Search

OBJECTIVE. Our goal was to determine whether maternal asthma and maternal smoking during pregnancy are associated with the incidence and severity of clinically significant bronchiolitis in term, otherwise healthy infants without the confounding factors of small lung size or underlying cardiac or pulmonary disease. PATIENTS AND METHODS. We conducted a population-based retrospective cohort study of term, non-low birth weight infants enrolled in the Tennessee Medicaid Program from 1995 to 2003. The cohort of infants was followed through the first year of life to determine the incidence and severity of bronchiolitis as determined by health care visits and prolonged hospitalization. RESULTS. A total of 101 245 infants were included. Overall, 20% of infants had [greater than or equal to] 1 health care visit for bronchiolitis. Compared with infants with neither factor, the risk of bronchiolitis was increased in infants with maternal smoking only, maternal asthma only, or both. Infants with maternal asthma only or with both maternal smoking and asthma had the highest risks for emergency department visits and hospitalizations. Infants with a mother with asthma had the highest risk of a hospitalization >3 days, followed by infants with both maternal asthma and smoking, and maternal smoking only. CONCLUSIONS. Maternal asthma and maternal smoking during pregnancy are independently associated with the development of bronchiolitis in term, non-low birth weight infants without preexisting cardiac or pulmonary disease. The risk of bronchiolitis among infants with mothers who both have asthma and smoke during pregnancy is ~50% greater than that of infants with neither risk factor. Efforts to decrease the illness associated with these 2 risk factors will lead to decreased morbidity from bronchiolitis, the leading cause of hospitalization for severe lower respiratory tract infections during infancy. Key Words bronchiolitis, risk factors, infant, smoking, asthma, BRONCHIOLITIS, CAUSED BY viruses such as respiratory syncytial virus (RSV) and rhinovirus, is the leading cause of lower respiratory tract infections in infants. (1-4) Bronchiolitis results in significant morbidity in [...]

OBJECTIVES. Although bronchiolitis is the leading cause of hospitalization for infants, there are limited data describing the epidemiology of bronchiolitis hospitalizations, and the associated cost is unknown. Our objective was to determine nationally representative estimates of the frequency of bronchiolitis hospitalizations and its associated costs. PATIENTS AND METHODS. We analyzed the 2002 Health Care Utilization Project-National Inpatient Sample, a federal, stratified random survey of hospital discharges. For admissions age RESULTS. In 2002, an estimated 149 000 patients were hospitalized with bronchiolitis. Frequency of hospitalizations was higher among children age < 1 year of age, male gender, and nonwhite race. Mean length of stay was 3.3 days. Total annual costs for bronchiolitis-related hospitalizations were $543 million, with a mean cost of $3799 per hospitalization. Mean cost of bronchiolitis with a codiagnosis of pneumonia was $6191. In a multivariate analysis controlling for 3 confounding factors (including length of stay), cost per hospitalization was higher for children [greater than or equal to]1 year and lower for those in the South versus Northeast. CONCLUSIONS. Bronchiolitis admissions cost more than $500 million annually. A codiagnosis of bronchiolitis and pneumonia almost doubles the cost of the hospitalization. Inpatient health care costs of bronchiolitis are higher than estimated previously and highlight the need for initiatives to safely reduce bronchiolitis hospitalizations and thereby decrease health care costs. Key Words bronchiolitis, cost, HCUP, Bronchiolitis is the leading cause of hospitalization for infants Estimating bronchiolitis hospitalization costs from RSV-related bronchiolitis may underestimate the true cost of bronchiolitis hospitalizations. Although RSV infection is the most [...]

