Post-extubation stridor in Respiratory Syncytial Virus bronchiolitis: Is there a role for prophylactic dexamethasone?

AIM: The purpose of this study was to determine the incidence of reintubation due to upper airway obstruction in a homogeneous group of ventilated infants with Respiratory Syncytial Virus bronchiolitis. Our secondary objective was to determine whether prophylactic administration of dexamethasone prior to extubation was associated with decreased risk of reintubation. METHODS: This retrospective observational study in two Pediatric Intensive Care Units in 2 university hospitals in The Netherlands included two hundred patients younger than 13 months admitted with respiratory insufficiency caused by Respiratory Syncytial Virus bronchiolitis, requiring invasive mechanical ventilation. A logistic regression analysis with propensity score method was used to adjust for possible confounding. RESULTS: Reintubation due to post-extubation stridor occurred in 17 (8.5%) of 200 patients. After propensity score matching, administration of dexamethasone prior to extubation was associated with a significantly (p = 0.0011) decreased risk of reintubation due to post-extubation stridor compared to patients not receiving prophylactic dexamethasone (absolute risk reduction 13%, 95% CI 5.3-21%). CONCLUSION: Reintubation due to post-extubation stridor is an important complication of ventilation for Respiratory Syncytial Virus bronchiolitis. Dexamethasone administered prior to extubation probably reduces the risk of post-extubation stridor necessitating reintubation in these infants. The results of this study support initiation of a placebo-controlled trial to confirm the beneficial effect of prophylactic dexamethasone.

Are central line bundles and ventilator bundles effective in critically ill neonates and children?

Central line-associated bloodstream infections (CLABSI) and ventilator-associated pneumonia (VAP) are common problems in adult, pediatric (PICU) and neonatal (NICU) intensive care unit patients. Care bundles have been developed to prevent these hospital-acquired infections and to provide best possible care. Studies in adults have proven that care bundles contribute to a decrease in CLABSI and VAP rates. The purpose of this literature review was to critically appraise the known evidence of the effectiveness of central line bundles and ventilator bundles in PICU and NICU patients. The number of publications of central line bundles and ventilator bundles in PICU and NICU patients is limited compared to adults. Ten studies in PICU patients demonstrated a significant decrease in the CLABSI or VAP rate after implementation of the bundle. Two studies in neonates demonstrated a reduction in the CLABSI rate after implementation of the central line bundle. No studies on the effectiveness of the ventilator bundle in neonates were found. Bundle elements differed between studies, and their scientific basis was not as robust as in adults. Monitoring of compliance to bundle elements seems required for optimal reduction of CLABSI and VAP. Bundle components that focus on maintenance of a central line probably are important to prevent CLABSI in children.