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Introduction: In remote Australian hospitals there are no onsite paediatric intensive care units (PICUs), increasing the reliance on aeromedical retrieval to access tertiary care. Nasal high flow (NHF) therapy is an oxygen therapy used in tertiary hospitals to treat paediatric patients with respiratory conditions. In rural and remote Queensland, Australia, the use of NHF therapy is inconsistent and there are no guidelines on how this therapy should be implemented in practice. Therefore, three remote hospitals within the Torres Strait and Cape York commenced a project to improve consistent and equitable access to NHF therapy. Implementing NHF therapy in remote hospitals may improve health and social outcomes for children with acute respiratory distress. A clinical guideline for the use of NHF therapy in the three participating remote hospitals was published on 28 October 2021. This study aimed to develop a clinical guideline for the use of NHF therapy in three remote hospitals. Methods: A modified Delphi technique was used to develop the guideline. Remote medicine and nursing clinicians at the three study sites, retrieval experts, a receiving tertiary-based paediatrician, PICU specialists and NHF therapy experts made up the expert panel of participants. These experts participated in an iterative round table discussion to develop remote-specific guidelines for the use of NHF therapy. Prior to the meeting, panellists were provided with an executive summary of the current literature on NHF therapy implementation with key questions for consideration. Participants were able to add relevant issues ad hoc. A final guideline representing the panellists' recommendations was submitted to the Torres and Cape Health Service for ratification. Results: Remote-specific decisions on the following topics were produced: environment of care, nasogastric tube usage, timings of chest X-ray, automatic approvals to arrange courier services for pathology, medication use, staff training; staff ratios, observations regimes, both tertiary and local medical consultation frequency and the experience level of the medical officer required to attend to these consultations, location of the on-call medical officer, documentation, escalation of care considerations and disposition of the patient in relation to retrievals. Discussion: Decisions were made to mitigate two highly representative remote factors: delays in the workplace practices, such as time to arrange treatment locally and delays in retrievals; and burden of the lack of access to services, such as lack of access to trained staff, staffing levels on-shift, adequate oxygen and equipment/consumable supplies. Conclusion: The aim was to develop a clinical guideline that was contextualised to the remote hospital. This outcome was achieved by using a modified Delphi technique, with a panel of experts providing the decision-making for the guideline. Consistency and safety were addressed by reducing delays in workplace practices; examples were time to arrange treatment locally and mitigate delays in an unknown time to retrievals, access to trained staff, staffing levels, and communication between remote and tertiary teams. [ABSTRACT FROM AUTHOR]

Heated humidified high flow nasal cannula therapy (HFNC) is a relatively new method of oxygen delivery that came into vogue only a decade ago. The additional physiological benefits it provides make HFNC more than just a fancy oxygen delivery device. Theoretically, Continuous Positive Airway Pressure (CPAP) continues to be the gold standard therapy for moderate to severe respiratory disease. Practically, there are limitations to its use especially in older children outside of an intensive care setting. Initially, thought of as a step-down or step-up from or towards CPAP i.e. halfway between CPAP and nasal oxygen, HFNC has now overtaken CPAP as the respiratory support mechanism of choice. Paediatricians go straight from failure of HFNC to intubation without a trial of CPAP, or extubate children straight onto HFNC. Today, more than a decade later, high quality evidence (FIRST-ABC and Tramontane Trials) is finally available to guide its use. The article summarises the evidence base behind the clinical safety, efficacy, cost-effectiveness and practical use of HFNC in managing sick children on high dependency and intensive care units. We outline what HFNC therapy is, the respiratory physiology underlying its use, currently available devices, practicalities of how to select the flow rate and its role in current paediatric practice with clinical examples. [ABSTRACT FROM AUTHOR]

