V A L E R I E R I S S , M D / M P H

Bronchiolitis, Updates on Management

Disclosures

I have no financial disclosures to report

Outline

Overview of bronchiolitis

Review 2014 AAP guidelines

Viral testing

Variability in practice

Pulse oximetry

HFNC

Enteral feeding

Bronchiolitis

By age 2 more than 1/3 of children have experienced bronchiolitis

About 10% of children with bronchiolitis are hospitalized Between 2 and 6% of all children with bronchiolitis require care in an

ICU

16% of all infant hospitalizations (< 2 years)

8% of hospitalized children with bronchiolitis have high risk medical conditions

In-hospital mortality in 2009 estimated at 0.03% (3/10,000)

Hospital cost in 2009 estimated at $1.73 billion

Pathophysiology

2014 AAP Guidelines

Children 1 month – 23 months of age Children with many co-morbidities excluded

Increasing number of patients with significant co-morbidities admitted annually

Do: Suction! Give IV vs. NG fluids (more to come) Consider O2 therapy (more to come)

Don’t: No CXR No Albuterol trials No epinephrine (other than potentially as rescue medication in severe disease) No oral steroids No antibiotics No chest PT No hypertonic saline (well…we don’t think so)

Variability in Care

22-75% order CBC

36-85% order CXR

19-91% bronchodilators

8-44% corticosteroids

17-43% antibiotics

38-93% IV

Variability in Care - CPAP

Variability in Care - Intubation

Prediction of Disease Severity

Hospitalization

Apnea

NIPPV

Mechanical Ventilation

ECMO

Chest X-Ray

No evidence to support routine use of CXR:

Risks: Unnecessary antibiotic use

CXR findings do not correlate with disease severity

Risk of bacterial pneumonia is low

Consider if increased pre-test probability for bacterial pneumonia:

> 2 days of fever

Asymmetric chest exam

No clinical improvement

Unusually high O2 need

Hypertonic Saline

? Shorten hospital stays: AAP 2014 consider if expected LOS > 3 days

Increased number of negative studies since 2014

2015 Pediatrics – no difference in LOS, clinical worsening, or 7-day readmission

2013 – AE 8.9% in HS vs. 3.9% in NS

2017 – French trial stopped early due to 4/61 with “severe” adverse events

2017 – comparison of three wards, hypertonic saline associated with longer period of desaturations and hospital stays

Viral Testing

Common culprits: RSV (73%)

Rhino (26%)

Influenza (1%)

Coronavirus (7%)

Human Metapneumovirus (7%)

Parainfluenza (3%)

Enterovirus (5%)

Adenovirus (8%)

M. pneumoniae (1%)

B. pertussis (0.2%)

Co-infections 30%

Viral Testing

Prognosis:

Rhinovirus may have shorter course of disease, may have a different phenotype associated with repeated wheezing

No difference in risk of apnea

Studies mixed with regard to LOS and severity associated with different pathogens

Rhino +/- co-infection with any organism other than RSV MAY have shorter LOS than RSV (although variable results)

Does not appear to impact risk of CPAP/need for intubation (although variable results)

Combined RSV/rhinovirus MAY have a longer LOS and a more severe course, but not clear at this point

Viral Testing

Not routinely recommended

Consider if: Need for cohorting

Uncertain clinical diagnosis

Age < 2 months

To assess for influenza

Recommended for: Patient with hospital acquired infection

High risk patients (immune-compromised, chronic lung/heart disease)

Child on Palivizumab (concern for breakthrough infection)

Pulse Oximetry

Healthy babies have oxygen desaturation events

Increased admissions since introduction

12.9/1000 to 31.2/1000 children under 1 year of age

90% vs. 94% SpO2 as cutoff- decreased LOS with no increased AE

Pulse Oximetry

Pulse Oximetry

Pulse Oximetry

Is there harm? Increased length of stay

Increased by 1.6 days in one study, a second showed that 58% of pts had increased LOS due to perceived oxygen need by 2.75 days (average LOS in this study was 72 hours)

