Transition to Weight-Based High-Flow Nasal Cannula Use Outside of the ICU for Bronchiolitis.

Importance: Most children's hospitals have adopted weight-based high-flow nasal cannula (HFNC) bronchiolitis protocols for use outside of the intensive care unit (ICU) setting. Whether these protocols are achieving their goal of reducing bronchiolitis-related ICU admissions remains unknown. Objective: To measure the association between hospital transition to weight-based non-ICU HFNC use and subsequent ICU admission. Design, Setting, and Participants: This multicenter retrospective cohort study was conducted with a controlled interrupted time series approach and involved 18 children's hospitals that contribute data to the Pediatric Health Information Systems database. The cohort included patients aged 0 to 24 months who were hospitalized with a diagnosis of bronchiolitis between January 1, 2010, and December 31, 2021. Data were analyzed from July 2023 to January 2024. Exposure: Hospital-level transition from ICU-only to weight-based non-ICU protocol for HFNC use. Data for the ICU-only group were obtained from a previously published survey. Main Outcomes and Measures: Proportion of patients with bronchiolitis admitted to the ICU. Results: A total of 86 046 patients with bronchiolitis received care from 10 hospitals in the ICU-only group (n = 47 336; 27 850 males [58.8%]; mean [SD] age, 7.6 [6.2] years) and 8 hospitals in the weight-based protocol group (n = 38 710; 22 845 males [59.0%]; mean [SD] age, 7.7 [6.3] years). Mean age and sex were similar for patients between the 2 groups. Hospitals in the ICU-only group vs the weight-based protocol group had higher proportions of Black (26.2% vs 19.8%) and non-Hispanic (81.6% vs 63.8%) patients and patients with governmental insurance (68.1% vs 65.9%). Hospital transition to a weight-based HFNC protocol was associated with a 6.1% (95% CI, 8.7%-3.4%) decrease per year in ICU admission and a 1.5% (95% CI, 2.8%-0.1%) reduction per year in noninvasive positive pressure ventilation use compared with the ICU-only group. No differences in mean length of stay or the proportion of patients who received invasive mechanical ventilation were found between groups. Conclusions and Relevance: Results of this cohort study of hospitalized patients with bronchiolitis suggest that transition from ICU-only to weight-based non-ICU HFNC protocols is associated with reduced ICU admission rates.

High-flow nasal cannula therapy for infants with bronchiolitis.

