Implications of sedation during the use of noninvasive ventilation in children with acute respiratory failure (SEDANIV Study).

BACKGROUND: The objective of this study was to analyze the effects of sedation administration on clinical parameters, comfort status, intubation requirements, and the pediatric intensive care unit (PICU) length of stay (LOS) in children with acute respiratory failure (ARF) receiving noninvasive ventilation (NIV). METHODS: Thirteen PICUs in Spain participated in a prospective, multicenter, observational trial from January to December 2021. Children with ARF under the age of five who were receiving NIV were included. Clinical information and comfort levels were documented at the time of NIV initiation, as well as at 3, 6, 12, 24, and 48 h. The COMFORT-behavior (COMFORT-B) scale was used to assess the patients' level of comfort. NIV failure was considered to be a requirement for endotracheal intubation. RESULTS: A total of 457 patients were included, with a median age of 3.3 months (IQR 1.3-16.1). Two hundred and thirteen children (46.6%) received sedation (sedation group); these patients had a higher heart rate, higher COMFORT-B score, and lower SpO2/FiO2 ratio than did those who did not receive sedation (non-sedation group). A significantly greater improvement in the COMFORT-B score at 3, 6, 12, and 24 h, heart rate at 6 and 12 h, and SpO2/FiO2 ratio at 6 h was observed in the sedation group. Overall, the NIV success rate was 95.6%-intubation was required in 6.1% of the sedation group and in 2.9% of the other group (p = 0.092). Multivariate analysis revealed that the PRISM III score at NIV initiation (OR 1.408; 95% CI 1.230-1.611) and respiratory rate at 3 h (OR 1.043; 95% CI 1.009-1.079) were found to be independent predictors of NIV failure. The PICU LOS was correlated with weight, PRISM III score, respiratory rate at 12 h, SpO2 at 3 h, FiO2 at 12 h, NIV failure and NIV duration. Sedation use was not found to be independently related to NIV failure or to the PICU LOS. CONCLUSIONS: Sedation use may be useful in children with ARF treated with NIV, as it seems to improve clinical parameters and comfort status but may not increase the NIV failure rate or PICU LOS, even though sedated children were more severe at technique initiation in the present sample.

Outcomes of viral coinfections in infants hospitalized for acute bronchiolitis.

BACKGROUND AND OBJECTIVE: The clinical relevance of the detection of multiple respiratory viruses in acute bronchiolitis (AB) has not been established. Our goal was to evaluate the effect of viral coinfections on the progression and severity of AB. METHODS: A retrospective observational study was conducted in a tertiary hospital in Spain from September 2012 to March 2020. Infants admitted for AB with at least one respiratory virus identified by molecular diagnostic techniques were included. A comparison was made between single-virus infections and viral coinfections. The evolution and severity of AB were determined based on the days of hospitalization and admission to the pediatric intensive care unit (PICU). RESULTS: Four hundred forty-five patients were included (58.4% male). The median weight was 5.2 kg (IQR 4.2-6.5), and the median age was 2.5 months (IQR 1.4-4.6). A total of 105 patients (23.6%) were admitted to the PICU. Respiratory syncytial virus (RSV) was the most frequent etiological agent (77.1%). A single virus was detected in 270 patients (60.7%), and viral coinfections were detected in 175 (39.3%), of which 126 (28.3%) had two viruses and 49 (11%) had three or more viruses. Hospital length of stay (LOS) increased in proportion to the number of viruses detected, with a median of 6 days (IQR 4-8) for single infections, 7 days (IQR 4-9) for coinfections with two viruses and 8 days (IQR 5-11) for coinfections with ≥ 3 viruses (p = 0.003). The adjusted Cox regression model showed that the detection of ≥ 3 viruses was an independent risk factor for a longer hospital LOS (HR 0.568, 95% CI 0.410-0.785). No significant association was observed between viral coinfections and the need for PICU admission (OR 1.151; 95% CI 0.737-1.797). CONCLUSIONS: Viral coinfections modified the natural history of AB, prolonging the hospital LOS in proportion to the number of viruses detected without increasing the need for admission to the PICU.