Increased admissions Adverse events during hospital stay up to 10/100 Expensive ($600 million – $1.73 billion a year on bronchiolitis admissions in US)

Benefits? Some evidence that lower oxygen saturations in CHD (90-94%) associated with

worse long term neurodevelopment outcome Some evidence that mild hypoxemia in other chronic conditions (COPD and

Asthma) does not have detrimental effects on neuro-cognitive outcomes No identified impact on neuro-cognitive outcomes in children with mild or

moderate OSA older than 6 months

Choosing wisely campaign – one of five recommendations from 2013 was to avoid continuous pulse ox in children admitted for respiratory illness who are not using supplemental oxygen

Changes in Interventions for Bronchiolitis 2000 - 2009

High Flow Nasal Cannula

Possibly decreases intubation rates, but VERY unclear

Decreases need for escalation of care?

Potentially increases patient comfort

Some studies suggest decreased respiratory rates and heart rates

No difference in length of stay or length of O2 need

Low complication rates

McKiernan Journal of Pediatrics 2010

McKiernan Journal of Pediatrics 2010

Schibler et al. Intensive Care Medicine 2011

HFNC Prevents Escalation of Care?

NEJM 2018

NEJM 2018

High Flow Nasal Cannula at UVM

Started November 15 on the floor:

Have re-worked guidelines twice

Data to date:

38 total children eligible for HFNC on the floor (< 48 months old, not intubated on arrival or en route)

28 primary diagnosis bronchiolitis

4 primary diagnosis asthma

29 admitted to hospital floor

9 had HFNC initiated on floor

20 initiated in ED

Flow ranged 4-15L on initiation, average 1.2L/kg/min

Average age 9 months

Children Transferred to PICU

18/29 children transferred to PICU

6 remained on HFNC and required no additional therapy

10 were transitioned to CPAP

1 was intubated due to apnea

1 month old ex-33 week infant, admitted for observation, on RA on hospital floor, had code called due to apnea and was started on HFNC in PICU.

Would have been admitted to hospital floor last year as well

Enteral Feeding in Bronchiolitis

Concern for aspiration based on historical results

NPO status associated with increased LOS

LFNC

No different in LOS or adverse events associated with NG feeds

Offer option of NG feeding to families, similar outcomes, decreased tries at placement

IV vs. NG Hydration

Enteral Feeding in Bronchiolitis

Concern for aspiration based on historical results

NPO status associated with increased LOS

LFNC

No different in LOS or adverse events associated with NG feeds

Offer option of NG feeding to families, similar outcomes, decreased tries at placement

HFNC

There are some AE related to oral/NG feeding

No clear predictors of who will have AE

Generally well-tolerated

Adverse Events with PO Feeding in HFNC

This Season at UVM

HFNC on the floor for select patients

Selective use of viral swabs for clinical utility (specifically consider during influenza season and for infants < 2 months when considering sepsis rule out, or for unclear diagnosis)

Consider NG for hydration rather than IV

Spot check SpO2

Otherwise continue to follow 2014 AAP guidelines, suction, hydration, oxygen support

Precautions

Nosocomial RSV Spread in PICU Managed by Re-enforcing Droplet Precautions

Decrease of Nosocomial RSV Infections with Introduction of Droplet Precautions

References

Amir Kugelman, MD1, Karine Raibin, MD1, Husein Dabbah, MD2, Irina Chistyakov, MD1, Isaac Srugo, MD1, Lea Even, MD2, Nurit Bzezinsky, RN1, and Arieh Riskin, MD1 Intravenous Fluids versus Gastric-Tube Feeding in Hospitalized Infants with Viral Bronchiolitis: A Randomized, Prospective Pilot Study Journal of Pediatrics Vol. 162, No. 3 Todd A Florin, Amy C Plint, Joseph J ZorcViral bronchiolitis Lancet 2017; 389: 211–24