BACKGROUND: Bronchiolitis is a common lower respiratory tract illness, usually of viral aetiology, affecting infants younger than 24 months of age and is the most common cause of hospitalisation of infants. It causes airway inflammation, mucus production and mucous plugging, resulting in airway obstruction. Effective pharmacotherapy is lacking and bronchiolitis is a major cause of morbidity and mortality. Conventional treatment consists of supportive therapy in the form of fluids, supplemental oxygen, and respiratory support. Traditionally, oxygen delivery is as a dry gas at 100% concentration via low-flow nasal prongs. However, the use of heated, humidified, high-flow nasal cannula (HFNC) therapy enables delivery of higher inspired gas flows of an air/oxygen blend, at 2 to 3 L/kg per minute up to 60 L/min in children. It can provide some level of continuous positive airway pressure (CPAP) to improve ventilation in a minimally invasive manner. This may reduce the need for invasive respiratory support, thus potentially lowering costs, with clinical advantages and fewer adverse effects. OBJECTIVES: To assess the effects of HFNC therapy compared with conventional respiratory support in the treatment of infants with bronchiolitis. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, and Web of Science (from June 2013 to December 2022). In addition, we consulted ongoing trial registers and experts in the field to identify ongoing studies, checked reference lists of relevant articles, and searched for conference abstracts. Date restrictions were imposed such that we only searched for studies published after the original version of this review. SELECTION CRITERIA: We included randomised controlled trials (RCTs) or quasi-RCTs that assessed the effects of HFNC (delivering oxygen or oxygen/room air blend at flow rates greater than 4 L/minute) compared to conventional treatment in infants (< 24 months) with a clinical diagnosis of bronchiolitis. DATA COLLECTION AND ANALYSIS: Two review authors independently used a standard template to assess trials for inclusion and extract data on study characteristics, risk of bias elements, and outcomes. We contacted trial authors to request missing data. Outcome measures included the need for invasive respiratory support and time until discharge, clinical severity measures, oxygen saturation, duration of oxygen therapy, and adverse events. MAIN RESULTS: In this update we included 15 new RCTs (2794 participants), bringing the total number of RCTs to 16 (2813 participants). Of the 16 studies, 11 compared high-flow to low-flow, and five compared high-flow to CPAP. These studies included infants less than 24 months of age as stated in our selection criteria. There were no significant differences in sex. We found that when comparing high-flow to low-flow oxygen therapy for infants with bronchiolitis there may be a reduction in the total length of hospital stay (mean difference (MD) -0.65 days, 95% confidence interval (CI) -1.23 to -0.06; P < 0.00001, I2 = 89%; 7 studies, 1951 participants; low-certainty evidence). There may also be a reduction in the duration of oxygen therapy (MD -0.59 days, 95% CI -1 to -0.18; P < 0.00001, I2 = 86%; 7 studies, 2132 participants; low-certainty evidence). We also found that there was probably an improvement in respiratory rate at one and 24 hours, and heart rate at one, four to six, and 24 hours in those receiving high-flow oxygen therapy when compared to pre-intervention baselines. There was also probably a reduced risk of treatment escalation in those receiving high-flow when compared to low-flow oxygen therapy (risk ratio (RR) 0.55, 95% CI 0.39 to 0.79; P = 0.001, I2 = 43%; 8 studies, 2215 participants; moderate-certainty evidence). We found no difference in the incidence of adverse events (RR 1.2, 95% CI 0.38 to 3.74; P = 0.76, I2 = 26%; 4 studies, 1789 participants; low-certainty evidence) between the two groups. The lack of comparable outcomes in studies comparing high-flow and CPAP, as well as the small numbers of participants, limited our ability to perform meta-analysis on this group. AUTHORS' CONCLUSIONS: High-flow nasal cannula therapy may have some benefits over low-flow oxygen for infants with bronchiolitis in terms of a greater improvement in respiratory and heart rates, as well as a modest reduction in the length of hospital stay and duration of oxygen therapy, with a reduced incidence of treatment escalation. There does not appear to be a difference in the number of adverse events. Further studies comparing high-flow nasal cannula therapy and CPAP are required to demonstrate the efficacy of one modality over the other. A standardised clinical definition of bronchiolitis, as well as the use of a validated clinical severity score, would allow for greater and more accurate comparison between studies.

Probabilistic Linkage Creates a Novel Database to Study Bronchiolitis Care in the PICU.

OBJECTIVES: Lack of a comprehensive database containing diagnosis, patient and clinical characteristics, diagnostics, treatments, and outcomes limits needed comparative effectiveness research (CER) to improve care in the PICU. Combined, the Pediatric Hospital Information System (PHIS) and Virtual Pediatric Systems (VPS) databases contain the needed data for CER, but limits on the use of patient identifiers have thus far prevented linkage of these databases with traditional linkage methods. Focusing on the subgroup of patients with bronchiolitis, we aim to show that probabilistic linkage methods accurately link data from PHIS and VPS without the need for patient identifiers to create the database needed for CER. METHODS: We used probabilistic linkage to link PHIS and VPS records for patients admitted to a tertiary children's hospital between July 1, 2017 to June 30, 2019. We calculated the percentage of matched records, rate of false-positive matches, and compared demographics between matched and unmatched subjects with bronchiolitis. RESULTS: We linked 839 of 920 (91%) records with 4 (0.5%) false-positive matches. We found no differences in age (P = .76), presence of comorbidities (P = .16), admission illness severity (P = .44), intubation rate (P = .41), or PICU stay length (P = .36) between linked and unlinked subjects. CONCLUSIONS: Probabilistic linkage creates an accurate and representative combined VPS-PHIS database of patients with bronchiolitis. Our methods are scalable to join data from the 38 hospitals that jointly contribute to PHIS and VPS, creating a national database of diagnostics, treatment, outcome, and patient and clinical data to enable CER for bronchiolitis and other conditions cared for in the PICU.

Impact of Preferred Written Language in Patients Discharged With Bronchiolitis From a Children's Hospital.

