Impact of a modification of the clinical practice guide of the American Academy of Pediatrics in the management of severe acute bronchiolitis in a pediatric intensive care unit

Abstract

Objective: To describe the characteristics and evolution of patients with bronchiolitis admitted to a pediatric intensive care unit, and compare treatment pre- and post-publication of the American Academy of Pediatrics clinical practice guide.

Design: A descriptive and observational study was carried out between September 2010 and September 2017.

Setting: Pediatric intensive care unit.

Patients: Infants under one year of age with severe bronchiolitis.

Interventions: Two periods were compared (2010-14 and 2015-17), corresponding to before and after modification of the American Academy of Pediatrics guidelines for the management of bronchiolitis in hospital.

Main variables: Patient sex, age, comorbidities, severity, etiology, administered treatment, bacterial infections, respiratory and inotropic support, length of stay and mortality.

Results: A total of 706 patients were enrolled, of which 414 (58.6%) males, with a median age of 47 days (IQR 25-100.25). Median bronchiolitis severity score (BROSJOD) upon admission: 9 points (IQR 7-11). Respiratory syncytial virus appeared in 460 (65.16%) patients. The first period (2010-14) included 340 patients and the second period (2015-17) 366 patients. More adrenalin and hypertonic saline nebulizations and more corticosteroid treatment were administered in the second period. More noninvasive ventilation and less conventional mechanical ventilation were used, and less inotropic support was needed, with no significant differences. The antibiotherapy rate decreased significantly (p=0.003).

Conclusions: Despite the decrease in antibiotherapy, the use of nebulizations and glucocorticoids in these patients should be limited, as recommended by the guide.

Keywords: Acute respiratory failure; Bronchiolitis; Bronquiolitis; Cuidados intensivos; Insuficiencia respiratoria aguda; Intensive care; Pediatrics; Pediatría.

Figure 1

Management algorithm corresponding to acute bronchiolitis in our hospital following publication of the Clinical Practice Guide (CPG) of the American Association of Pediatrics (AAP). ABCDE: sequential evaluation; BROSJOD: Bronchiolitis Score of Sant Joan de Deu (bronchiolitis clinical severity scale); CPAP: continuous positive airway pressure; FiO₂: fraction of inspired oxygen; HFO: high-flow oxygen therapy; PCO₂: blood carbon dioxide partial pressure; Sat: hemoglobin saturation; 3% HSS: 3% hypertonic saline solution; PET: pediatric evaluation triangle.