A novel single-use, analyser-free, molecular point-of-care test for SARS-CoV-2 (Veros COVID-19 test, Sherlock Biosciences) could reduce time to results and improve patient care and flow in the emergency department (ED), but its performance in this setting is unknown. Adults aged ≥18 years presenting to Southampton General Hospital (UK) with suspected COVID-19 were tested with the Veros COVID-19 test in addition to standard of care near-patient PCR. Measures of diagnostic accuracy were calculated for the Veros COVID-19 test stratified by Ct value. Discrepant results underwent viral culture. Between Jan 16 and May 2, 2023, 400 patients were enrolled with a median (IQR) age of 60 (34−77) and 141 (35·3%) were SARS-CoV-2 positive by PCR. The Veros test gave valid results on the first test in 384 (96·0%), and sensitivity and specificity were 127/141 (90·1%, 95%CI 83·9–94·5) and 258/259 (99·6%, 95%CI 97·9–100) overall. For those with high or moderate viral load (Ct ≤30), sensitivity was 125/129 (96·9%, 95%CI 92·3–99·2). One (7·1%) of 14 PCR positive/Veros test negative samples was culture positive. Median (IQR) time from sample collection to result was 19 (18−20) mins with the Veros test versus 73 (59−92) mins with PCR (p < 0·0001). The Veros COVID-19 test generated results in near real-time, around 1 h sooner than rapid, near-patient, analyser-based PCR, and accuracy was excellent for samples with moderate and high viral loads. The Veros test represents a step-change in molecular diagnostics for infection and could significantly reduce time to results and improve patient management in EDs and other settings. • Veros COVID-19 is a handheld, single-use, molecular test for COVID-19. • Performance was compared to rapid PCR in 400 patients in the Emergency Department. • Veros COVID-19′s sensitivity was 90.1% and specificity was 99.6%. • In patients with moderate or high viral loads, sensitivity was 96.9%. • Veros returned results in under 20 min, around 1 h faster than rapid PCR. [ABSTRACT FROM AUTHOR]

The immunocompromised patient with an acute respiratory illness (ARI) may present with fever, chills, weight loss, cough, shortness of breath, or chest pain. The number of immunocompromised patients continues to rise with medical advances including solid organ and stem cell transplantation, chemotherapy, and immunomodulatory therapy, along with the continued presence of human immunodeficiency virus and acquired immunodeficiency syndrome. Given the myriad of pathogens that can infect immunocompromised individuals, identifying the specific organism or organisms causing the lung disease can be elusive. Moreover, immunocompromised patients often receive prophylactic or empiric antimicrobial therapy, further complicating diagnostic evaluation. Noninfectious causes for ARI should also be considered, including pulmonary edema, drug-induced lung disease, atelectasis, malignancy, radiation-induced lung disease, pulmonary hemorrhage, diffuse alveolar damage, organizing pneumonia, lung transplant rejection, and pulmonary thromboembolic disease. As many immunocompromised patients with ARI progress along a rapid and potentially fatal course, timely selection of appropriate imaging is of great importance in this setting. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking, or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. [ABSTRACT FROM AUTHOR]

Background and Objectives: Although acute respiratory illness (ARI) is a leading cause of hospitalization among young children, few data are available about cost of hospitalization in middle-income countries. We estimated direct and indirect costs associated with severe ARI resulting in hospitalization among children aged <10 years in El Salvador and Panama through the societal perspective.Methods: During 2012 and 2013, we surveyed caregivers of children hospitalized with ARI about their direct medical (i.e., outpatient consultation, medications, hospital fees), non-medical (transportation, childcare), and indirect costs (lost wages) at discharge and 7 days after discharge. We multiplied subsidized hospital bed costs derived from administrative data by hospitalization days to estimate provider costs.Results: Overall, 638 children were enrolled with a median age of 12 months (IQR 6-23). Their median length of hospitalization was 4 days (IQR 3-6). In El Salvador, caregivers incurred a median of US$38 (IQR 22-72) in direct and indirect costs per illness episode, while the median government-paid hospitalization cost was US$118 (IQR 59-384) generating an overall societal cost of US$219 (IQR 101-416) per severe ARI episode. In Panama, caregivers incurred a median of US$75 (IQR 39-135) in direct and indirect costs, and the health-care system paid US$280 (IQR 150-420) per hospitalization producing an overall societal cost of US$393 (IQR 258-552).Conclusions: The cost of severe ARI to caregivers and the health care system was substantive. Our estimates will inform models to estimate national costs of severe ARI and cost-benefit of prevention and treatment strategies. [ABSTRACT FROM AUTHOR]