OBJECTIVES: This study aimed to identify differences in length of stay and readmission in patients admitted with bronchiolitis based on preferred written language. A secondary aim was to assess adherence to providing written discharge instructions in patients' preferred language. METHODS: In this cross-sectional study, we included 384 patients aged 0 to 2 years discharged from 2 children's hospitals with bronchiolitis from May 1, 2021, through April 30, 2022; patients were excluded for history of prematurity, complex chronic condition, or ICU stay during the study period. A manual chart review was performed to determine preferred written language and language of written discharge instructions. RESULTS: Patients preferring a written language other than English had a longer length of stay compared with English-preferring patients (37.9 vs 34.3 hours, P < .05), but there was no significant difference in unplanned 7-day readmissions. All patients who preferred English and Spanish received written discharge instructions in their preferred written language; no patients with other preferred languages did. CONCLUSIONS: Patients who preferred a written language other than English had a longer length of stay than those preferring English but there was no difference in 7-day readmissions, though power for readmissions was limited. The study also identified significant disparities in the provision of written discharge instructions in languages other than English and Spanish.

Patient-Centered Outcomes in Bronchiolitis.

OBJECTIVES: We examined the impact of hospitalization for bronchiolitis on patient-centered outcomes across patients with varying levels of support. METHODS: The participants included primary caregivers of children aged 0 to 24 months hospitalized for bronchiolitis at an 150-bed tertiary care children's hospital. Data were collected using a 30-item questionnaire examining quality of life impact, adapted from the previously validated survey, the Impact of Bronchiolitis Hospitalization Questionnaire.1 The survey contained questions asking to what extent the hospitalization interfered with different aspects of care. After all surveys were collected, the patients were split into groups categorized by level of support and defined as no support, low support (low-flow nasal cannula only or nasogastric [NG] only), moderate support (high-flow nasal cannula without NG), high support (high-flow nasal cannula with NG support), and positive pressure (with or without NG support). Descriptive statistics were used to examine the distribution of mean impact scores across these groups. RESULTS: A total of 92 caregivers and their children were included. The mean impact score for variables of difficult to hold, difficult to bond, and breastfeeding disruption increased with greater levels of support with P values of P = .003, P = .04, and P < .001, respectively. CONCLUSIONS: We found that the impact on patient-reported outcomes varied by level of support, as defined here, among children hospitalized with bronchiolitis, with significant impacts being in areas of caregiver bonding, caregiver holding, and breastfeeding.

Predictors of prolonged length of hospital stay and in-hospital mortality in patients aged 1-24 months with acute bronchiolitis in Douala, Cameroon.

INTRODUCTION: In Cameroon, acute bronchiolitis has been reported as the third commonest lower respiratory infection and is usually associated with low mortality. Nonetheless, respiratory distress associated with non-adherence to management guidelines can prolong hospital stay. This study aimed to explore predictors of prolonged hospital stay (≥ 5 days) and mortality in patients aged < 2years hospitalised for acute bronchiolitis. METHODOLOGY: We conducted a retrospective cohort study at three paediatric units in the city of Douala, Cameroon. Factors associated with prolonged hospital stay and mortality were determined using multivariable linear regression model. Threshold for significance was set at p ≤ 0.05. RESULTS: A total of 215 patients with bronchiolitis were included with mean age of 6.94 ± 5.71 months and M/F sex ratio of 1.39/1. Prolonged hospital stay was reported in 46.98% and mortality in 10.70% of patients hospitalised for bronchiolitis. Factors independently associated with prolonged hospital duration were oxygen administration [b = 0.36, OR = 2.35 (95% CI:1.16-4.74), p = 0.017], abnormal respiratory rate [b = 0.38, OR = 2.13 (1.00-4.55), p = 0.050] and patients presenting with cough [b = 0.33, OR = 2.35 (95% CI: 1.22-4.51), p = 0.011], and diarrhoea [b = 0.71, OR = 6.44 (95% CI: 1.6-25.86), p = 0.009] on admission. On the other hand, factors independently associated with mortality were age of the patient [b= -0.07, OR = 0.84 (95% CI: 0.74-0.97), p = 0.014] and oxygen administration [b = 1.08, OR = 9.64 (95% CI:1.16-79.85), p = 0.036] CONCLUSION: Acute bronchiolitis represented 1.24% of admissions and was common in the rainy season, in males and 3-11-month-old patients. Management guidelines were poorly respected. Prolonged length of stay was reported in half of the patients hospitalized and mortality was high, especially in younger patients and in patients receiving oxygen.