SIGNIFICANCE: What is KnownThe main etiological agent of acute bronchiolitis (AB) is respiratory syncytial virus (RSV); however, other viruses are frequently detected. All viruses may be the sole etiological cause or may occur in association, and a high prevalence of viral coinfection has been described.To date, there are conflicting results on the role of viral coinfections in the severity of bronchiolitis.What is NewViral coinfections influence the progression of AB. The simultaneous detection of 3 or more respiratory viruses is a risk factor for longer hospital stay.The presence of viral coinfections does not condition a greater need for admission to the PICU.

Characteristics and management of patients with SARS-CoV2 infection admitted to pediatric intensive care units: Data analysis of the Spanish national multicenter registry.

INTRODUCTION: The purpose of this study is to describe the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) disease characteristics and management in children admitted to the pediatric intensive care units (PICU). METHODS: The present study was based on a national multicentric prospective registry including PICU patients with SARS-CoV2 infection or symptoms of multisystem inflammatory syndrome in children (MIS-C). RESULTS: A total of 298 patients were admitted to 41 different Spanish PICUs. A total of 76% of them were previously healthy. The most frequent manifestation was MIS-C (69.8%). On admission, 59.4% of patients did not have respiratory distress, and only 17.4% needed conventional mechanical ventilation (MV). The need for MV was associated with age (incidence rate ratios [IRR] 1.21, p < .012), pediatric sequential organ failure assessment score (p-SOFA) Score (IRR 1.12, p = .001), and need for transfusion (IRR 4.5, p < .004) in MIS-C patients, and with vasoactive drug use (IRR 2.73, p = .022) and the diagnosis of acute respiratory distress syndrome (IRR 2.83, p = .018) in patients admitted for other reasons. During the first day of admission, 56% of patients met shock criteria and 50.7% needed vasoactive drugs. In MIS-C patients, their use was associated with higher p-SOFA score (IRR 1.06, p < .001) and with the diagnosis of shock (IRR 5.78, p < .001). In patients without MIS-C, it was associated with higher p-SOFA score (IRR 1.05, p = .022). The mortality rate was 3%, being lower in MIS-C patients compared to patients admitted for other reasons (0.5% vs. 9.4%, p < .001). It was also lower in previously healthy patients compared to patients with previous comorbidities (0.9% vs. 9.7%, p < .001). CONCLUSIONS: Severe SARS-CoV2 infection is uncommon in the pediatric population. In our series, respiratory distress was rare, being MIS-C the most frequent cause of PICU admission related to SARS-CoV2. In most cases, the course of the disease was mild except in children with previous diseases.

Thrombotic microangiopathies in critically ill children: The MATUCIP registry in Spain.

INTRODUCTION: Thrombotic microangiopathies (TMA) are rare diseases usually presenting with renal, haematological, neurologic and cardiovascular involvement and nonspecific but severe symptoms. A registry of TMA cases managed in Spanish paediatric intensive care units (the MATUCIP Registry) was established with the aim of gaining knowledge on their clinical characteristics, diagnosis and acute-phase treatment. METHODS: We conducted a prospective multicentre observational study in 20 paediatric intensive care units (PICUs) in Spain from January 2017 to December 2021 in children aged more than 1 month with TMAs, who were followed up through the discharge from the PICU. RESULTS: The sample included 97 patients (51.5% female) with a median age of 2.6 years (interquartile range [IQR], 1.6-5.7). The initial manifestations were gastrointestinal (74.2%), respiratory (14.4%), fever (5.2%), neurologic (3.1%) and other (3.1%). At admission, 75.3% of patients had microangiopathic haemolytic anaemia, 95.9% thrombocytopenia and 94.8% acute kidney injury. Of the total sample, 57.7% of patients received a diagnosis of Shiga toxin-associated haemolytic uraemic syndrome (HUS), 14.4% of Streptococcus pneumoniae-associated HUS, 15.6% of atypical HUS, 10.3% of secondary TMA and 2.1% of thrombotic thrombocytopenic purpura. Eighty-seven patients (89.7%) developed arterial hypertension, and 49.5% gastrointestinal, 22.7% respiratory, 25.8% neurologic and 12.4% cardiac manifestations. Also, 60.8% required renal replacement therapy and 2.1% plasma exchange. Twenty patients received eculizumab. The median PICU stay was 8.5 days (IQR, 5-16.5). Two children died. CONCLUSIONS: The MATUCIP registry demonstrates the clinical variability of TMA cases requiring admission to the PICU. Knowledge of the presentation and outcomes of TMAs can facilitate early aetiological diagnosis. This registry can help improve our understanding of the clinical spectrum of these diseases, for which there is a dearth of published data.