Elizabeth Kepreotes, Bruce Whitehead, John Attia, Christopher Oldmeadow, Adam Collison, Andrew Searles, Bernadette Goddard, Jodi Hilton, Mark Lee, Joerg Mattes High- flow warm humidified oxygen versus standard low- flow nasal cannula oxygen for moderate bronchiolitis (HFWHO RCT): an open, phase 4, randomised controlled trial Lancet 2017; 369: 930–39

Steve Cunningham, Aryelly Rodriguez, Tim Adams, Kathleen A Boyd, Isabella Butcher, Beth Enderby, Morag MacLean, Jonathan McCormick, James Y Paton, Fiona Wee, Huw Thomas, Kay Riding, Steve W Turner, Chris Williams, Emma McIntosh, Steff C Lewis, for the Bronchiolitis of Infancy Discharge Study (BIDS) group*

Oxygen saturation targets in infants with bronchiolitis (BIDS): a double-blind, randomised, equivalence trial Lancet 2015; 386: 1041–48

Ed Oakley, MBBS, FACEM1, Sonny Bata, MD1, Sharmila Rengasamy, MBBS1, David Krieser, MBBS, FRACP2, John Cheek, MBBS, FACEM3, Kim Jachno, PG Dip4, and Franz E. Babl, MD, MPH, FRACP, FAAP, FACEP1

Nasogastric Hydration in Infants with Bronchiolitis Less Than 2 Months of Age J Pediatr 2016;178:241-5

Gordana Mlinaric -Galinovic a,*, Dijana Varda-Brkic bNosocomial respiratory syncytial virus infections in children’s wards Diagnostic Microbiology and Infectious Disease

37 (2000) 237–246

Ricardo A QuinonezWhen technology creates uncertainty: pulse oximetry and overdiagnosis of hypoxaemia in bronchiolitis BMJ 2017;358:j3850 doi: 10.1136/bmj.j3850 (Published 2017 August 16)

Franklin et al. Early high flow nasal cannula therapy in bronchiolitis, a prospective randomised control trial (protocol): A Paediatric Acute Respiratory Intervention Study (PARIS) BMC Pediatrics (2015) 15:183 DOI 10.1186/s12887-015-0501-x

Patricia A. Abboud, MD; Patrick J. Roth, BS, RRT, RCP; Cheryl L. Skiles, RN, BSN; Adrienne Stol , MSPH; Mark E. Rowin, MD Predictors of failure in infants with viral bronchiolitis treated with high- ow, high-humidity nasal cannula therapy* Pediatr Crit Care Med 2012 Vol. 13, No. 6

Previously Healthy Infants May Have Increased Risk of Aspiration During Respiratory Syncytial Viral Bronchiolitis PEDIATRICS Vol. 104 No. 6 December 1999

A. Schibler et al. Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery Intensive Care Med (2011) 37:847–852 DOI 10.1007/s00134-011-2177-5

Charles G. Macias, MD, MPH; Jonathan M. Mansbach, MD, MPH; Erin S. Fisher, MD; Mark Riederer, MD; Pedro A. Piedra, MD; Ashley F. Sullivan, MS, MPH;Janice A. Espinola, MPH; Carlos A. Camargo, Jr., MD, DrPH

Variability in Inpatient Management of Children Hospitalized With Bronchiolitis Academic Pediatrics Volume 15, Number 1 January–February 2015

References

Grewal, S. (2013). A comparison of nebulized 3% hypertonic saline and epinephrine versus nebulized normal saline and epinephrine in the treatment of acute bronchiolitis. Http://isrctn.org/>. doi:10.1186/isrctn66632312

Shmueli, E., Berger, T., Herman, Y. A., Chodick, G., Rom, E., Bilavsky, E., . . . Prais, D. (2017). Real-life comparison of three general paediatric wards showed similar outcomes for children with bronchiolitis despite different treatment regimens. Acta Paediatrica,106(9), 1507-1511. doi:10.1111/apa.13921