Increased bronchiolitis burden and severity after the pandemic: a national multicentric study.

BACKGROUND: The coronavirus 2019 (COVID-19) related containment measures led to the disruption of all virus distribution. Bronchiolitis-related hospitalizations shrank during 2020-2021, rebounding to pre-pandemic numbers the following year. This study aims to describe the trend in bronchiolitis-related hospitalization this year, focusing on severity and viral epidemiology. METHODS: We conducted a retrospective investigation collecting clinical records data from all infants hospitalized for bronchiolitis during winter (1st September-31th March) from September 2018 to March 2023 in six Italian hospitals. No trial registration was necessary according to authorization no.9/2014 of the Italian law. RESULTS: Nine hundred fifty-three infants were hospitalized for bronchiolitis this last winter, 563 in 2021-2022, 34 in 2020-2021, 395 in 2019-2020 and 483 in 2018-2019. The mean length of stay was significantly longer this year compared to all previous years (mean 7.2 ± 6 days in 2022-2023), compared to 5.7 ± 4 in 2021-2022, 5.3 ± 4 in 2020-2021, 6.4 ± 5 in 2019-2020 and 5.5 ± 4 in 2018-2019 (p < 0.001), respectively. More patients required mechanical ventilation this winter 38 (4%), compared to 6 (1%) in 2021-2022, 0 in 2020-2021, 11 (2%) in 2019-2020 and 6 (1%) in 2018-2019 (p < 0.05), respectively. High-flow nasal cannula and non-invasive respiratory supports were statistically more common last winter (p = 0.001 or less). RSV prevalence and distribution did not differ this winter, but coinfections were more prevalent 307 (42%), 138 (31%) in 2021-2022, 1 (33%) in 2020-2021, 68 (23%) in 2019-2020, 61 (28%) in 2018-2019 (p = 0.001). CONCLUSIONS: This study shows a growth of nearly 70% in hospitalisations for bronchiolitis, and an increase in invasive respiratory support and coinfections, suggesting a more severe disease course this winter compared to the last five years.

Understanding the use and outcomes of high-flow nasal cannula among infants admitted to Canadian hospitals with bronchiolitis (CanFLO): a protocol for a multicentre, retrospective cohort study.

INTRODUCTION: Bronchiolitis is the most common viral lower respiratory tract infection in children under 2 years of age. Respiratory support with high-flow nasal cannula (HFNC) is increasingly used in this patient population with limited understanding of the patients most likely to benefit and considerable practice variability of use. This study aims to understand the factors associated with failure of HFNC support among patients with bronchiolitis and to describe the current practice variations of HFNC use in patients with bronchiolitis in Canadian hospitals including fluid management and parameters to initiate, escalate and discontinue HFNC support. METHODS AND ANALYSIS: This is a multicentre retrospective cohort study including hospitalised patients aged 0-24 months with bronchiolitis requiring support with HFNC between January 2017 and December 2021. Clinical data will be collected from patient medical records from Canadian hospitals (n=12), including academic and community centres. HFNC failure will be defined as the need for escalation to non-invasive or invasive mechanical ventilation. Factors associated with HFNC failure will be analysed using logistic regression. Descriptive statistics will be used to describe practice variations of HFNC utilisation and management. ETHICS AND DISSEMINATION: Approval from the Research Ethics Boards (REBs) has been obtained for each participating study site prior to onset of data collection including Clinical Trials Ontario for all Ontario hospital sites and REBs from British Columbia Children's Hospital, Stollery Children's Hospital, Montreal Children's Hospital and CHU Sainte-Justine. Study results will be disseminated through presentation at national/international conferences and publication in high-impact, peer-reviewed journals.

Normal saline for children with bronchiolitis: study protocol for a randomised controlled non-inferiority trial.