Bronchiolitis is a disorder most commonly caused in infants by viral lower respiratory tract infection. It is the most common lower respiratory infection in this age group. It is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, increased mucus production, and bronchospasm. The American Academy of Pediatrics convened a committee composed of primary care physicians and specialists in the fields of pulmonology, infectious disease, emergency medicine, epidemiology, and medical informatics. The committee partnered with the Agency for Healthcare Research and Quality and the RTI International-University of North Carolina Evidence-Based Practice Center to develop a comprehensive review of the evidence-based literature related to the diagnosis, management, and prevention of bronchiolitis. The resulting evidence report and other sources of data were used to formulate clinical practice guideline recommendations. This guideline addresses the diagnosis of bronchiolitis as well as various therapeutic interventions including bronchodilators, corticosteroids, antiviral and antibacterial agents, hydration, chest physiotherapy, and oxygen. Recommendations are made for prevention of respiratory syncytial virus infection with palivizumab and the control of nosocomial spread of infection. Decisions were made on the basis of a systematic grading of the quality of evidence and strength of recommendation. The clinical practice guideline underwent comprehensive peer review before it was approved by the American Academy of Pediatrics. This clinical practice guideline is not intended as a sole source of guidance in the management of children with bronchiolitis. Rather, it is intended to assist clinicians in decision-making. It is not intended to replace clinical judgment or establish a protocol for the care of all children with this condition. These recommendations may not provide the only appropriate approach to the management of children with bronchiolitis. Key Word bronchiolitis Abbreviations CAM--complementary and alternative medicine LRTI--lower respiratory tract infection AHRQ--Agency for Healthcare Research and Quality RSV--respiratory syncytial virus AAP--American Academy of Pediatrics AAEP--American Academy of Family Physicians RCT--randomized, controlled trial CLD--chronic neonatal lung disease SBI--serious bacterial infection UTI--urinary tract infection AOM--acute otitis media Sp[O.sub.2]--oxyhemoglobin saturation LRTD--lower respiratory tract disease, INTRODUCTION THIS GUIDELINE EXAMINES the published evidence on diagnosis and acute management of the child with bronchiolitis in both outpatient and hospital settings, including the roles of supportive therapy, oxygen, [...]

OBJECTIVE. Hypoxia is a common reason for hospital admission in infants and children with acute bronchiolitis. No study has evaluated discharge from the emergency department (ED) on home oxygen. This study evaluated the feasibility and safety of ED discharge on home oxygen in the treatment of acute bronchiolitis. METHODS. This was a prospective, randomized trial of infants and children with acute bronchiolitis and hypoxia (room-air saturations of [less than or equal to] 7%) aged 2 to 24 months presenting to an urban, academic, tertiary care children&apos;s hospital ED from December 1998 to April 2001. Subjects received inpatient admission or home oxygen after an 8-hour observation period in the ED. We measured the failure to meet discharge criteria during the observation period, return for hospital admission, and incidence of serious complications. RESULTS. Ninety-two patients were enrolled. Fifty three (58%) were randomly assigned to home and 39 (42%) to inpatient admission. There were no differences between the groups in age, initial room-air saturation, and respiratory distress severity score. Of 53 patients, 37 (70%) randomly assigned to home oxygen completed the observation period and were discharged from the hospital. The remaining 16 patients were excluded from the study (6), resolved their oxygen requirement (5), or failed to meet the discharge criteria and were admitted (5). One discharged patient (2.7%) returned to the hospital and was admitted for a cyanotic spell at home after the 24-hour follow-up appointment. The patient had an uncomplicated hospital course with a length of stay of 45 hours. The remaining 36 patients (97%) were treated successfully as outpatients with home oxygen. Satisfaction with home oxygen was high from the caregiver and the primary care provider. CONCLUSIONS. Discharge from the ED on home oxygen after a period of observation is an option for patients with acute bronchiolitis. Secondary to the low incidence of complications, the safety of this practice will require a larger study. Key Words bronchiolitis, hypoxia, oxygen, home therapy, observation Abbreviations PCP--primary care provider ED--emergency department RDSS--respiratory distress severity score, BRONCHIOLITIS IS THE most common cause of hospital admission in children < 1 year of age. An estimated 80 000 to 120 000 children < 1 year of age are [...]

