Characteristics and Outcomes of Pediatric Rapid Response With a Respiratory Trigger.

BACKGROUND AND OBJECTIVES: Authors of adult rapid response (RRT) studies have established that RRT triggers play an important role in outcomes, but this association is not studied in pediatrics. In this study, we explore the characteristics and outcomes of pediatric rapid response with a respiratory trigger (Resp-RRT). We hypothesize that outcomes differ on the basis of patients' primary diagnoses at the time of Resp-RRT. METHODS: We conducted a 2-year retrospective observational study at an academic tertiary care pediatric hospital. RESULTS: Among the 1287 Resp-RRTs in 1060 patients, those with a respiratory diagnosis (N = 686) were younger, less likely to have complex chronic conditions, and less likely to have concurrent triggers (P < .01) than those with a nonrespiratory diagnosis (N = 601). Patients with a respiratory diagnosis were more likely to receive noninvasive ventilation, less likely to receive vasoactive support, and had lower 30-day mortality (P < .01). Among those with a respiratory diagnosis, the 541 patients with acute illness were younger, less likely to have complex chronic conditions, and less likely to receive vasoactive support than those with acute on chronic illness (N = 100) (P < .01). CONCLUSIONS: Among pediatric respiratory-triggered RRT events, patients with a respiratory diagnosis were more likely to receive acute respiratory support in ICU but have better long-term outcomes. Presence of complex chronic conditions increases risk of acute respiratory support and mortality. The interplay of primary diagnosis with RRT trigger can potentially inform resource needs and outcomes for pediatric Resp-RRTs.

Focused Research Infrastructure for Postgraduate Pediatric Emergency Medicine Fellows Increases Dissemination of Scholarly Work.

BACKGROUND: Many fellows in clinically driven subspecialties may have difficulty completing and publishing their scholarly projects due to lack of prior experience in research, selection of projects that are difficult to complete during fellowship, or mentorship challenges. This may be particularly true in pediatric emergency medicine (PEM) because research time may be longitudinally integrated with clinical rotations, rather than blocked as is common in other subspecialties. We describe the creation and outcomes of a structured program to increase academic productivity of PEM fellows. METHODS: This was a retrospective cohort study of scholarly productivity (publications in peer-reviewed journals, presentation at national meetings) for PEM fellows over 17 years in one fellowship program, before and after the implementation of a structured program. We reviewed obstacles to publication for prior fellow projects when developing the curriculum. Our multifaceted program consisted of milestone development, four in-person committee meetings, and abstract and manuscript development workshops. We utilized existing faculty members, most of whom were junior faculty, as committee members. Our primary outcome was the percentage of fellows who were first authors for peer-reviewed publications for their fellowship projects. National conference presentations were the secondary outcome. RESULTS: Data for 76 PEM fellows were eligible for analysis: 44 (58%) before and 32 after programmatic implementation. There was a statistically significant increase in the percentage of fellows who published their studies (32% vs. 63%; odds ratio [OR] = 3.6, 95% confidence interval [CI] = 1.4 to 9.3) after programmatic implementation. There were no differences in conference presentations (45% vs. 63%; OR = 2.0, 95% CI = 0.8-5.1) after implementation. CONCLUSIONS: Utilizing a small group of existing, predominantly junior faculty members, we created a structured program that enhanced PEM fellows' scholarly productivity and increased publications. We believe that this model is sustainable for and generalizable to other PEM fellowship programs.

Clinical factors associated with intubation in the high flow nasal cannula era.

