER, on need of hospitalization, on treatment mode in hospital and on LOS. Both studies were performed during the same late-autumn and early-winter months. RESULTS: In the ER, 96% of the children with preschool wheeze were treated with salbutamol using MDIs with spacers. Hospitalization rate was 51%, and all but one were treated with MDIs with spacers in hospital at both day and night time. Mean LOS was 2.48 days, being shorter than 4 years earlier. CONCLUSION: Administration of salbutamol using MDI with spacer became an established emergency treatment of preschool wheeze within 4 years after the initial change from nebulizers to MDIs with spacers.

Emergency treatment of obstructive bronchitis: change from nebulizers to metered dose inhalers with spacers.

AIM: To evaluate how the change from drug nebulizers to metered dose inhalers (MDI) with spacers succeeded and influenced the hospitalization rate and the length of the emergency room (ER) and hospital stay in wheezing preschool-aged children. METHODS: After educating and training the nurses and physicians, the use of MDIs with spacers was started on 1 November 2006 in the ER and acute wards of our hospital. All of the 1-to-5-year-old patients admitted for bronchial obstruction from 1 November 2004 to 28 February 2005 and from 1 November 2006 to 28 February 2007 were included in this retrospective hospital chart review. RESULTS: In 2004-2005, 78% of the children were treated with salbutamol administered by nebulizers, and in 2006-2007, 84% with salbutamol administered by MDIs with spacers. The hospitalization rate was about 50% in both groups, and no difference was seen in the length of the hospital stay. The children treated with the MDIs with spacers stayed in the ER for a longer time. CONCLUSION: The change from drug nebulizers to MDIs with spacers in the treatment of acute bronchial obstruction in 1-to-5-year-old children was successful after the staff was educated and trained.

The cost-effectiveness of hypertonic saline inhalations for infant bronchiolitis: a decision analysis.

BACKGROUND: This study evaluated the cost-effectiveness of hypertonic saline (HS) inhalations for infant bronchiolitis, compared to normal saline inhalations or standard treatment without inhalations as controls. METHODS: The decision tree in the decision analysis was used to calculate the expected costs. Actual cost data were obtained from our retrospective case-control study on bronchiolitis treatment. The effectiveness of treatment, based on the hospitalization rate of those admitted to the emergency department and the length of stay (LOS) of those who were hospitalized, was collected from previous studies. For the effectiveness estimations, we made a meta-analysis summarizing the results of the meta-analysis of the Cochrane review in 2013 and the results of 10 studies published after it. RESULTS: The mean hospitalization rate was 24.7% in the HS inhalation group and 32.6% in the control group [risk ratio: 0.80, 95% confidence interval (CI) 0.67-0.96] and the mean LOS was 3.736 (HS group) and 4.292 (controls) days (mean difference: - 0.55 days, 95% CI - 0.96 to - 0.15), respectively. The expected costs per patient, when both inpatients and outpatients were included, were €816 ($1111) in the HS inhalation group and €962 ($1310) in the control group. The expected costs per hospitalization, when only inpatients were included, were €2600 ($3540) in the HS inhalation group and €2890 ($3935) in the control group. CONCLUSIONS: HS inhalations slightly reduced the expected hospitalization costs of infant bronchiolitis. However, the low effectiveness, rather than the cost, is the factor that will limit the use of HS inhalations in infant bronchiolitis.