Bronchiolitis obliterans (BO) in children is a rare, inflammatory/fibrosing process involving the small airways that often results in progressive, irreversible obstructive pulmonary disease. Because treatment has focused mainly on supportive care and generally unsuccessful immunosuppression, children with BO experience significant morbidity and mortality. We report a case of biopsy-proven BO after bone marrow transplantation in a child who, after failed corticosteroid therapy, was treated with infliximab, a monoclonal antibody with binding specificity for human tumor necrosis factor-[alpha]. With initiation of treatment, her pulmonary symptoms and radiographic and spirometric evidence of BO resolved. Nine months later, she remains asymptomatic and shows no evidence of pulmonary decompensation. This case illustrates a successful treatment of BO with selective tumor necrosis factor-[alpha] blockade. Pediatrics 2005;116:767-770; bone marrow transplant, bronchiolitis obliterans, tumor necrosis factor-alpha., ABBREVIATIONS. BO, bronchiolitis obliterans; BMT, bone marrow transplantation; TNF-[alpha], tumor necrosis factor-[alpha]; GVHD, graft-versus-host disease; HRCT, high-resolution computed tomography; IVIG, intravenous immunoglobulin; RSV, respiratory syncytial virus; [FEV.sub.1], forced expiratory volume [...]

Objective. To determine the incidence of preventable adverse events (AEs) and near misses (NMs) among infants hospitalized for bronchiolitis at a pediatric tertiary care hospital and the impact of these errors on hospital length of stay (LOS). Methods. We studied 143 infants with bronchiolitis, ages 0 to 12 months, admitted from December 2002 to April 2003. Using prospective chart review and staff reports, we captured medical errors and AEs. Each event was classified as a (1) preventable AE, (2) nonpreventable AE, (3) intercepted NM, (4) nonintercepted NM, or (5) error with little or no potential for harm. Results. Of 143 patients, 15 (10%) suffered an AE or NM. The incidence of preventable AEs was 10 per 100 admissions. We found a higher incidence of preventable AEs and NMs among critically ill patients (CIPs) compared with non-CIPs (68 vs 5 per 100 admissions, respectively), making the absolute risk of an AE or NM 14 times more likely in CIPs. Mean LOS was significantly longer for CIPs with at least 1 AE (9.1 + 8.8 days) than for CIPs without AEs (2.9 [+ or -] 1.5 days). Mean LOS was not significantly different between non-CIPs who did (3.8 [+ or -] 2.6 days) and did not (4.2 [+ or -] 5.0 days) experience an AE. Conclusions. Preventable AEs occur frequently among patients admitted for bronchiolitis, especially those who are critically ill. CIPs who suffer AEs during their hospitalization have longer hospital LOSs. Future studies should investigate error-prevention strategies with a focus on those patients with severe disease. Pediatrics 2005;116:603-608; adverse events, bronchiolitis, medical errors., ABBREVIATIONS. AE, adverse event; NM, near miss; LOS, length of stay; CIP, critically ill patient. Pediatric inpatients frequently suffer medical errors, which may cause severe harm. Although the numbers are [...]

