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Chest physiotherapy (CP) using passive expiratory manoeuvres is widely used in Western Europe for the treatment of bronchiolitis, despite lacking evidence for its efficacy. We undertook an open randomised trial to evaluate the effectiveness of CP in infants hospitalised for bronchiolitis by comparing the time to clinical stability, the daily improvement of a severity score and the occurrence of complications between patients with and without CP. Children

Objetivo: Descrever as características e a evolução de lactantes com bronquiolite aguda submetidos à ventilação mecânica. Métodos: Estudo retrospectivo desenvolvido entre março 2004 e setembro 2006 (três invernos consecutivos), recrutando todos os lactantes (menos de 12 meses de idade) com diagnóstico de bronquiolite viral aguda e submetidos à ventilação mecânica em uma unidade de terapia intensiva, brasileira, ligada a uma universidade. Os parâmetros de ventilação mecânica adotados no 1°, 2° 3° e 7° dia e antes da extubação foram avaliados, assim como a evolução (taxa de mortalidade, presença da síndrome de desconforto respiratório agudo) e prevalência de complicações. Os grupos foram comparados usando o teste t de Student, o teste U de Mann-Whitney e o teste Qui-Quadrado. Resultados: Foram incluídos 59 lactantes (3,8 ± 2,7 meses de idade, 59% de sexo masculino) com 9,0 ± 9,4 dias em ventilação mecânica. Antes da ventilação mecânica, ventilação não-invasiva foi instituída em 71% dos lactantes. Foi observada anemia em 78% da amostra. Em 51 lactantes (86,5%), o padrão obstrutivo de vias aéreas inferiores foi mantido até extubação intratraqueal, com mortalidade nula e baixa prevalência de pneumotórax (7,8%). A síndrome de desconforto respiratório agudo, ocorreu em 8 lactantes (13,5%) com mortalidade mais elevada e alta prevalência de pneumotórax (62,5%). Conclusões: O declínio na mortalidade em crianças com bronquiolite viral aguda tem sido observado mesmo em regiões não desenvolvidas, com altas taxas de anemia e partos prematuros. A baixa mortalidade está associada à manutenção o padrão obstrutivo de vias aéreas inferiores durante o tempo em ventilação mecânica. O desenvolvimento da síndrome de desconforto respiratório agudo está associado a uma mortalidade mais elevada e maior porcentagem de complicações representando o desafia atual para o tratamento de crianças com bronquiolite viral aguda. Objective: To describe the characteristics and the outcome of infants with acute viral bronchiolitis submitted to mechanical ventilation. Methods: We performed a retrospective study enrolling all infants (less than 12 months old) admitted with the diagnosis of acute viral bronchiolitis and submitted to mechanical ventilation in an university affiliated Brazilian pediatric intensive care unit between March, 2004 and September, 2006 (3 consecutives winters). The mechanical ventilation parameters’ employed on 1st, 2nd, 3rd, 7th day and before extubation were evaluated as well as the evolution (mortality rate, presence of acute respiratory distress syndrome and the prevalence of complications). The groups were compared using the Student t test, the Mann-Whitney U test and the Chi-square test. Results: Fifty-nine infants were included (3.8 ± 2.7 months old, 59% male), with 9.0 ± 9.4 days on mechanical ventilation. Prior mechanical ventilation, non invasive ventilation was instituted in 71% of children. Anemia was observed in 78% of the sample. In 51 infants (86.5%) the lower airway obstructive pattern was maintained up to tracheal extubation with a nil mortality and low prevalence of pneumothorax (7.8%). Acute respiratory distress syndrome occurred in 8 infants (13.5%), with higher mortality and a higher prevalence of pneumothorax (62.5%). Conclusions: The declining mortality in acute viral bronchiolitis is observed even in non developed regions, involving children with high rates of anemia and premature labor. The low mortality is associated with the maintenance of the lower airway obstructive pattern during the period on mechanical ventilation. The development of acute respiratory distress syndrome is associated with increased mortality and higher prevalence of complications, representing the actual challenge in the management of children with severe acute viral bronchiolitis.

Infants hospitalized for bronchiolitis associated with respiratory syncytial virus are isolated for the duration of their hospitalization. This article reviews whether a negative rapid antigenic test could be used to shorten the duration of isolation measures. Rapid respiratory syncytial virus tests were performed from day 3 on alternate days in all patients hospitalized for bronchiolitis. Isolation measures were removed when the test result was negative. The result of the antigenic test was confirmed by viral culture and polymerase chain reaction. Surveillance of nosocomial cases was performed daily. Forty-one patients were analyzed. On day 3, 51.2% of patients were negative by viral culture and 56.1% were negative by rapid testing. On day 5, a further 26.8% were negative by viral culture and 31.7% by rapid testing. The rapid antigen test had a low sensitivity at 60% and a specificity of 76% compared with viral cultures; therefore this test alone cannot be used to lift isolation measures.

OBJECTIVE: To describe the time course of high frequency oscillatory ventilation (HFOV) in respiratory syncytial virus (RSV) bronchiolitis. DESIGN: Retrospective charts review. SETTING: A tertiary paediatric intensive care unit. PATIENTS AND PARTICIPANTS: Infants with respiratory failure due to RSV infection. INTERVENTION: HFOV. MEASUREMENTS AND RESULTS: Pattern of lung disease, ventilatory settings, blood gases, infant's vital parameters, sedation and analgesia during the periods of conventional mechanical ventilation (CMV, 6 infants), after initiation of HFOV (HFOVi, 9 infants), in the middle of its course (HFOVm), at the end (HFOVe) and after extubation (Post-Extub) were compared. All infants showed a predominant overexpanded lung pattern. Mean airway pressure was raised from a mean (SD) 12.5 (2.0) during CMV to 18.9 (2.7) cmH(2)O during HFOVi (P < 0.05), then decreased to 11.1(1.3) at HFOVe (P < 0.05). Mean FiO(2) was reduced from 0.68 (0.18) (CMV) to 0.59 (0.14) (HFOVi) then to 0.29 (0.06) (P < 0.05) at HFOVe and mean peak to peak pressure from 44.9 (12.4) cmH(2)O (HFOVi) to 21.1 (7.7) P < 0.05 (HFOVe) while mean (SD) PaCO(2) showed a trend to decrease from 72 (22) (CMV) to 47 (8) mmHg (HFVOe) and mean infants respiratory rate a trend to increase from 20 (11) (HFOVi) to 34 (14) (HFOVe) breaths/min. With usual doses of sedatives and opiates, no infant was paralysed and all were extubated to CPAP or supplemental oxygen after a mean of 120 h. CONCLUSION: RSV induced respiratory failure with hypercapnia can be managed with HFOV using high mean airway pressure and large pressure swings while preserving spontaneous breathing.