INTRODUCTION: Bronchiolitis is one of the most common reasons for hospital admissions in early childhood. As supportive treatment, some treatment guidelines suggest using nasal irrigation with normal saline (NS) to facilitate clearance of mucus from the airways. In addition, most paediatric departments in Denmark use nebulised NS for the same purpose, which can mainly be administered as inpatient care. However, no studies have ever directly tested the effect of saline in children with bronchiolitis. METHODS AND ANALYSIS: The study is an investigator-initiated, multicentre, open-label, randomised, controlled non-inferiority trial and will be performed at six paediatric departments in eastern Denmark. We plan to include 300 children aged 0-12 months admitted to hospital with bronchiolitis. Participating children are randomised 1:1:1 to nebulised NS, nasal irrigation with NS or no saline therapy. All other treatment will be given according to standard guidelines.The primary outcome is duration of hospitalisation, analysed according to intention-to-treat analysis using linear regression and Cox regression analysis. By including at least 249 children, we can prove non-inferiority with a limit of 12 hours admission, alpha 2.5% and a power of 80%. Secondary outcomes are need for respiratory support with nasal continuous positive airway pressure or high-flow oxygen therapy and requirement of fluid supplements (either by nasogastric tube or intravenous). ETHICS AND DISSEMINATION: This study may inform current practice for supportive treatment of children with bronchiolitis. First, if NS is found to be helpful, it may be implemented into global guidelines. If no effect of NS is found, we can stop spending resources on an ineffective treatment. Second, if NS is effective, but nasal irrigation is non-inferior to nebulisation, it may reduce the workload of nurses, and possible duration of hospitalisation because the treatment can be delivered by the parents at home. TRIAL REGISTRATION NUMBER: NCT05902702.

ROX index as a predictor of failure of high-flow nasal cannula in infants with bronchiolitis.

High-flow nasal cannula (HFNC) is a relatively recent therapy that has been used to treat respiratory failure. Until now, the criterion for failure requiring escalation to other forms of ventilatory support has remained unclear. This study evaluated how the ROX index predicts the success or failure of HFNC in infants with bronchiolitis. A prospective, observational, multicenter study was conducted in 2 pediatric ICUs. The data were collected at 7 moments. Patients were categorized into failure and success groups according to HFNC. A total of 102 infants were included, 18(17.6%) of whom failed HFNC therapy. For the ROX index, significant differences were observed between the failure 5.8(95%CI 4.7-7.1) and success 7.7(95%CI 7.2-8.2) groups (p = 0.005) at the 12 h evaluation. According to the analysis of the performance of the ROX index, the AUC at 12 h was 0.716(95%CI 0.591-0.842; p = 0.016). The best cutoff range for the ROX index at 12 h was 6.50-7.18, with a sensitivity of 42% and a specificity of 66% at the cutoff of 6.50, and a sensitivity of 92% and a specificity of 54% at the cutoff of 7.18. We concluded that the ROX index could be effective at predicting the failure of HFNC therapy in infants with bronchiolitis beginning at 12 h after installation.

Trends in emergency department visits for bronchiolitis, 1993-2019.

INTRODUCTION: Bronchiolitis is a leading indication for pediatric emergency department (ED) visits and hospitalizations. Our objective was to provide a comprehensive review of national trends and epidemiology of ED visits for bronchiolitis from 1993 to 2019 in the United States. METHODS: We retrospectively reviewed the National Hospital Ambulatory Medical Care Survey (NHAMCS) reporting of ED visits for bronchiolitis for children age <2 years from 1993 to 2019. Bronchiolitis cases were identified using billing codes assigned at discharge. The primary outcome was bronchiolitis ED visit rates, calculated using NHAMCS-assigned patient visit weights. We then evaluated for temporal variation in patient characteristics, facility location, and hospitalizations among the bronchiolitis ED visits. RESULTS: There were an estimated 8 million ED visits for bronchiolitis for children <2 years between 1993 and 2019. Bronchiolitis ED visits rates ranged from 28 to 36 per 1000 ED visits from 1993 to 2010 and increased significantly to 65 per 1000 ED visits in the 2017-2019 time period (p < 0.001). There was no significant change over time in patient age, sex, race and ethnicity, insurance status, hospital type, or triage level upon ED presentation. Approximately half of bronchiolitis ED visits occurred in the winter months throughout the study period. CONCLUSION: In this analysis of 27 years of national data, we identified a recent rise in ED visit rates for bronchiolitis, which have almost doubled from 2010 to 2019 following a period of relative stability between 1993 and 2010.