Objectives. We know little about the variation in diagnosis and management of bronchiolitis. The objectives of this study were (1) to document variations in treatment and diagnostic approaches, lengths of stay (LOSs), and readmission rates and (2) to determine which potentially modifiable process of care measures are associated with longer LOSs and antibiotic usage. Methods. We used the Pediatric Health Information System, which includes demographic, diagnostic, and detailed patient-level data on 30 large children&apos;s hospitals. We examined infants who were younger than 1 year and hospitalized for bronchiolitis (October 2001-September 2003). Multivariate analysis of variance was used to determine whether the variance in the outcomes was hospital related after controlling for other covariates. Linear regression was used to model predictors of increased LOS. Logistic regression was used to model antibiotic usage. Analyses were stratified by age group ( Results. A total of 17397 patients were included in the analysis. The mean LOS was 2.97 days; 72% of patients received chest radiographs, 45% received antibiotics, and 25% received systemic steroids. The mean LOS varied considerably across hospitals (range: 2.40-3.90 days), and hospital remained a significant contributor to LOS variation after controlling for our covariates. Variations in the use of diagnostic tests and medications as well as readmission rates also existed and also remained significant after controlling for covariates. The factors associated with the greatest increases in LOS in the regression analyses included higher severity scores and use of antibiotics, bronchodilators, and corticosteroids. The strongest predictors of antibiotic use in the logistic regression analyses were higher severity scores and receipt of a blood or cerebrospinal fluid culture. Receiving a chest radiograph was a significant predictor of antibiotic use in older but not younger infants. Conclusions. Considerable, unexplained variation exists in the inpatient management of bronchiolitis. The development of national guidelines and controlled trials of new therapies and different management approaches are indicated. Pediatrics 2005;115:878-884; bronchiolitis, infants, quality of care., ABBREVIATIONS. LOS, length of stay; APR-DRG, All-Patient Refined Diagnosis Related Group; OR, odds ratio; CI, confidence interval. Most commonly caused by respiratory syncytial virus, bronchiolitis is a clinical syndrome characterized [...]

Objective. To assess the therapeutic effects of breathing a low-density gas mixture (heliox: 70% helium and 30% oxygen) in infants with bronchiolitis. Design. Prospective, interventional, comparative study. Setting. A pediatric intensive care unit (PICU) in a tertiary care, teaching hospital. Patients. Thirty-eight infants, 1 month to 2 years old, consecutively admitted to the PICU for treatment of moderate-to-severe acute respiratory syncytial virus bronchiolitis. Interventions. The first 19 patients were enrolled as the control group and received supportive care and nebulized epinephrine. In the next 19 patients, heliox therapy was added through a nonrebreather reservoir face mask. Measurements and Outcomes. Respiratory distress score, respiratory rate, heart rate, end-tidal C[O.sub.2] (etC[O.sub.2]), and pulse oximetry oxygen saturation (sat[O.sub.2]) values were recorded at baseline and at regular intervals. Data obtained during the first 4 hours were analyzed for comparison purposes. Demographic data, age, time elapsed from the start of the symptoms to the admission to PICU, length of stay in PICU (PICU-LOS), and duration of heliox therapy were also collected for each patient. Reductions in clinical scores and PICU-LOS were considered primary outcomes. Main Results. At baseline, the heliox and control groups had similar age (5.5 [+ or -] 3.1 vs 5.9 [+ or -] 3 months), previous length of course (47.3 [+ or -] 19.3 vs 45.4 [+ or -] 18.6 hours), clinical score (6.7 [+ or -] 1.1 vs 6.6 [+ or -] 1), heart rate (160 [+ or -] 24 vs 165 [+ or -] 20 beats per minute), respiratory rate (64 [+ or -] 7 vs 61 [+ or -] 7 respirations per minute), sat[O.sub.2] (91 [+ or -] 2.3 vs 91 [+ or -] 2.5%), and etC[O.sub.2] (34 [+ or -] 7 vs 33 [+ or -] 6 mm Hg). Clinical score, heart rate, respiratory rate, and sat[O.sub.2] improved during the study in both groups. After 1 hour, the improvement in clinical score was significantly higher in the heliox group than in the control group (3.6 [+ or -] 1.16 vs 5.5 [+ or -] 0.89), and these differences continued to be significant at the end of the observation period (2.39 [+ or -] 0.69 and 4.07 [+ or -] 0.96, respectively), with a total average decrease in the score of 4.2 points in the heliox group versus 2.5 points in the control group. Heart and respiratory rates were also significantly lower in the heliox group compared with the control group after 1 hour and stayed lower throughout the rest of the study period. No changes were noted either in sat[O.sub.2] between groups or in etC[O.sub.2] within or between groups throughout the study. Mean duration of heliox administration was 53 [+ or -] 24 hours (range: 24-112 hours) and no adverse effects were detected. PICU-LOS was significantly shorter in the heliox group (3.5 [+ or -] 1.1 days) than in the control group (5.4 [+ or -] 1.6 days). Conclusions. In infants with moderate-to-severe respiratory syncytial virus bronchiolitis, heliox therapy enhanced their clinical respiratory status, according to the marked improvement in their clinical scores and the reduction of the accompanying tachycardia and tachypnea. This beneficial response occurred within the first hour of its administration and was maintained as long as heliox therapy continued. In addition, PICU-LOS was reduced in heliox-treated patients. Long-term prospective studies are required to corroborate these findings and to establish the proper place of heliox in the therapeutic schedule of bronchiolitis. Pediatrics 2002;109:68-73; infant, helium-oxygen mixture, heliox, bronchiolitis, respiratory syncytial virus infections, airway obstruction, respiratory therapy, work of breathing, epinephrine, pediatrics. ABBREVIATIONS. RSV, respiratory syncytial virus, PICU, pediatric intensive care unit; M-WCAS, modified Wood&apos;s Clinical Asthma Score; 1pm, liters per minute; sat[O.sub.2], pulse oximetry oxygen saturation; etC[O.sub.2], end-tidal C[O.sub.2]; PICU-LOS, length of stay in pediatric intensive care unit., Since use of helium-oxygen mixtures (heliox) was proposed by Barach, (1,2) as a medical therapy for severe asthma and upper airway obstruction, several studies on its role in respiratory therapy [...]

