Head-to-Head Comparison Between Respiratory Syncytial Virus and Human Metapneumovirus Bronchiolitis in the Setting of Increased Viral Testing.

We compared the epidemiology, severity and management of hospitalized respiratory syncytial virus (n = 305) and human metapneumovirus (n = 39) bronchiolitis in a setting with high respiratory virus testing (95% of admissions tested). Respiratory syncytial virus-positive infants were younger and tended to require more hydration support and longer hospital stays compared to human metapneumovirus-positive infants. Respiratory support requirements were similar between groups despite significant age differences.

Multilevel analysis identifying the factors associated with RSV detection in infants admitted for viral bronchiolitis in the era of the COVID-19 pandemic.

OBJECTIVES: To identify factors independently associated with respiratory syncytial virus (RSV) detection in infants admitted for viral bronchiolitis during 3 consecutive years, before and during the COVID-19 pandemic, in Bogota, Colombia, a middle-income country with a subtropical highland climate. METHODS: An analytical cross-sectional study was conducted before and during the COVID-19 pandemic, including patients with a diagnosis of viral bronchiolitis admitted to all the hospitals of the city between January 2019 and November 2021. We evaluated a set of a priori-selected predictor variables that included individual, healthcare system, meteorological, air pollutant, and COVID-19 variables. Since the variables analyzed are hierarchical in nature, multilevel modeling was used to identify factors independently associated with detection of RSV as the causative agent of viral bronchiolitis. RESULTS: A total of 13,177 patients were included in the study. After controlling for potential confounders, it was found that age (odds ratio [OR] 0.86; 95% confidence interval [CI] 0.76-0.97), a third level of medical care institution (OR 3.05; 95% CI 1.61-5.76), temperature (OR 1.60; 95% CI 1.24-2.07), rainfall (OR 1.003, 95% CI 1.001, 1.005), NO2 (OR 0.97; 95% CI 0.95-0.99), CO (OR 0.99; 95% CI 0.99-0.99), and COVID-19 pandemic period (OR 0.84, 95% CI 0.71-0.99) were independently associated with RSV detection in our sample of patients. CONCLUSIONS: The identified factors associated with RSV detection provide additional scientific evidence that may be useful in the development of specific interventions aimed at ameliorating or preventing the impact of RSV in Bogota and probably other similar low- to middle-income countries in high-risk infants.

Increased RSV-A Bronchiolitis Severity in RSV-Infected Children Admitted to a Reference Center in Catalonia (Spain) Between 2014 and 2018.

Between 2014 and 2018, we evaluated the severity of 687 cases of bronchiolitis caused by respiratory syncytial virus (RSV) in Catalonia, Spain. Compared to RSV-B, RSV-A cases required intensive care (adjusted relative risk (aRR) = 1.44, p < 0.01) and respiratory support (aRR = 1.07, p < 0.01) more often; hospital stay was one day longer (p < 0.01). Subgroup identification may aid clinical evaluation and seasonal healthcare planning.

Respiratory Syncytial Virus is the Most Common Causative Agent of Viral Bronchiolitis in Young Children: An Updated Review.

BACKGROUND: Viral bronchiolitis is a common condition and a leading cause of hospitalization in young children. OBJECTIVE: This article provides readers with an update on the evaluation, diagnosis, and treatment of viral bronchiolitis, primarily due to RSV. METHODS: A PubMed search was conducted in December 2021 in Clinical Queries using the key terms "acute bronchiolitis" OR "respiratory syncytial virus infection". The search included clinical trials, randomized controlled trials, case control studies, cohort studies, meta-analyses, observational studies, clinical guidelines, case reports, case series, and reviews. The search was restricted to children and English literature. The information retrieved from the above search was used in the compilation of this article. RESULTS: Respiratory syncytial virus (RSV) is the most common viral bronchiolitis in young children. Other viruses such as human rhinovirus and coronavirus could be etiological agents. Diagnosis is based on clinical manifestation. Viral testing is useful only for cohort and quarantine purposes. Cochrane evidence-based reviews have been performed on most treatment modalities for RSV and viral bronchiolitis. Treatment for viral bronchiolitis is mainly symptomatic support. Beta-agonists are frequently used despite the lack of evidence that they reduce hospital admissions or length of stay. Nebulized racemic epinephrine, hypertonic saline and corticosteroids are generally not effective. Passive immunoprophylaxis with a monoclonal antibody against RSV, when given intramuscularly and monthly during winter, is effective in preventing severe RSV bronchiolitis in high-risk children who are born prematurely and in children under 2 years with chronic lung disease or hemodynamically significant congenital heart disease. Vaccines for RSV bronchiolitis are being developed. Children with viral bronchiolitis in early life are at increased risk of developing asthma later in childhood. CONCLUSION: Viral bronchiolitis is common. No current pharmacologic treatment or novel therapy has been proven to improve outcomes compared to supportive treatment. Viral bronchiolitis in early life predisposes asthma development later in childhood.