Early Halt of a Randomized Controlled Study with 3% Hypertonic Saline in Acute Bronchiolitis.Ania Carsin Emilie Sauvaget Violaine Bresson Karine Retornaz Maria Cabrera Elisabeth Jouve Romain Truillet Emmanuelle Bosdure Jean-Christophe DubusRespiration. , 2017, Vol.94(3), p.251-257

Hospital Pediatrics August 2017, VOLUME 7 / ISSUE 8. Multicenter Observational Study of the Use of Nebulized Hypertonic Saline to Treat Children Hospitalized for Bronchiolitis From 2008 to 2014. Joshua Davis, Amy D. Thompson, Jonathan M. Mansbach, Pedro A. Piedra, Kohei Hasegawa, Ashley F. Sullivan, Janice A. Espinola, Carlos A. Camargo, Jr

Pediatrics. February 2017, VOLUME 139 / ISSUE 2. Update on Pediatric OveruseEric R. Coon, Paul C. Young, Ricardo A. Quinonez, Daniel J. Morgan, Sanket S. Dhruva, Alan R. Schroeder

Silver AH, Esteban-Cruciani N, Azzarone G, et al. 3% Hypertonic Saline Versus Normal Saline in Inpatient Bronchiolitis: A Randomized Controlled Trial. Pediatrics.2015;136(6):1036–1043pmid:26553190

Kohei Hasegawa, MD, MPH,a,b Yusuke Tsugawa, MD, MPH,b,c,d David F.M. Brown, MD,a,b Jonathan M. Mansbach, MD, MPH,a,e and Carlos A. Camargo Jr, MD, DrPHa,bTrends in Bronchiolitis Hospitalizations in the United States, 2000-2009. (2013). Pediatrics, 132(1). doi:10.1542/peds.2012-3877dRalston et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics 2014;134:e1474–e1502

GangLuoaFlory L.NkoybPer H.GestelandbTiffany S.GlasgowbBryan L.Stone. A systematic review of predictive modeling for bronchiolitis. International Journal of Medical Informatics. Volume 83, Issue 10, October 2014, Pages 691-714. https://doi.org/10.1016/j.ijmedinf.2014.07.005

Elizabeth Eby Halvorson, MD,1 Nicole Chandler, MD,2 Rebecca Neiberg, MS,3 and Sean E. Ervin, MD, PhD1 Association of NPO Status and Type of Nutritional Support on Weight and Length of Stay in Infants Hospitalized With Bronchiolitis. Hospital Pediatrics; 4 (3), 2013. www.hospitalpediatrics.org

doi:10.1542/hpeds.2013-0011

Effect of Oxygen Supplementation on Length of Stay for Infants Hospitalized With Acute Viral BronchiolitisStefan Unger and Steve Cunningham

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Sara Mayfield,1,2 Fiona Bogossian,2 Lee O’Malley1 and Andreas Schibler1,3 High-flow nasal cannula oxygen therapy for infants with bronchiolitis: Pilot study Journal of Paediatrics and Child Health 50 (2014) 373–378

Tuomas Jartti, MD,* Matilda Aakula, BM,* Jonathan M. Mansbach, MD, MPH,† Pedro A. Piedra, MD,‡ Eija Bergroth, MD,§ Petri Koponen, MD,¶ Juho E. Kivisto , MD,¶** Ashley F. Sullivan, MS, MPH,‖ Janice A. Espinola, MPH,‖ Sami Remes, MD,§ Matti Korppi, MD,¶ and Carlos A. Camargo, Jr., MD, DrPH‖ Hospital Length-of-stay Is Associated With Rhinovirus Etiology of Bronchiolitis Pediatr Infect Dis J 2014;33:829–834

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Questions

Risk Factors for Failing HFNC

Risk Factors for Failing HFNC