[Influence of the COVID-19 pandemic on the epidemiology of acute bronchiolitis]. / Influencia de la pandemia COVID-19 sobre la epidemiología de la bronquiolitis aguda.

Introduction: The COVID-19 pandemic has changed the circulation of some viruses associated with acute bronchiolitis. We analyzed the epidemiology of bronchiolitis admissions during the COVID-19 pandemic compared with 8 previous epidemic seasons. Methods: An observational and ambispective study was performed, including infants admitted with bronchiolitis in a tertiary hospital during 2 periods: COVID-19 pandemic (15th March 2020 to 3 rd August 2021) and pre-pandemic (1st September 2012 to 14th March 2020). Demographic, clinical data and etiologies were collected. Results: Five hundred ten patients were hospitalized with bronchiolitis: 486 in the pre-pandemic period with an average of 61 admissions per season vs. 24 during the pandemic, observing a 60.7% reduction in bronchiolitis admissions. During the pandemic, bronchiolitis outbreak was delayed until spring-summer 2021. Respiratory syncytial virus was the most frequent etiological agent in both periods. Conclusion: We observed a change in the seasonality of bronchiolitis during the pandemic COVID-19, possibly influenced by control measures against SARS-CoV-2.

Influence of the COVID-19 pandemic on the epidemiology of acute bronchiolitis.

INTRODUCTION: The COVID-19 pandemic has changed the circulation of some viruses associated with acute bronchiolitis. We analyzed the epidemiology of bronchiolitis admissions during the COVID-19 pandemic compared with 8 previous epidemic seasons. METHODS: An observational and ambispective study was performed, including infants admitted with bronchiolitis in a tertiary hospital during 2 periods: COVID-19 pandemic (15th March 2020 to 3rd August 2021) and pre-pandemic (1st September 2012 to 14th March 2020). Demographic, clinical data and etiologies were collected. RESULTS: Five hundred ten patients were hospitalized with bronchiolitis: 486 in the pre pandemic period with an average of 61 admissions per season vs 24 during the pandemic, observing a 60.7% reduction in bronchiolitis admissions. During the pandemic, bronchiolitis outbreak was delayed until spring-summer 2021. Respiratory syncytial virus was the most frequent etiological agent in both periods. CONCLUSION: We observed a change in the seasonality of bronchiolitis during the pandemic COVID-19, possibly influenced by control measures against SARS-CoV-2.

Variation in the seasonality of the respiratory syncytial virus during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has caused a variation in the circulation of common respiratory viruses. Our objective was to analyse the epidemiology of respiratory syncytial virus (RSV) bronchiolitis admissions during the COVID-19 pandemic in comparison with previous epidemic seasons. METHODS: We conducted an observational study involving infants with RSV bronchiolitis admitted to a tertiary hospital during two periods: pandemic COVID-19 (15 March 2020-30 September 2021) and pre-pandemic (1 October 2014-14 March 2020). Demographic and clinical characteristics were collected. RESULTS: A total of 270 patients were admitted for RSV bronchiolitis: 253 in the pre-pandemic period with an average of 42 admissions per season vs 17 in the pandemic. During the pandemic, the RSV outbreak started late in June 2021 with a higher percentage of prematurity and PICU admissions. CONCLUSION: A change in RSV seasonality was observed during the COVID-19 pandemic, with an unusual outbreak in summer 2021 of lower magnitude than previous seasons.