Efforts to decrease hospital revisits often focus on improving access to outpatient follow-up. Our objective was to assess the relationship between perceived access to timely office-based care and subsequent 30-day revisits following hospital discharge for 4 common respiratory illnesses. This was a prospective cohort study of children 2 weeks to 16years admitted to 5 US children's hospitals for asthma, bronchiolitis, croup, or pneumonia between July 2014 and June 2016. Hospital and emergency department (ED) (in the case of croup) admission surveys administered to caregivers included the Consumer Assessments of Healthcare Providers and Systems Timely Access to Care. Access composite scores (range 0–100, with greater scores indicating better access) were linked with 30-day ED revisits and inpatient readmissions from the Pediatric Health Information System. The relationship between access to timely care and repeat utilization was assessed using multivariable logistic regression adjusting for demographics, hospitalization, and home/outpatient factors. Of the 2438 children enrolled, 2179 (89%) reported an office visit in the previous 6 months. Average access composite score was 52.0 (standard deviation, 36.3). In adjusted analyses, greater access scores were associated with greater odds of 30-day ED revisits (odds ratio [OR] = 1.07; 95% confidence interval [CI], 1.02–1.13)—particularly for croup (OR = 1.17; 95% CI, 1.02–1.36)—but not inpatient readmissions (OR = 1.02; 95% CI, 0.96–1.09). Perceived access to timely office-based care was associated with significantly greater odds of subsequent ED revisit. Focusing solely on enhancing timely access to care following discharge for common respiratory illnesses may be insufficient to prevent repeat utilization. [ABSTRACT FROM AUTHOR]

Background: Respiratory viruses are detectable in a large proportion of adults hospitalised with acute respiratory illness. For influenza and other viruses there is evidence that viral load and persistence are associated with certain clinical outcomes but it is not known if there is an association between viral load and hospital length of stay.Methods: 306 adults hospitalised with viral acute respiratory illness were studied. Associations between viral load and length of stay were examined. Multiple linear regression analysis was performed to control for age, comorbidity, influenza vaccine status, duration of illness prior to hospitalisation, bacterial co-infection, clinical group and virus subtype.Results: High viral load was associated with a longer duration of hospitalisation for all patients (p < 0.0001). This remained significant across all virus types and clinical groups and when adjusted for age, comorbidity, duration of illness prior to hospitalisation, bacterial co-infection and other factors.Conclusions: High viral loads are associated with prolonged hospital length of stay in adults with viral acute respiratory illness. This further supports existing evidence demonstrating that viral acute respiratory illness is a viral load driven process and suggests that viral load could be used in clinical practise to predict prolonged hospitalisation and prioritise antivirals. International Standard Randomised Controlled Trial Number (ISRCTN): 21521552. [ABSTRACT FROM AUTHOR]

Nurses', respiratory therapists' (RTs), and physicians' concerns about oxygen weaning practices and pulse oximetry use in healthy children during inpatient admissions prompted this multidisciplinary evidence-based project. A nurse-led inter-professional team found lack of consistent oxygen weaning practices and lack of guidelines for nurses or RTs regarding pulse oximetry use with children admitted for acute respiratory illness. The team created and piloted evidence-based oxygen weaning and pulse oximetry protocols. After a 6 month pilot, children in the pilot had shorter length of stay, time on oxygen, and time on continuous pulse oximetry. Protocols improved patient outcomes and decreased associated charges. [ABSTRACT FROM AUTHOR]

Respiratory viruses are responsible for a large proportion of acute respiratory illness in adults as well as children, and are associated with a huge socio-economic burden worldwide. Development of accurate point-of-care tests (POCT) for respiratory viruses has been listed as a priority by the World Health Organisation and replacing the current paradigm of empirical antimicrobial use with directed use is a listed goal of the movement for reduction in antimicrobial resistance. POCTs for respiratory viruses have previously been limited by the poor sensitivity of antigen detection based tests and by a limited range of detectable viruses. Highly accurate molecular platforms are now able to test for a comprehensive range of viruses, can be operated by non-laboratory staff and can generate a result in approximately 1 h, making them potentially deployable as POCTs. The potential clinical benefits of POC testing for respiratory viruses in adults include a reduction in unnecessary antibiotic use, improved antiviral prescribing for influenza and rationalisation of isolation facilities. We review here the burden of disease, the currently available molecular platforms with potential for POCT use and the existing evidence for clinical and economic benefits of testing for respiratory viruses in adults. [ABSTRACT FROM AUTHOR]

