Improved clinical and economic outcomes in severe bronchiolitis with pre-emptive nCPAP ventilatory strategy

Abstract

Purpose: Severe bronchiolitis is the leading cause of admission to the pediatric intensive care unit (PICU). Nasal continuous positive airway pressure (nCPAP) has become the primary respiratory support, replacing invasive mechanical ventilation (MV). Our objective was to evaluate the economic and clinical consequences following implementation of this respiratory strategy in our unit.

Methods: This was a retrospective cohort analysis of 525 infants with bronchiolitis requiring respiratory support and successively treated during two distinct periods with invasive MV between 1996 and 2000, P1 (n = 193) and nCPAP between 2006 and 2010, P2 (n = 332). Costs were estimated using the hospital cost billing reports.

Results: Patients' baseline characteristics were similar between the two periods. P2 is associated with a significant decrease in the length of ventilation (LOV) (4.1 ± 3.5 versus 6.9 ± 4.6 days, p < 0.001), PICU length of stay (LOS) (6.2 ± 4.6 versus 9.7 ± 5.5 days, p < 0.001) and hospital LOS. nCPAP was independently associated with a shorter duration of ventilatory support than MV (hazard ratio 1.8, 95% CI 1.5-2.2, p < 0.001). nCPAP was also associated with a significant decrease in ventilation-associated complications, and less invasive management. The mean cost of acute viral bronchiolitis-related PICU hospitalizations was significantly decreased, from 17,451 to 11,205 € (p < 0.001). Implementation of nCPAP led to a reduction of the total annual cost of acute viral bronchiolitis hospitalizations of 715,000 €.

Conclusion: nCPAP in severe bronchiolitis is associated with a significant improvement in patient management as shown by the reduction in invasive care, LOV, PICU LOS, hospital LOS, and economic burden.

Fig. 1

Distribution of ventilatory support in our PICU since 2000. The percentage of invasive ventilation (IV) among all ventilatory support (solid line) dramatically decreases from 2003 with a concomitant increase of the nasal continuous positive pressure (nCPAP) (dashed line). The dotted line represents the percentage of infants admitted to the unit without any ventilatory support, remaining in spontaneous breathing (SB) during their PICU stay. This percentage remains stable over the whole period

Fig. 2

a Probability curves of being on ventilatory support were established on the basis of the whole cohort using the Kaplan–Meier method, then compared across period groups by using the log-rank test. During the second period, there was a significant decrease of length of ventilatory support relative to the first period with an HR (95 % CI) of 1.83 (1.53–2.19). b HRs and 95 % CIs for length of ventilator support in the second period as compared with the first period. This effect remains significant after adjustment for prognostic baseline covariates: PRISM score, age, gestational age, RSV infection, and antibiotics