Effect of prenatal and postnatal exposure to tobacco in the development of acute bronchiolitis in the first two years of life.

INTRODUCTION: Environmental exposure to tobacco increases the risk of respiratory disease in infants. However, the impact of maternal smoking on the development of acute bronchiolitis has hardly been assessed. The aim of this study was to determine the incidence of acute bronchiolitis and to analyse the effect of prenatal and postnatal maternal smoking on the development of this disease. PATIENTS AND METHODS: A prospective, observational study was performed on healthy newborns from a third level hospital born between October 2015 and February 2016. Questionnaires were completed by the mothers at discharge from maternity and followed-up for two years. These collected information about prenatal and postnatal smoking, lifestyle, family and personal history, and the development of bronchiolitis. A bivariate and multivariate logistic regression analysis was performed. RESULTS: A total of 223 newborns were included, of whom 13.9% were exposed to tobacco smoking during gestation, 21.4% in the postnatal period, and 12.4% in both times. The incidence of bronchiolitis was 28.7% at one year of life, and 34.5% at two years. The multivariate analysis demonstrated that the prenatal and postnatal exposure to tobacco is an independent risk factor for the development of bronchiolitis (OR 4.38; 95% CI; 1.63-11.76), while prolonged breastfeeding is a protective factor (OR 0.13; 95% CI; 0.04-0.48). Other factors that were statistically significant were: atopic dermatitis (OR 2.91; 95% CI; 1.26-6.73), and gestational age (OR 1.42; 95% CI; 1.08-1.88). CONCLUSIONS: Children exposed to prenatal and postnatal maternal smoking have a higher risk of suffering bronchiolitis. Reducing the smoking habit in women that intend to become pregnant must be a priority in preventive medicine.

[High flow nasal cannula oxygen therapy in the treatment of acute bronchiolitis in neonates]. / Oxigenoterapia de alto flujo con cánula nasal en el tratamiento de la bronquiolitis aguda en neonatos.

OBJECTIVE: To determine whether the availability of heated humidified high-flow nasal cannula (HFNC) therapy was associated with a decrease in need for mechanical ventilation in neonates hospitalised with acute bronchiolitis. METHODS: A combined retrospective and prospective (ambispective) cohort study was performed in a type II-B Neonatal Unit, including hospitalised neonates with acute bronchiolitis after the introduction of HFNC (HFNC-period; October 2011-April 2015). They were compared with a historical cohort prior to the availability of this technique (pre-HFNC; January 2008-May 2011). The need for mechanical ventilation between the two study groups was analysed. Clinical parameters and technique-related complications were evaluated in neonates treated with HFNC. RESULTS: A total of 112 neonates were included, 56 after the introduction of HFNC and 56 from the period before the introduction of HFNC. None of patients in the HFNC-period required intubation, compared with 3.6% of the patients in the pre-HFNC group. The availability of HFNC resulted in a significant decrease in the need for non-invasive mechanical ventilation (30.4% vs 10.7%; P=.01), with a relative risk (RR) of .353 (95% CI; .150-.829), an absolute risk reduction (ARR) of 19.6% (95% CI; 5.13 - 34.2), yielding a NNT of 5. In the HFNC-period, 22 patients received high flow therapy, and 22.7% (95% CI; 7.8 to 45.4) required non-invasive ventilation. Treatment with HFNC was associated with a significant decrease in heart rate (P=.03), respiratory rate (P=.01), and an improvement in the Wood-Downes Férres score (P=.00). No adverse effects were observed. CONCLUSIONS: The availability of HFNC reduces the need for non-invasive mechanical ventilation, allowing a safe and effective medical management of neonates with acute bronchiolitis.