Noninvasive ventilation (NIV) for pediatric acute respiratory illness reduces work of breathing, improves ventilation, and potentially avoids complications associated with endotracheal intubation and mechanical ventilation. Modalities of NIV include continuous positive airway pressure and bilevel positive airway pressure, which have been used in a range of pediatric diseases. In addition, high-flow nasal cannula is a newer modality that is increasingly used in pediatric patients. This article describes the properties of different modalities of NIV and reviews the medical literature regarding use of NIV in pediatric patients with acute respiratory illness. [ABSTRACT FROM AUTHOR]

Summary Objectives Many adult patients hospitalised with acute respiratory illness have viruses detected but the overall importance of viral infection compared to bacterial infection is unclear. Methods Patients were recruited from two acute hospital sites in Leicester (UK) over 3 successive winters. Samples were taken for viral and bacterial testing. Results Of the 780 patients hospitalised with acute respiratory illness 345 (44%) had a respiratory virus detected. Picornaviruses were the most commonly isolated viruses (detected in 23% of all patients). Virus detection rates exceeded 50% in patients with exacerbation of asthma (58%), acute bronchitis and Influenza-like-illness (64%), and ranged from 30 to 50% in patients with an exacerbation of COPD (38%), community acquired pneumonia (36%) and congestive cardiac failure (31%). Bacterial detection was relatively frequent in patients with exacerbation of COPD and pneumonia (25% and 33% respectively) but was uncommon in all other groups. Antibiotic use was high across all clinical groups (76% overall) and only 21% of all antibiotic use occurred in patients with detectable bacteria. Conclusions Respiratory viruses are the predominant detectable aetiological agents in most hospitalised adults with acute respiratory illness. Antibiotic usage in hospital remains excessive including in clinical conditions associated with low rates of bacterial detection. Efforts at reducing excess antibiotic use should focus on these groups as a priority. Registered International Standard Controlled Trial Number: 21521552. [ABSTRACT FROM AUTHOR]

Objective: We ask whether subjective social status (SSS) predicts rates of wintertime febrile acute respiratory illness (ARI). Methods: 1,373 women and 346 men were enrolled from September 1 through November 30, 2010 as part of a prospective cohort study of health care personnel (HCP) at two medical centers. A questionnaire was completed at enrollment followed by 20 weeks of surveillance. ARI was an illness with fever and cough self-reported via weekly telephone or Internet-based surveillance. Results: For both sexes, lower SSS was associated with younger age, less education, lower neighborhood household income, being unmarried, lower occupational status, working in outpatient settings, and poorer self-rated health status. Demographic and occupational covariates explained 23% and 42% of the variance (R2) in SSS among women and men, respectively. Smoking, exercise frequency, and sleep quality were also associated with SSS, but these factors explained little additional variance (3-4%). Among women HCP, lower SSS at enrollment was associated with higher rates of subsequent ARI (unadjusted ß = -.21 [±.05], p < .001 for ordinal data). Adjusting for all covariates reduced the effect size of the SSS minimally (adjusted ß = -.19 [±.06], p < .001). Among men HCP, there was no univariate SSS-ARI association and after adjusting for all covariates the effect was opposite of our hypothesis (adjusted ß = .33 [±.\7],p < .05). Conclusions: Women (but not men) with lower SSS were more likely to report an ARI during surveillance, and the SSS-ARI association was independent of demographics, occupational status, health, and health behaviors. [ABSTRACT FROM AUTHOR]

The respiratory system is often affected by complications of immunodeficiency, typically manifesting clinically as acute respiratory illness. Ongoing literature reviews regarding the appropriateness of imaging in these patients are critical, as advanced medical therapies such as stem cell transplantation, chemotherapy, and immunosuppressive therapies for autoimmune disease continue to keep high the population of immunosuppressed patients in our health care system today. This ACR Appropriateness Criteria® topic describes clinical scenarios of acute respiratory illness in immunocompromised patients with cough, dyspnea, chest pain, and fever; in those with negative, equivocal, or nonspecific findings on chest radiography; in those with diffuse or confluent opacities on chest radiography; and in those in whom noninfectious disease is suspected. The use of chest radiography, chest CT, transthoracic needle biopsy, and nuclear medicine imaging are all discussed in the contexts of these clinical scenarios. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. [ABSTRACT FROM AUTHOR]

