Critical Care Thresholds in Children with Bronchiolitis

Abstract

Reduction in mortality from bronchiolitis in developed health is principally achieved from the availability of critical care. Different health care providers and countries demonstrate considerable variance in admission rates, but globally the use and cost of this resource are increasing. The reasons of this are multifold and include organizational, cultural, and clinical aspects. The organization of care has evolved differently in different health care settings at the threshold of critical need, with local priorities and resources determining the location of care (ward or critical care). Critical care areas adopting high-flow oxygen therapy (HFOT) (a ward-based therapy in some institutions) have seen significant increase in their occupancy, without change in rates of mechanical ventilation. Culturally, some countries appear to have a lower threshold for intubation and mechanical ventilation: United States (18%), Finland (4%), and even in countries with high rates of critical care admission (27% in Australia and New Zealand), intubation rates can decline with time (reducing from 27% to 11%). Baseline clinical characteristics of children admitted to critical care are remarkably similar, children are young (c30–60 days) and often born prematurely (21–46%). Clinical thresholds for admission as predefined by critical care units in online guidance focus on presence of apnea (observed in 7–42% of admissions), low pulse oxygen saturation and subjective measures (exhaustion and reduced consciousness). Clinical characteristics of children at the time of admission are commonly reported in relation to the modified Woods Clinical Asthma Score (mean = 3.8 to ≥7) and raised pCO₂ (range = 8.0–8.8 kPa), with pCO₂ the only significant parameter in a multivariate analysis of factors associated with intubation.

Key Points

• More children are being admitted to intensive care over time with increased costs.

• Cultural, organizational, and clinical variance exist between centers and countries.

• Comparing and aligning admissions is difficult as there are no standardized criteria.

Keywords

bronchiolitis - respiratory syncytial virus - intensive care - mechanical ventilation - high flow oxygen therapy

Publication History

Article published online:
08 September 2020

• References

• 1 Shi T, McAllister DA, O'Brien KL. , et al; RSV Global Epidemiology Network. Global, regional, and national disease burden estimates of acute lower respiratory infections due to respiratory syncytial virus in young children in 2015: a systematic review and modelling study. Lancet 2017; 390 (10098): 946-958
• 2 Green CA, Yeates D, Goldacre A. , et al. Admission to hospital for bronchiolitis in England: trends over five decades, geographical variation and association with perinatal characteristics and subsequent asthma. Arch Dis Child 2016; 101 (02) 140-146
• 3 Duke T, Wandi F, Jonathan M. , et al. Improved oxygen systems for childhood pneumonia: a multihospital effectiveness study in Papua New Guinea. Lancet 2008; 372 (9646): 1328-1333
• 4 Chisti MJ, Salam MA, Smith JH. , et al. Bubble continuous positive airway pressure for children with severe pneumonia and hypoxaemia in Bangladesh: an open, randomised controlled trial. Lancet 2015; 386 (9998): 1057-1065
• 5 Hasegawa K, Tsugawa Y, Brown DFM, Mansbach JM, Camargo Jr CA. Trends in bronchiolitis hospitalizations in the United States, 2000-2009. Pediatrics 2013; 132 (01) 28-36
• 6 Schlapbach LJ, Straney L, Gelbart B. , et al; Australian & New Zealand Intensive Care Society (ANZICS) Centre for Outcomes & Resource Evaluation (CORE) and the Australian & New Zealand Intensive Care Society (ANZICS) Paediatric Study Group. Burden of disease and change in practice in critically ill infants with bronchiolitis. Eur Respir J 2017; 49 (06) 1601648
• 7 McAllister DA, Liu L, Shi T. , et al. Global, regional, and national estimates of pneumonia morbidity and mortality in children younger than 5 years between 2000 and 2015: a systematic analysis. Lancet Glob Health 2019; 7 (01) e47-e57
• 8 Fujiogi M, Goto T, Yasunaga H. , et al. Trends in bronchiolitis hospitalizations in the United States: 2000-2016. Pediatrics 2019; 144 (06) e20192614
• 9 Guillot C, Le Reun C, Behal H. , et al. First-line treatment using high-flow nasal cannula for children with severe bronchiolitis: applicability and risk factors for failure. Arch Pediatr 2018; 25 (03) 213-218
• 10 Dumas O, Mansbach JM, Jartti T. , et al. A clustering approach to identify severe bronchiolitis profiles in children. Thorax 2016; 71 (08) 712-718
• 11 Soshnick SH, Carroll CL, Cowl AS. Increased use of noninvasive ventilation associated with decreased use of invasive devices in children with bronchiolitis. Crit Care Explor 2019; 1 (08) e0026
• 12 Pierce HC, Mansbach JM, Fisher ES. , et al. Variability of intensive care management for children with bronchiolitis. Hosp Pediatr 2015; 5 (04) 175-184
• 13 Mecklin M, Heikkilä P, Korppi M. The change in management of bronchiolitis in the intensive care unit between 2000 and 2015. Eur J Pediatr 2018; 177 (07) 1131-1137
• 14 Franklin D, Babl FE, Schlapbach LJ. , et al. A randomized trial of high-flow oxygen therapy in infants with bronchiolitis. N Engl J Med 2018; 378 (12) 1121-1131
• 15 Wood DW, Downes JJ, Lecks HI. A clinical scoring system for the diagnosis of respiratory failure. Preliminary report on childhood status asthmaticus. Am J Dis Child 1972; 123 (03) 227-228
• 16 Durand P, Guiddir T, Kyheng C. , et al; Bronchopti study group. A randomised trial of high-flow nasal cannula in infants with moderate bronchiolitis. Eur Respir J 2020; 1901926: 1901926