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- Title
Respiratory Support Practices for Bronchiolitis in the Pediatric Intensive Care Unit.
- Authors
Pelletier, Jonathan H.; Maholtz, Danielle E; Hanson, Claire M.; Nofziger, Ryan A.; Forbes, Michael L.; Besunder, James B.; Horvat, Christopher M.; Page-Goertz, Christopher K.
- Abstract
This cross-sectional study examines whether an increase in pediatric intensive care unit admissions is associated with changes in the use of high-flow nasal cannula and noninvasive ventilation in children with bronchiolitis aged younger than 2 years. Key Points: Question: Are changes in high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) use associated with an increase in pediatric intensive care unit (PICU) admissions for bronchiolitis? Findings: In this cross-sectional study of 33 816 encounters for patients aged younger than 2 years with bronchiolitis across 27 PICUs between 2013 and 2022, PICU admissions increased by 350 per year. This was associated with a simultaneous increase of 242 HFNC and 126 NIV admissions per year, but no significant change in invasive mechanical ventilation admissions. Meaning: Findings of this study suggest that increased use of HFNC and NIV is associated with increased PICU admissions for bronchiolitis. Importance: Admissions to the pediatric intensive care unit (PICU) due to bronchiolitis are increasing. Whether this increase is associated with changes in noninvasive respiratory support practices is unknown. Objective: To assess whether the number of PICU admissions for bronchiolitis between 2013 and 2022 was associated with changes in the use of high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) and to identify factors associated with HFNC and NIV success and failure. Design, Setting, and Participants: This cross-sectional study examined encounter data from the Virtual Pediatric Systems database on annual PICU admissions for bronchiolitis and ventilation practices among patients aged younger than 2 years admitted to 27 PICUs between January 1, 2013, and December 31, 2022. Use of HFNC and NIV was defined as successful if patients were weaned to less invasive support (room air or low-flow nasal cannula for HFNC; room air, low-flow nasal cannula, or HFNC for NIV). Main Outcomes and Measures: The main outcome was the number of PICU admissions for bronchiolitis requiring the use of HFNC, NIV, or IMV. Linear regression was used to analyze the association between admission year and absolute numbers of encounters stratified by the maximum level of respiratory support required. Multivariable logistic regression was used to analyze factors associated with HFNC and NIV success and failure (defined as not meeting the criteria for success). Results: Included in the analysis were 33 816 encounters for patients with bronchiolitis (20 186 males [59.7%]; 1910 patients [5.6%] aged ≤28 days and 31 906 patients [94.4%] aged 29 days to <2 years) treated at 27 PICUs from 2013 to 2022. A total of 7615 of 15 518 patients (49.1%) had respiratory syncytial virus infection and 1522 of 33 816 (4.5%) had preexisting cardiac disease. Admissions to the PICU increased by 350 (95% CI, 170-531) encounters annually. When data were grouped by the maximum level of respiratory support required, HFNC use increased by 242 (95% CI, 139-345) encounters per year and NIV use increased by 126 (95% CI, 64-189) encounters per year. The use of IMV did not significantly change (10 [95% CI, −11 to 31] encounters per year). In all, 22 381 patients (81.8%) were successfully weaned from HFNC to low-flow oxygen therapy or room air, 431 (1.6%) were restarted on HFNC, 3057 (11.2%) were escalated to NIV, and 1476 (5.4%) were escalated to IMV or extracorporeal membrane oxygenation (ECMO). Successful use of HFNC increased from 820 of 1027 encounters (79.8%) in 2013 to 3693 of 4399 encounters (84.0%) in 2022 (P =.002). In all, 8476 patients (81.5%) were successfully weaned from NIV, 787 (7.6%) were restarted on NIV, and 1135 (10.9%) were escalated to IMV or ECMO. Success with NIV increased from 224 of 306 encounters (73.2%) in 2013 to 1335 of 1589 encounters (84.0%) in 2022 (P <.001). In multivariable logistic regression, lower weight, higher Pediatric Risk of Mortality III score, cardiac disease, and PICU admission from outside the emergency department were associated with greater odds of HFNC and NIV failure. Conclusions and Relevance: Findings of this cross-sectional study of patients aged younger than 2 years admitted for bronchiolitis suggest there was a 3-fold increase in PICU admissions between 2013 and 2022 associated with a 4.8-fold increase in HFNC use and a 5.8-fold increase in NIV use. Further research is needed to standardize approaches to HFNC and NIV support in bronchiolitis to reduce resource strain.
- Subjects
HEART disease complications; RISK assessment; CROSS-sectional method; HEART diseases; PATIENTS; EXTRACORPOREAL membrane oxygenation; T-test (Statistics); RESEARCH funding; BRONCHIOLE diseases; HOSPITAL admission &; discharge; OXYGEN therapy; BODY weight; LOGISTIC regression analysis; PROBABILITY theory; TREATMENT effectiveness; RESPIRATORY syncytial virus infections; MANN Whitney U Test; CHI-squared test; MULTIVARIATE analysis; TREATMENT duration; PEDIATRICS; KAPLAN-Meier estimator; LOG-rank test; INTENSIVE care units; NASAL cannula; ARTIFICIAL respiration; PATIENT-professional relations; VENTILATOR weaning; DATA analysis software; CONFIDENCE intervals; REGRESSION analysis; SENSITIVITY &; specificity (Statistics)
- Publication
JAMA Network Open, 2024, Vol 7, Issue 1, pe2410746
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2024.10746