BACKGROUND: Bronchiolitis is the most common cause for hospitalization in infants. While the use of high flow nasal cannula (HFNC) has increased, it has not uniformly reduced intubation rates. OBJECTIVE: We identified factors associated with respiratory failure in children with bronchiolitis on HFNC. METHODS: We conducted a retrospective study of previously healthy children <24 months of age with bronchiolitis, who were treated with HFNC in two pediatric emergency departments from 1/2014-1/2018. The primary outcome was the identification of demographic and clinical factors that are associated with intubation after an antecedent trial of HFNC. A multivariable logistic regression model was constructed to identify predictors of respiratory failure. RESULTS: Of 2657 children on HFNC, the median age was 7 months, while the median age of the intubated cohort was 3 months. Ten percent (271) progressed to mechanical ventilation within 48 h of PED presentation. Of the 301 patients that needed escalation to CPAP and/or BiPAP, 91 required intubation. Factors associated with intubation were young age and a high respiratory tool score; factors associated with no progression to intubation were a reduction in tachycardia after initiation of HFNC and presentation after day 5 of illness. A secondary analysis also revealed decreased rate of intubation with the use of bronchodilators. We identified demographic, clinical, and therapeutic factors that are associated with requiring intubation. CONCLUSION: Given the high burden of bronchiolitis in pediatric emergency departments, these factors can be considered upon presentation of children with bronchiolitis to selectively identify children at higher risk for respiratory failure.

Respiratory Virus Co-infection in Acute Respiratory Infections in Children.

PURPOSE OF REVIEW: This investigation aims to understand the role and burden of viral co-infections for acute respiratory illnesses in children. Co-infection can be either viral-viral or viral-bacterial and with new technology there is more information on the role they play on the health of children. RECENT FINDINGS: With the proliferation of multiplex PCR for rapid diagnosis of multiple viruses as well as innovations on identification of bacterial infections, research has been attempting to discover how these co-infections affect each other and the host. Studies are aiming to discern if the epidemiology of viruses seen at a population level is related to the interaction between different viruses on a host level. Studies are also attempting to discover the burden of morbidity and mortality of these viral-viral co-infections on the pediatric population. It is also becoming important to understand the interplay of certain viruses with specific bacteria and understanding the impact of viral-bacterial co-infections. RSV continues to contribute to a large burden of disease for pediatric patients with acute respiratory illnesses. However, recent literature suggests that viral-viral co-infections do not add to this burden and might, in some cases, be protective of severe disease. Viral-bacterial co-infections, on the other hand, are most likely adding to the burden of morbidity in pediatric patients because of the synergistic way they can infect the nasopharyngeal space. Future research needs to focus on confirming these conclusions as it could affect hospital cohorting, role of molecular testing, and therapeutic interventions.

Prevalence of co-infection between respiratory syncytial virus and influenza in children.

BACKGROUND: Respiratory syncytial virus (RSV) and influenza have varying degree of seasonal overlap. OBJECTIVE: To determine the prevalence of co-infection of RSV and influenza compared to the prevalence of those infections independently when both are in season. METHODS: This was a retrospective cross-sectional study of children evaluated between July 2010 and June 2013 for viral respiratory infection using multiplex PCR. Seasonality was defined retrospectively as weeks when >2% of the total annual positive tests were obtained and was calculated for influenza A, influenza B, and RSV independently. Periods of overlapping seasonality of RSV and influenza A and RSV and influenza B were identified. The expected incidences of co-infection were modeled as the product of the incidences of the individual viruses. RESULTS: 13,664 specimens were sent for PCR during the study period. Over all 3 seasons, RSV overlapped with influenza A and B for 22 and 18weeks, respectively; in 2011-12, RSV overlapped with neither influenza A nor B. Based on modeling, there were 6-7 fold fewer cases of RSV/influenza co-infection observed than expected: RSV/influenza A 77 vs. 12, (p≤0.001; RSV/influenza B 76 vs. 11 (p≤0.001). CONCLUSIONS: The observed incidence of co-infectivity of RSV and influenza was significantly less than the expected incidence even when both were co-circulating. In light of these data, it may be reasonable to forgo rapid influenza testing or empiric antiviral treatment for children whom rapid RSV testing is positive and who are at low risk of influenza-related complications, especially in times of antiviral therapy shortages.