ROX (Respiratory rate-OXygenation) index to predict early response to high-flow nasal cannula therapy in infants with viral bronchiolitis.

INTRODUCTION: High-flow nasal cannula (HFNC) is commonly used as first step respiratory support in infants with moderate-to-severe acute viral bronchiolitis (AVB). This device, however, fails to effectively manage respiratory distress in about a third of patients, and data are limited on determinants of patient response. The respiratory rate-oxygenation (ROX) index is a relevant tool to predict the risk for HFNC failure in adult patients with lower respiratory tract infections. The primary objective of this study was to assess the relationship between ROX indexes collected before and 1 h after HFNC initiation, and HFNC failure occurring in the following 48 h in infants with AVB. METHOD: This is an ancillary study to the multicenter randomized controlled trial TRAMONTANE 2, that included 286 infants of less than 6 months with moderate-to-severe AVB. Collection of physiological variables at baseline (H0), and 1 h after HFNC (H1), included heart rate (HR), respiratory rate (RR), fraction of inspired oxygen (FiO2), respiratory distress score (modified Wood's Clinical Asthma Score [mWCAS]), and pain and discomfort scale (EDIN). ROX and ROX-HR were calculated as SpO 2 FiO 2 RR $\frac{\left(\frac{{\mathrm{SpO}}_{2}}{{\mathrm{FiO}}_{2}}\right)}{\mathrm{RR}}$ and 100 × ROX HR $100\times \frac{\mathrm{ROX}}{\mathrm{HR}}$ , respectively. Predefined HFNC failure criteria included increase in respiratory distress score or RR, increase in discomfort, and severe apnea episodes. The accuracies of ROX, ROX-HR indexes and clinical variable to predict HFNC failure were assessed using receiver operating curve analysis. We analyzed predictive factors of HFNC failure using multivariate logistic regressions. RESULT: HFNC failure occurred in 111 of 286 (39%) infants, and for 56 (50% of the failure) of them within the first 6 h. The area under the curve of ROX indexes at H0 and H1 were, respectively, 0.56 (95% confidence interval [CI] 0.48-0.63, p = 0.14), 0.56 (95% CI 0.49-0.64, p = 0.09). ROX-HR performances were better but remained poorly discriminant. HFNC failure was associated with higher mWCAS score at H1 (p < 0.01) and lower decrease in EDIN scale during the first hour of HFNC delivery (p = 0.02). In the multivariate analyses, age and mWCAS score were were found to be independent factors associated with HFNC failure at H0. At H1, weight and mWCAS were associated factors. CONCLUSION: In this study, neither ROX index, nor physiological variables usually collected in infants with AVB had early discriminatory capacity to predict HFNC failure.

Understanding the uptake and adaption of targeted implementation interventions for reducing bronchiolitis investigations and therapies.

AIM: To understand and evaluate the uptake and local adaptations of proven targeted implementation interventions that have effectively reduced unnecessary investigations and therapies in infants with bronchiolitis within emergency departments. METHODS: A multi-centred, mixed-methods quality improvement study in four Australian hospitals that provide paediatric emergency and inpatient care from May to December 2021. All hospitals were provided with the same implementation intervention package and training. Real-time tracking logs of adaptions were completed followed by semi-structured interviews. Interviews were recorded, transcribed and subsequently coded using FRAME-IS to further describe the adaptions made. RESULTS: Tracking logs were summarised and data from 12 interviews were compared from participating sites. The intervention resulted in 116 education sessions and a total of 23 adaptations made to educational materials, both content and contextual. Shortening education presentations, addition of bronchiolitis definitions, formatting of materials and novel interventions were the most common modifications. Audit and feedback were completed across all sites with varying utilisation. Targeted teaching was noted to dictate adaptions prior to and during implementation. CONCLUSION: Quantitative and qualitative analysis of clinical 'real-world' adaptations to proven targeted implementation interventions allows invaluable insight for future de-implementation initiatives and national roll-out of implementation packages in the ED setting.