Bronchiolitis.

Viral bronchiolitis is the most common cause of admission to hospital for infants in high-income countries. Respiratory syncytial virus accounts for 60-80% of bronchiolitis presentations. Bronchiolitis is diagnosed clinically without the need for viral testing. Management recommendations, based predominantly on high-quality evidence, advise clinicians to support hydration and oxygenation only. Evidence suggests no benefit with use of glucocorticoids or bronchodilators, with further evidence required to support use of hypertonic saline in bronchiolitis. Evidence is scarce in the intensive care unit. Evidence suggests use of high-flow therapy in bronchiolitis is limited to rescue therapy after failure of standard subnasal oxygen only in infants who are hypoxic and does not decrease rates of intensive care unit admission or intubation. Despite systematic reviews and international clinical practice guidelines promoting supportive rather than interventional therapy, universal de-implementation of interventional care in bronchiolitis has not occurred and remains a major challenge.

Evaluation of reported medical services provided to pediatric viral bronchiolitis diagnoses during the COVID-19 pandemic.

BACKGROUND: Mitigation strategies were implemented during the coronavirus disease 2019 (COVID-19) pandemic that slowed the spread of this virus and other respiratory viruses. The objective of this study is to assess the impact of COVID-19 mitigation strategies on the medical services that children less than 1 year of age with acute bronchiolitis required (emergency department services, hospitalization, critical care services, and mechanical ventilation). METHODS: This was a retrospective observational cohort study utilizing TriNetX ® electronic health record (EHR) data. We included subjects less than 1 year of age with a diagnosis of acute bronchiolitis. After the query, the study population was divided into two groups [pre-COVID-19 (March 1st, 2019 until February 29th, 2020) and COVID-19 (March 1st, 2020 until February 1th, 2021)]. We analyzed the following data: age, sex, race, diagnostic codes, common terminology procedures (CPT), and antimicrobials administered. RESULTS: A total of 5063 subjects (n,%) were included [4378 (86.5%) pre-COVID-19 and 685 (13.5%) during the COVID-19 pandemic]. More subjects were diagnosed with acute bronchiolitis in the pre-COVID time frame (4378, 1.8% of all hospitalizations) when compared to the COVID-19 pandemic time frame (685, 0.5%). When diagnosed with acute bronchiolitis, the frequency of emergency department services, critical care services, hospitalization, and mechanical ventilationwere similar between the two cohorts. CONCLUSIONS: During the COVID-19 pandemic, less infants were diagnosed with acute bronchiolitis but the frequency of emergency department services, hospitalization, and mechanical ventilation, reportedly required was similar. Longer-term studies are needed to evaluate the benefits of COVID-19 mitigation strategies on common viruses that require critical care.

For which infants with viral bronchiolitis could it be deemed appropriate to use albuterol, at least on a therapeutic trial basis?

Although there is increasing evidence showing that infants with viral bronchiolitis exhibit a high degree of heterogeneity, a core uncertainty shared by many clinicians is with regard to understanding which patients are most likely to benefit from bronchodilators such as albuterol. Based on our review, we concluded that older infants with rhinovirus (RV) bronchiolitis, especially those with a nasopharyngeal microbiome dominated by Haemophilus influenzae; those affected during nonpeak months or during non-respiratory syncytial virus (RSV) predominant months; those with wheezing at presentation; those with clinical characteristics such as atopic dermatitis or a family history of asthma in a first-degree relative; and those infants infected with RSV genotypes ON1 and BA, have the greatest likelihood of benefiting from albuterol. Presently, this patient profile could serve as the basis for rational albuterol administration in patients with viral bronchiolitis, at least on a therapeutic trial basis, and it could also be the starting point for future targeted randomized clinical trials (RCTs) on the use of albuterol among a subset of infants with bronchiolitis.

Trends Over Time in Use of Nonrecommended Tests and Treatments Since Publication of the American Academy of Pediatrics Bronchiolitis Guideline.