Group B streptococcus (GBS) can cause severe infection in neonates. Characterized by sepsis, pneumonia and cardiovascular collapse, GBS claims anywhere from 25% to 75% of those infected. Among the survivors there can be long-term neurologic morbidity, including seizures, mental retardation, hearing disorders, blindness, cerebral palsy and delays in development. A minimal risk of chronic pulmonary disease exists but has not been extensively studied. A case of a neonate with early-onset GBS sepsis and pneumonitis who developed severe respiratory failure, requiring extracorporeal membrane oxygenation support (ECMO), is reported. The patient developed bronchiolitis obliterans (BO), a nonspecific reaction to pulmonary injury, and died 14 days later. There is conjecture that ECMO support may have permitted the severe pulmonary response to become lethal and may have contributed to the development of BO as well.

An evidence-based clinical practice guideline for treating babies with bronchiolitis in a hospital can substantially reduce costs and lead to more effective management of this lung disease. Practice guidelines are suggestions for treating diseases according to the best scientific evidence. A bronchiolitis practice guideline was implemented at Cincinnati Children's Hospital Medical Center in January 1997. Compared to the treatment of bronchiolitis before this date, the guidelines decreased the number of diagnostic chest X-rays, admissions rates, length of stay, medication use, and average costs of respiratory services., Objective. To describe the effect of implementing an evidence-based clinical practice guideline for the inpatient care of infants with bronchiolitis at the Children&apos;s Hospital Medical Center in Cincinnati, Ohio. Methodology. A multidisciplinary team generated the guideline for infants [is less than or equal to] 1 year old who were admitted to the hospital with a first-time episode of typical bronchiolitis. The guideline was implemented January 15, 1997, and data on all patients admitted with bronchiolitis from that date through March 27, 1997, were compared with data on similar patients admitted in the same periods in the years 1993 through 1996. Data were extracted from hospital charts and clinical and financial databases. They included LOS and use and costs of resources ancillary to bed occupancy. Results. After implementation of the guideline, admissions decreased 29% and mean LOS decreased 17%. Nasopharyngeal washings for respiratory syncytial virus were obtained in 52% fewer patients. Twenty percent fewer chest radiographs were ordered. There were significant reductions in the use of all respiratory therapies, with a 30% decrease in the use of at least 1 [Beta]-agonist inhalation therapy. In addition, 51% fewer repeated inhalations were administered. Mean costs for all resources ancillary to bed occupancy decreased 37%. Mean costs for respiratory care services decreased 77%. Conclusions. An evidence-based clinical practice guideline for managing bronchiolitis was highly successful in modifying care during its first year of implementation. Pediatrics 1999;104:1334-1341; guideline, bronchiolitis, evidence-based medicine, pediatrics, outcome research., ABBREVIATIONS. RSV, respiratory syncytial virus; CHMC, Children's Hospital Medical Center; LOS, length of stay. With a peak incidence usually from late autumn to early spring, bronchiolitis in the United States [...]