Oxygen Saturation Targets in Infants Hospitalized With Bronchiolitis: A Multicenter Cohort Study.

OBJECTIVES: To examine 2 hospital oxygen saturation target policies and clinical outcomes in infants hospitalized with bronchiolitis. METHODS: This multicenter cohort study used data collected from a randomized clinical trial of infants aged 4 weeks to 24 months, hospitalized with bronchiolitis at children's and community hospitals from 2016 to 2019. We modeled the association between hospital oxygen saturation target policy, either 90% while awake and 88% while asleep (90%/88%) or 90% while awake and asleep (90%/90%), and clinical outcomes. RESULTS: A total of 162 infants were enrolled at 4 hospitals using a 90%/88% oxygen saturation target and 67 infants at 2 hospitals using a 90%/90% target policy. No significant differences between the 90%/88% group and 90%/90% groups were observed for time to discharge (adjusted hazard ratio, 0.83; 95% confidence interval [CI], 0.61-1.14; P = .25), initiation of supplemental oxygen (adjusted odds ratio [aOR], 0.98; 95% CI, 0.47-2.02; P = .95), time to discontinuation of supplemental oxygen (adjusted hazard ratio, 0.75; 95% CI, 0.44-1.27; P = .28), revisits (aOR, 1.38; 95% CI, 0.52-3.71; P = .52), and parent days missed from work (aOR, 2.41; 95% CI, 0.90-6.41; P = .08). Three infants in the 90%/88% group and none in the 90%/90% group were transferred to the ICU. CONCLUSIONS: Among infants hospitalized with bronchiolitis, clinical outcomes were similar between a hospital oxygen saturation target policy of 90% while awake and 88% while asleep compared with 90% while awake and asleep. These findings may inform the design of future trials of oxygen saturation targets in bronchiolitis hospital care.

Association between goal nutrition and intubation in patients with bronchiolitis on noninvasive ventilation: A retrospective cohort study.

BACKGROUND: Acute bronchiolitis causes many hospitalizations in children younger than 2 years. Early enteral nutrition is associated with improved outcomes in these patients. However, often nutrition is withheld when patients require noninvasive respiratory support because of the risk of aspiration worsening respiratory failure, possibly requiring intubation. We hypothesize that achieving goal energy intake is associated with a lower intubation rate in hospitalized children with bronchiolitis who require noninvasive ventilation. METHODS: This retrospective cohort study examined the association between goal enteral nutrition (60% of dietary reference energy intake) and intubation rates. We grouped patients by severity of illness and compared intubation rates in those who met goal energy to those who did not. We use stratified analysis methods (for both level of respiratory support and feeding route) to evaluate progression to intubation. RESULTS: Of the 272 patients, 215 met goal feeds. These groups had similar demographics, but the goal-feeds group started on higher respiratory support in the pediatric intensive care unit. We found that 4.65% of the patients who met goal feeds required intubation compared with 24.6% of patients who did not meet goal feeds (P < 0.0001), even after controlling for respiratory status at admission and time of feed initiation and feeding route. CONCLUSION: We observed when adjusting for severity, feeding route, and respiratory support, achieving goal energy intake remained associated with a lower rate of intubation, without higher rates of aspiration. Confounding factors include practice variation and difference in severity of illness that objective scoring may have missed.

High-flow nasal cannula use in pediatric patients for other indications than acute bronchiolitis-a scoping review of randomized controlled trials.

The objective of the study is to summarize current literature on high-flow nasal cannula (HFNC) use for different indications in pediatric patient excluding acute bronchiolitis and neonatal care. The study design is a systematic scoping review. Pubmed, Scopus, and Web of Science databases were searched in February, 2023. All abstracts and full texts were screened by two independent reviewers. Randomized controlled trials focusing on HFNC use in pediatric patients (age < 18 years) were included. Studies focusing on acute bronchiolitis and neonatal respiratory conditions were excluded. Study quality was assessed by Cochrane risk of bias 2.0 tool. The main outcomes are patient groups and indications, key outcomes, and risk of bias. After screening 1276 abstracts, we included 22 full reports. Risk of bias was low in 11 and high in 5 studies. We identified three patient groups where HFNC has been studied: first, children requiring primary respiratory support for acute respiratory failure; second, perioperative use for either intraprocedural oxygenation or postoperative respiratory support; and third, post-extubation care in pediatric intensive care for other than postoperative patients. Clinical and laboratory parameters were assessed as key outcomes. None of the studies analyzed cost-effectiveness.Conclusion: This systematic scoping review provides an overview of current evidence for HFNC use in pediatric patients. Future studies should aim for better quality and include economic evaluation with cost-effectiveness analysis.Protocol registration: Protocol has been published https://osf.io/a3y46/ .