Importance: Acute viral bronchiolitis is a common and costly pediatric condition for which clinical practice guidelines discourage use of diagnostic tests and therapies. Objective: To evaluate trends over time for use of nonrecommended services for bronchiolitis since publication of the American Academy of Pediatrics clinical practice guideline on bronchiolitis (originally published in October 2006 and updated in November 2014). Design, Setting, and Participants: This cohort study was conducted using interrupted time-series regression analysis adjusting for the hospital providing service, patient demographic characteristics, and payer, with 2014 guideline update publication as the event point. Included patients were children younger than 2 years old discharged from the emergency department (ED) or hospital inpatient setting with a primary diagnosis of bronchiolitis at US Children's Hospitals contributing data to the Pediatric Health Information Systems database. Data were analyzed from June through December 2020. Main Outcomes and Measures: Rates of nonrecommended tests (ie, chest radiography, viral testing, and complete blood cell count) and treatments (ie, bronchodilators, corticosteroids, antibiotics) were measured. Results: Among 602 375 encounters involving children with a primary diagnosis of bronchiolitis, 404 203 encounters (67.1%) were ED discharges and 198 172 encounters (32.9%) were inpatient discharges; 468 226 encounters (77.7%) involved children younger than 12 months, and 356 796 encounters (59.2%) involved boys. In the period after initial guideline publication (ie, November 2006 to November 2014), a negative use trajectory was found in all measures except viral testing in the ED group. Using the 2014 guideline update as the event point, several measures showed decreased use between study time periods. The greatest decrease was in bronchodilator use, which changed by -13.5 percentage points in the ED group (95% CI, -15.2 percentage points to -11.8 percentage points) and -11.3 percentage points in the inpatient group (95% CI, -13.1 percentage points to -9.4 percentage points). In the period after the 2014 guideline update (ie, December 2014 to December 2019), bronchodilators also showed the greatest change in usage trajectory, steepening more than 2-fold in both groups. In the ED group, the negative trajectory steepened from -0.11% monthly (95% CI, -0.13% to -0.09%) in the first guideline period to a new mean monthly slope of -0.26% (95% CI, -0.30% to -0.23%). In the inpatient group, the mean monthly slope steepened from -0.08% (95% CI, -0.10 to -0.05%) to -0.26% (95% CI, 0.30% to -0.22%). Length of stay decreased from 2.0 days (95% CI, 1.9 days to 2.1 days) to 1.7 days (95% CI, 1.7 days to 1.8 days). Hospital admission rate decreased from 18.0% (95% CI, 13.8% to 22.2%) to 17.8% (95% CI, 13.6 to 22.1%). Conclusions and Relevance: This cohort study with interrupted time-series analysis found that use of most nonrecommended bronchiolitis services decreased continuously after 2006. The rate of decline in bronchodilator use increased more than 2-fold after the 2014 guideline update. These findings support potential associations of practice guidelines with improved bronchiolitis care.

Lung function trajectories and bronchial hyperresponsiveness during childhood following severe RSV bronchiolitis in infancy.

BACKGROUND: Children with severe respiratory syncytial virus (RSV) bronchiolitis in infancy have increased risks of asthma and reduced lung function in later life. There are limited studies on the longitudinal changes of lung function and bronchial hyperreactivity from early to late childhood in infants hospitalized for RSV bronchiolitis. METHODS: In a prospective cohort of 206 children with their first episode of RSV-confirmed bronchiolitis in the first year of life, 122 had spirometry performed at least twice between 5-16 years of age. Methacholine bronchoprovocation was available in 127 and 79 children at 7 and 12 years of age, respectively. Longitudinal changes in FEV1 , FVC, and FEV1 /FVC z-scores and methacholine PC20 were analyzed. RESULTS: 55% of the study cohort (N = 122) were male, and 55% were Caucasian. During follow-up, longitudinal changes in z-scores for pre- and post-bronchodilator FEV1 (P < .0001) FVC (P < .0001) and FEV1 /FVC (P < .0001 for pre- and 0.007 for post-bronchodilator) from age 5 to 10-16 years were observed. Declined lung function in late childhood was significantly associated with gender, physician diagnosis of asthma, and allergic sensitization. PC20 geometric mean increased from 0.28 mg/mL at 7 years to 0.53 mg/mL at 12 years of age, and the frequency of abnormal bronchial hyperreactivity decreased from 96% to 78% (P = .0003). CONCLUSIONS: Following severe RSV bronchiolitis, there appear to be significant longitudinal changes in pre- and post-bronchodilator lung function during childhood. The study has several limitations including significant dropouts and the lack of a control group and post-bronchodilator measurements. Bronchial hyperreactivity is common in children following severe RSV bronchiolitis; however, it appears to decrease as they enter late childhood.