Despite advances over the past ten years lower respiratory tract infections still comprise around a fifth of all deaths worldwide in children under five years of age with the majority in low- and middle-income countries. Known risk factors for severe respiratory infections and poor chronic respiratory health do not fully explain why some children become sick and others do not. The respiratory tract hosts bacteria that can cause respiratory infections but also normal commensal bacteria. Together, this microbial population is called the microbiome. The composition of the respiratory microbiome in the first few months of life is likely influenced by external factors such as environment, mode of delivery and infant feeding practices, which are also associated with susceptibility to respiratory infections and wheezing illness/asthma. Recently, multiple studies have shown that respiratory microbiota profiles early in life are associated with an increased risk and frequency of subsequent respiratory infections, disease severity and occurrence of wheeze in later childhood. Early interactions between infectious agents such as viruses and the respiratory microbiome have shown to modulate host immune responses potentially affecting the course of the disease and future respiratory health. Deeper understanding of these interactions will help the development of new therapeutic agents or preventive measures that may modify respiratory health outcomes and help us to stratify at risk populations to better target our current interventional approaches. [ABSTRACT FROM AUTHOR]

Background Rhinovirus is linked to asthma exacerbations and chronic obstructive pulmonary disease exacerbations in adults. The severity and rates of rhinovirus acute respiratory illnesses (ARIs) in adults are uncertain. Objectives We sought to determine rhinovirus-associated ARI rates in adults presenting for care in multiple settings and identify factors associated with rhinovirus detection. Methods This prospective, population-based cohort enrolled Tennessee residents 18 years or older in the emergency department (ED), outpatient clinics, or hospitalized for ARI from December 2008 to May 2010. Nasal/throat swabs were collected and tested for rhinovirus and other viruses by using RT-PCR. Rates of ED visits and hospitalizations were calculated and rhinovirus-positive and rhinovirus-negative patients were compared. Results Among 2351 enrollees, rhinovirus was detected in 247 (11%). There were 7 rhinovirus-associated ED visits and 3 hospitalizations per 1000 adults annually. Patients with rhinovirus, compared with virus-negative ARI, were more likely to present with wheezing (odds ratio [OR], 1.7; 95% CI, 1.23-2.35; P < .001), to be a current smoker (OR, 2.31; 95% CI, 1.68-3.19) or live with a smoker (OR, 1.72; 95% CI, 1.10-2.67), have a history of chronic respiratory disease (OR, 1.61; 95% CI, 1.17-2.22), and were less likely to be hospitalized versus seen in the outpatient setting (OR, 0.58; 95% CI, 0.41-0.83). Conclusions Rhinovirus is associated with a substantial number of ED visits and hospitalizations for ARIs in adults. There may be modifiable factors that can reduce the likelihood of presenting with rhinovirus-associated ARIs. [ABSTRACT FROM AUTHOR]

Objective The objective of the study was to identify characteristics of influenza illness contrasted with noninfluenza acute respiratory illness (ARI) in pregnant women. Study Design ARI among pregnant women was identified through daily surveillance during 2 influenza seasons (2010-2012). Within 8 days of illness onset, nasopharyngeal swabs were collected, and an interview was conducted for symptoms and other characteristics. A follow-up telephone interview was conducted 1-2 weeks later, and medical records were extracted. Severity of illness was evaluated by self-assessment of 12 illness symptoms, subjective ratings of overall impairment, highest reported temperature, illness duration, and medical utilization. Results Of 292 pregnant women with ARI, 100 tested positive for influenza viruses. Women with influenza illnesses reported higher symptom severity than those with noninfluenza ARI (median score, 18 vs 16 of 36; P < .05) and were more likely to report severe subjective feverishness (18% vs 5%; P < .001), myalgia (28% vs 14%; P < .005), cough (46% vs 30%; P < .01), and chills (25% vs 13%; P < .01). More influenza illnesses were associated with fever greater than 38.9°C (20% vs 5%; P < .001) and higher subjective impairment (mean score, 5.9 vs 4.8; P < .001). Differences in overall symptom severity, fever, cough, chills, early health care–seeking behavior, and impairment remained significant in multivariate models after adjusting for study site, season, age, vaccination status, and number of days since illness onset. Conclusion Influenza had a greater negative impact on pregnant women than noninfluenza ARIs, as indicated by symptom severity and greater likelihood of elevated temperature. These results highlight the importance of preventing and treating influenza illnesses in pregnant women. [ABSTRACT FROM AUTHOR]