Measurement of the interbronchial angle in acute viral bronchiolitis.

BACKGROUND: Acute viral bronchiolitis (AVB) is the most common lower airway infection in children under 2 years. Attempts to determine disease severity based on clinical and radiological manifestations are a major challenge. Measurements of the anatomy of the trachea and main bronchi are not only limited to pure anthropometry, but are also useful for better care of critically ill patients. The purpose of the study is to verify the association between measurements of the interbronchial angle (ITB) and the severity of respiratory disease. METHODS: A cross-sectional study, which included all patients admitted to the Santo Antônio Children's Hospital, over a period of 1 year, with diagnosis of AVB by respiratory syncytial virus (RSV) was designed. ITB angle was measured and clinical characteristics were analyzed. Quantitative variables were compared and correlation analysis was performed using Pearson's correlation coefficient. A receiving operator characteristic (ROC) curve was performed. P-value <0.05 was statistically significant. RESULTS: A total of 425 patients with AVB due to RSV were included. Most of these patients were male and the median age was 130 days, 91.11% of them required oxygen therapy through a nasal catheter, 3.3% used noninvasive ventilation and 4% used mechanical ventilation. Those who required MV or NIV and intensive care unit support were considered severe. The mean ITB was lower for these patients than for those of lesser severity (p < 0.05). CONCLUSION: The present study demonstrates that there is an association between ITB and AVB severity. The smaller the ITB, the greater the disease severity.

Acute Bronchiolitis: The Less, the Better?

BACKGROUND: Acute bronchiolitis is a viral infection of the lower respiratory tract affecting infants aged under 12 months, variably presenting with respiratory distress, diffuse crackles and inflammatory wheezing. The main causative agent is Respiratory Syncytial Virus (RSV). The diagnosis is clinical and treatment mainly supportive. Despite the availability of more than 30 international guidelines, consistent management recommendations are lacking and considerable variability in patients' care persists among different providers. OBJECTIVE: To review and describe current knowledge about epidemiology, physiopathology, clinic, diagnosis and management of acute bronchiolitis, with particular emphasis on updated evidence and future perspectives in terms of treatment and prevention. METHODS AND RESULTS: We searched Cochrane for systematic reviews and PubMed for scientific articles published in the last 10 years, using a combination of the following search terms: "bronchiolitis", "respiratory syncytial virus", "epidemiology", "risk factors", "severity", "diagnosis", "clinic", "diagnostic imaging", "management", "asthma", "wheezing", "bronchodilator", "steroids", "hypertonic saline", "oxygen", "blood gas analysis", "HHHFNC", "rehydration", "enteral feeding", "parenteral hydration", "prevention", "vaccine" and "COVID-19 or SARS-CoV2". We accordingly performed a deep and extensive selection of the most updated and considerable literature on the matter, summarizing the most significant evidence concerning all aspects of acute bronchiolitis (epidemiology, clinic, diagnosis, management and prevention). Furthermore, we examined references and available guidelines from UK, USA, Canada, Italy and Spain. Results are extensively discussed below. CONCLUSION: Although acute bronchiolitis has been a widely known disease for decades, its therapeutic approach remained unchanged and essentially limited to respiratory and metabolic support. Despite the abundance of studies, there is no significant evidence concerning therapeutic alternatives (e.g. steroids, inhaled hypertonic solution), which are therefore not recommended. According to most recent data, "acute bronchiolitis" definition encompasses a plethora of different clinical entities related to each subject's genetic and immune predisposition. Therefore, future research should focus on the precise characterization of such subcategories in order to individualize therapeutic management and ensure the most appropriate evidence-based care.