Identifying and managing bronchiolitis.

Bronchiolitis is a common viral illness that affects the lower respiratory tract of infants and young children. The disease is characterized by wheezing and increased mucus production and can range from mild to severe in terms of respiratory distress. This article reviews the epidemiology, clinical presentation, and treatment of bronchiolitis.

Decision-making in acute viral bronchiolitis: A universal guideline and a publication gap.

BACKGROUND: Acute viral bronchiolitis is very common in infants and children up to 2 years. Some patients develop serious respiratory symptoms and need to be hospitalized. In 2014, the American Academy of Pediatrics (AAP) published a guideline on acute bronchiolitis which has gained global acceptance. We hypothesized that a publication gap, which is increasingly perceived in clinical medicine, might have also affected these universal recommendations. METHODS: We determined the proportion of published and unpublished studies registered at ClinicalTrials.gov that were marked as completed by October 1st 2018. The major trial and literature databases were used to search for publications. In addition, the study investigators were contacted directly. RESULTS: Of the 69 registered studies on the treatment of acute viral bronchiolitis, only 50 (72%) have been published by November 2019. Published trials contained data from n = 9403 patients, whereas n = 4687 patients were enrolled in unpublished trials. Median time to publication was 20 months, and only 8 of 50 trials were published within 12 months after completion. Only 40% of the clinical trials that were completed after the release of the AAP guideline were subsequently published as compared to 80% before 2014. CONCLUSION: There is a significant publication gap regarding therapy of acute viral bronchiolitis that may have influenced certain recommendations of the AAP guideline. In turn, recommendations of the guideline might have discouraged investigators to publish their results after its release.

Predictors for the prescription of albuterol in infants hospitalized for viral bronchiolitis.

INTRODUCTION AND OBJECTIVES: Despite the recommendation against routine use of inhaled bronchodilators in infants with viral bronchiolitis given in the main clinical practice guidelines (CPGs) on viral bronchiolitis, albuterol is widely prescribed to patients with this disease. The aim of this study was to identify predictors of prescription of albuterol in a population of infants hospitalized for viral bronchiolitis. MATERIAL AND METHODS: An analytical cross-sectional study performed during the period from March 2014 to August 2015, in a random sample of patients <2 years old hospitalized in the Fundacion Hospital La Misericordia, a hospital located in Bogota, Colombia. After reviewing the electronic medical records, we collected demographic, clinical, and disease-related information, including prescription of albuterol at any time during the course of hospitalization as the outcome variable. RESULTS: For a total of 1365 study participants, 1042 (76.3%) were prescribed with albuterol therapy. After controlling for potential confounders, it was found that age (OR 1.11; CI 95% 1.08-1.15; p<0.001), and a prolonged length of stay (LOS) (OR 1.93; CI 95% 1.44-2.60; p<0.001) were independent predictors of prescription of albuterol in our sample of patients. By contrast, albuterol prescription was less likely in the post-guideline assessment period (OR 0.41; CI 95% 0.31-0.54; p<0.001), and in infants with RSV isolation (OR 0.71; CI 95% 0.52-0.97; p=0.035). CONCLUSIONS: Albuterol was highly prescribed in our population of inpatients with the disease. The independent predictors of prescription of albuterol in our sample of patients were age, implementation of a CPG on viral bronchiolitis, RSV isolation, and LOS.

Association between multiple respiratory viral infections and pediatric intensive care unit admission among infants with bronchiolitis.

BACKGROUND: It is unclear whether multiple respiratory viral infections are associated with more severe bronchiolitis requiring pediatric intensive care unit (PICU) admission. We aimed to identify the association between multiple respiratory viral infections and PICU admission among infants with bronchiolitis. METHODS: We performed a 1:1 case-control study enrolling previously healthy full-term infants (≤12 months) with bronchiolitis admitted to the PICU as cases and those to the general pediatric ward as controls from 2015 to 2017. Multiplex polymerase chain reaction (PCR) was used for detection of the respiratory viruses. We summarized the characteristics of infants admitted to the PICU and the general pediatric unit. Multivariable logistic regression analysis was used to fit the association between multiple respiratory viral infections (≥2 strains) and PICU admission. RESULTS: A total of 135 infants admitted to the PICU were compared with 135 randomly selected control infants admitted to the general pediatric unit. The PICU patients were younger (median: 2.2 months, interquartile range: 1.3-4.2) than the general ward patients (median: 3.2 months, interquartile range: 1.6-6.4). Respiratory syncytial virus (74.1%), rhinovirus (28.9%), and coronavirus (5.9%) were the most common viruses for bronchiolitis requiring PICU admission. Patients with bronchiolitis admitted to the PICU tended to have multiple viral infections compared with patients on the general ward (23.0% vs. 10.4%, P<0.001). In the multivariable logistic regression analysis, bronchiolitis with multiple viral infections was associated with higher odds of PICU admission (adjusted odds ratio: 2.56, 95% confidence interval: 1.17-5.57, P=0.02). CONCLUSION: Infants with multiviral bronchiolitis have higher odds of PICU admission compared with those with a single or nondetectable viral infection.

