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Multicenter Study
. 2023 Dec 1;24(12):1010-1021.
doi: 10.1097/PCC.0000000000003333. Epub 2023 Jul 26.

Variation in Early Pediatric Intensive Care Management Strategies and Duration of Invasive Mechanical Ventilation for Acute Viral Bronchiolitis in the United Kingdom: A Retrospective Multicenter Cohort Study

Mariana Miranda  1 , Samiran Ray  2   3 , Elizabeth Boot  4 , David Inwald  5 , Daleep Meena  6 , Ramesh Kumar  7 , Patrick Davies  8 , Maria Rivero-Bosch  9 , Philippa Sturgess  10 , Charlotte Weeks  11 , Kathryn Holliday  12 , Sofia Cuevas-Asturias  13 , Peter Donnelly  14 , Ahmed Elsaoudi  2 , Jon Lillie  4 , Simon Nadel  1   15 , Shane Tibby  4 , Rebecca Mitting  1
Affiliations
Multicenter Study

Variation in Early Pediatric Intensive Care Management Strategies and Duration of Invasive Mechanical Ventilation for Acute Viral Bronchiolitis in the United Kingdom: A Retrospective Multicenter Cohort Study

Mariana Miranda et al. Pediatr Crit Care Med. .

Abstract

Objectives: Management of mechanically ventilated patients with bronchiolitis is not standardized and duration of mechanical ventilation has been shown to vary widely between centers. The aim of this study was to examine practice in a large number of U.K. PICUs with a view to identify if early management choices relating to fluid prescription, sedative agent use, and endotracheal tube (ETT) placement were associated with differences in duration of invasive mechanical ventilation (IMV).

Design: Retrospective multicenter cohort study. Primary outcome was duration of IMV. A hierarchical gamma generalized linear model was used to test for associations between practice variables (sedative and neuromuscular blocking agents, route of endotracheal intubation at 24 hr and fluid balance at 48 hr) and duration of IMV after adjustment for known confounders.

Setting: Thirteen U.K. PICUs. Duration of 2 months between November and December 2019.

Patients: Three hundred fifty infants receiving IMV for bronchiolitis. Excluded were patients receiving long-term ventilation, extracorporeal life support, or who died before separation from IMV.

Interventions: None.

Measurements and main results: After adjustment for confounders, several variables were associated with an increase in the geometric mean duration of IMV (expressed as a percentage) including: nasal ETT use, 16% (95% CI, 1-32%); neuromuscular blockade use, 39% (95% CI, 21-61%); and fluid balance at 48 hr, 13% per 100 mL/kg positive fluid balance (95% CI, -1% to 28%). The association of sedative use varied with class of agent. The use of an alpha-2 agonist alone was associated with a reduction in duration of IMV by 19% in relation to no sedative agent (95% CI, -31 to -5%), whereas benzodiazepine uses alone or with alpha-2 agonist in combination were similar to using neither agent.

Conclusions: Early management strategies for bronchiolitis were associated with the duration of IMV across U.K. centers after adjustment for confounders. Future work should prospectively assess the impact of fluid restriction, route of endotracheal intubation, and alpha-2 agonist use on duration of IMV in infants with bronchiolitis, with the aim of reducing seasonal bed pressure.

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Conflict of interest statement

Dr. Miranda’s institution received funding from the U.K. Pediatric Critical Care Society. Dr. Ray’s institution received support from the National Institute for Health Research Great Ormond Street Hospital Biomedical Research Centre; he received funding from the U.K. National Institute for Health Research, the U.K. Engineering and Physical Sciences Research Council; his institution received funding from La Roche Limited. The remaining authors have not disclosed any potential conflicts of interest.

References

    1. National Institute for Health and Care Excellence: Bronchiolitis in children: Diagnosis and management (NICE guideline NG9). Last updated 9 August 2021. Available at: https://www.nice.org.uk/guidance/ng9 . Accessed on May 23, 2022
    1. Ralston SL, Lieberthal AS, Meissner HC, et al.; American Academy of Pediatrics: Clinical practice guideline: The diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014; 134:e1474–e1502
    1. Friedman JN, Rieder MJ, Walton JM; Canadian Paediatric Society, Acute Care Committee, Drug Therapy and Hazardous Substances Committee: Canadian Paediatric Society Position Statement—Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age. Paediatr Child Health. 2014; 19:485–498
    1. Mitting RB, Peshimam N, Lillie J, et al.: Invasive mechanical ventilation for acute viral bronchiolitis: Retrospective multicenter cohort study. Pediatr Crit Care Med. 2021; 22:231–240
    1. Milési C, Baudin F, Durand P, et al.: Clinical practice guidelines: Management of severe bronchiolitis in infants under 12 months old admitted to a pediatric critical care unit. Intensive Care Med. 2023; Advance online publication 49:5–25

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