AN AMERICAN ACADEMY of Pediatrics clinical practice guideline on the diagnosis and management of bronchiolitis was published recently in Pediatrics. (1) This Important guideline was evidence based and intended to [...]

Patel H, Gouin S, Platt R. J Pediatr. 2003;142:509-514 Purpose of the Study. To determine whether oral albuterol therapy is effective in reducing symptoms of mild/ moderate acute viral bronchiolitis. [...]

Objective. High incidence, rising admission rates, and relatively ineffective therapies make the management of bronchiolitis controversial. Since 1980, the rate of hospitalization for children with bronchiolitis has increased by nearly 250%, whereas mortality rates for the disease have remained constant. It has been speculated that the increasing use of pulse oximetry has lowered the threshold for admission and may have contributed to the rise in bronchiolitis-related admissions. The objective of this study was to describe pediatric emergency medicine physicians&apos; management preferences regarding infants with moderately severe bronchiolitis and to assess the influence of specific differences in oxygen saturation as measured by pulse oximetry (Sp[o.sub.2]) and respiratory rate (RR) on the decision to admit. Methods. Physicians who are members of the American Academy of Pediatrics Section of Emergency Medicine and living in the United States were randomized into 4 groups and mailed a survey that contained 1 of 4 vignettes. Vignettes were identical except for given Sp[o.sub.2] values (94% or 92%) and RR (50/min or 65/min). Subjects were asked to answer questions regarding laboratory tests, treatment options, and the decision to admit for the patient in their vignette. Results. We received completed surveys from 519 (64%) of the 812 physicians contacted. Most respondents recommended use of bronchodilators (96%), nasal suction (82%), and supplemental oxygen (57%). Few respondents recommended decongestants (9%), steroids (8%), or antibiotics (2%). When asked to rank therapies, respondents gave nasal suction 182 number 1 votes; bronchodilators received 164. The decision to admit varied with Sp[o.sub.2] and RR. Forty-three percent of respondents who received a vignette featuring Sp[o.sub.2] of 94% and a RR of 50/min recommended admission for the infant in their vignette. Fifty-eight percent recommended admission when the vignette Sp[o.sub.2] was 94% and RR was 65/min ([chi square] = 5.021). Respondents who received a vignette with Sp[o.sub.2] of 92% were nearly twice as likely to recommend admission: 83% recommended admission when vignette RR was 50/min, and 85% recommended admission when vignette RR was 65/min ([chi square] = 0.126). Conclusions. When treating infants with moderately severe bronchiolitis, pediatricians who work in emergency departments frequently use bronchodilators and nasal suction, 2 practices for which supporting data are either conflicting (bronchodilators) or nonexistent (nasal suction). In addition, their decisions to admit differ markedly on the basis of only a 2% difference in Sp[o.sub.2]. It is possible that increased reliance on pulse oximetry has contributed to the increase in bronchiolitis hospitalization rates seen during the past 2 decades. Pediatrics 2002;111:e45-e51. URL: http://www.pediatrics.org/cgi/ content/full/111/1/e45; bronchiolitis, bronchodilators, steroids, nasal suction, pulse oximetry, practice variation.