[Respiratory syncytial virus]. / Respiratorisches Synzytialvirus.

Respiratory syncytial virus (RSV) is worldwide a very important virus leading to infection of the respiratory system. In particular preterm babies, infants and elderly adults are prone to developing severe diseases such as bronchiolitis or pneumonia, which require intensive care and cause increased mortality. Although RSV is rapidly detected, preventive and therapeutic measures are limited. New antivirals are already in clinical trials.

Respiratory health inequality starts early: The impact of social determinants on the aetiology and severity of bronchiolitis in infancy.

AIM: To define the impact of demographics on the incidence, aetiology and clinical course of viral bronchiolitis in infants younger than 2 years of age. METHODS: Retrospective case review of all viral bronchiolitis admissions for patients aged younger than 2 years old from January 1 2014 to 31 December 2015 at Wellington Regional Hospital, New Zealand. Demographic data, second-hand smoke exposure (SHSE) and presence of predisposing conditions were collected, along with outcome data including use of respiratory support and intensive care unit (ICU) admission. This was compared to background rates calculated from regional census data. RESULTS: There were 556 admissions included (11% of paediatric medical admissions); 49% tested positive for respiratory syncytial virus (RSV) (84% tested), and 40% of admissions received positive pressure respiratory support and 10% ICU admission. Admission rates ranged from 9.6 to 77 per 1000/year, with higher rates seen in those from areas of high deprivation. Admission rates by deprivation varied according to aetiology. RSV-positive admission rates increased from 9.7 per 1000/year to 24.6 per 1000/year in the least to most deprived areas, whereas non-RSV admissions showed even greater disparity, increasing from 10.1 per 1000/year to 37.5 per 1000/year (both P < 0.0001). CONCLUSIONS: This study further reinforces that material deprivation contributes significantly to poor health outcomes that are apparent in infancy. SHSE is a potent risk factor for adverse respiratory outcomes in this patient population. Ongoing efforts to eradicate smoking and reduce material inequality need to continue.

The Use of Procalcitonin for Prediction of Pulmonary Bacterial Coinfection in Children With Respiratory Failure Associated With Viral Bronchiolitis.

Objectives. Viral bronchiolitis is a frequent cause of pediatric hospitalization and respiratory failure. Procalcitonin (PCT) is a biomarker used to identify serious bacterial infection and can distinguish bacterial and viral infections. Concomitant bacterial pneumonia is not rare in viral bronchiolitis and can lead to a worse clinical course. This study examined the use of PCT in pediatric patients with respiratory failure attributed to viral bronchiolitis to predict concomitant bacterial pneumonia. Methods. This prospective descriptive study evaluated children less than 4 years of age who underwent endotracheal intubation for respiratory failure due to viral bronchiolitis. PCT levels and endotracheal aspirate cultures were obtained at admission. Bacterial pneumonia was defined as at least moderate growth of a single pathogenic organism from endotracheal culture. PCT levels were evaluated in groups with and without concomitant bacterial pneumonia. Results. Thirty-five patients were enrolled between February 2013 and May 2015. All subjects tested positive for at least 1 viral pathogen by nasal wash polymerase chain reaction or enzyme immunoassay. The top viruses obtained were respiratory syncytial virus (n = 15, 42.8%) and rhinovirus (n = 8, 22.9%). The incidence of bacterial pneumonia was 60% (21/35). The PCT median was 0.93 ng/mL (interquartile range = 0.25-6.64) in the bacterial pneumonia group and 1.85 ng/mL (interquartile range = 0.28-7.94) in the nonbacterial pneumonia group. No correlation was found between PCT and bronchiolitis with bacterial coinfection (P = .74). Conclusion. Incidence of bacterial coinfection in patients with respiratory failure and viral bronchiolitis was high. PCT did not predict concomitant bacterial pneumonia in children with viral bronchiolitis.